Decentralisation in Healthcare
Jeni Bremner
Director
European Health Management
Association
The Policy Challenge
• What is the optimum level or tier of
governance and administration for health
services?
• Resistance to change vs Perceived necessity of
doing things differently
• What can we learn from Europe?
Decentralisation is…
• Transfer of power and authority from higher
to lower levels of government
• Multiple dimensions
– Fiscal
– Political
– Administrative
• Contested, should devolution and
privatisation also be seen as a form of
decentralisation?
Complexity
• Different names for similar levels of governance;
countries, Autonomous Communities, Provinces,
Lander, Regions
• Areas with Special status; Copenhagen, Maderia
• Even sub nationally in country there are
differences, Trentino-Alto
• Some countries have intermediate bodies
without specific functions – groups of swedish
regions, associations of local government
Country
Levels of Gov
Number Population Appointed
per entity /elected
x1000
Tax Raising
Powers
Finland
Central Gov
Regions
Districts
Hospital Districts
Local Gov
1
6
20
21
444
5206
868
260
248
12
Elected
Appointed
Appointed
Appointed
Elected
X
1
16
29
439
82537
5159
2846
188
Elected
Elected
Appointed
Appointed
X
X
1603
51
Appointed
14703
6
Elected
Germany Central Gov
Regions
Districts
Kreisfreie
Stadte/Landkreise
Amter/Gemeinderveban
de
Local Gov
X
X
Adapted from Bankauskaite, Dubois and Saltman
The Key Arguments
• Efficiency
– Allocative VS Cost efficiency
• Democracy
– Enhance democratic content of local decision
making VS Low turn out at elections
Arguments for Decentralisation
• Greater penetration of services to ‘hard to reach’
communities
• Greater representation of needs of diverse
communities
• Enhanced civic participation
• Reduce red tape
• Strengthen local administration
• More effective in implementation of policy due to
simplified monitoring and evaluation.
Latvia
• Decentralisation in early 90’s, some
recentralisation in 97
• Local fiscal constraints led to high variability in
provision of healthcare
• Responsibility but low fiscal and
administrative capacity
• National and EU policy frameworks significant
in setting minimum standards for local
provision for social services, education etc
Evidence
• Equity impact
– Cross subsidisation of services
– appropriate services for populations with
particular needs
– Access to reproductive health services
• Evidence to support claims in favour of
decentralisation ambiguous
• Decentralisation decisions essentially political
• Complexity and contextual differences make
comparison difficult
Implications
• Powers and Accountabilities likely to continue
to move round health system
• Contextual factors, demography and need for
integrated care may lead to more
decentralisation
• England more heavily centralised than any
other European country – decentralisation
more likely?
Conclusions
• Managers and clinicians need skills to meet
the changing circumstances – for example
working with local politicians
• Minimise organisational’churn’
• Diversity across Europe gives opportunity to
learn
• Essential to understand the context when
looking at other systems
• Immunity
• Initiation
Arguments for Decentralization
• Improve Technical efficiency by;
– Learning from diversity
– Simplified monitoring and evaluation [?]
– Increase political stability [?]
– Reduce diseconomies of scale.
• Overcomes perceived limitations of centrally
controlled national planning
• Locally Responsive
Decentralisation of Health Care in
Europe
“For me context is the key - from that comes
the understanding of everything”
Kenneth Noland
Arguments for Decentralisation
“local provision is able to put to use local
goodwill, enthusiasm and knowledge. Services
can be more easily tailored to the
requirements of local people, which can vary
greatly from one place to another.”
JS Mill
Decentralisation – of what?
• Delegation
– Transfer to lower organisational level
• De-concentration
– Transfer to a lower administrative level
• Devolution
– Transfer to a lower political level
• Privatisation
– Transfer from Public to Private ownership
Decentralisation in Europe
• Varied Picture
– Policy/Politics
– Funding
– Administration