The governance of regional health systems between fiscal federalism and budget constraints

The reform of Title V of the Constitution, Legislative Decree 56/2000 on fiscal federalism and the approval of the Prime Minister's Decree on the Essential Levels of Care (LEA) have completed and strengthened the process of regionalization of health care initiated with the reforms passed in the 90s, making it, in all probability, the most significant test of the broad debate on federal reform in our country. The new constitutional framework, followed by the delegated law on fiscal federalism n. 42/2009, confirms the desire to decentralize healthcare to the regions, which have been granted fiscal and economic, organizational and managerial autonomy, as well as the responsibility for allocating resources among the Regional Health Authorities (ASR) in order to guarantee the provision of the Essential Levels of Care defined at the national level. This is the context in which the present work is set, aimed at outlining both the evolution of the methods of financing Essential Levels of Care, as a gradual transition from a centralist model outlined by the law of 1978 to a regional model where, however, the difficult compromise between the need to keep the public accounts and that of guaranteeing equity of access to health services has contributed to a return of the re-centralization of the governance of the system increasingly oriented towards an approach of consultation between the state and the regions, which emphasizes how the economic sustainability of the system is directly linked to governance actions aimed at the recovery of efficiency and appropriateness in the provision of the current LEAs.