Andrea Terlizzi holds a BA in Political Science from the University of Naples “Federico II” (2009) and a MA in Political Science and Decision-Making Processes from the University of Florence (2012). During his time at the University of Florence, he worked as an intern at the Inter-University Centre for Research on Southern Europe (CIRES) within the Department of Political and Social Sciences. Andrea also received an Advanced Master’s Degree in Public Policy and Social Change from Collegio Carlo Alberto, Turin (2013). Since January 2014, he is a Ph.D. student in Political Science at the Institute of Humanities and Social Sciences, Scuola Normale Superiore, Florence. Andrea’s main research interests include comparative public policy, institutional and policy change, federalism and decentralization, health systems and policy.
Supervisor: Professor Giliberto Capano
Dynamics of Health System Decentralization and Recentralization in Italy, Spain and Denmark: Ideas, Discourse, and Institutions
Decentralization is a key feature of contemporary governmental institutions. All over the world, authority and responsibility over public policy are shared to a greater or lesser extent between different levels of government. Since the end of the Second World War, decentralization has been in fashion and has often been considered as a normatively superior mode of allocation of authority. The main argument for advocates of decentralization is that the shift of authority towards lower levels brings government closer to citizens, enhancing accountability and responsiveness.
In Europe, most countries have transferred key dimensions of decision-making authority from the national to lower levels during the late 1960s and early 1970s. Health systems, as the welfare state in general, did not escape this decentralization wave. However, decentralization has been interpreted in different ways in different countries, and policy-makers across Europe have introduced decentralization strategies which have resulted in a variety of institutional arrangements. Moreover, in the last two decades, in several European countries the role of the central government in steering health system decentralization has increased, though to a different extent. Some observers have referred to this trend as a new wave of recentralization . The reasons for implementing elements of recentralization in the governance of health systems reflect common worries about the potential drawbacks of decentralization. Skeptics argue that decentralization can generate and trigger inequalities within countries. Other concerns regard the possible failure in meeting national objectives, especially of fiscal policy, with subnational governments pursuing policies that are inconsistent with national goals.
This thesis contributes to the literature on federalism, decentralization and institutional change. It explores the dynamics of health system decentralization and recentralization, investigating why and how the territorial organization of health systems changes or remains stable over time. The analysis focuses on the tax-funded health systems of Italy, Spain and Denmark. Besides being of the same type, the three systems present a decentralized architecture consisting of three levels: national, regional and municipal. Moreover, they all have experienced changes, albeit of a different nature, in their territorial organization. It is thus possible to analyze the dynamics of continuity and change in health system decentralization under a most similar system design. Moreover, Denmark represents a typical case of recent strong political and fiscal recentralization, which is a pattern common to all the Scandinavian countries.
Through a comparative-historical analysis of the reform trajectories in light of decentralization and recentralization processes, the thesis aims to analyze and reconstruct the mechanisms through which distinct patterns of continuity and change in the territorial organization of the health systems have occurred over time. In identifying the set of explanatory factors, I draw from historical and discursive institutionalism, mainly pointing at the interplay between institutional and ideational factors. The methods include inductive process tracing and Qualitative Content Analysis. Empirical material is drawn from documents and in-depth interviews to key informants, experts and decision-makers.