Decentralization, re-centralization and future European health policy

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Abstract
A major shift appears to be underway in Europe in the relationship between national, regional, and local control over health sector decision-making. Since World War II, a central thrust of health policy has been to decentralize key dimensions of decision-making authority to increasingly lower levels of government, as well as (in Social Health Insurance systems and recently in some tax-based systems) to private sector organizations.1 This strategy, to adapt Kondratiev's business-cycle framework,2 has been one of two overlapping ‘long waves’ that helped frame structural decisions in most Western European health systems. The second wave—market-influenced-entrepreneurialism—has run simultaneously with decentralization since the late 1980s. However, while this second, market-oriented wave has generated considerable controversy in some health policy circles, the concept of decentralization was readily accepted in many national policy contexts. As a result, over the second half of the 20th century, expanded decentralization of authority to regional, municipal and non-governmental control has become part of the ‘received wisdom’ about what good health policy should include.

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