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Allocation of Authority in European Health Systems

Allocation of Authority in European Health Systems. S.L. Greer, University of Michigan School of Public Health, slgreer@umich.edu E. Massard da Fonseca, University of Edinburgh, e.m.fonseca@sms.ed.ac.uk. Explaining Authority Allocation. Allocation of authority is not : Decentralization

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Allocation of Authority in European Health Systems

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  1. Allocation of Authority in European Health Systems S.L. Greer, University of Michigan School of Public Health, slgreer@umich.edu E. Massardda Fonseca, University of Edinburgh, e.m.fonseca@sms.ed.ac.uk

  2. 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

  3. 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.

  4. Economic Prediction

  5. Political Prediction 1: Credit-Claiming

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

  7. 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

  8. 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

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

  10. The Results: Secondary/Tertiary

  11. The Results: Public Health

  12. The Results: Pharmaceuticals

  13. 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.

  14. 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

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