Devolution is in vogue. Over the second half of the 20th century, several Western European countries witnessed major processes of institutional change leading to profound changes in the territorial distribution of government power. However, little topics in political science and health systems research have proven as resistant to conceptualization as devolution has. This explains the scarce advances made in assessing its dynamics, causes and impact. Although devolution constitutes one of the most relevant transformations in the governance of modern health care since its inception, little is known about (1) what does it mean in different countries and how it is related to neighboring concepts such as federalism; (2) where (=in which countries and sectors) it prevails, and how it has evolved in time; (3) which are its causes; (4)which factors contribute to its success or failure; (5) and which effects has on health care.
These questions make up a comprehensive research agenda on which more theoretical and empirical analysis is needed. But the basic elements required to build sound analysis on the topic are still missing: namely a clear and simple definition of devolved systems and the policy instruments and institutional tools involved in the dynamics of health care devolution. Tackling these unresolved questions would assist us in overcoming conceptual complexity and empirical diversity and to better describe and compare the main trends of devolution across countries and historical periods. The present paper aims at laying the ground for further systematic debate and investigation on the pending research agenda of health care devolution by addressing the most basic research topics (questions 1 and 2 above) and tracing their relationships with other, more complex issues (questions 3, 4 and 5). We deal with the second question (how devolution has evolved over time) by presenting an analytical overview of the process of health care devolution in countries that have long experienced devolution (the Nordic countries -Denmark, Finland, Norway, Sweden - and the two devolved Southern European countries - Italy and Spain). The main purpose of the empirical analysis is to investigate whether different types of devolved government evolve differently. All those countries share a very important common characteristic, namely a tax-funded National Health System (NHS) that guarantees universal access to health care, although they differ in the way they structure devolution. This allows us to compare the dynamics of health care devolution in different devolved systems under a relatively ontrolled research design.
The analysis is structured as follows. First, we delve into what devolution means and how it is related to other forms of local self-rule and present the dimensions according to which we believe devolved systems should be classified. The second section structures the empirical work by introducing the hypotheses on the dynamics of institutional change. It also conceptualizes the variable of analysis through the classification of devolution reform policies in three different groups, according to the substantive policy goals and institutional tools involved in the dynamics of devolved governments. We complete this section with a detailed analysis of recent reforms in the devolved European NHS. In the last (third) section, we summarize the main findings and discuss them in the light of the relative small available evidence on causes, consequences and prospects of devolution in health care.