Decentralisation in Healthcare

Jeni BremnerDirector

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 per entity x1000

Appointed/elected

Tax Raising Powers

Finland Central GovRegionsDistrictsHospital DistrictsLocal Gov

162021444

520686826024812

ElectedAppointedAppointedAppointedElected

X

X

Germany Central GovRegionsDistrictsKreisfreie Stadte/LandkreiseAmter/GemeindervebandeLocal Gov

11629439

1603

14703

8253751592846188

51

6

ElectedElectedAppointedAppointed

Appointed

Elected

XX

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