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Brief analytical summaries or syntheses #9

Recentralization tendencies within healthcare services: Implementation of a new idea?


Decentralization has been a widespread trend in European health sectors for many years. More recently, however, a new set of reforms is observable, implying ambitions to regain lost control. This paper by Renate Minas, Associate professor of Social Work at Stockholm University in Sweden, looks at what this general trend toward recentralization is about and what happens when reforms promoting recentralization are implemented in different national contexts. The establishment of regional health authorities in Norway and regional hospital agencies in France are used as examples to analyze the spread of recentralization reforms.


General context of health care

Health care is a highly political area, subject to intense negotiations on the distribution of power and resources between the institutions responsible for financing, planning and delivering health services. Pressures to control spending and increase productivity combine with moral imperatives of universal access and equity of care. In the coming years, health systems will also need to face the challenge of assuring financial sustainability as the population across Europe ages.

Reforms to decentralize health care

Beginning in the 1990s, if not before, a tendency to replace centralized hierarchical power structures by decentralized management environments was evident in public service reforms across Europe. More recently, it has been recognized that decentralization has created new problems, such as poor coordination and unequal service to citizens in different parts of a country. Such problems have created a need for new reforms. This paper focuses on recent reforms aimed at recentralizing health care.

Analysis and results

A number of factors influence the implementation of recentralization reforms:

  • Propensity to change and adopt new ideas.
  • Reform as a reaction to coordination problems.
  • Recentralization to improve efficiency.
  • Recentralization as a response to domestic conflicts.
  • Different starting points for reform initiatives (for example, Norway already had a decentralized structure whereas France had a complex vertical structure).

The different models of power distribution (upwards and downwards) in France and Norway are directly linked to domestic administrative and political structures. The two recentralization reforms studied in this paper share a common aim of solving problems of poor coordination and inefficiency. Renewed interest in central control can be partly understood as a need to strengthen the state’s stewardship role in health care.


Recentralization can provide better possibilities for setting standards on principles such as universal access and equity in health care. The impact of an aging population in healthcare financing is worrisome to local authorities.

The political context of each country must be taken into account when analyzing the potential impact of recentralization reforms. The move towards coordination by the central level may also be supported by the European Union through its Open Method of coordination.

Implications and recommendations

This paper demonstrates the importance of achieving balance between central and local levels of power in the organization of health care. Countries that are more centralized to start with tend to shift power between various stakeholders, while countries starting with more decentralized structures tend to transfer power vertically.


(Re)centralizing tendencies within health care services: Implementation of a new idea ? Fichier PDF.