Exploring the Pathways of Inequality in Health, Access and Financing in Decentralised Spain

The extent to which equality in the access to and the financing of health care reduces inequalities in health is a key question for health-care reform policy-making. Cross-country studies, when they exist suffer from marked comparability limitations due to data heterogeneity and differences between organisational and financing systems. The Spanish devolved national health system offers a “unique field” for exploring these issues, and also for testing the effects of institutional reform, in the form of political decentralisation. The data used is from 2001, the last year before decentralisation was extended to all region states or Autonomous Communities (ACs). This paper contributes to the literature by examining two questions. First, we evaluate the heterogeneity in within regional inequalities in health, health-care access and health financing and we examine whether these are associated with the political decentralisation of health care responsibilities. Second, we explore whether inequalities in health care between regional health services can be explained by inequalities in health-care use and health-care financing, using cross-correlation analysis along with other relevant variables. The results of the study suggest that inequalities in health are not associated with the regional uptake of health-care responsibilities. Instead they appear to be driven by income inequalities and regional health care capacity whilst the influence of inequalities in health-care use depends on quality of life adjustments.