Analyses

Centralization versus decentralization in cancer care delivery

Centralization of healthcare services is defined as the reorganization of numerous services into fewer units serving a higher volume of patients in order to improve outcomes and efficiency, often in the context of specialized care (Ramsay, 2025). Correspondingly, in cancer care, centralized, multidisciplinary care models and highly specialized expertise have become a cornerstone of modern oncology services (Sorensen, 2022). The centralization of cancer services, particularly for rare, complex or high-risk treatments, is often associated with better clinical outcomes, driven by higher provider volumes, concentrated expertise and more efficient use of advanced technologies. Economic considerations, increasing treatment complexity and workforce shortages are likely to further reinforce trends towards centralization in the future (Sorensen, 2022).

However, the implications of centralization for travel costs, patient accessibility and equity remain contested. While specialization may reduce per-patient treatment costs and improve clinical outcomes for certain procedures, it may also have unintended consequences for access, notably by increasing travel distances and time to care for patients. And, while some patients may be willing to accept longer travel times for one-off high-risk surgical interventions, prolonged travel can become a substantial barrier for patients requiring regular consultations, systemic therapies or long-term follow-up. Especially older adults and socially disadvantaged populations are affected by this. In this context, excessive service concentration risks delayed access, reduced adherence and widening health inequalities (Sorensen, 2022).

Predominantly in rural, mountainous and hard-to-reach areas with older and widely dispersed populations, a decentralized approach can therefore be advantageous. By delivering care locally, this model ensures consistent cancer treatment and continuity of care (Fattore et al., 2025).

This cross-cutting analysis presents different centralized and decentralized service delivery approaches implemented within the health care systems of Italy, Greece and Belgium.

Belgium: Centralization of complex cancer surgery

Following a study on upper gastrointestinal cancer conducted in Belgium demonstrating a strong volume-outcome relationship in cancer surgery (Vlayen et al., 2013), the Ministry of Health mandated the National Institute for Health and Disability Insurance (NIHDI) to assess the reorganization of care for rare and complex cancers. The aim was to implement a nationally coordinated centralization strategy for oesophageal and pancreatic cancer surgery.

In the assessment, based on nationwide data from the Belgian Cancer Registry, substantial variation in hospital surgical volumes was identified, with higher-volume centres achieving lower 90-day postoperative mortality and improved five-year survival rates (van Walle et al., 2023). Grounded on this evidence, a nationwide centralization of oesophageal and pancreatic cancer surgeries was enforced through formal conventions between NIHDI and selected hospital centres meeting predefined quality and volume criteria (for more info on selection criteria, visit case study).

By 2019, oesophageal surgery was consolidated from 79 hospitals into 10 centres, and pancreatic surgery from 93 hospitals into 15 centres. Continuous monitoring and evaluation were embedded into the policy, allowing for adaptation and potential expansion to other cancer types, such as head and neck or ovarian cancers.

This policy aligns with a broader health system reform trend in Belgium aimed at increasing centralization and cooperation in inpatient care. So far it shows promising outcomes, as the Belgian health system performs well overall. Access to high-quality health services is generally good, and the geographical distribution of hospitals and curative beds across provinces broadly reflects population distribution. Likewise, there are no major regional disparities in physician density, although some rural provinces have slightly lower ratios compared with urban areas (Gerkens & Merkur, 2020; 2024).

Far greater regional disparities in healthcare provision are found in Italy and Greece.

Italy: Decentralized and patient-centred delivery of routine oncology care

In Italy’s healthcare system, the regional authorities are responsible for financing, planning and organizing healthcare services, which are delivered locally through local health authorities. This decentralized structure has, however, led to persistent regional disparities. Differences in the availability of health professionals, financial resources, waiting times and travel distances mean that residents of less wealthy regions are more likely to report unmet healthcare needs than those living in regions better-off (de Belvis et al., 2024).

In 2016, the Local Health Authority of Piacenza launched a pilot initiative in Bettola, a remote mountainous town with a high proportion of older residents and lacking hospital or emergency facilities. The initiative aimed to bring oncological and haematological care closer to patients by strengthening the role of the Community Health Centre (Casa della Salute, CDS).

The CDS was equipped to deliver chemotherapy, oral and injectable therapies, blood tests, ECGs, ultrasound examinations and minor procedures. Oncological care is provided through a weekly clinic, led by a mobile outreach team (usually an oncologist or haematologist, as well as an oncology nurse), and supported by emergency-ready equipment and trained staff. Patients were selected primarily based on geographical proximity, with treatment protocols shared electronically with the central hospital in Piacenza. Regular multidisciplinary case discussions ensured consistent quality of care and facilitated inclusion in clinical research where appropriate.

The initiative strengthened hospital-territory integration, reduced travel burden for rural patients and demonstrated scalability to other underserved areas. Importantly, while routine care was decentralized, diagnostics and management of complex or high-risk cases remained concentrated within hospital settings. Here, the central hospital in Piacenza played a vital role. In addition to the responsibilities outlined above, it was responsible for the preparation of chemotherapy drugs, which were then safely transported to Bettola. This arrangement ensured both high safety standards and logistical efficiency.

Other solutions for dealing with regional disparities are offered by Greece.

Greece: Balancing central expertise with local accessibility through patient accommodation and distributed mobile medical units

Greece’s healthcare system is strongly centred on hospital care, while primary care faces persistent challenges related to access, continuity, coordination, and the comprehensiveness of services. In particular, specialized ambulatory care is marked by an uneven geographical distribution of public physicians and shortages of certain medical specialties across the country (Economou, 2017; OECD & European Observatory on Health Systems and Policies, 2025).

Cancer care also remains highly centralized, with specialized services, particularly radiotherapy, largely confined to major urban centres. As a result, patients from remote areas are often required to temporarily relocate for treatment, frequently without public support for accommodation or travel. This imposes significant financial and emotional strain on patients and their families and exacerbates existing health inequalities.

To address this gap, the Hellenic Cancer Federation (ELLOK) launched a patient accommodation programme in 2020, providing free temporary housing for patients and one accompanying person near major treatment centres in Athens, Thessaloniki and Patras. Eligibility is based on treatment duration and documented social or financial hardship. The programme operates through a public–private partnership involving patient advocacy organizations, private real estate management and the Ministry of Health.

A dedicated social worker coordinates applications, assesses needs and maintains ongoing contact with beneficiaries. Since its launch, the programme has expanded in scope and efficiency, including the introduction of a simplified digital application process and broader eligibility criteria to include more cancer types and treatment scenarios. To date, over 1,250 individuals have benefited, with steady growth in annual uptake.

A further approach currently under development in Greece involves the deployment of Mobile Medical Units. As part of the “Fofi Gennimata” programme, these units are designed to improve access to breast cancer screening services for women living in hard-to-reach or underserved regions, and shall be equipped with the necessary diagnostic tools and staffed by trained healthcare professionals. By delivering screening services directly within local communities, the initiative aims to reduce geographic, logistical, and socio-economic barriers to early detection and timely diagnosis.

Taken together, Greece illustrates two complementary strategies for addressing regional access barriers in a highly centralized cancer care system. On the one hand, access can be improved by bringing services closer to patients, as exemplified by the mobile screening units. On the other hand, barriers can be mitigated by facilitating patients’ access to existing specialized services, as demonstrated by the patient accommodation programme. These approaches highlight that, even within centralized systems, targeted interventions can enhance equity and continuity of care without fundamentally altering the underlying service configuration. It also illustrates how decentralized and centralized approaches can complement each other, even within a single country.

Between quality assurance and access improvement

The examples presented illustrate the inherent tension between ensuring high-quality care and improving access to services in both centralized and decentralized cancer care models. While the initiatives pursue different primary objectives (i.e., focusing predominantly on improving health outcomes (Belgium) and others on enhancing access (Greece and Italy)) and are embedded in distinct structural and governance arrangements, they should not be understood as mutually exclusive. Rather, they are complementary approaches that can jointly contribute to more effective, equitable cancer care systems. 

Belgium demonstrates how the centralization of highly specialized services can lead to measurable improvements in quality and outcomes, particularly for complex surgical interventions. However, while centralization is associated with quality improvements for complex surgical interventions, many cancer patients require more ongoing treatment and frequent follow-up. For these patients, proximity to care remains essential. Long travel distances disproportionately affect patients in rural or remote areas and can lead to delayed treatment, reduced adherence, and poorer outcomes. Italy and Greece offer contrasting but complementary examples of how health systems can mitigate regional disparities while ensuring quality of care.

Together, these cases underline that combining centralized specialized excellence with decentralized, proximity-based primary care can help reconcile quality assurance with equitable access across diverse health system contexts. Nevertheless, despite their overall success, the initiatives also reveal a set of shared and context-specific barriers that constrain implementation, scalability and long-term sustainability.

Access barriers still persist due to service delivery limitations and uneven coverage

In Greece, the geographic reach of the ELLOK programme is limited to three major cities, potentially excluding patients receiving care elsewhere. In addition, limited awareness of the programme and difficulties navigating the application process may have prevented some eligible patients from accessing available support.

In Italy, although routine oncology care was decentralized, diagnostic imaging services were not available locally, requiring patients still to travel to the central hospital in Piacenza. Furthermore, referrals to the CDS often relied on informal professional networks, pointing to the absence of standardized institutional referral pathways. These factors underscore the need for stronger formal integration, clearer governance arrangements, and institutionalization of decentralized access pathways to support sustainable scale-up (governance).

Resource constraints, capacity limitations and sustainability concerns are hindering scalability

In Greece, the ELLOK accommodation programme faced capacity constraints due to the limited number of available apartments, which at times restricted the number of patients who could be supported despite demonstrated need (resources). Additionally, while the programme successfully mobilized financial resources in its initial phase, concerns remain regarding long-term financial sustainability and the feasibility of programme expansion beyond its current scope (financing). And while facilitating access to services in urban centres can be beneficial for patients from rural areas, temporary relocation may also impose additional burdens on patients and their families/accompanying people. For example, individuals may need to temporarily suspend employment or education, which could lead to financial and social consequences.

Belgium was also experiencing financial barriers. Here, the absence of dedicated financial compensation for the administrative and organizational investments required by the centralization conventions created challenges in implementation. These difficulties were compounded by prevailing provider payment mechanisms, which made it harder to secure buy-in from healthcare institutions affected by the reorganization (financing). Moreover, the Belgian healthcare system is characterized by a complex distribution of responsibilities across three levels of governance: the federal government, the federated entities, and local authorities, including provinces and municipalities. At the federated level, Belgium is further divided into three regions (based on territory) and three communities (based on language) (Gerkens & Merkur, 2020). Within this multi-level governance structure, the centralization process required balancing the expectations and demands of different geographical regions, adding considerable political and administrative complexity to efforts aimed at reorganizing the healthcare services (governance). As a result, the final number of designated hospital centres remained higher than initially envisaged. And although the reform initially aimed to promote multidisciplinary care for oesophageal and pancreatic cancer patients, in practice it focuses primarily on surgical services, limiting broader system integration across the full care pathway. In addition, efforts to centralize services and redistribute clinical activity were met with public concerns, particularly in this case from health professionals working in low-volume hospitals. However, these concerns should be viewed in the context of Belgium’s overall strong health system performance and generally positive patient experiences in general hospitals (Gerkens & Merkur, 2024).

Despite these limitations, the initiatives also provide valuable insights into conditions required to design and implement different service delivery models. Even with differences in objectives and structural arrangements, several common enabling factors emerge across countries, highlighting that political commitment, supportive policy environments, and strong partnerships are critical regardless of the degree of centralization.

Clear governance structures and political will played a decisive role in enabling implementation and long-term sustainability, across all initiatives

In Belgium, strong political commitment at national level was central to reorganizing care for complex cancers (governance). Similarly, Italy’s initiative benefited from a longstanding regional policy environment in Emilia-Romagna that actively supports decentralized, community-based healthcare. Political and institutional alignment between local authorities and health departments provided essential governance, logistical backing and legitimacy, framing the model as a shared effort across sectors and levels of care. In Greece, governance arrangements differed by initiative. The Fofi Gennimata programme benefited from central coordination by the Ministry of Health and funding through the Recovery and Resilience Fund, both of which will be essential for the deployment and operation of the mobile medical units (financing). The ELLOK accommodation programme, however, was enabled through a strong partnership between the Hellenic Cancer Federation (ELLOK), Piraeus Real Estate S.A., and the Ministry of Health, combining patient advocacy expertise, operational capacity and institutional oversight.

Strategic use of data, information, and human resources supported safe, targeted and efficient care delivery

In Belgium, the availability of high-quality, population-based data from the Belgian Cancer Registry enabled evidence-based assessments and informed decisions for centralized cancer surgery. In Italy, an integrated digital information infrastructure facilitated seamless data exchange and real-time sharing of treatment protocols between CDS and the central hospital, ensuring continuity and safety of care. Furthermore, the commitment of healthcare professionals (many of whom participated on a voluntary basis) was instrumental, reflecting strong professional motivation and community engagement (resources).

Adaptive service delivery models, characterized by flexibility and coordination across levels of care, further facilitated implementation

In Italy, service delivery was facilitated by the centralized preparation of chemotherapy drugs at the hospital pharmacy unit in Piacenza, which ensured high safety standards while enabling efficient and reliable distribution to peripheral settings. In Greece, the ELLOK programme’s ability to adapt administrative procedures over time (such as simplifying application processes) reduced bureaucratic barriers for patients and caregivers and improved the overall user experience. Furthermore, collaboration with additional organizations expanded the scope of support beyond accommodation, contributing to a more holistic model of care. Finally, relying on clearly defined, needs-based eligibility criteria, the ELLOK programme allows resources to be directed towards patients facing the greatest social and financial barriers (service delivery).

Lessons learned

These initiatives demonstrate the importance of people-centred approaches in addressing access and quality challenges in cancer care, as well as the value of adaptability and continuous learning during implementation. Both Greek initiatives and the Italian model demonstrate that interventions that explicitly account for patients’ practical, emotional and social needs, such as accommodation support, proximity-based service delivery, or the inclusion of caregivers, can significantly reduce barriers to care and improve patient experience. Additionally, they highlight that decentralized care models are most effective when they remain flexible and can be tailored to local contexts while maintaining core quality and safety standards. Centralized care models benefit from robust data monitoring frameworks, as demonstrated in the Belgian case study. While outcome evaluation was embedded from the outset, the experience suggests that more standardized datasets, stricter reporting guidelines, and the inclusion of patient-reported outcomes and experiences would further strengthen the assessment of centralization policies and their broader system impact.

Additionally, across all countries, effective implementation relied on strong collaboration and coordination between healthcare providers, public authorities, patient organizations and supporting services. Clear communication channels and shared responsibilities proved essential for ensuring continuity of care, patient awareness and operational efficiency.

Taken together, these lessons underline that centralization and decentralization can function as complementary policy tools when carefully designed. Health systems seeking to balance quality, equity and efficiency can draw on these experiences to tailor integrated solutions aligned with their governance structures and population needs.

For more information

https://www.unibocconi.it/en/news/decentralizing-cancer-care-benefits-people-and-environment

References

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