Decentralized autonomy: how regions feather their own nests

The risk of fragmenting the Italian National Health Service once and for all is real, after the Government supported a new decentralization plan for regional Autonomia differenziata (Decentralized Autonomy, henceforth DA).¹ 
DA will allocate further decision-making, organizational, and financing responsibilities on a series of public policies to regions.¹ In the health sector it is the culmination of a 30-year-long decentralization process that was expected to cure long-standing inequalities while spending more efficiently.² Inevitably, it has achieved the opposite. 
The logic that decentralized governance can decrease inequalities holds true under certain assumptions. Health sector decentralization, for example, is rooted to Alma Ata’s vision of a system universally accessible “to individuals and families in the communities”, “in the spirit of self-reliance and self-determination”.³ A strong political will for social justice and an open dialogue between government and communities is essential to ensure that decentralization achieves equity.⁴
This begs the question: who did benefit from decentralization and who will benefit from DA?
Italian style decentralization has introduced privatization at the local level (e.g., through austerity and the autonomization of local health trusts), increased supplier-induced demand (e.g., through the inter-regional patients’ mobility), and limited the cross-subsidization effect between high- and low-income groups and areas (e.g., through fiscal decentralization).² Local private interests seem to have been far more crucial objectives than solidarity and universality. 
The rapid deterioration of availability of and accessibility to local health care should be the basis for a national political intervention to end secessionism and restore adequate and fairly distributed levels of public health spending.
Instead, it is used to justify further fragmentation: the local governments of the three high-income Italian Regions (Veneto, Lombardia, and Emilia-Romagna) are the main champions for DA with a proposal that ought to feather their own nests.⁵ 
At the core of the process is the demand to end expenditure constraints on health care in these three regions, while respecting national fiscal balance requirements.⁵ The health spending cap belongs to a set of nation-wide austerity measures introduced in the Great Recession era.² Removing it is a nation-wide exigency rather than a region-specific demand.
Even without spending caps, regions are meant to maintain fiscal balance within their health services.⁵ However, this will not be feasible without making further compromises on the public side.
In fact, two equally dangerous approaches are embedded to DA. On the one hand, the introduction of new hiring processes for untrained graduates, thereby dealing with the scarcity of workers and bypassing conventional training. This will occur at the expense of casualization and further fragmentation.
On the other hand, the expansion of employment-based private health insurance to compensate for a limited public health care package.⁵ Although convenient for certain local private stakeholders, this signals a shift away from the public, solidarity-based, universalistic system envisioned in 1978, towards a more commodified one. 
Autonomia differenziata is a backdoor for privatization, casualization, and competition. Built on the uneven distribution of possibilities and resources, it will ultimately shift the focus from the needs of the population to the interests of the market. Against this backdrop, it must be stopped.

Conflicts of interest: none declared.

References

1. Italian Cabinet of Ministers. Comunicato Stampa del Consiglio dei Ministri - Press Release from the Cabinet of Ministers. Italian Government, 02.02.2023. Available from: https://www.governo.it/sites/governo.it/files/Cdm_19-2023.pdf
2. Rotulo A, Paraskevopoulou C, Kondilis E. The Effects of Health Sector Fiscal Decentralisation on Availability, Accessibility, and Utilisation of Healthcare Services: A Panel Data Analysis. Int J Health Policy Manag 2021;11(11):2440-50.
3. World Health Organization. Declaration of Alma Ata: International Conference on Primary Health Care. In: International Conference on Primary Health Care. Alma Ata, Kazakhstan: World Health Organisation; 1978.
4. Rotulo A, Epstein M, Kondilis E. Fiscal federalism vs fiscal decentralisation in healthcare: a conceptual framework. Hippokratia 2020;24(3):107-13.
5. Fucito L, Frati M. Il regionalismo differenziato e gli accordi preliminari con le regioni Emilia-Romagna, Lombardia e Veneto. 2018. Available from: https://www.senato.it/service/PDF/PDFServer/BGT/01067303.pdf