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  • Print publication year: 2020
  • Online publication date: May 2020

2 - The Multilevel Nature of Healthcare Governance

from Part II - The Political Contexts of Healthcare Policies


Decision-making in healthcare is typically delivered and run by different levels of government. That is, the locus of political decisions tends to be scattered vertically between local, state and supranational powers, in multilevel governance structures. These structures (with a central and subcentral tiers of governments) require a well-informed patient citizen (PC) who is able to judge how well each level of government has managed its responsibilities. As we argue below, if this is the case, the PC will be able to reward successful innovation in health policy by re-electing the incumbent, or by “voting with their feet” to another jurisdiction that exhibits better healthcare performance. We contend that the PC will typically attempt to change the health system on a first instance through the political mechanisms in place, whilst mobility (Tiebout, 1956) is conceived as a last resort option. This chapter describes some of the main issues guiding multilevel health governance, and specifically the difficulty in dealing with the needs of centralising, and decentralising decisions related to global health problems which produce large effects beyond countries’ borders (what economists call spillover effects). This includes examining how best to organise a health system between local and central levels within countries. This is the case in legal federations, like the USA or Germany. But it is also the case in regional countries, like Italy or Spain, and also in unitary states, like the Nordic European countries, where municipal governments are the subnational entities. For the purpose of this chapter, we will generalise the observed variety of institutions by using neutral terms like ‘central government’ and ‘subnational governments’, and government interactions between them are generally regarded as ‘multilevel governance’.

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