Organizational innovations and health care decentralization: a perspective from Spain

Recent policy developments in public health care systems lead to a greater diversity in health care. Decentralization, 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 'deconstruction' 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 the results. These organizations may retain financial surpluses, develop 'spin-off' companies, and commission a range of specialized 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 a lack of commitment to a national health service and ultimately a loss of social cohesion. Through fiscal decentralization to regional authorities or planned delegation of financial agreements to 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 of the 'pros' and 'cons' of the health care decentralization process in Spain, drawing on the experience of regional reforms from the pioneering organizational innovations implemented in Catalonia in 1981, up to the currently observed dispersion of health care spending per capita across the regions.