Is a Decentralised Health Policy Associated With Better Self-rated Health and Health Services Evaluation? A Comparative Study of European Countries

Document Type : Original Article


Department of Sociology and Political Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway


While decentralisation has come to be a major policy strategy in many healthcare systems, there is still insufficient evidence about its impact. Most studies have been of developing countries, and they have provided mixed results. This study is the first to test the relevance of political decentralisation across European countries, thus meeting the demand for more studies of decentralisation in developed countries, and building on an indicator of decentralisation reflecting the allocation of authority for both health policy tasks and health policy areas.

As indicators of health system outcome, we employed 2 measures that have not previously been investigated in the context of decentralisation: self-rated health and satisfaction with healthcare system. Using multilevel modelling and controlling for individual-level demographic and socioeconomic variables, the paper utilised the 2014 (7th) and 2016 (8th) round of the European Social Survey (ESS), including more than 70 000 individuals from 20 countries.

The results suggest that decentralisation has a positive and significant association with health system satisfaction, but not with self-rated health. Of the different operationalisations, decentralised healthcare provision had the strongest association with health system satisfaction.

Our study fails to provide clear support for decentralised health systems. There is a need for more research on the impact of such reforms in order to provide policy-makers with knowledge of desirable governance, organisational designs, management and incentives in healthcare.


Supplementary File 1 (Download)


  1. Jiménez-Rubio D. Is fiscal decentralisation good for your health? Evidence from a panel of OECD countries. HEDG Working paper 10/30. Published 2020.
  2. Saltman RB, Bankauskaite V. Conceptualizing decentralization in European health systems: a functional perspective. Health Econ Policy Law. 2006;1(Pt 2):127-147. doi:10.1017/s1744133105001209
  3. Saltman RB, Figueras J. European Health Care Reform: Analysis of Current Strategies. Copenhagen: World Health Organization, Regional Office for Europe; 1997.
  4. Saltman RB, Figueras J. Analyzing the evidence on European health care reforms: experience in western European health care systems suggests lessons for reform in the United States, according to a major international comparison by the World Health Organization. Health Aff (Millwood). 1998;17(2):85-108. doi:10.1377/hlthaff.17.2.85
  5. Dwicaksono A, Fox AM. Does decentralization improve health system performance and outcomes in low‐and middle‐income countries? a systematic review of evidence from quantitative studies. Milbank Q. 2018;96(2):323-368. doi:10.1111/1468-0009.12327
  6. Cobos Muñoz D, Merino Amador P, Monzon Llamas L, Martinez Hernandez D, Santos Sancho JM. Decentralization of health systems in low and middle income countries: a systematic review. Int J Public Health. 2017;62(2):219-229. doi:10.1007/s00038-016-0872-2
  7. Adolph C, Greer SL, Massard da Fonseca E. Allocation of authority in European health policy. Soc Sci Med. 2012;75(9):1595-1603. doi:10.1016/j.socscimed.2012.05.041
  8. Bhatia M, Rannan-Eliya R, Somanathan A, Huq MN, Pande BR, Chuluunzagd B. Public views of health system issues in four Asian countries. Health Aff (Millwood). 2009;28(4):1067-1077.
  9. Blendon RJ, Kim M, Benson JM. The public versus the World Health Organization on health system performance. Health Aff (Millwood). 2001;20(3):10-20. doi:10.1377/hlthaff.20.3.10
  10. Munro N, Duckett J. Explaining public satisfaction with health-care systems: findings from a nationwide survey in China. Health Expect. 2016;19(3):654-666. doi:10.1111/hex.12429
  11. Busse R, Valentine N, Lessof S, Prasad A, van Ginneken E. Being responsive to citizens’ expectations: the role of health services in responsiveness and satisfaction. In: McKee M, Figueras J, eds. Health Systems, Health, Wealth and Societal Well-being: Assessing the Case for Investing in Health Systems. Maidenhead: Open University Press; 2011:175-208.
  12. Bleich SN, Özaltin E, Murray CK. How does satisfaction with the health-care system relate to patient experience? Bull World Health Organ. 2009;87(4):271-278. doi:10.2471/blt.07.050401
  13. Papanicolas I, Cylus J, Smith PC. An analysis of survey data from eleven countries finds that 'satisfaction' with health system performance means many things. Health Aff (Millwood). 2013;32(4):734-742. doi:10.1377/hlthaff.2012.1338
  14. Borisova LV, Martinussen PE, Rydland HT, Stornes P, Eikemo TA. Public evaluation of health services across 21 European countries: the role of culture. Scand J Public Health. 2017;45(2):132-139. doi:10.1177/1403494816685920
  15. Footman K, Roberts B, Mills A, Richardson E, McKee M. Public satisfaction as a measure of health system performance: a study of nine countries in the former Soviet Union. Health Policy. 2013;112(1-2):62-69. doi:10.1016/j.healthpol.2013.03.004
  16. Munro N, Duckett J. Explaining public satisfaction with health-care systems: findings from a nationwide survey in China. Health Expect. 2016;19(3):654-666. doi:10.1111/hex.12429
  17. Papanicolas I, Cylus J, Smith PC. An analysis of survey data from eleven countries finds that 'satisfaction' with health system performance means many things. Health Aff (Millwood). 2013;32(4):734-742. doi:10.1377/hlthaff.2012.1338
  18. Wendt C, Kohl J, Mischke M, Pfeifer M. How do Europeans perceive their healthcare system? patterns of satisfaction and preference for state involvement in the field of healthcare. Eur Sociol Rev. 2009;26(2):177-192. doi:10.1093/esr/jcp014
  19. Falconer J, Quesnel-Vallée A. Pathway from poor self-rated health to mortality: explanatory power of disease diagnosis. Soc Sci Med. 2017;190:227-236. doi:10.1016/j.socscimed.2017.08.008
  20. Au N, Johnston DW. Self-assessed health: what does it mean and what does it hide? Soc Sci Med. 2014;121:21-28. doi:10.1016/j.socscimed.2014.10.007
  21. Dalstra JA, Kunst AE, Borrell C, et al. Socioeconomic differences in the prevalence of common chronic diseases: an overview of eight European countries. Int J Epidemiol. 2005;34(2):316-326. doi:10.1093/ije/dyh386
  22. Idler EL, Benyamini Y. Self-rated health and mortality: a review of twenty-seven community studies. J Health Soc Behav. 1997;38(1):21-37.
  23. Bombak AE. Self-rated health and public health: a critical perspective. Front Public Health. 2013;1:15. doi:10.3389/fpubh.2013.00015
  24. Eikemo TA, Bambra C, Judge K, Ringdal K. Welfare state regimes and differences in self-perceived health in Europe: a multilevel analysis. Soc Sci Med. 2008;66(11):2281-2295. doi:10.1016/j.socscimed.2008.01.022
  25. Bennett IM, Chen J, Soroui JS, White S. The contribution of health literacy to disparities in self-rated health status and preventive health behaviors in older adults. Ann Fam Med. 2009;7(3):204-211. doi:10.1370/afm.940
  26. van der Wel KA, Saltkjel T, Chen WH, Dahl E, Halvorsen K. European health inequality through the 'Great Recession': social policy matters. Sociol Health Illn. 2018;40(4):750-768. doi:10.1111/1467-9566.12723
  27. Delaruelle K, Buffel V, Bracke P. The reversal of the gender gap in education: what does it mean for gender differences in the relationship between education and health. Eur Sociol Rev. 2018;34(6):629-644. doi:10.1093/esr/jcy032
  28. Delaruelle K, van de Werfhorst H, Bracke P. Do comprehensive school reforms impact the health of early school leavers? results of a comparative difference-in-difference design. Soc Sci Med. 2019;239:112542. doi:10.1016/j.socscimed.2019.112542
  29. Oates WE. Fiscal Federalism. New York: Harcourt Brace Jovanovich; 1972.
  30. Gravelle H. A Comment on Weale's Paper from an Economic Perspective. London: Health Equity Network; 2003:59-65.
  31. Khaleghian P. Decentralization and Public Services: The Case of Immunization. Washington, DC: The World Bank; 2003.
  32. Rubio DJ. The impact of decentralization of health services on health outcomes: evidence from Canada. Appl Econ. 2011;43(26):3907-3917. doi:10.1080/00036841003742579
  33. Saltman RB, Bankauskaite V, Vrangbæk K. Decentralization in Health Care: Strategies and Outcomes. Maidenhead: McGraw-Hill, Open University Press; 2007.
  34. Habibi N, Huang C, Miranda D, et al. Decentralization in Argentina. New Haven, CT: Yale University, Economic Growth Center; 2001.
  35. Yee E. The effects of fiscal decentralization on health care in China. University Avenue Undergraduate Journal of Economics. 2001;5(1):5.
  36. Jin Y, Sun R. Does fiscal decentralization improve healthcare outcomes? empirical evidence from China. Public Finance and Management. 2011;11(3):234-261.
  37. Asfaw A, Frohberg K, James KS, Jütting J. Fiscal decentralization and infant mortality: empirical evidence from rural India. J Dev Areas. 2007;41(1):17-35.
  38. Samadi AH, Keshtkaran A, Kavosi Z, Vahedi S. The effect of fiscal decentralization on under-five mortality in Iran: a panel data analysis. Int J Health Policy Manag. 2013;1(4):301-306. doi:10.15171/ijhpm.2013.60
  39. Cantarero D, Pascual M. Analysing the impact of fiscal decentralization on health outcomes: empirical evidence from Spain. Appl Econ Lett. 2008;15(2):109-111. doi:10.1080/13504850600770913
  40. Robalino DA, Picazo OF, Voetberg A. Does Fiscal Decentralization Improve Health Outcomes? Evidence from a Cross-Country Analysis. Washington: The World Bank; 2001.
  41. Hodge A, Firth S, Jimenez-Soto E, Trisnantoro L. Linkages between decentralisation and inequalities in neonatal health: evidence from Indonesia. J Dev Stud. 2015;51(12):1634-1652. doi:10.1080/00220388.2015.1081172
  42. Kengia JT, Igarashi I, Kawabuchi K. Effectiveness of health sector reforms in reducing disparities in utilization of skilled birth attendants in Tanzania. Tohoku J Exp Med. 2013;230(4):241-253. doi:10.1620/tjem.230.241
  43. Vargas Bustamante A. The tradeoff between centralized and decentralized health services: evidence from rural areas in Mexico. Soc Sci Med. 2010;71(5):925-934. doi:10.1016/j.socscimed.2010.05.022
  44. Khaleghian P. Decentralization and public services: the case of immunization. Soc Sci Med. 2004;59(1):163-183. doi:10.1016/j.socscimed.2003.10.013
  45. Kruse I, Pradhan M, Sparrow R. Marginal benefit incidence of public health spending: evidence from Indonesian sub-national data. J Health Econ. 2012;31(1):147-157. doi:10.1016/j.jhealeco.2011.09.003
  46. Maharani A, Tampubolon G. Has decentralisation affected child immunisation status in Indonesia? Glob Health Action. 2014;7:24913. doi:10.3402/gha.v7.24913
  47. Faguet JP, Sánchez F. Decentralization and access to social services in Colombia. Public Choice. 2014;160(1-2):227-249.
  48. European Social Survey. European Social Survey Cumulative File, ESS 7-82016.
  49. Eikemo TA, Bambra C, Huijts T, Fitzgerald R. The first pan-European sociological health inequalities survey of the general population: the European Social Survey rotating module on the social determinants of health. Eur Sociol Rev. 2016;33(1):137-153. doi:10.1093/esr/jcw019
  50. OECD. OECD Health Statistics 2018: Health Care Resources. Published  2018.
  51. OECD. OECD Health Statistics 2018: Health Expenditure and Financing. Published 2018.
  52.  OECD. OECD Regions and Cities Statistics 2018: Subnational Government Expenditure by category.  Published 2018.
  53. European Observatory on Health Systems and Policies. Health in Transition series. Published 2017.
  54. Wendt C. Mapping European healthcare systems: a comparative analysis of financing, service provision and access to healthcare. J Eur Soc Policy. 2009;19(5):432-445. doi:10.1177/0958928709344247
  55. Bremner J. The complexities of decentralization. Euro Observer. 2011;13(1):1-3.
  56. Vrangbæk K. Key factors in assessing decentralization and recentralization in health systems. In: Saltman RB, Bankauskaite V, Vrangbæk K, eds. Decentralization in Health Care: Strategies and Outcomes. Maidenhead: McGraw-Hill, Open University Press; 2007:63.
  57. Koivusalo M, Wyss K, Santana P. Effects of decentralization and recentralization on equity dimensions of health systems. In: Saltman RB, Bankauskaite V, Vrangbæk K, eds. Decentralization in Health Care: Strategies and Outcomes. Maidenhead: McGraw-Hill, Open University Press; 2007:189.
  58. Collins C, Green A. Decentralization and primary health care: some negative implications in developing countries. Int J Health Serv. 1994;24(3):459-475. doi:10.2190/g1xj-px06-1lvd-2fxq
  59. Jommi C, Fattore G. Regionalization and drugs cost-sharing in the Italian NHS. Euro Observer. 2003;5(3):1-4.
  60. Sumah AM, Baatiema L, Abimbola S. The impacts of decentralisation on health-related equity: a systematic review of the evidence. Health Policy. 2016;120(10):1183-1192. doi:10.1016/j.healthpol.2016.09.003
  61. Bankauskaite V, Saltman RB. Central issues in the decentralization debate. In: Saltman RB, Bankauskaite V, Vrangbæk K, eds. Decentralization in Health Care: Strategies and Outcomes. Maidenhead: McGraw-Hill, Open University Press; 2007:9.
  62. World Health Organization (WHO). Progressing the Sustainable Development Goals through Health in All Policies: Case Studies from Around the World. Adelaide: Government of South Australia; 2017.
  63. Atun R. Health systems, systems thinking and innovation. Health Policy Plan. 2012;27 Suppl 4:iv4-8. doi:10.1093/heapol/czs088
  64. Bossert T. Analyzing the decentralization of health systems in developing countries: decision space, innovation and performance. Soc Sci Med. 1998;47(10):1513-1527. doi:10.1016/s0277-9536(98)00234-2
  65. Marchildon G, Bossert TJ. Federalism and Decentralization in Health Care: A Decision Space Approach. Toronto: University of Toronto Press; 2018.
  66. Roman TE, Cleary S, McIntyre D. Exploring the functioning of decision space: a review of the available health systems literature. Int J Health Policy Manag. 2017;6(7):365-376. doi:10.15171/ijhpm.2017.26
Volume 10, Issue 2
February 2021
Pages 55-66
  • Receive Date: 05 July 2019
  • Revise Date: 22 January 2020
  • Accept Date: 25 January 2020
  • First Publish Date: 01 February 2021