Allocation of Authority in European Health Systems S.L. Greer, University of Michigan School of Public Health, E. Massard da Fonseca, University of Edinburgh,

Explaining Authority Allocation Allocation of authority is not: - Decentralization - Privatization or moving offices around - A policy - A technical product of health policy debates - Allocation of authority is: - A phenomenon - Something that takes place between elected, general-purpose territorial governments - Explicable

Two Approaches to Explanation Political approach: explains authority allocation as result of the behavior and decisions of the politicians who determine what governments do Economic approach: explains authority allocation as result of functional imperatives to avoid negative externalities and provide efficiently. As much subsidiarity as permits each government to internalize its costs.

Economic Prediction StateRegionLocal FinanceYesNo LegislateYes No ProvideNo Yes

Political Prediction 1: Credit-Claiming StateRegionLocal FinanceMaybe LegislateMaybe ProvideMaybe

Political Prediction 2: Constitutions (Strong Regional Gov’t) StateRegionLocal FinanceYes No LegislateYes No ProvideNoMaybeYes

The Test Our basic test: - For four policy areas, see if the allocation of authority in most countries fits any one prediction. - Secular expectation: smaller countries will have weaker or no regional levels

The Data - Observatory HiT reports and literature survey (especially) for countries with older or incomplete reports - Three stylised tiers of government: the state, regional (meso-level elected) and local. Only general-purpose elected governments count - Finance= raise and allocate health budget; Legislate= set main legal framework - Provide= organise the provision of services

The Results: Primary Care (number of countries per cell) StateRegionLocal Finance2421 Legislate1981 Provide2614

The Results: Secondary/Tertiary StateRegionLocal Finance2440 Legislate18135 Provide61718

The Results: Public Health StateRegionLocal Finance2032 Legislate1952 Provide101115

The Results: Pharmaceuticals StateRegionLocal Finance2530 Legislate2510 Regulate*2231

Conclusion, 1 Allocation of authority is broadly compatible with the predictions of the economic theory of fiscal federalism But political science is not useless. Deviations from the predictions of economics (plus country size) were all explicable with reference to particular histories of constitutional politics.

Conclusion, 2 Allocation of authority matters to health services. That is conclusively demonstrated by the existing literature. But health services research is not going to explain it. Within the scope allowed by the economy, constitutional politics will explain it. …among territorial, elected, governments, there is no such thing as “decentralization policy” in Europe