Allocation of Authority in Allocation of Authority in European Health SystemsEuropean Health Systems

S.L. Greer, University of Michigan School of Public S.L. Greer, University of Michigan School of Public Health, slgreer@umich.eduHealth, slgreer@umich.edu

E. Massard da Fonseca, University of Edinburgh, E. Massard da Fonseca, University of Edinburgh, e.m.fonseca@sms.ed.ac.uke.m.fonseca@sms.ed.ac.uk

Explaining Authority AllocationExplaining Authority AllocationAllocation of authority is Allocation of authority is notnot::

- DecentralizationDecentralization- Privatization or moving offices aroundPrivatization or moving offices around- A policyA policy- A technical product of health policy debatesA technical product of health policy debates

- Allocation of authority Allocation of authority isis::- A phenomenonA phenomenon- Something that takes place between elected, Something that takes place between elected,

general-purpose territorial governmentsgeneral-purpose territorial governments- ExplicableExplicable

Two Approaches to ExplanationTwo Approaches to Explanation

Political approachPolitical approach: explains authority allocation as : explains authority allocation as result of the behavior and decisions of the result of the behavior and decisions of the politicians who determine what governments dopoliticians who determine what governments do

Economic approachEconomic approach: explains authority allocation as : explains authority allocation as result of functional imperatives to avoid negative result of functional imperatives to avoid negative externalities and provide efficiently. As much externalities and provide efficiently. As much subsidiarity as permits each government to subsidiarity as permits each government to internalize its costs.internalize its costs.

Economic PredictionEconomic Prediction

State Region Local

Finance Yes No No

Legislate Yes Yes No

Provide No No Yes

Political Prediction 1: Credit-ClaimingPolitical Prediction 1: Credit-Claiming

State Region Local

Finance Maybe Maybe Maybe

Legislate Maybe Maybe Maybe

Provide Maybe Maybe Maybe

Political Prediction 2: Political Prediction 2: Constitutions (Strong Regional Gov’t)Constitutions (Strong Regional Gov’t)

State Region Local

Finance Yes Yes No

Legislate Yes Yes No

Provide No Maybe Yes

The TestThe Test

Our basic test:Our basic test:- For four policy areas, see if the allocation of For four policy areas, see if the allocation of

authority in most countries fits any one authority in most countries fits any one prediction.prediction.

- Secular expectation: smaller countries will Secular expectation: smaller countries will have weaker or no regional levelshave weaker or no regional levels

The Data The Data

- Observatory HiT reports and literature Observatory HiT reports and literature survey (especially) for countries with older survey (especially) for countries with older or incomplete reportsor incomplete reports

- Three stylised tiers of government: the state, Three stylised tiers of government: the state, regional (meso-level elected) and local. Only regional (meso-level elected) and local. Only general-purpose elected governments countgeneral-purpose elected governments count

- Finance= raise and allocate health budget; Finance= raise and allocate health budget; Legislate= set main legal frameworkLegislate= set main legal framework

- Provide= organise the provision of servicesProvide= organise the provision of services

The Results: Primary CareThe Results: Primary Care(number of countries per cell)(number of countries per cell)

State Region Local

Finance 24 2 1

Legislate 19 8 1

Provide 2 6 14

The Results: Secondary/TertiaryThe Results: Secondary/Tertiary

State Region Local

Finance 24 4 0

Legislate 18 13 5

Provide 6 17 18

The Results: Public HealthThe Results: Public Health

State Region Local

Finance 20 3 2

Legislate 19 5 2

Provide 10 11 15

The Results: PharmaceuticalsThe Results: Pharmaceuticals

State Region Local

Finance 25 3 0

Legislate 25 1 0

Regulate* 22 3 1

Conclusion, 1Conclusion, 1

Allocation of authority is broadly compatible with Allocation of authority is broadly compatible with the predictions of the economic theory of the predictions of the economic theory of fiscal federalismfiscal federalism

But political science is not useless. Deviations But political science is not useless. Deviations from the predictions of economics (plus from the predictions of economics (plus country size) were all explicable with country size) were all explicable with reference to particular histories of reference to particular histories of constitutional politics. constitutional politics.

Conclusion, 2Conclusion, 2Allocation of authority matters to health services. That Allocation of authority matters to health services. That

is conclusively demonstrated by the existing is conclusively demonstrated by the existing literature.literature.

But health services research is not going to explain it. But health services research is not going to explain it. Within the scope allowed by the economy, Within the scope allowed by the economy, constitutional politics will explain it. constitutional politics will explain it.

……among territorial, elected, governments, there is no among territorial, elected, governments, there is no such thing as “decentralization policy” in Europesuch thing as “decentralization policy” in Europe