Decentralization is a cornerstone of health policy reforms across Europe and beyond. This article analyses some of the effects of decentralization using the Italian National Health System (NHS) as a case study. The authors evaluate the risks of welfare state retrenchment and the rise of territorial inequalities in accessing healthcare, using document analysis, secondary sources and micro-data elaboration. The analysis does not confirm an overall welfare state retrenchment, but reveals an increase in territorial inequalities. The results highlight a paradox: if decentralization is to be implemented in a country with strong territorial socioeconomic divides and a critical financial situation, it needs a strong central government in order to support and control local authorities. Otherwise, decentralization may cause a zero-sum game where the gains for the better-off regions counterbalance the losses in performance of the weaker ones; a situation which could lead to the growth of social inequalities, including gender inequalities.
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