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, [email protected], [email protected]
E. Massard da Fonseca, University of Edinburgh, E. Massard da Fonseca, University of Edinburgh, [email protected]@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 : explains authority allocation as result of functional imperatives to avoid as result of functional imperatives to avoid negative externalities and provide efficiently. As negative externalities and provide efficiently. As much subsidiarity as permits each government much subsidiarity as permits each government to internalize its costs.to 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
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