Devolution and the regional health divide: a longitudinal ecological study of 14 countries in Europe

BACKGROUND:Greater regional devolution can reduce economic inequalities between regions; however, the impact on health inequalities is not clear. We investigated the association between changes over time in the level of devolution in European countries and regional economic and health inequalities. METHODS:We used the proportion of government expenditure controlled by subnational levels of government as our measure of devolution in 14 European countries between 1995 and 2011. Fixed effects linear regression models were used to analyse trends in the level of devolution, trends in regional economic inequalities (Gini-coefficient) and trends in regional health inequalities (slope index) in life expectancy. RESULTS:Each additional percentage of government expenditure managed at subnational level reduced the Gini-coefficient of regional GDP by -0.17 points (95% CI: -0.33 to -0.01; P = 0.04). However, it increased the slope index of regional life expectancy by 23 days (95% CI: -2 to 48; P = 0.07). When trends in regional economic inequalities were controlled for, as a potential mediator-increased devolution-was significantly associated with an increase in health inequalities between regions (P = 0.01). CONCLUSIONS:Increased devolution does not appear to reduce regional health inequalities-even when it reduces regional economic inequalities-and it could be associated with increased health inequalities