Certain tasks, however, must be centralized. They include, for example, health policy development and the development of a quality strategy, to make sure that patients across the country can expect the same conditions of access, coverage and service delivery. Public health institutes, health technology agencies and other regulatory agencies are also preferably placed at national level, even if they have decentralized offices at regional and local levels.

The challenge, however, is that even if organizations and tasks occur at the right level they may not yield the expected benefits because of shortcomings in the governance. Ministries of health, for example, often lack the capacity to steer the system. The have difficulties developing complex policies because of a lack of qualified staff due to continuous public service staff cuts. Leading on health policy may also be difficult if all the operational work is handled by arms-length executive bodies or by sickness funds that have stronger analytical powers and much better insights into the workings of the system. At regional or local level, empowerment of providers will not yield benefits if they are not aligned with national policy, which is often the case because of a lack of transparency and accountability between central and subnational organizations.

The European Observatory’s work programme supports governments by reviewing the evidence on how to master the centralization/decentralization challenge: