Decentralization… hb 6/12/06 10:46 am Page 1 European Observatory on Health Systems and Policies Series Decentralization in health care Strategies and outcomes D e Decentralization has become a popular management strategy in many European c e health care systems. The term describes a wide variety of power transfer n t r arrangements and accountability systems. The logic of decentralization is a l grounded in an intrinsically powerful idea: that smaller organizations, properly i z structured and steered, are inherently more agile and accountable than larger a t i organizations. In a world where large organizations control wide swathes of o n both public and private sector activity, the possibility of establishing more in locally operated, locally responsible institutions holds out great attraction. Decentralization in h e This text explores the capacity and impact of decentralization within European a l t health care systems. It examines both the theoretical underpinnings as well as h recent practical experiences, drawing upon both published literature and c health care a r evidence collected directly from the field. The book also assesses the e appropriateness of management processes within health systems for implementing a successful decentralization strategy. Decentralization in Health Care will appeal to health policy makers, / Vrangbaek Saltman /Bankauskaite by Edited postgraduates taking courses in health services management, human resources, health policy and health economics, and human resource professionals. The Editors Richard B. Saltman is Associate Head of Research Policy at the European Observatory on Health Systems and Policies, and Professor of Health Policy and Management at the Rollins School of Public Health, Emory University in Atlanta, Georgia. Vaida Bankauskaite is Scientific Project Officer at the European Commission and previously worked as a Research Fellow at the European Observatory on Health Systems and Policies. Karsten Vrangbaek is a lecturer at the University of Copenhagen, Denmark. Edited by Richard B. Saltman Vaida Bankauskaite Karsten Vrangbaek ISBN 0-335-21926-8 www.openup.co.uk 9 780335 219261 Decentralization in Health Care The European Observatory on Health Systems and Policies is a partnership between the World Health Organization Regional Office for Europe, the Gov- ernments of Belgium, Finland, Greece, Norway, Slovenia, Spain and Sweden, the Veneto Region of Italy, the European Investment Bank, the Open Society Institute, the World Bank, CRP-Santé Luxembourg, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine. European Observatory on Health Systems and Policies Series Edited by Josep Figueras, Martin McKee, Elias Mossialos and Richard B. Saltman Decentralization in Health Care Strategies and outcomes Edited by Richard B. Saltman, Vaida Bankauskaite and Karsten Vrangbæk Open University Press McGraw-Hill Education McGraw-Hill House Shoppenhangers Road Maidenhead Berkshire England SL6 2QL email: [email protected] world wide web: www.openup.co.uk and Two Penn Plaza, New York, NY 10121–2289, USA First published 2007 Copyright © World Health Organization 2007 on behalf of the European Observatory on Health Systems and Policies. The views expressed by authors or editors do not necessarily represent the decisions or the stated policies of the European Observatory on Health Systems and Policies or any of its partners. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the European Observatory on Health Systems and Policies or any of its partners concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitations of its frontiers or boundaries. Where the designation “country or area” appears in the headings of tables, it covers countries, territories, cities, or areas. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the European Observatory on Health Systems and Policies in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. 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Details of such licences (for reprographic reproduction) may be obtained from the Copyright Licensing Agency Ltd of Saffron House, 6–10 Kirby Street, London, EC1N 8TS. A catalogue record of this book is available from the British Library ISBN 0 335 21925 X (pb) 0 335 21926 8 (hb) ISBN 978 0 335 21925 4 (pb) 978 0 335 21926 1 (hb) Library of Congress Cataloging-in-Publication Data CIP data has been applied for Typeset by RefineCatch Limited, Bungay, Suffolk Printed in the UK by Bell & Bain Ltd, Glasgow European Observatory on Health Systems and Policies Series The European Observatory on Health Systems and Policies is a unique project that builds on the commitment of all its partners to improving health care systems: • World Health Organization Regional Office for Europe • Government of Belgium • Government of Finland • Government of Greece • Government of Norway • Government of Slovenia • Government of Spain • Government of Sweden • Veneto Region of Italy • European Investment Bank • Open Society Institute • World Bank • CRP-Santé Luxembourg • London School of Economics and Political Science • London School of Hygiene & Tropical Medicine The series The volumes in this series focus on key issues for health policy-making in Europe. Each study explores the conceptual background, outcomes and lessons learned about the development of more equitable, more efficient and more effective health systems in Europe. With this focus, the series seeks to contribute to the evolution of a more evidence-based approach to policy formulation in the health sector. These studies will be important to all those involved in formulating or evaluating national health care policies and, in particular, will be of use to health policy-makers and advisers, who are under increasing pressure to rationalize the structure and funding of their health systems. Academics and students in the field of health policy will also find this series valuable in seeking to understand better the complex choices that confront the health systems of Europe. The Observatory supports and promotes evidence-based health policy-making through comprehensive and rigorous analysis of the dynamics of health care systems in Europe. Series Editors Josep Figueras is the Director of the European Observatory on Health Systems and Policies, and Head of the European Centre for Health Policy, World Health Organization Regional Office for Europe. Martin McKee is Head of Research Policy and Head of the London Hub of the European Observatory on Health Systems and Policies. He is Professor of European Public Health at the London School of Hygiene & Tropical Medicine as well as a co-director of the School’s European Centre on Health of Societies in Transition. Elias Mossialos is the Co-director of the European Observatory on Health Systems and Policies. He is Brian Abel-Smith Professor in Health Policy, Department of Social Policy, London School of Economics and Political Science and Director of LSE Health. Richard B. Saltman is Associate Head of Research Policy and Head of the Atlanta Hub of the European Observatory on Health Systems and Policies. He is Professor of Health Policy and Management at the Rollins School of Public Health, Emory University in Atlanta, Georgia. European Observatory on Health Systems and Policies Series Series Editors: Josep Figueras, Martin McKee, Elias Mossialos and Richard B. Saltman Published titles Primary care in the driver’s seat Richard B. Saltman, Ana Rico and Wienke Boerma (eds) Human resources for health in Europe Carl-Ardy Dubois, Martin McKee and Ellen Nolte (eds) Health policy and European Union enlargement Martin McKee, Laura MacLehose and Ellen Nolte (eds) Regulating entrepreneurial behaviour in European health care systems Richard B. Saltman, Reinhard Busse and Elias Mossialos (eds) Social health insurance systems in western Europe Richard B. Saltman, Reinhard Busse and Josep Figueras (eds) Health care in central Asia Martin McKee, Judith Healy and Jane Falkingham (eds) Hospitals in a changing Europe Martin McKee and Judith Healy (eds) Funding health care: options for Europe Elias Mossialos, Anna Dixon, Josep Figueras and Joe Kutzin (eds) Regulating pharmaceuticals in Europe: striving for