[Regional autonomy in health already exists and it produces inequality.]

In Italy an institutional reform is underway which includes an uneven power shift from the central government to the local regional authorities. Amid growing concern about the impact of this reform on the equality of individual rights and the balanced development of the country as a whole, the health system could possibly exemplify the effects of regional autonomy, since health care was largely regionalized in 2001 through a selective change of the Italian constitutional law. Twenty years later, according to the results of this study, very large differences exist among regions in per capita health expenditures, up to a 40% gap between the highest spending region (Emilia-Romagna) and the lowest (Calabria). Moreover, regional health expenditures are related to gross regional product and not to population health status. Health status is generally better in the highest spending regions, with a standardized mortality ratio in Emilia-Romagna which is 15% lower than in Calabria, however seven out of the ten highest spending regions show the highest index of health inequality. The regionalization of health care is apparently associated with large differences in expenditures among regions, widely different health status, and within regions marked inequalities, particularly in high spending regions. A farther devolution of power to regional authorities will hardly change this situation.