1. Decentralisation in Healthcare Jeni Bremner Director European Health Management Association

2. 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?

3. 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?

4. 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

5. CountryLevels of GovNumberPopulation per entity x1000 Appointed /elected Tax Raising Powers FinlandCentral Gov Regions Districts Hospital Districts Local Gov 1 6 20 21 444 5206 868 260 248 12 Elected Appointed Elected XXXX GermanyCentral Gov Regions Districts Kreisfreie Stadte/Landkreise Amter/Gemeinderveban de Local Gov 1 16 29 439 1603 14703 82537 5159 2846 188 51 6 Elected Appointed Elected XXXXXX Adapted from Bankauskaite, Dubois and Saltman

6. The Key Arguments Efficiency – Allocative VS Cost efficiency Democracy – Enhance democratic content of local decision making VS Low turn out at elections

7. 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.

8. 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

9. 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

10. 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?

11. 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

13. Immunity Initiation

14. 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

15. Decentralisation of Health Care in Europe “For me context is the key - from that comes the understanding of everything” Kenneth Noland

16. 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

17. 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

18. Decentralisation in Europe Varied Picture – Policy/Politics – Funding – Administration