The Spanish Constitution reserved to the central legislative power the competence to establish the minimum fundamental services in health (art. 149.1.16 CE), while the Autonomous Communities are the competent ones for their legislative development and management. During these more than forty years of validity of the constitutional text there has been a progressive decentralization in health management, which would culminate in 2001, along with an important legislative centralization. This competence distribution contrasts with the financing system designed for healthcare provision since 2001. A system in which the weight of the responsibility for spending rests primarily with the Autonomous Communities. This paper analyzes the competency distribution in Spain in health matters and relates it to the financing system designed, showing the inconsistency that exists in this regard in the design of health care.
Spain is a country where the nationalist cleavage has a fundamental importance to understand the party systems and the dynamics of electoral competition in some Autonomous Communities. This article analyzes the electoral bases of the main regionalist parties in Spain and, specifically, it focuses on the electoral bases of Canary Coalition (CC). Despite its importance at the regional level, this party has received little attention by the academic literature. This article confirms the idea that CC is a party able to mobilize an electorate whose preferences are for a more decentralized territorial organization than the current one. However, the key finding is that, unlike what happens with the main regionalist parties in Spain, the identity associated with the Autonomous Community is not an explanatory factor of the vote for CC, what shows that the Canarian identity is not politically activated.
Antonio V. Lozano Peña, Felicidad García de Bustos
Resumen:Las sucesivas reformas del sistema de financiación de las Comunidades Autónomas han permitido a éstas avanzar en su grado de autonomía financiera, pese a lo cual, continúa siendo escasa en la práctica. Si tenemos en cuenta los retos que los servicios públicos fundamentales que ellas gestionan suponen para las finanzas públicas en el medio y largo plazo, en particular, los servicios de cuidados de larga duración, resultaría conveniente reflexionar sobre la necesidad de establecer procedimientos que eviten que las CC.AA. tengan que recurrir periódicamente a la presión sobre la Administración Central para obtener recursos suficientes para financiar sus competencias, junto con algunos otros aspectos que permitirían mejorar el funcionamiento del futuro nuevo sistema.Abstract: The intense process of Spanish political decentralization has been accompanied by a permanent debate about regional demands to finance their competencies. The result of this has been a malfunctioning system, and an image of fiscal irresponsibility of the Autonomous Communities that does not correspond to reality. This has damaged their credibility, and also the whole of the territorial system born of the 1978 Constitution. Two factors have contributed to this conflict: the imbalances between the capacity to decide between income and expenditure at different levels of government (vertical imbalances), and a division of powers that has assigned to the regional governments the management of three out of the four pillars of the welfare state, whose expenditure is structural and growing. With each reform of the funding system, the vertical gap is revised, although without knowing exactly how the insufficiency is estimated. This approach does not seem to be correct, since it encourages the expectations of the Autonomous Communities of receiving additional funds, and harms the system's efficiency. On the part of the central government, system reviews always end up with an injection of funds whose amount is not associated with known and transparent criteria. Spain was relatively late in developing a system of Long-Term Care, only after Law 39/2006 to Support the Personal Autonomy and Dependent Care, which attempted to overcome a model based on family support and informal care for another that consecrated the universality, accessibility and equity of beneficiaries to services. To finance the service, the Government favored a mixed model in which the central government would contribute 50% and the regions the remaining 50% from its own resources, but without altering the financial system. The implementation of this fourth pillar of the welfare state has implied a huge public financial effort, going from 0.3% of GDP of expenditure in 2003 that was estimated before the implementation of the law by the White Book to 1% which is reflected by the Commission in its latest report on ageing dated in 2013. Spending on long-term care has grown 64% since 2009, having tripled in ten years, well above all forecasts. However, while the private contribution to funding has doubled, the public contribution has increased only 55%. Within it, the evolution is very different between the central government and the regions: the latter have increased their contribution making it 62.7% of the total, while the central government has reduced it, representing now 18%. If the expenditure differential with the European Union already foresees a growth of our long-term care expenditure, the predictable evolution of the three factors that influence spending on these cares, as indicated by different international organizations: increased longevity, longer duration of dependency and evolution of the price of care services, , an exponential growth of the financial effort will be necessary. If we take the convergence scenario in care and cost systems with the EU average, in 15 years the spending will be at 1.6% of GDP and by the 2060 horizon it will exceed 4%. That means that expenditure on long-term care would be above education expenditure and not far from health expenditure, i.e. the three major welfare state policies managed by the Autonomous Communities will account for almost 15% of GDP. If the current distribution is not changed, the Autonomous Communities should assume an additional 2.5 points of GDP, which is impossible with the current financing system. The overwhelming intensity of the economic crisis and the fiscal consolidation process have revealed a phenomenon that the medium-term forecasts were already pointing out: how to fit within the public budget constraints the expected growth of the expenditure associated with the ageing of the population, which with the Spanish territorial organization leads to discuss the distribution of resources between the various levels of government. The Autonomous Communities have proved that raising their own taxes is not enough to obtain resources with which to mitigate the adjustment that has been demanded. The need to have a margin for the exercise of autonomy is indispensable since the growth of expenditure is restricted by the limit established in Article 12 of the Organic Law of Budgetary Stability and Financial Sustainability. If the Autonomous Communities can hardly modify their revenues through taxes, the application of the expenditure benchmark implies to anchor the expenditure to a percentage of the GDP. This can only be modified by means of an agreement with the Central Government so that it can transfer a part of its income to regions. As long as this does not take place, the pressure on the regional spending on basic public services will force to reduce the rest of the items and, in particular, will hamper the recovery of public investment. Projections of age-related expenditure (health services and long-term care, mainly), together with the new regulatory scenario established by the budgetary stability law (structural balance and expenditure rule, mainly) reveal the need to correct vertical funding gaps. Regulated procedures that do not place on one side the role of perpetual claimant and, at the same time, serve the State to require greater fiscal discipline to the Autonomous Communities are needed. Besides, the debate and decisions about which and what level of public services people are demanding, their financing and it consequent distribution among governments surpass existing Fiscal and Financial Policy Council. Economic recovery is boosting public revenues, but the expenditure rule established in the stability law impede similar expenditure increases, so we can expect the appearance of regional budgetary surpluses in the short term. With current regulations, regions can only use these surpluses to pay off debt. We would consider very interesting a reform of the law in order to have the option to create rainy-day funds that would allow the Autonomous Communities to accumulate the product of those surpluses and use it in future crisis. In short, the new system of regional financing should be simpler than the existing model and should not be just a new injection of funds. It is necessary to advance in solving the structural problems of our territorial architecture and funding and in particular in the reduction of vertical imbalances, in order to avoid a regression in the welfare state.
Frédéric Le Mouël, Carlos Barrios-Hernandez, Oscar Carrillo, Gabriel Pedraza
The globalization of trade and the organization of work are currently causing a large migratory flow towards the cities. This growth of cities requires new urban planning where digital tools take a preponderant place to capture data and understand and decide in face of changes. These tools however hardly resist to natural disasters, terrorism, accidents, etc. Based on the expertise of the CITI laboratory of INSA Lyon and SC3 of the Industrial University of Santander, we propose to create the ALERT project - Autonomous Liable Emergency service in Real Time - with decentralized, reliable and efficient services, physically close to the citizens, taking decisions locally, in a relevant manner without risk of disconnection with a central authority. These information gathering and decision-making will involve the population with participatory and social approaches.
Jesús Ruiz-Huerta Carbonell, Miguel Ángel García Díaz
In Spain, as a consequence of the persistence of the economic crisis, the deficit and debt of the public administrations have become a main issue on the current economic and political debates In the case of a highly decentralized scenario, such it is the Spanish one, even if we recognize the principal role of Central Government´s debt, a large part of the increased Autonomous Communities’ deficit and indebtedness is explained by the difficulties they have to face in financing services they have to cover. The paper describes the main characteristics of public accounts’ disequilibria in Spain and the regulatory limits established to make use of public debt. Also, the article offers different explanations of those disequilibria, putting the emphasis on those linked to the crisis: i.e. the increasing weight of basic welfare services covered by the Autonomous Communities (such as public health and as education); as the expansive policies implemented to fight the initial effects of the crisis; as the existence of previous and large “extraordinary” resources coming from the housing sector and its consequent collapse; as growth of the debt of the autonomous-community quangos and as the lack of effective accountability mechanisms addressed to control the expenditures of the autonomous communities.
Across this article we try to do a tour for the decentralized cooperation, for his characters, his principal virtualidades, the still hanging challenges and the innovations that this approach has experienced in the last years, since appeared in the Plan The Director 2009-2012 or the bet of the Autonomous Communities for collaborating with multinational organizations.
In this paper we describe and evaluate recent changes in the Spanish public programs that foster training among the Spanish active population. The analysis updates and complements the Martínez-Lucio and Stuart study of 2003 in this journal because it covers certain aspects related to training not considered there, especially those relating to public policy. Our analysis may also be useful for other countries that have similar characteristics to those of the Spanish training system, such as a high degree of administrative decentralization, a tripartite organization (involving public authorities and social agents) as well as a supply-driven and demand-driven training differentiation. Spain is located in southwestern Europe. Its mainland is bordered to the north by France and to the West by Portugal. In 2008 the population of Spain reached 46.2 million people. With the exception of Madrid, the capital area, the most populated areas lie around the coast. Life expectancy is 82.2 years for women and 77.8 years for men. The basic political units in the territorial distribution are the municipalities (there are 8,112), provinces (50) and regions (17).1 The last named have some political responsibilities because Spain is quite similar to a Federal State. In 2008 Spain was the eighth largest economy in the world, according to nominal gross domestic product (GDP). This was 1,095 million euros. GDP per capita was 24,020 euros. In fact, Spanish GDP per capita was 5.5 per cent above the average of the 27 states of the European Union (EU). The percentage of employed people by productive sector is as follows: agriculture (4 per cent), construction (12.1 per cent), industry (15.8 per cent) and services (68.1 per cent). The 2008 annual average rate of change in the Consumer Price Index was 1.4 per cent (being 1.6 per cent in the Euro area), but it has reached negative figures in 2009, as in most Western economies. Thus, Spain presents good figures in life expectancy, GDP and inflation. Its main economic problems are unemployment and current external deficit. Related to the former, in the second quarter of 2009, the active population was 23 million and the employed 18.9. Therefore, there were 4.1 million unemployed workers. The rate of unemployment was 17.9 per cent, more than double the EU average unemployment rate (8.3 per cent). Although Spain managed to reduce its unemployment level from 24 per cent in 1994 to 8 per cent in 2007, the rate of unemployment has increased sharply in the present economic crisis. With regard to the current external deficit, the accumulated deficit in 2008 increased to 104,664 million euros (9.6 per cent of GDP, one of the highest in the world in relative terms). The Spanish educational system has the following levels: pre-primary, primary, secondary education, which includes lower secondary (named Educación Secundaria Obligatoria) and upper-secondary education, either academic (bachillerato) or vocational [ciclos formativos de grado medio (CFGM)], and higher education [professional, named ciclos formativos de grado superior (CFGS) and university]. Compulsory education comprises primary and lower secondary (from 6 to 16 years old). Pre-primary education is organized in two cycles of 3 years each for children aged 0–6 years old. Primary education includes six academic courses (for students between the ages of 6 and 12). Lower secondary education has four courses, and it is expected that at the end, 16-year-old students finish compulsory education. However, in Spain, around 30 per cent of students fail to satisfactorily complete their compulsory education. Pupils who succeed in compulsory education may follow the academic track (bachillerato) for 2 years or vocational education (CFGM). To enter CFGS pupils must have satisfactorily finished bachillerato; however, there are specific exams to enter both vocational levels for those without the required academic degrees. Because of the implementation of the European higher education area, nowadays university studies (named grado) have a duration of four courses (with some exceptions) and substitute previous licenciatura (5 years) and diplomatura (3 years). Students have to pass a national exam to enter university, although for some groups there are also other ways to get in, such as for those over 25 or those who graduated from CFGS. Finally, university graduate students may attend masters and doctorate courses. In 2008 there were 7.2 million pupils in non-university studies, 36.4 per cent of whom were in private centers (around 80 per cent in private, publicly funded or ‘concerted’ schools). Thus, Spain is one of the countries with the highest percentage of students in private centers, especially because of the ‘concerted’ schools (Escardíbul & Villarroya, 2009). Moreover, there were 1.4 million university students (10 per cent in private institutions). In 2006, public expenditure on education amounted to 4.3 per cent of GDP (the EU average was 5.1 per cent). Training programs, together with vocational education, have constituted a unified system of vocational education and training since the 1990 Educational Act. The training system is made up of a scheme for training for the unemployed (traditionally called occupational training) and training for employed individuals (continuous training). The two types of training were originally independent, but they were merged in 2007 through the Royal Decree 395/2007. The merged system is governed by the Ministry of Labor and Immigration (MLI), which establishes a common legal framework for the whole country and has management responsibilities. Since the 1990s, however, regional governments known as Autonomous Communities (ACs) have also taken on some responsibilities for training. In addition, social agents also take part, especially in continuous training. The completion of vocational education leads to vocational degrees (títulos profesionales), whereas finishing occupational and continuous training may lead to professional certificates (certificados de profesionalidad). Both are linked through the National Catalog of Professional Qualifications (Catálogo Nacional de Cualificaciones Profesionales), which today contains 390 qualifications. Training for the unemployed comprises a general Plan for Training and Professional Insertion (Plan Nacional de Formación e Inserción Professional or ‘FIP’ Plan), established in 1993, as well as working/training programs (focused on services of social interest) such as school workshops (Escuelas Taller) and trades centers (Casas de Oficios) for younger unemployed individuals and employment workshops (Talleres de Empleo) for those over 25. Working/training programs last from 6 months to 2 years. Training programs for the employed started to be implemented in 1993, when the Foundation for Continuous Training (Fundación para la Formación Continua, FORCEM) was created as a result of the First National Agreement on Continuous Training. The foundation, although publicly funded by the MLI [and the European Social Fund (ESF)], had bipartite management bodies. On the one hand, there were the two main employers' organizations and, on the other, the main national trade unions. Training was regulated through two National Agreements on Continuous Training (covering the periods 1993–1996 and 1997–2000) reached by these social agents. The third agreement covered the 2001–2004 period and was administered by the Tripartite Foundation for In Service Training (Fundación Tripartita para la Formación en el Empleo), which was run by the social agents indicated above and the MLI through the National Employment Institute [Instituto Nacional de Empleo (INEM)], after some irregularities involving public funds had been uncovered. With the third agreement, a distinction was introduced between supply- and demand-driven training plans. The former has been aimed at the personal and professional development of workers (and it is mainly organized through sector and inter-sector plans, managed by social agents), whereas the latter has sought to address firms' needs (companies ask for subsidies for training and employees may demand training leave). The Royal Decree 1046/2003 altered the third agreement by introducing major changes to the system, such as changes to the demand-driven training system and to the role of ACs in supply-driven training. With respect to the first change, the Royal Decree enabled companies to secure training resources with much less bureaucracy because it eliminated the need to present projects annually to the Tripartite Foundation and allowed companies to finance their training by reducing the amount they pay to the Social Security Treasury if resources were devoted to the training of their employees. The calculation of the training ‘credit’ or ‘bonus’ for each company is based on the application of a percentage (set by the National Budget Act) of the amount paid by the company through the previous year's compulsory training levy. Companies with at least 10 employees also have to invest in training with their own funds (see details in next section). Firms have to keep the employees' legal representative (if one exists) informed about training matters, otherwise they lose their bonus, and there is a procedure in case of dispute where social agents are involved. With respect to the second change, AC governments with labor competences (16 out of 17) were allowed to supply and manage national centrally collected public resources (and their own) for supply-driven training activities within their regional boundaries. However, INEM still manage training activities developed in more than one AC. Finally, the fourth agreement (2006–2010) set out several aims that were developed in Royal Decree 395/2007, such as merging training for the employed and the unemployed and fostering professional certification (see next section). The funding structure for training is supported by the Public Treasury's collection of a training levy paid by employers and workers. The levy is 0.7 per cent of gross salary. Companies pay 0.6 per cent, whereas 0.1 per cent is covered by employees. Since 1997 the training levy is equally distributed between training for the unemployed and for the employed (0.35 per cent to each system). Resources are managed by the National Employment Institute (INEM) and those AC governments that assume this responsibility. They are mainly distributed to regions according to the number of unemployed. During the 2000–2003 period, the ‘FIP’ Plan accounted for around 700 million euros (around one third came from the ESF), whereas resources for the working/training programs were almost 480 million (30 per cent from the ESF). For continuous training, Tripartite Foundation's financial resources are provided annually by INEM. For the 1995–2005 period, the training levy accounted for approximately 75 per cent, whereas it was 81 per cent in 2006 (the rest was provided by the ESF). AC governments also spend their own funds. Funds to regions are allocated mainly on the basis of the average number of workers excluding public sector employees (who have their own training plans). The number of participants across all kinds of occupational training is shown in Table 1. More than 80 per cent of learners take part in training related to the FIP Plan. In addition, 15–20 per cent of all unemployed workers (based on the Active Population Survey) have received training since the beginning of this century. The small increase observed in the 2003–2006 period is due to the declining size of the unemployed population. Table 2 shows information related to continuous training since 2004, when the ‘credit’ system began. However, it has to be emphasized that since 1993 the number of employees trained and total funds for training have greatly increased, the first sixfold (it started with 0.3 million trainees), although the figure has been quite stable since the late 1990s, and the second figure 14-fold (in 1993, only 56 million euros were devoted to training). The overall percentage of women trained has reached 42 per cent (it was 30 per cent in 1993). There are more trainees in demand-driven activities than in supply-driven activities. However, the credit system administers less than 30 per cent of the total resources. With respect to demand-driven activities, the bonus used has increased sharply, though, as a percentage of available bonus it is below 60 per cent. In addition, the overall bonus percentage of training costs (including the wages of employees who train during working hours) is almost 60 per cent. Demand-driven training activities that are not in the workplace account for less than 30 per cent of the total, although this figure has increased each year. With respect to supply-driven activities, most trainees participate in sector plans. Regarding the distribution of funds between levels of administration, the contribution of the national authorities has decreased sharply (from 75.1 per cent in 2004 to 49.5 per cent in 2006) in favour of the ACs. Looking at the type of plan involved, roughly 85 per cent of total funds are devoted to sector plans. As previously indicated, the Royal Decree 395/2007 merged continuous and occupational training. It states that training may be provided as follows. Public administrations with responsibility for training may provide training through their own centers or through agreements with public organizations or companies certified to train. A public administration's centers include National Centers of Excellence (Centros de Referencia Nacional), Integrated Centers (Centros Integrados), and other centers for vocational education (schools) and training (INEM's National Centers for Occupational Training, which may be transferred to ACs). Integrated Centers were regulated in 2005 (Royal Decree 155/2005) and, among other tasks, they are to provide all vocational education and and training in that they are to by Labor and Educational centers may be or from the of Integrated Centers has been quite and between ACs. The National Centers of Excellence were regulated in 2008 (Royal Decree They are to be centers for all Spain in a specific of vocational education and training. Thus, they have to the needs of the productive and training to these needs as well as to provide training to all agents in the training system in centers also have to be by and Labor of are to be created from INEM although it is not that they be to out the in the present centers for vocational education that have been by the public provide training professional In addition, other private centers provide training not related to professional certificates if they are in established by labor trade and other organizations from training provide training through their own centers or through other Companies that train their own employees or the unemployed with a to provide training in their own or through Training is for both the employed and the with to groups considered to have in in Royal Decree 395/2007 four types of training Although these all to 2007, the main between the Decree and previous was the of its It covered all training demand-driven activities, supply-driven activities, training involving a of training and and activities. In addition, the of of professional competences through is considered as a of the Although professional certificates were regulated in 2008 only the recent of has established the by which professional certificates or of a vocational degree be by those with competences through working or education. As in previous funds for training from the training levy paid by companies and the and other resources provided to INEM from the national The governments also funds. Funds by the MLI are in the of the National Employment Nacional de Empleo), which includes one representative from each number from the and from the main employers' organizations and trade The of each social the as the levels of in to the tripartite The the Tripartite Foundation and ACs manage the resources allocated to training, as in the previous Finally, is on the of training National and regional labor authorities may evaluate the training system at levels by participants on the training received and by the training centers, and the of training centers may be in the Moreover, centers have to per cent of the they to the of the training As shown in Table recent changes in the bonus system are related to the amount of credit available for training, the percentage of private funding required and the amount of per Thus, the credit available has increased for all is not required to companies with less than 10 employees 2007 it only to companies with up to and the of training per and of training has With regard to training by companies may finance the gross costs of participants through the bonus They have amount of per cent of annual Training is up to per academic or it must be on the and the not Since 2007 supply-driven training activities are aimed at the personal and of both workers and the unemployed of company They are by the labor at national with the and of the Tripartite Moreover, from ACs and social agents are considered through their in the of the National Employment Social agents also participate in the that are created through between employers' organizations and trade among other activities, the main and overall of sector training activities. In 2007, to 56 sector plans, 42 of which came out of ACs may have their own training plans, national training activities are set out as The employed must at least 60 per cent of overall may be sector or and public administrations the of each in each The Tripartite Foundation is mainly in of the and of the implementation of the training Thus, the the for subsidies and or of INEM the a plan is it is developed through agreements between INEM and the the main national employers' trade organizations in the social economy and as well as organizations created by and employers' through in sector plans. The to activities developed at regional level with regional In that organizations may be representative at national or regional training activities must run between six and in The unemployed must at least 60 per cent of overall include training for the of professional certificates in the National Catalog of Professional allowed to funds for this of training include employers' trade training centers and public In 2007, per cent of all participants were trained in centers by labor administrations or per cent by employers' trade and organizations related to the social per cent by and per cent by centers for training. these companies and employers' the unemployed to get professional as well as to at least 60 per cent of all Companies in the first may up to six euros per and training and participants may for and Firms in the second financial subsidies for which are to be This is for those with in the labor or in professional as well as training activities for those in those in the (with labor and (in their country of who This of training is provided by administrations and other public authorities as well as The first two kinds of are through public subsidies through a procedure from The rest are through There are two types of activities that training and within for training and the working/training programs indicated in the previous In for training, which have been in since the to training be less than per cent of total working and must be the education and working be in or must be between 16 and years (the is not and the is between 6 months and 2 years. a based on the agreement, but it must not be less than the to their to Firms the of education through the credit system, but in that case financial resources are linked to the employment of the Social Security Treasury and not from the training levy. activities mainly and aimed at training and information about the training system as well as to individuals to secure training, of and The recent changes provide a by training for the employed and the unemployed one This the of training activities in the structure of the Spanish vocational education and training. It is also that the credit system in activities has been because it the of training for However, the level of used bonus in respect to total bonus available per cent) that more is from public to foster The role of the Tripartite Foundation in small companies be to include on management (Escardíbul The role of social agents in training is through their in set up in the framework of the This is in with the of trade to the role of labor in areas such as training because much of their has been external to the workplace & In addition, are to keep the employees' legal representative informed about training matters, and there is a procedure in case of dispute where they take Resources to training activities, which has a role than a specific role in among employees. However, groups of people have to be such as and and there also needs to be a on the especially in the current of economic with unemployment rate of per cent in The over training centers and the of training This is much because the high of private centers has educational supply in courses and the of students more to enter the labor as because training that the to the labor for the of public funding However, other have to be to the training The of professional competences is to be a of the Professional be established in a that trainees and the unemployed not only information and from training social but also have a who professional that to training and their professional life & that it is of be developed to a of because at present it covers only Moreover, it be the to foster training for those less The role of ACs is not are their activities as regional authorities in There are between regional and national authorities that are taken to the for The role of social agents through be the the role of because these are to firms' training is linked for or the of employees to train Training have to the of training that training and for training). have some of to Thus, some between (and their and vocational education (and their is 2009). In addition, training not only but also are known as such as the to in a and all of which are required by Public funding of training centers on the by As in and be considered as a system, which increase in be among Although all recent have increased the number and of training as well as funds devoted to training, we that and the to training for employees (in per for Moreover, public training the to areas where private centers are not established More is to out these be Nacional de Tripartita para la Formación en el Empleo de Educación de e and Nacional de Empleo (INEM) de de la and de de de de Nacional de and
espanolLa evolucion de la prestacion sanitaria media parece moverse a impulsos de dos grandes factores: los tecnologicos, en gran medida exogenos a las autoridades sanitarias, y los politicos, o endogenos en respuesta a las expectativas y preferencias sociales sobre las posibilidades de la medicina en las sociedades occidentales. Como resultado, las capacidades de tratamiento sanitario se expanden, de la mano de la presion ciudadana, en sociedades cada vez mas medicalizadas y en las que la industria sanitaria tiene un gran peso mediatico. En Espana, el incremento de la prestacion sanitaria media registrada en los ultimos anos aparece como coetanea a la descentralizacion sanitaria. Asi, existe diversidad no solo en razon del contenido de algunas prestaciones sanitarias, sino tambien de su utilizacion por parte de la poblacion. Nos interrogaremos en este trabajo acerca de la influencia de la descentralizacion sanitaria como inductor del crecimiento del gasto sanitario. A dicho fenomeno se asociaran aspectos relativos aprocesos de financiera, o de emulacion de politicas con falta de corresponsabilizacion en el gasto por parte de sus gestores. La tesis que deseamos mantener es que la devolucion de responsabilidades fiscales a las comunidades autonomas puede ser un buen antidoto para el control del gasto sanitario y, en particular, de los diferenciales de utilizacion. Con el nuevo sistema de financiacion autonomica, la integracion de la financiacion sanitaria en la general permite introducir los mecanismos necesarios para el autocontrol del gasto que aseguren una efectiva sostenibilidad de la financiacion de la sanidad publica en el proximo futuro. EnglishTechnological and social factors are beyond the increasing share of health expenditure on GDP. This implies that a mix of exogenous and endogenous factors influence health care delivery. Professional aims and social expectations on the production possibility frontier of health, on cure and care treatments, make for a rather difficult control of public health expenditure in OECD countries if reforms are not undertaken in the near future. In Spain, the rise in public health expenditure seems to go hand by hand, with an important decentralization power of health care delivery to Regional Authorities. Whether this is just a coetaneous or a relevant explanatory factor is examined in this paper.The lack of accountability and some fiscal ilusion aspects may undoubtedly influence, overall, public expenditure. But the absence of a rational distribution formula of regional health expenditure at he national level is an important factor too. The argument of the paper focusses on the need of devolution of full responsabilities on health expenditure to the Spanish Autonomous Communities. A fiscal room process is proposed as a result of some technical adjustments on a capitative finance basis. Cross-boundary flows of patients, age structure of the population, teaching and research externalities