It is right to do so: A comparative study on the influence of healthcare decentralisation on equity in Scotland and Sardinia

1-06-2020

Francesco Filigheddu - s2066262

Dr Ir. A.A.H.E. (Ellen) van Reuler

International Relations and Organisations

The Welfare State in International Perspective

Bachelor Thesis

Wordcount: 8300

It is right to do so: A comparative study on the influence of

Table of Content

1

Introduction ... 3

2

Literature Review ... 4

2.1

Healthcare Equity ... 4

2.1.1

Healthcare Equality ... 4

2.1.2

Healthcare Equity: Theories and Origins ... 5

2.1.3

Geographical and Local Inequities... 6

2.2

Decentralisation ... 7

2.2.1

Decentralisation: General Framework ... 7

2.2.2

Healthcare Decentralisation ... 8

2.2.3

Decentralisation and Equity: A Contested Relationship? ... 9

2.3

Why a different approach is needed ... 10

3

Methodology ... 11

3.1

Theoretical Expectations ... 11

3.2

Conceptualisation ... 12

3.2.1

Healthcare Decentralisation ... 12

3.2.2

Healthcare Equity ... 12

3.3

Research Design ... 13

3.4

Case Selection ... 14

3.5

Operationalisation ... 15

4

Results ... 16

4.1

Sardinia ... 16

4.1.1

1978 - 1992 ... 16

4.1.2

1992 - 2017 ... 17

4.2

Scotland... 19

4.2.1

1978 - 1999 ... 19

4.2.2

1999 - 2019 ... 20

5

Interpretation ... 22

5.1

Contingent Factors ... 22

5.2

The Role of Institutions... 23

5.3

Ideology and Partisanship ... 24

6

Conclusion ... 25

6.1

Main Pitfalls ... 25

6.2

Implications ... 26

6.2.1

Academic implications ... 26

6.2.2

Societal Implications ... 26

7

References ... 27

7.1

Primary Sources ... 27

7.1.1

Sardinia ... 27

7.1.2

Scotland ... 29

7.2

References ... 32

7.3

List of Abbreviations ... 41

8

Appendix I ... 42

8.1

Sardinia and Italy ... 42

8.2

Scotland and The United Kingdom ... 43

9

Appendix II ... 44

9.1

Sardinia ... 44

9.1.1

Before Decentralisation (1981-1992) ... 44

9.1.2

After Decentralisation (1992-2018) ... 51

9.2

Scotland... 66

9.2.1

Before Decentralisation (1978-1999) ... 66

9.2.2

After Decentralisation (1999-2018) ... 81

1 Introduction

It is not controversial to say that everyone deserves to live a healthy and fulfilling life. The right

to health, that is, “the enjoyment of the highest attainable standard of health” (WHO, 2006

[1946], p. 1) is officially recognised in the preamble of the Constitution of the World Health

Organisation (WHO), as well as in numerous international declarations and agreements

(Backman et al., 2008). Nonetheless, important inequities persist worldwide, undermining the

enjoyment of this right (Marmot et al., 2008). Inequities are known to be reinforced by

geographic and socioeconomic disparities (Nuti & Seghieri, 2014). Nowadays, about one billion

people still live in slums or underdeveloped communities (Marmot et al., 2008).

Since the emergence of the new public management (NPM) paradigm in the early 1980s,

governments with different healthcare systems have tried to reduce the problem (Simonet, 2011).

Healthcare decentralisation is seen as one of the most effective measures (Paris, Devaux & Wei,

2010). Accordingly, several scholars have tried to determine whether healthcare decentralisation

increases equity. Most of these studies are limited in that they only focus on the healthcare sector

itself, without acknowledging the complex web of the determinants of health. Equity, however,

cannot be solely measured through quantitative and financial indicators, but it also comprises a

more sophisticated, normative side. This dimension is inherently political and discursive, and

greatly impacts implementation (Plamondon et al., 2019). Such nuances have been largely

ignored in the literature.

Therefore, this thesis will contribute to mending this gap by analysing the relationship

between decentralisation and healthcare equity discourses in two rural, decentralised regions,

namely, Scotland and Sardinia. It will adopt an in-depth exploratory, qualitative design. The

research question guiding the project is the following:

RQ: What is the influence of decentralisation on discourses about healthcare equity?

This thesis is divided into four sections. Firstly, the main academic debates on equity and

decentralisation are reviewed. Subsequently, the main components of the theoretical framework

are introduced and theoretical expectations are drawn from them. Then, the main variables are

conceptualised and operationalised. The methodology and selected cases are also discussed and

justified, and the results of the analysis are presented and compared. Finally, the main pitfalls

and implications of the study are discussed.

2 Literature Review

The following literature review provides an overview of the main debates concerning equity and

healthcare decentralisation. First, the difference between health equality and equity is debated.

This thesis will focus on the latter concept, as it allows for more conceptual subtlety.

Accordingly, the origin of the term and its relationship with geographical and socioeconomic

factors are discussed. In the second part of this section, the notion of decentralizing the

healthcare sector to achieve equity is introduced. Finally, a brief selection of the empirical

studies testing the correlation is reviewed.

2.1 Healthcare Equity

2.1.1 Healthcare Equality

It is commonly understood that the right to health implies the attainment of an equal and

equitable healthcare system (Marmot et al., 2008). What this entails is often left unspecified.

Braveman (2016) observes how the words “healthcare equality” and “healthcare equity” are

regularly used interchangeably, both in academic and non-academic settings. However, many

argue that the two terms ought to be seen as conceptually distinct rather than overlapping

(Macinko & Starfield, 2002). Whitehead’s (1991) seminal reflection on these concepts paved the

way for more contemporary definitions (e.g. Braveman, 2016). Whiteman argued that healthcare

equality refers to systematic, observable disparities between the healthcare systems of two or

more regions. Healthcare equality can also refer to differences in health conditions among groups

in general. These might be caused by several factors. For instance, geographical and

socioeconomic disparities, such as large income inequalities and limited healthcare investments,

are likely to be correlated with poorer healthcare quality (e.g. Franzini & Giannoni, 2010). From

a methodological perspective, healthcare inequalities are generally measured econometrically

(e.g. Cantarero, 2005; Costa-Font & Rico, 2006; Booysen, 2003). As an empirical concept,

health inequality per se does not imply undesirability, i.e. the term does not presuppose any

normative judgement on the value thereof. It is for this reason that Kawachi, Subramanian, and

Almeida-Filho (2002) contend that healthcare equality mainly serves as a descriptive concept,

and thus has relatively limited analytical capacity.

2.1.2 Healthcare Equity: Theories and Origins

On the other hand, most scholars associate healthcare inequity with the idea that systematic

healthcare inequalities are unfair, unjust, and ought to be eliminated (Whitehead, 1991).

Healthcare equity is a normative idea in that it is essentially connected with concerns for social

justice, fairness, human rights, and more holistic reflections on how society should be governed

(Braveman & Gruskin, 2002; Starfield, 2006). Before introducing the origins and contemporary

interpretations of the term, it is necessary to stress the subjective nature of any discussion of

healthcare equity. Insofar as different theories of justice conceptualise fairness differently, the

meaning of equity will vary accordingly. However, these differences have not prevented the

emergence of a common school of thought on what the term generally entails.

Most scholars trace the philosophical origin of healthcare equity to Rawls’s (2009

[1971]) highly-influential theory of distributive justice (Oswald, 2015). The implications are

manifold. Reflecting on how to ensure that everyone has a fair chance of achieving their

potential, Daniels (2001) contends that healthcare has special moral importance in that it helps

individuals fulfil their duties by protecting equality of opportunity. In other words, by

guaranteeing that everyone has the same fair chance of living a healthy life, the healthcare sector

plays an essential role in promoting social justice (Braveman et al., 2011). Nevertheless, as

Rawls originally argued not all inequalities ought to be considered inequitable, that is, unfair and

unjust. One’s imprudent life choices, for example, may lead to health disparities. Similarly,

genetic and biological variations among individuals, such as differences in life expectancy

among genders, do create significant health inequalities (Kawachi, 1999) This would not mean,

however, that such inequalities should be considered inequities. Only the disparities that are

originated from preventable injustice ought to be categorised as inequitable (Whitehead, 1991).

Therefore, avoidability is the essential feature that renders health inequalities unfair, and thus

inequitable.

Large differences in access to healthcare, a shortage of facilities, ethnic disparities, and

deteriorating environmental conditions have been identified as some of the factors that make

healthcare systems comparatively unequitable, thus hindering individuals’ right to health (e.g.

Schulz & Northridge, 2004; Zsembik & Fennell, 2005). Several theories have been developed in

this regard. Kawachi, Subramanian, and Almeida-Filho (2002) mention poverty and deprivation

as the main sources of inequity. It has been observed that people at the lower end of the

socioeconomic gradient systematically show worse health conditions than those at the opposite

side of the spectrum. This, in turn, aggravates the pressure on the healthcare system: poorer

people need its services more often, provided that they can access it (Arcaya, Arcaya &

Subramanian, 2015). Another fundamental determinant of health inequity is the absence of

universal health coverage, which can significantly limit access to healthcare (de Andrade et al.,

2015). However, even when universal coverage is guaranteed socioeconomic disparities might

persist. Furthermore, in addition to these material explanations psychosocial theories have

demonstrated how worse socioeconomic conditions are linked to lower levels of mental and

physical health, thus accentuating inequities among groups (e.g. Ball et al., 2017; Gallo, 2009).

In general, socioeconomic and health inequities are known to be significantly correlated:

disadvantaged, poorer groups see their right to health constantly threatened. However, not only

socioeconomic factors but also geographical variables can generate health inequities.

2.1.3 Geographical and Local Inequities

Geographical variables include, for instance, the extent to which regions are connected

and how isolated communities are. Disparities are globally widespread and significantly

undermine the efficient functioning of healthcare services. One can argue that not only might

there be inequities within social groups, but also more generally between the healthcare services

across different areas and regions. Due to their geographical nature, such inequities can be found

at any level, including between national constituencies, districts, cities, and even neighbourhoods

(Marmot et al., 2008). Some observers have theorised the existence of a chronic “inverse care

law” concerning healthcare supply and delivery: those areas that need the most, tend to receive

the least (Mohapatra, 2017; Zere et al., 2007).

Numerous scholars attempted to explain the emergence of geographic inequities with the

aim of eliminating them. They did so by focusing on different factors. Marmot et al.

recommended that “the strengthening of public finance to improve social determinants of health

will entail the building of national capacity for progressive taxation and the assessment of

potential for new national and global public finance mechanisms; fair allocation between

geographical regions and ethnic groups is also necessary” (2008, p. 1666). Costa-Font and Gil’s

(2009) study of the Spanish healthcare confirmed that income inequality between regions is

again one of the main determinants of healthcare inequities. They did not find, however, that

differences in financing systems (i.e. progressive or regressive) were associated with healthcare

inequities. Other scholars have found that the degree of ruralness of areas is positively correlated

with health inequities (Erwin et al., 2010). The more social groups are segregated and disperse,

the more difficult it is for them to access healthcare services. Delivery is also significantly more

complicated in regions with poor infrastructure. The negative consequences of ruralness are

especially visible in developing countries. For example, Balarajan, Selvaraj and Subramanian

(2011) observed that healthcare supply in India is significantly impaired in rural areas as opposed

to the more urbanised regions. Empirically, they found that government hospitals in rural areas

had on average less than half of the beds that urban hospitals have. However, geographical

disparities are not only found in Global South countries, but they can be observed in numerous

OECD countries such as Italy (Iammarino, Rodriguez-Pose & Storper 2019; Mangano, 2010)

and the United Kingdom (Asaria et al., 2016). It can be inferred that disparities emerge

independently of the specific variety of healthcare system adopted (see Wendt, Frisina &

Rothgang, 2009), even in universal national healthcare systems. For instance, Norman and Boyle

(2014) observed large mortality inequalities between England and Wales, which were generated

by different levels of deprivation; at the same time.

Overall, it has been observed that healthcare policies that are designed for urban areas

might not translate as intended to less densely-populated and accessible areas (Smith et al.,

2013). Therefore, governments and international organisations alike searched for ways to

identify geographical inequities and subsequently eliminate them. These reforms were informed

by the emergence of the new public management paradigm and often were aimed at reducing

costs and increase efficiency (Simonet, 2010). Measures included redistributing economic

resources to disadvantaged regions and creating institutions that would monitor the development

of a more efficient infrastructure (Iammarino, Rodríguez-Pose & Storper, 2019). The most

commonly adopted and systematic policy, however, was decentralisation.

2.2 Decentralisation

2.2.1 Decentralisation: General Framework

From a general perspective, decentralisation refers to the practice of transferring certain

competencies from a higher level of government to a lower one (Pollitt, 2005). Although the

term is often used to indicate a transfer of power from the central government to one or more of

its regional constituents, decentralisation per se does not imply this specific meaning.

Rondinelli’s (1981) seminal work, albeit dated, is conventionally considered as the core

theoretical framework for understanding decentralisation practices (Sumah, Baatiema &

Abimbola, 2016). Rondinelli identified several kinds of decentralisation such as delegation,

deconcentration and devolution, with the latter being the most impactful. In the case of the

United Kingdom, for instance, the education, housing, and transport domains are now

competences of her sub-national units (Scotland, Wales, and Northern Ireland) (MacKinnon,

2015). It is also worth mentioning that decentralisation need not exclusively be a political

process because it is often conceived as an administrative and financial process as well (Oates,

1999; Saltman & Bankauskaite, 2006).

2.2.2 Healthcare Decentralisation

In respect to the healthcare sector, all of the above-mentioned processes can be observed at the

same time. One can argue that the healthcare sector is to different degrees one of most

decentralised welfare domains in the OECD area as well as in a majority of developing countries

(Simonet, 2010). Following Rondinelli’s (1981) suggestions, the rationale behind healthcare

decentralisation lies in the idea that healthcare inequalities generated by geographical disparities

between regions are inequitable and thus ought to be eliminated. Historically speaking, the 1978

Alma Ata conference on Primary Health Care had established the principle that decentralisation

would improve resource allocation as well as accountability, and since then numerous countries

sought to apply it (Kawonga, Maceira & Nunn, 2005). Recent, notable experiments in healthcare

decentralisation include for instance the creation of a Great Manchester area in the United

Kingdom where health and social care are devolved (Walshe et al., 2018).

However, whether decentralisation has effectively reduced inequities, especially in rural

regions, remains a contested issue. A plethora of longitudinal and cross-sectional exploratory

studies have been conducted in numerous and diverse areas, including Western Europe (Simonet,

2010), China (Zhou et al., 2013), Oceania ( Leeder, 2003; Mohammed & Ashton, 2016), several

African regions (Abimbola et al., 2015; Asante & Zwi, 2009; Zere et al., 2007; Zon et al., 2017),

and Central and South-East Asia (Jacobs & Camargo, 2020; Langran, 2011; Madon, Krishna, &

Michael, 2010). Evidence tends to be contradictory and can vary widely across areas, not least

because of the abundance of different conceptualisations of healthcare equity (Braveman, 2006;

Lane, Sarkies, & Haines, 2017). In what follows, a brief, selected review of this body of

literature will be provided.

2.2.3 Decentralisation and Equity: A Contested Relationship?

To begin with, Jimenez and Smith (2005) found that fiscal decentralisation in Canada

substantially helped provinces’ efforts to reduce infant mortality. As they argue, however, only

employing fiscal indicators for assessing the effects of decentralisation leads to a partial picture

of the real situation. Using once again mostly financial indicators, Costa-Font and Rico (2006)

observed that the devolution of healthcare competencies to Spanish provinces did not generate

more inter-regional inequalities. Nonetheless, they also note that comparisons with other

countries are made difficult by the absence of universal, widespread decentralisation models.

Regarding the Italian healthcare system, Mangano (2010) depicted a complex scenario where

decentralisation led the already wealthier regions to invest more in healthcare, with no significant

changes as for the other regions. He also found institutional and regional healthcare

arrangements to significantly vary, thus making it difficult to provide a clear picture of whether

decentralisation had positive effects on equity. Similar findings, namely, that decentralisation

might lead to lower levels of income redistribution and more inequities, were also presented by

Ferrario and Zanardi (2009), and Giannoni and Hitiris (2002).

Not all scholars have adopted quantitative methods, but some conducted in-depth

interviews with policymakers and healthcare workers (see e.g. Abimbola et al., 2015; Jacobs &

Camargo, 2020). These studies indicate that the effects of decentralisation may significantly vary

depending on a variety of circumstantial cultural and political factors, such as corruption and

accountability. Others focused on implementation from an abstract meta-theoretical perspective,

that is, the extent to which studies on decentralisation aligned to the general goal of promoting

good equity practices (Plamondon et al., 2019). It is complicated to derive a systematic theory

from these investigations, mostly due to the idiosyncratic natures of the decentralisation

processes analysed. That healthcare decentralisation is an ill-defined term and that can have

varied effects on equity depending on which aspect thereof are analysed is also suggested by

Greener et al.’s (2009) study of decentralisation of the British National Health Care System

(NHS). Perhaps crucially, the authors emphasise the importance of local peculiarities when

studying healthcare decentralisation: outcomes might be highly dependent on the political and

institutional characteristics of the regional entities in which it is applied.

An equivalent conclusion is reached in Sumah, Baatiema, and Abimbola (2016)’s

extensive review of the effects of decentralisation on equity in seven countries. These authors

argue that it is not possible to provide univocal answers to the question of whether

decentralisation positively affects equity; they find that decentralisation might not necessarily

reduce inequities in healthcare access and financing, as opposed to Costa-Font and Turati’s

(2018) later study. They also suggest that pre-existing historical inequalities might explain why

even after decentralisation inequities are not eliminated.

2.3 Why a different approach is needed

Overall, what one can derive from the abovementioned studies is that contingencies and

path-dependency play an important mediating role vis-à-vis the effectiveness of decentralisation

as an intervention to reduce inequities. It does not follow, however, that outcomes are

pre-determined. Different regional institutions might implement decentralisation in different ways:

some might invest more financial resources in healthcare infrastructure, while others might focus

on the management of healthcare personnel. Such decisions might have a significant impact on

equity, given that certain areas, especially the rural ones, have special health needs (Marmot,

2008). Unfortunately, few studies analyse the discursive development of these decisions. It is not

clear, for instance, whether the framings of equity change after decentralisation is introduced.

This is the fundamental gap that this thesis aims to fill: if one is to fully understand the effects of

decentralisation on equity, a nuanced approach that goes beyond the quantitative analysis of

inequalities indexes is required. Following Sumah, Baatiema, and Abimbola (2016) one can also

argue that comparisons between cases might help discern the effects of the contingent variations

of institutional arrangements. The next section addresses these theoretical and methodological

issues.

3 Methodology

3.1 Theoretical Expectations

To the author’s knowledge, no overarching theoretical framework on the discursive relationship

between decentralisation and equity exists: it is not possible to test a specific theory on a new set

of cases. Instead, this thesis will adopt an exploratory approach. One can still elaborate some

theoretical expectations on whether and how discourses around equity change after

decentralisation; it is possible to do so by extrapolating some of the major findings from the

aforementioned literature. Since it is not clear in which ways discourses are affected by

decentralisation, the following expectations ought to be considered tentative and not definitive.

Hence, their main purpose is to provide a general idea of the main discursive strands that could

be found in the analysis.

To begin with, one of the main expectations is that pre-existing socioeconomic inequities

affect the way equity is framed. Countries where decentralisation is entrenched are more likely to

tackle equity successfully, especially from a financial point of view (Mosca, 2006). An example

of this is provided by Finland, where healthcare decentralisation has historically helped rural,

sparsely-populated areas to retain more resources to satisfy their health needs (Koivusalo, 1999).

To generalise, poorer, geographically disadvantaged regions might decide to specifically target

such inequities through healthcare decentralisation (Sumah, Baatiema, and Abimbola, 2016). In

other words, after decentralisation one is expected to observe the development of discourses

concerning the elimination of socioeconomic inequities. The effect might be strengthened by the

concomitance of two factors.

First, democratic accountability is expected to improve health outcomes (Wigley &

Akkoyunlu-Wigley, 2011). This variable is of uttermost importance in regions where corruption

and mismanagement of healthcare resources are widespread (e.g. Jacobs & Camargo, 2020;

Madon et al., 2010), but it is also important in already-established democracies. Some scholars

emphasise that healthcare equity can only be fully achieved when a multitude of socioeconomic

factors are taken into considerations, such as whether food security is present (Ottersen, 2014). It

is then expected that health equity will be consistently framed in terms of democratic

accountability (Oickle & Clement, 2019).

Second, as Andrews and Martin (2010) suggested ideological and political interests play

a fundamental role in framing discourses around healthcare. It is more likely to see measures that

promote healthcare equity in those regions ruled by parties that reflect a general, active

commitment to the issue. An interesting example of this dynamic is provided by Wales, where

after devolution the parties that controlled the regional parliament pushed for equity policies that

would directly contrast the pro-austerity measures enacted in the previous years by the central

government in London (Greer, 2016).

The following paragraphs further specify the dimensions and variables that will be

explored in the thesis.

3.2 Conceptualisation

In this subsection, the main variables of the study will be conceptualised. As formulated in the

research question (p. 1), these are healthcare decentralisation and discourses on equity.

3.2.1 Healthcare Decentralisation

As mentioned in the literature review (p. 6), decentralisation conventionally refers to “the notion

of authority being spread out from a smaller to a larger number of actors” (Pollitt, 2005, p. 3).

Decentralisation can be also conceptualised as a state, as a process, or both (Bankauskaite &

Saltman, 2007). Regarding the decentralisation of the healthcare sector, two analytical

approaches are possible. First, a degreeist approach, i.e., studying the extent to which the sector

is decentralised. Second, a longitudinal approach, that is, how decentralisation affects the

sector’s functioning over time. This thesis will adopt the latter approach: it will consider

healthcare decentralisation as a dynamic process that occurs over a prolonged timeframe.

(Byrkjeflot & Neby, 2008).

3.2.2 Healthcare Equity

Equity in the healthcare sector can be conceptualised in several, oft-contrasting ways (Braveman,

2006). Braveman et al.’s (2018) definition is perhaps one of the most comprehensive:

Health equity means that everyone has a fair and just opportunity to be as healthy as

possible. Achieving this requires removing obstacles to health, such as poverty and

discrimination and their consequences, which include powerlessness and lack of access to

good jobs with fair pay; quality education, housing, and health care; and safe

Relatedly, another fundamental aspect to be conceptualised is the difference between horizontal

equity and vertical equity (Sumah, Baatiema & Abimbola, 2016). The former means that equity

is framed so that “there are no differences in health services where health needs are equal”

(Starfield, 2001, p. 546). Horizontal equity is thus associated with a uniform healthcare supply

across all areas. On the other hand, vertical equity refers to the practice whereby “enhanced

health services are provided where greater health needs are present” (Starfield, 2001, p. 546).

Vertical equity will be framed in terms of specific, targeted interventions aimed at certain

disadvantaged groups or areas; the aim is to provide equal health outcomes.

Concerning the binomial “discourses about equity”, different conceptualisations are

possible. From an academic standpoint, discourse is generally taken to mean the way explicit

(written) and non-explicit (non-written) language are integrated to convey specific meanings

(Gee, 2014). Thus, discourses around healthcare equity do not only include the written policies

and measures taken to improve it but also every circumstantial meaning related to the term.

Discourses might include, but are by no means limited to, how financial resources are allocated

to equity programs (Lane et al., 2017), how policies developed for different welfare domains can

foster healthcare equity (Davison, Ndumbe-Eyoh, & Clement, 2015), and conversely, how

healthcare equity can promote equity in other welfare domains (Plamondon et al., 2019).

3.3 Research Design

As mentioned before (p. 7), studies on the effect of healthcare decentralisation on equity are

carried out through numerous designs. Scholars tend to agree on the idea that comparative

designs allow one to identify patterns and recurrent themes (e.g. Mosca, 2006). At the same time,

some scholars emphasise the need for taking into account the contingent factors that inform

country-specific decentralisation policies and regional healthcare practices (Sumah, Baatiema,

and Abimbola, 2016). Since the effectiveness of policy implementation depends on how goals

are framed, discourses around equity acquire crucial importance. To the author’s knowledge, few

studies have engaged with primary sources, such as policy documents, health plans and alike. To

mend this gap, the following research design will be implemented.

First, discourse analysis will be performed on the policy documents and health plans of

two decentralised regions to understand how discourses around equity are framed before and

after decentralisation is introduced. More specifically, discourse analysis does not only entail

observing the recurrence of specific terms such as equity but also interpreting the context and

meanings around them (Wodak & Meyer, 2009). Results will be then discussed and compared to

investigate whether similar patterns and recurrences can be found in the two regions.

3.4 Case Selection

To study the development of discourses around equity after healthcare decentralisation, two

cases were selected. Some general criteria behind the choice included whether they had an

established pattern of decentralisation with a clear historical beginning (Byrkjeflot & Neby,

2008), as well as whether it was possible to obtain enough documentation in a language the

author could read. Possible cases included Sicily, Wales, Veneto, or Northern Ireland.

Eventually, Scotland (United Kingdom) and the Autonomous Region of Sardinia (Italy) were

selected due to the author’s familiarity with both cases. Overall, these two cases can be

considered typical or representative for the following reasons (Seawright & Gerring, 2008, p.

299). Firstly, both regions belong to countries that possess a universal healthcare system and

have devolved their national healthcare competencies to their subnational units, albeit to

different degrees. Secondly, in both regions a significant portion of the population lives in rural

areas (Pacione, 2004; Cois, 2020). Ruralness has important implications on the socioeconomic

features of both cases. For instance, 45% of the Sardinian municipalities suffer from major

socioeconomic deprivations due to ruralness (ATS Sardegna, 2018). It is known that

decentralisation is especially aimed at disadvantaged and sparsely populated areas such as rural

regions (Zhou et al, 2013). Therefore, it is expected that by analysing the typical cases of

Scotland and Sardinia one can better understand how discourses on equity develop after

decentralisation.

The sources of this study will be a selection of major legal documents and health plans

(see Appendix II). These were accessed online via the Sardinian Region website (RS, 2020), the

National Archives (TNA, 2020), and Government of Scotland website (SG, 2020). Sources

mostly consist of major documents such as health plans and primary legislation. When

necessary, discourse analysis was supplemented with sources such as governmental responses to

parliamentary committees, deliberations, and secondary literature.

The research timeframe, 1978-2019, was selected for the following reasons. First, the

Italian National Healthcare Service was established in 1978, while regional governments

(including Sardinia) had been formally established eight years before. At the same time, the

Scottish National Healthcare Services, which was formed in 1948, underwent a fundamental

reform in 1978. Therefore, the starting year of 1978 was chosen to match data for both regions.

Furthermore, healthcare decentralisation will be considered to have taken place, respectively, in

1992 for Italy and 1999 for the United Kingdom (see France et al., 2005; Greener et al., 2009). A

brief timeline of the major developments of both the Italian and British healthcare systems is

provided in Appendix I.

3.5 Operationalisation

Given the exploratory nature of the present study, it might be difficult to provide a precise list of

discursive terms that are expected to convey the meaning of equity. The endeavour is

complicated by the fact that there is no exact linguistic match between Italian and English

regarding the word “equity”. Italian tends not to differentiate between “uguaglianza” and

“inequità”, both of which can be translated either with inequality or inequity. To ensure

systematic results, a flexible approach will be adopted whereby larger semantic blocks consisting

of multiple contextual cues will be treated as distinct discursive framing tools. The sole presence

of words such as “disadvantage” or “equity” will be deemed as not sufficient to fully convey

discourses around equity. Instead, a broader, more contextual approach will be used to determine

whether specific semantic blocks refer to horizontal, vertical equity, or other related concepts. A

sample of the relevant indicators for horizontal and vertical equity is outlined in Table 1. The

results of the analysis are presented in the next section.

Table 1: Indicators for horizontal and vertical equity

Category Italian

English

Horizontal equity Uniforme/uniformità,

armonizzare, omogeneità,

adeguamento, centrale,

organico, complessivo

Comprehensive, uniform

planning, homogenous, joint

planning, all Regions,

Vertical equity

Esigenze territoriali, modello

diffuso, rurale, iniziative locali,

priorità, interventi specifici,

emarginazione di gruppo,

autonomia, peculiarità,

universalismo selettivo

Local needs, individual needs,

delegation of responsibilities,

targeted interventions,

disadvantaged communities,

rural communities

4 Results

The next section is structured as follows. To begin with, the findings for Sardinia will be

presented. The first subsection concerns the period before decentralisation (1978-1992), whereas

the second covers the post-decentralisation phase (1992-2018). Subsequently, the findings for

Scotland will be presented according to similar criteria: first, before devolution (1978-1999),

then, after devolution (1999-2018). The complete rendition of the analysis is included in

Appendix II.

4.1 Sardinia

4.1.1 1978 - 1992

The pre-decentralisation period in Sardinia is characterised by the attempt to locally implement

the 1978 National Healthcare reform, which had established a universal, Beveridgean system. In

this regard, the 1981 reform (RS, 1981, art. 2) highlighted the presence of notable demographic

and geomorphological disparities between the healthcare of Sardinia and other regions: “[the

goal of the healthcare system is to] plan, reorganise, and coordinate the integration of social and

health services with the aim of gradually eliminate the existing disparities [squilibri] […]” (RS,

1981, art. 2). This reform did not elaborate, however, on the determinants of such health

inequities. Some of the priorities that emerge in the documents, such as promoting democratic

accountability and the active involvement of citizens (RS, 1981, art. 21; 1992) quickly lost

importance in the following years, mainly due to negative healthcare politicisation (see France et

al., 2005). This is indicated by the progressive marginalisation of terms such as partecipazione

dei cittadini (citizens’ participation), which played a fundamental role in the early documents

(RS, 1981). On the other hand, integrating social care with healthcare remained a recurrent goal.

However, the focus at that time was still on creating a uniform care model to be applied

homogeneously across all areas: “The unitary management of health protection will be provided

uniformly across the entire territory of the region” (RS, 1981, art. 2).

On a more practical level, the goal was to promote horizontal equity by providing an

integrated infrastructure model that covered both social care and healthcare (RS, 1985). This

would be later extended to any Sardinian and non-Sardinian citizens (RS, 1991). The scope of

integration, however, remained limited in that the relative 1988 reform (RS, 1988) strictly

addressed socioeconomic and psychological inequities, as opposed to later, broader plans. This

might be partially explained by the structure of regional competencies, that is, by the fact that

healthcare was still treated as a distinctive legislative domain. National health plans are also

prioritised: “The dispositions of the Regional Health Plans can be applied insofar as they are not

in contrast with the relative dispositions in the National Health Plan” (RS, 1985, art. 8). On the

other hand, in the following years the institutional boundaries between welfare competencies

started to blur more. This can be inferred by the progressive disappearance of formulations such

as “organic and comprehensive response” (RS, 1988, art. 3), or “uniform model” (RS, 1981, art.

27), which univocally referred to the healthcare and social sectors only.

During this period, equity is mainly framed in terms of equity of access: “The following

principles must be guaranteed: a) equality, when same needs are present, in terms of the quality

of delivery and social care interventions […]” (RS, 1988, art. 4). Measures to reduce the

inequities that arose from the peculiar geographical disadvantages of Sardinia included the

possibility for citizens to be reimbursed when accessing healthcare services in other regions,

including transportation and living costs (RS, 1991). Another intervention was allocating

additional subsidies for research concerning specific Sardinian diseases, such for instance Beta

Thalassemia (RS, 1990). Tangentially, these measures were also intended to tackle social

exclusion and inter- and intra-group inequities. Nonetheless, no systematic health plan nor

comprehensive attempt to tackle such issues was put in place until decentralisation was

introduced.

4.1.2 1992 - 2017

The 1992 National Healthcare reform represented a significant effort to decentralise the whole

system. It was translated to Sardinia three years later (RS, 1995). The 1995 provisions mainly

contained financial measures designed to eliminate the budget deficits that the local healthcare

units had accumulated in the previous years. However, their long-term consequences were

significant, as indicated by the goal to “decentralise the [Local Health Units’] functions in the

territory” (RS, 1995, art. 16). This reform still retained a commitment to horizontal equity:

“…the Region shall pursue the objectives of promoting, securing, and rehabilitating the physical

and mental health of citizens, under uniform conditions across the entire regional territory” (RS,

1995, art. 1). Yet, it also marked a significant shift towards a different approach. This is

suggested by the increasing importance of terms such as “economic-financial autonomy” (RS,

1995, art. 30).

A later revision of the integrated healthcare-social care system (RS, 2005a) introduced

the notion of selective universalism: “[The Region shall follow the principle of] a) selective

universalism, to ensure equality of access to the integrated system [eguaglianza delle persone

nell’accesso al sistema integrato] and to the services, following priority criteria based on the

evaluation of need” (RS, 2005a, art. 2). Equity of access both for Sardinians and non-Sardinians

remained the main objective (RS, 2006a), but the necessity of helping local communities, both

through financial means and collaborative projects, was recognised more systematically. Some

deliberations were put in place which would grant more power to local healthcare units,

especially in rural areas: “[The Region shall promote] the activation of Health Districts as

organisational and functional units that are closer to the citizens, with real [reale] autonomy”

(RS, 2005b). Another reform (RS, 2006b) framed equity in terms of a healthy lifestyle and

recommended that the Regional Health Plans would “illustrate the health needs of the population

living in the territory [of the Region] with particular regard to the social and territorial

inequalities [diseguaglianze] concerning health” (RS, 2006b, art. 12). Local peculiarities started

to refer not only to Sardinia as a whole but also to single territories that were deemed to require

special attention, called areas of prioritised intervention [aree prioritarie di intervento].

Subsequently, the 2007 Health plan (NS, 2007a) represented the first systematic attempt

to identify the key determinants of health inequities, which now included environmental

differences as a major form of disparity between rural and urban areas. The shift towards vertical

equity and micro-level targeted interventions is also evident in the 2007 deliberations (NS,

2007b) and 2014 primary health care reform (NS, 2014). Interestingly, the latter reintroduced

centralisation measures to rationalise the system and decrease the number of autonomous

healthcare units. Nonetheless, it was still framed as an effort to promote equity of access, and

interestingly, social justice [giustizia sociale]. The similar 2016 reform (NS, 2016) used

formulations that had not been employed since the 1981 reform such as “homogeneity and

harmonisation of the management processes across the entire regional territory” (RS, 2016, art.

2). Two years later a new health plan (ATS, 2018) synthesized the older concerns for horizontal

equity with the newer ones for vertical equity by hinting at the necessity of acknowledging

newly-emerging social and health challenges (called new poverty [nuove povertà]), including the

environment. The Region intended to tackle these through the further integration of healthcare

with other welfare domains, but did not systematically plan in this regard.

To summarise, decentralisation in Sardinia coincided with a shift from the early attempt

to create a uniform and harmonious healthcare system across the entire region to more targeted

interventions aimed at specific areas and social groups. Discourses regarding the integration of

social care with healthcare have remained important throughout the whole period and have

progressively taken into account more factors and health determinants. Overall, one can interpret

such discursive changes as a general move towards vertical equity.

4.2 Scotland

4.2.1 1978 - 1999

As for Scotland, one can observe two very distinct pre-decentralisation discursive phases. The

first covers Thatcher and Major’s Conservative governments; the other starts in 1997 and

coincides with the years immediately preceding devolution. The key difference in terms of how

equity is framed is that in the former it mainly refers to financial equity, whereas in the latter to

vertical equity. Firstly, the 1978 Health reform prioritised health improvements for Scottish

citizens (TNA, 1978, art. 1), while a few years later the need of coordination between local

Health Boards was reinstated (TNA, 1983, art. 13). The 1980 Black Report on health inequities

described numerous socioeconomic disparities that undermined the functioning of the NHS

(Black et al., 1980). In the following decade, however, Conservative governments focused on

incentivising competition and economic efficiency. Control of expenditure, as delineated in the

Griffiths’s Report (1983) became the central priority, while no systematic attempt to reduce

inequities was made. The same trend can be observed in documents such as Enthoven’s (1985)

Report and the Cumberledge Report (1986). Concretely, the prominence of financial concerns is

signalled by the institution of NHS Trusts and other cost-efficiency measures, such as GP

fundholding practices (TNA, 1990; 1992). Equity, and especially equity of access was framed as

largely dependent on the financial resources available. No special provisions for the

disadvantaged areas of Scotland were to be formulated during this first phase.

When the Labour party rose to power in 1997, however, priorities drastically changed.

First, numerous reports were released which emphasised the distinctive health needs of Scotland

(TNA, 1997a). Not only did the government start to elaborate on the recommendations advanced

in the 1980 Black Report (TNA, 1998, par. 33), but they also acknowledge the need to integrate

the notion of socioeconomic deprivation into their health plans. The measures introduced in 1990

were kept but reframed in terms of giving more autonomy to local communities and promoting

interregional financial equity (TNA, 1997b, par. 4). Furthermore, the first Blair government

paved the way for the devolution of health competencies to the soon-to-be established Scottish

parliament, a policy that was intended to incentivise a cohesive response to health inequities

across all regions. Therefore, concerns for horizontal equity were now supplemented by the goal

of prioritising certain social groups and areas, thus promoting vertical equity. Since devolution

was yet to be fully implemented, however, discourses around equity tended to be still influenced

by the idea that Westminster could coordinate all interventions. Such a perspective would also

rapidly change in the following years.

4.2.2 1999 - 2019

The process of devolution entailed a significant reform of the Scottish institutional setting. With

the 1998 Scotland Act the only exclusive competencies Westminster kept were benefits and

social security, defence, employment, equal opportunities, foreign policy, immigration, and trade

and industry. The new Scottish Parliament acquired a large degree of autonomy and thus the

government could adopt autonomous, innovative discourses around healthcare equity. Firstly, the

2004 Health Reform (SG, 2004, art. 1) dissolved the 1990 NHS Trusts and repealed most of the

associated cost-efficiency provisions on the grounds that they would undermine an equitable

service for all (see also SG, 2007, p. 34). The integration of the healthcare sector with other

welfare practices at the local level became a key priority, as well as vertical equity. The

overarching goal was to raise the NHS standards to higher European levels (SG, 2018, p. 5). A

major difference with the pre-devolution period is that now the integration of services sought to

include all domains of welfare, including education, justice, and environment (SG, 2007, p. 19).

Equity of access started to be framed in terms of targeted interventions that would

eliminate disparities caused by an increasingly long list of variables, including “gender,

ethnicity, geographic location or socio-economic status” (SG, 2010, p. 23). The impact of

rurality on health outcomes is particularly emphasised as a justification for extensive investments

towards disadvantaged communities. This is demonstrated by telling passages such as “We will

do this, not just because it is a legal requirement. It is right to do so and we believe that it will

lead to services that are equitable and fair for all the communities we serve” (SG, 2010, p. 24).

Healthcare equity ceased to be a separate function of health outcomes and socioeconomic

indicators; it was now framed more as a holistic aggregate of personal and socioeconomic

wellbeing factors that are highly dependent on the levels of relative community deprivation (SG,

2018, p. 2). Hence, the Scottish government promoted the idea that although healthcare is a

distinct institutional competency, boundaries between welfare domains should be overcome to

promote an integrated, systematic answer to health inequities (SG, 2016, par. 11).

In sum, discourses around healthcare equity in Scotland significantly changed with

devolution. They shifted from prioritising horizontal and financial equity to making vertical

equity as the central priority. Moreover, healthcare equity became increasingly associated with

welfare at large, hence the focus on the systematic integration of competencies and policy

domains.

5 Interpretation

In this section, results will be interpreted and compared. Overall, the analysis showed that

healthcare decentralisation coincided with a significant discursive shift. In both Sardinia and

Scotland, vertical equity became the central priority of health plans and legislative acts alike. The

shift appears to have been more drastic and abrupt in Scotland, whereas the Sardinian

governments followed a more gradual path. The following explanations for why this might be

the case are not intended to be comprehensive, but they demonstrate the importance of political

factors when studying healthcare decentralisation and equity.

5.1 Contingent Factors

Firstly, some of the similarities and differences between Scotland and Sardinia can be ascribed to

contingent and historical factors, as expected by Sumah, Baatiema & Abimbola (2016). For one,

the expectation that geographical disparities and ruralness would a major role in the framing of

health inequities was met. Both regions’ post-decentralisation priorities seem to have been partly

informed by some of the World Health Organisation guidelines, especially the 1996 report on

public health (WHO, 1996). Policy translation (Stone, 2012) might have played a role in shifting

the regions’ priorities towards vertical equity in that the World Health Organisation explicitly

suggested to prioritise targeted interventions.

Timing might have played an important role as well. Discourses about the idea that

democratic accountability improves healthcare equity (Oickle & Clement, 2019) were only

observed in the case of Sardinia, and even then, they tended to quickly lose their importance in

the 1990s. The reason might be that the 1992 National Health Reform made clear that the

previous healthcare management system needed to be de-politicised, partly due to the increasing

number of scandals that eventually led to the collapse of the First Italian Republic (France,

Taroni & Donatini, 2005). More in general, it seems that the correlation between healthcare

decentralisation and democratic accountability might be more relevant for developing countries

than for regions with already-established democracies such as Scotland and Sardinia (cf. Madon,

Krishna & Michael, 2010).

5.2 The Role of Institutions

One of the reasons why discourses have shifted more quickly and more forcefully in

Scotland than in Sardinia might be related to their institutional setting. In the case of Sardinia,

national health plans remained the main yardstick even after 1992. Although regions obtained

more powers concerning the financial distribution of resources, the institutional distribution of

competences did not significantly change. The regions are still largely unable to legislate, for

instance, on education or housing policies. This is notwithstanding the fact that Sardinia, being

an island, has been historically granted a larger degree of autonomy than most Italian regions

(Hepburn, 2010). On the other hand, with decentralisation Scotland acquired a larger set of

competences and elaborate a more systematic and integrated approach.

Institutional differences might be associated with how decentralisation was implemented.

Costa-Font and Perdikis (2018) identified different varieties of healthcare decentralisation,

namely, a federacy and a systems model. Whereas the former is “typically one based on the

transfer of governmental responsibilities only to certain specific territories while the bulk of the

country remains centrally managed” (Costa-Font & Perdikis, 2018, p. 1), the latter is

conceptualised as a “model where all territorial units are held responsible for a specific policy

domain, e.g., health care policy” (Costa-Font & Perdikis, 2018, p. 2). The federacy model

tendentially arises out of historical rights, while the systems model can be established regardless

of demand s for self-governance. This is important in that a federacy model is likelier to push for

autonomous and regionally distinct discourses, whereas in a systems model discourses are less

likely to differ across regions. Costa-Font and Perdikis argue that The United Kingdom is an

archetypical case of a federacy model, whereas Italy can be considered an example of a systems

model, similar to Spain. Since decentralisation was designed to be uniform across all regions,

Sardinia did not gain any special legislative powers which would help her to elaborate a more

systematic response to the issue of healthcare equity. On the contrary, devolution in the United

Kingdom was asymmetrical, leading regions to have “distinctive institutional forms and modi

operandi” (Jeffery, 2009, p. 289).

Perhaps the most evident institutional difference between the decentralisation processes

of Sardinia and Scotland is that the former it was solidly grounded on a rigid, fixed constitutional

setting, whereas the latter had indigenous and much more destabilising roots, as argued by

Tierney (2009). To assess the historical impact of decentralisation in Italy and the United

Kingdom is beyond the scope of this thesis. However, what one can discern from the extensive

literature on the topic is that decentralisation did not undermine the unitary core of the Italian

constitution, nor did it introduce political federalism, whereas in the case of Scotland it led to

much stronger autonomy (Bilancia, 2005). One might argue that this is the reason why Scotland

was able to promote discourses that overcame the fixed institutional boundaries that the

Sardinian administration was limited to.

5.3 Ideology and Partisanship

Lastly, ideological differences and partisanship might have also had a significant impact on the

development of discourses about equity. Marks, Hooghe, and Schakel (2008) contended that

strong regional identity and unique ethnocultural norms are positively correlated with regional

authority. Hepburn (2009a) explains how Sardinian parties never managed to create a strong,

autonomous national identity as the Scottish National Party (SNP) did, notwithstanding the

constant presence of strong secessionist sentiments (Sorens, 2005). Sardinian regional

governments have always consisted of coalitions including numerous parties with different

ideologies, ranging from Eurocommunism and socialism to liberalism and conservatism

(Hepburn, 2009b). The high number of veto players and the alternation between ideologically

opposed coalitions (see Appendix I) might explain while discursive shifts have been more

gradual in Sardinia.

This is significantly different from Scotland, where after-devolution politics has been

dominated by the centre-left Labour Party and the green-left-wing SNP. As Greer suggested

(2010), the Scottish government adopted evident, unsympathetic stances towards the priorities

set by the previous, Conservative national administrations. This signalled by the strong will to

not focus anymore on financial concerns and horizontal equity. The same dynamics took place in

Wales, but again, due to asymmetrical devolution the Welsh response was more limited (Greer,

2009). One might argue that conflicts between national and regional priorities intensify when

ideologically opposed administrations have to coexist at the same time, especially in a

6 Conclusion

The objective of this thesis was to explore the impact of healthcare decentralisation on discourses

about healthcare equity. To this aim, discourse analysis was performed on major policy

documents from two rural regions, namely, Scotland and Sardinia. It was found that discourses

around equity did substantially change over the period investigated. Before decentralisation, they

centred around uniform interventions, financial concerns, and horizontal equity. After

decentralisation, healthcare equity began to be systematically framed in terms of vertical equity,

that is, targeted interventions aimed at specific, disadvantaged groups. Furthermore, a key

finding is that the two regions’ discourses concerning the integration of healthcare with other

welfare domains (e.g. social care) started to converge after decentralisation, albeit to different

degrees. Differences and similarities were explained in terms of contingent, institutional, and

ideological factors. Due to space constraints, interpretation was necessarily inexhaustive. In the

following, the thesis’s main pitfalls and implications will be presented.

6.1 Main Pitfalls

As for the main limitations, a reflection on discourse analysis as a heuristic method is in

order. One must acknowledge that since the outcomes of discourse analysis depend on the

researcher’s interpretation of both texts and subtexts, i.e. of circumstantial content, results will be

neither fully generalisable nor fully replicable (Breeze, 2011). Concerns for validity and

reliability do not necessarily compromise one’s attempts at obtaining a more detailed, in-depth

picture of the ways specific concepts can be politically framed. Having said that, the present

study only analysed major legal documents and political statements, such as health plans and

legal frameworks. Numerous pre-decentralisation documents are still not openly accessible but

should be considered. More diverse sources could be used as well, such as parliamentary debates

and interviews with policy-makers. These would allow obtaining a more precise picture of the

priorities and interests that led politicians and experts alike to reframe healthcare equity over

time.

Second, this thesis failed to explain whether decentralisation was caused the discursive

shift towards vertical equity, or whether the opposite was true. It may be possible to obtain a

clearer answer by analysing the national, international, and transnational contexts wherein

decentralisation policies originated. Doing so would allow determining whether concerns for

vertical equity developed autonomously or not.

6.2 Implications

6.2.1 Academic implications

Research on healthcare decentralisation and equity could further implement discourse

analysis and apply it to different cases, especially considering that Sardinia and Scotland might

be only considered representative of the OECD area. Discourse analysis should also be

integrated with a more detailed exploration of institutional and historical settings. Such analysis

should include at least the mechanisms whereby competencies are shared and transferred

between different welfare domains, and the extent to which health plans are inter-correlated.

Moving beyond methodological nationalism (Wimmer & Glick Schiller, 2002) might help

understand whether discursive shifts were also influenced by policy translation processes at the

international or transnational level (Stone, 2012). In general, this thesis can be seen as a starting

point for more research on the political framing of decentralisation (see e.g. Cheney, 2013).

Possible questions might include: to what extent are discourses influenced by ideological

partisanship? How does the distribution of institutional competencies affect discourses? Such

investigations could be also carried out through quantitative and mixed designs.

6.2.2 Societal Implications

Third, this thesis suggested that decentralisation policies might be associated with more

attention given to marginalised groups, at least from a discursive perspective. In general,

legislators might want to consider loosening welfare boundaries, as Scotland did, as a way to

incentivise systematic, integrated answers to healthcare inequities. Moreover, they might also

want to assess the effects of geographical disparities on welfare. In general, shifting

competencies to the local level might constitute an effective tool to pay more attention to areas

and groups with special needs. Even without full devolution, legislators should consider

consulting and collaborating more closely with different subsections of civil society as a way to

ease policy translation.

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