Decentralisation in the health sector

Decentralisation is a fundamental characteristic of many health systems, and subnational governments are often responsible for the delivery and financing of health services. However, the degree of decentralisation varies significantly across OECD countries. While it may be driven by historical factors, such as the influence of federal or unitary systems, decentralisation is often prompted by the central government’s need to alleviate budgetary pressures (OECD, 2015[1]). The decentralisation of the health system can also be viewed as a means of improving health outcomes by promoting efficiency or by offering a more targeted package of health services based on specific needs.

More broadly, OECD countries are experiencing a trend toward governmental decentralisation and the subsequent dispersal of power. This has led to greater recognition of the significant impact of decentralisation on shaping the management and spending frameworks of public services, as well as on monitoring productivity and service quality. Most central governments consider it their role to ensure that health services are delivered efficiently and equitably, for a variety of economic, social, and financial reasons. As a result, subnational health expenditures and service delivery standards are often influenced by central government regulations, legislation, and conventions, which in turn reduce the authority of subnational governments over health policy and service provision.

This article presents both quantitative and qualitative information on the decentralised nature of health systems, primarily focusing on hospitals, and on how the degree of decentralisation and spending capacity vary depending on different institutional characteristics. The questionnaire on performance measurement systems in health care and the division of responsibilities across governance levels is included in Annex A.

Source: Organisation for Economic Co-operation and Development, material: English https://one.oecd.org/document/COM/DELSA/GOV(2019)2/en/pdf