Decentralization in Health Care: Strategies and Outcomes

Decentralization in Health Care: Strategies and Outcomes

Decentralization in Health Care: Strategies and Outcomes

Decentralization in Health Care: Strategies and Outcomes


Exploring the capacity and impact of decentralization within European health care systems, this book examines both the theoretical underpinnings as well as practical experience with decentralization.


Richard B. Saltman, Vaida Bankauskaite and Karsten Vrangbæk

The logic of decentralization is based on an intrinsically powerful idea. It is, simply stated, that smaller organizations, properly structured and steered, are inherently more agile and accountable than are larger organizations. in a world where large organizations control wide swaths of both public and private sector activity, the possibility of establishing more locally operated, locally responsible institutions, holds out great attraction. Even Max Weber, the turn-of-the-twentieth-century German sociologist who first formulated the key attributes of the bureaucratic model, and who himself reluctantly concluded that bureaucracy was inevitable in human organization, still yearned for the fruits of decentralization. “The only alternative to bureaucracy,” he wrote, “is a return to small-scale organization” (Weber 1947).

Given the strength of this idea, it is not surprising that national and regional policy-makers in many countries across Europe have introduced decentralization strategies. in a restructuring process that has accelerated since the Second World War, the institutional landscape – particularly in the health sector – now incorporates an extraordinary range and variety of decentralized operating and managerial arrangements.

It is precisely this broad range and scope of decentralization, however, that make analysis of this concept difficult. the single, seemingly simple character of decentralization, when probed more deeply, opens up into a broad array of concepts, objectives, and consequences. Far from being a unitary, clearly defined concept, decentralization breaks apart into a kaleidoscope of different, sometimes contradictory definitions, each hallowed in its own theoretical and, often, practical context. As Chapter 2 explores, once one moves beyond Rondinelli’s (1983) traditional public administration00AD nation to date of the assumptions, methods, and conclusions of the field of psychiatric genetics. This is no small feat, given that belief in the genetic origins of mental disorders is one of the most enduring and fervently held among mental health professionals as well as laypersons; and given that a prodigious quantity of studies purporting to demonstrate genetic influences on schizophrenia, depression, bipolar disorder, and adhd have appeared over the last half century and more.

The book also serves as an exemplar for critical analysis: studies and methods are scrutinized logically, and the ethical, ideological, and political undercurrents of the whole field are also described. and all of it in plain English! Throughout its pages, part critical analysis and part cultural history, Joseph’s scholarship never ceases to impress, and his unearthing of inconsistencies, contradictions, and fabrications in the writings of some of the field’s leaders makes for fascinating, though at times embarrassing, reading. I felt that all graduate students in the health sciences should read this book if only to understand the topics of conceiving and evaluating scientific studies, especially the fundamental topic of what is needed to reject a null hypothesis.

But there is of course much more to this book. After reading it, I am convinced that progress in psychiatric genetics can only occur if researchers in this field are compelled, either by their sponsors or by their own scientific integrity, to read and try to refute Jay Joseph’s charge that such profound errors and biases — in design, measurement, interpretation, and reporting — pervade all the foundational twin and adoption studies that we must take seriously his conclusion . . .

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