Devolution and the Interregional Inequalities in Health and Healthcare in Spain

The desirability of devolution of government responsibilities is often questioned on the grounds of regional cohesion concerns. This feature is especially relevant in welfare policy areas such as healthcare services given their impact on an individual's well-being. This paper examines the effects of health system devolution on the emergence of inter-territorial inequalities in healthcare outcomes (mortality) and outputs (healthcare expenditure) in the Spanish National Health System (NHS). Based on an empirical model for regional health expenditure, and drawing from a battery of inequality indicators (some taken from previous studies, other estimated anew), the following results are obtained. First, healthcare devolution has not led to an expansion of regional inequalities in healthcare outcomes and outputs. Second, there is no clear-cut evidence that devolution increases public health expenditure (in real terms) in devolved region-states, with the exception of fiscally accountable autonomous communities (ACs). Finally, regional health expenditure is explained by differences in need and higher reliance healthcare inputs use, size effects as well as the region-specific economic and demographic dimension in addition to regional income