Organisational innovations and health care decentralisation: A perspective from Spain

Recent policy developments in public health care systems lead to a greater diversity in health care. Decentralisation, either geographically or at an institutional level, is the key force, because it encourages innovation and local initiatives in health care provision. The devolution of responsibilities allows for a sort of de-construction of the status quo by changing both organizational forms and service provision. The new organizations enjoy greater freedom in the way they pay their staff, and are judged according to their results. These organizations may retain financial surpluses, develop spin-off companies and commission a range of specialised services (such as Diagnostic and Treatment Centres in UK) from providers outside the institutional setting in order to have more access to capital markets. However this diversity may generate a feeling of lack of commitment to a national health service and ultimately a loss of social cohesion. By fiscal decentralisation to regional authorities or planned delegation of financial agreements to the providers, financial incentives are more explicit and may seem to place profit-making above a commitment to better health care. An evaluation of the myths and realities of the decentralization process is needed. Here, I offer an assessment pros and cons of the decentralization process of health care in Spain, drawing on the experience of regional reforms from the pioneering organisational innovations implemented in Catalonia in 1981, up to the observed dispersion of health care spending per capita among regions at present.

Descentralisation, integration and polycentrism in Barcelona

In this study the employment subcentres of the Metropolitan Region of Barcelona are identified using different criteria. Once catalogued according to their nature,i.e. subcentres arising from integration and decentralisation, they are analysed to see whether their impact on population density depends on their origin. The results obtained confirm a greater impact of integrated subcentres in comparison with decentralised ones, amplified in turn by the fact that the former are further from the CBD and present a greater degree of self-containment in the labor market.

Party competition in regional elections: a framework for analysis

Whilst scholars have long recognised that processes of decentralisation create new regional arenas where distinct patterns of party competition are likely to emerge, there has been little systematic analysis of the dynamics of such competition. This working paper thus proposes a framework for analysing party competition between regional branches of state-wide parties, and autonomist parties, in regional arenas. Firstly, the different strategies political parties may adopt in response to their perceptions of voter preferences and to the strategies pursued by their competitors are identified. Secondly, different factors that impact on parties' strategic choices, and which may constrain a party's ability to select electorally optimal strategies in a given political context, are proposed.

Decentralization in Croatia: problems and possible solutions

El 2001 Croàcia va posar en marxa la iniciativa destinada a afluixar un alt grau de centralització mitjançant l'ampliació dels mandats de les unitats locals i el canvi de les fonts de finançament de les funcions públiques. No obstant això, els passos inicials en el procés de descentralització no ha estat seguida per altres mesures de descentralització fiscal, i en conseqüència, el seu nivell s'ha mantingut pràcticament sense canvis. El treball es proposa elaborar els principals problemes i obstacles en relació amb l'aplicació efectiva del procés de descentralització i donar tres grups de propostes per a la descentralització: (i) la divisió dels poders obligatoris entre les diferents unitats locals, (ii) el canvi en el finançament i (Iii) modificar la divisió territorial del país.

Federalism and democracy. The case of minority nations: a federalist deficit

In this chapter, after pointing out the different logics that lie behind the familiar ideas of democracy and federalism, I have dealt with the case of plurinational federal democracies. Having put forward a double criterion of an empirical nature with which to differentiate between the existence of minority nations within plurinational democracies (section 2), I suggest three theoretical criteria for the political accommodation of these democracies. In the following section, I show the agonistic nature of the normative discussion of the political accommodation of this kind of democracies, which bring monist and pluralist versions of the demos of the polity into conflict (section 3.1), as well as a number of conclusions which are the result of a comparative study of 19 federal and regional democracies using four analytical axes: the uninational/plurinational axis; the unitarianism-federalism axis; the centralisation-decentralisation axis; and the symmetry-asymmetry axis (section 3.2). This analysis reveals shortcomings in the constitutional recognition of national pluralism in federal and regional cases with a large number of federated units/regions with political autonomy; a lower degree of constitutional federalism and a greater asymmetry in the federated entities or regions of plurinational democracies. It also reveals difficulties to establish clear formulas in these democracies in order to encourage a “federalism of trust” based on the participation and protection of national minorities in the shared government of plurinational federations/regional states. Actually, there is a federal deficit in this kind polities according to normative liberal-democratic patterns and to what comparative analysis show. Finally, this chapter advocates the need for a greater normative and institutional refinement in plurinational federal democracies. In order to achieve this, it is necessary to introduce a deeper form of “ethical” pluralism -which displays normative agonistic trends, as well as a more “confederal/asymmetrical” perspective, congruent with the national pluralism of these kind of polities.

Financement et autonomie fiscale de la Catalogne: Deux décénnies de problèmes non résolus

From the perspective of redistributing income fromrich to poor, equalizing intergovernmental grants are bound to have some perverse effects. For suchgrants, although transfering income from wealthy topoor on average, will inevitably result in some incometransfers from poor individuals who reside in wealthyjurisdictions to rich persons in generally poor areas.

Health care management autonomy: Evidence from the Catalonian hospital sector in a decentralised Spain

The organisation of inpatient care provision has undergone significant reform in many southern European countries. Overall across Europe, public management is moving towards the introduction of more flexibility and autonomy . In this setting, the promotion of the further decentralisation of health care provision stands out as a key salient policy option in all countries that have hitherto had a traditionally centralised structure. Yet, the success of the underlying incentives that decentralised structures create relies on the institutional design at the organisational level, especially in respect of achieving efficiency and promoting policy innovation without harming the essential principle of equal access for equal need that grounds National Health Systems (NHS). This paper explores some of the specific organisational developments of decentralisation structures drawing from the Spanish experience, and particularly those in the Catalonia. This experience provides some evidence of the extent to which organisation decentralisation structures that expand levels of autonomy and flexibility lead to organisational innovation while promoting activity and efficiency. In addition to this pure managerial decentralisation process, Spain is of particular interest as a result of the specific regional NHS decentralisation that started in the early 1980 s and was completed in 2002 when all seventeen autonomous communities that make up the country had responsibility for health care services.Already there is some evidence to suggest that this process of decentralisation has been accompanied by a degree of policy innovation and informal regional cooperation. Indeed, the Spanish experience is relevant because both institutional changes took place, namely managerial decentralisation leading to higher flexibility and autonomy- alongside an increasing political decentralisation at the regional level. The coincidence of both processes could potentially explain why some organisation and policy innovation resulting from policy experimentation at the regional level might be an additional featureto take into account when examining the benefits of decentralisation.

La “ciudad arqueológica” en el área catalana ante la irrupción del Islam

Se presenta un breve estado de la cuestión sobre la realidad arqueológica de los principales núcleos urbanos del este de la provincia Tarraconensis y a finales del Regnum Gothorum. Existe un nivel de conocimiento desigual para estas ciudades, fruto del contexto actual de la investigación, y también de una evolución histórica diferenciada, como consecuencia de unas características geopolíticas propias que, posiblemente, indujeron a una modificación de las jerarquías entre las ciudades. Planteamos la ciudad visigoda como el centro de gestión civil y religioso de una unidad territorial donde la arqueología identifica los vestigios de la arquitectura del poder, pero todavía no consigue definir con precisión los procesos domésticos inherentes a toda comunidad urbana. Conocemos globalmente los diferentes procesos de la desestructuración urbana de la Antigüedad tardía pero no los parámetros de la ocupación agrourbana de los recintos amurallados. Para este período histórico se supone que la redimensión demográfica del hecho urbano más una reducción de las relaciones económicas entre la ciudad y el territorio son factores determinantes de las nuevas ciudades visigodas, pero se reconoce una incertidumbre fruto de la dificultad arqueológica de estudiar las nuevas pautas constructivas y una cultura material más restringida.

Incidencia territorial de la política universitaria

La tendencia descentralizadora impulsada por la política universitaria española ha tenido, sin lugar a dudas, un impacto importante sobre la economía de las regiones en las que se ha asentado una Universidad de nueva creación. Los estudios del impacto económico de la Universidad sobre el área geográfica en la que se desenvuelve, son un importante instrumento para justificar e incentivar la descentralización geográfica de la educación superior, especialmente en tiempos en los que las rigideces presupuestarias exigen racionalizar al máximo los niveles de gasto público. Una de las técnicas habitualmente utilizadas para evaluar los efectos de la Universidad sobre la economía regional, es la basada en el análisis input-output. Dicho análisis estima el impacto total del gasto, incluyendo los efectos directos, los efectos indirectos y los efectos inducidos del consumo. La metodología input-output es precisamente, la que se aplica en este trabajo para poder cuantificar el impacto que las actividades de la Universidad de Lleida han tenido sobre la economía territorial.