This section of the study explores the major developments in health systems across Europe over the past decade based on the responses to the survey carried out amongst CEMR’s associations. Other issues that were the focus of the survey, were whether or not these reforms had any effect on the competences ofLRGsin the area of health. Furthermore if there were effects, whether the impact was of a decentralising or centralising nature, or whether other changes to governance arrangements were triggered.

Health reforms since 2010

In the last decade, health systems in 22 countries have undergone a major overall reorganisation, as can be seen in Figure 5. Some reforms have significantly affected many governance aspects of these systems. In Austria, health reforms undertaken in 2012 and 2013 introduced a ‘target-based governance’ system to foster closer cooperation and increased coordination of operations between key target stakeholders as well as between different areas of care. Later in 2019, structural reforms led to mergers among the 21 existing social insurance institutions, reducing their number to only 5. Additional healthcare reforms currently underway for the 2017-2021 period aim to strengthen primary care.


Figure 5: Health reforms in the past 10 years in 38CEMRcountries

Source: TERRI Survey 2021 | CEMR[1]


Other important recent developments mentioned in responses include modernisation efforts to improve the performance of health systems. In Scotland,COSLAhas been working alongside the Scottish Government spearheading efforts to improve the health system through greater collaboration between tiers of government, which has also entailed collaboration with the National Public Health system and local governments. Nonetheless, concerns remain as to whether this national health and local social care integration may foster advances in centralisation, given the announcement by the Scottish Government in September 2021 that it aims to set up a new National Care Service.


The goal of increased financing for health systems has also been a major driver behind reorganisation efforts. The experience of Portugal provides a good example of this kind of cost-efficiency reform initiative. Partial privatisation of health care is also increasingly used as a means of reducing the cost of public financing and new developments, as can be seen in Slovakia, which has undergone extensive privatisation in the area of healthcare provision. This has led to a system of shared competences where responsibilities have been divided between the state, the regional governments and the private sector. In addition, lucrative medical procedures have been privatised and several health insurance companies have been established. In Poland, primary and secondary care have been largely privatised, even if such entities enjoy contracts with the National Health Fund.


It has been observed that, frequently, these reforms take place over a period of several years or that multiple reforms are often carried out one after the other. This holds true in Austria and in Finland, where social and healthcare reforms have taken on a variety of forms and date as far back as 2006. In France too, discussions on reforms to the health sector have been ongoing for many years, given the interconnection between this issue and the wider concerns about financing of the social security system. All this goes to underline that health system reform is an inherently complex process. It takes time to gain a deep understanding of the system to ensure that any changes will produce positive and desired outcomes.

[1] Two countries did not respond to this question: Bosnia and Herzegovina and Greece

Impact of health reforms on local and regional competences, powers and responsibilities

The trend over the last few decades has been towards the decentralisation of government responsibilities in the health domain and, as a result a greater devolution of powers to the subnational level. So, while decision-making over health care tends to remain in the hands of the central governments,LRGsare often tasked with the delivery of health services and, therefore, inherently possess important decision-making powers over healthcare inputs and resources.CEMRmembers’ survey responses regarding recent health reforms substantiate these observations. 


A majority of respondents (17 associations),[1] out of the 22 countries where health sector reforms have taken place in the past decade, stated that the changes did have an impact on LRGs’ tasks and responsibilities.


Only five associations[2] reported that the reforms had had no impact on LRGs´ health-related responsibilities. The case of Moldova stands out given that, ordinarily,LRGsthere have no powers or responsibilities in health care. Nevertheless, they were called upon to execute a few specific actions introduced during the COVID-19 pandemic.


Taking a closer look at the data, of the 17 associations who responded that health reforms affected LRGs’ responsibilities, the majority stated that the changes had led to greater collaboration and/or decentralisation (13 associations).[3]


In France, health reforms have led to improved territorial cooperation. The 2009 “HPST” law[4] (Hôpital Patient Santé Territoire) confirmed the role of the central government in defining and implementing health policy and reinforced a territorial approach through the creation of a regional health agency (the ‘ARS’), an authority responsible for implementing national policy at the regional tier.LRGshave the option of signing local health contracts with their ARS, the role of which is to coordinate actions developed byLRGsto ensure that they are in line with the health objectives and policy defined by the ARS for the regional tier.


In the case of the Netherlands, important healthcare reforms have resulted in both decentralisation and in closer collaboration between health actors.


Undertaking health reforms with the aim of providing services that are more ‘patient-focused’, as highlighted by the examples from Norway and Sweden, demonstrates how health system reforms can coincide with better collaboration and/or decentralisation outcomes.


In Norway, the Care Coordination Reform set out to address three main challenges and needs: provide patients with more coordinated services, boost prevention and address the changing health needs associated with demographic changes. Key outcomes of the reform include having achieved improved coordination of care between municipalities and hospitals, strengthened primary care and public health and greater public choice.


Similarly, in Sweden, new legislation improving patient choice for outpatient care has increased the power of patients/citizens. Furthermore, this new legislation fostering greater cooperation relating to discharge from in-patient care has led to increased collaboration between municipalities and regions. 


Although it is the case in Hungary and North Macedonia, the survey results provide few examples to highlight health reforms that have resulted in greater centralisation.


CEMR’s members have confirmed however, that the responsibilities and powers of subnational governments in the domain of health continue to evolve, following the broader pattern of governance and territorial reforms underway. Although decisions on healthcare are likely to remain in the hands of the central governments, the management of public health will continue to be shaped by shared competences across different tiers of government. As demands increase for more efficient, cost-effective, joined-up, patient-centric services,LRGsare increasingly likely to be delegated responsibilities and powers to implement and deliver on these health provision objectives. The nature of shared responsibilities between different tiers of government and the management of the COVID-19 crisis is explored in Part Three of this study. 

[1] Austria, Czech Republic, Finland, France, Germany, Hungary, Italy, Netherlands, Norway, Poland, Portugal, Serbia, Slovakia, Spain, Sweden, Ukraine, United Kingdom (LGA)

[2] Albania, Cyprus, Georgia, Malta, Moldova (the responses for the remaining respondents were N/A or blank)

[3] Czech Republic, Finland, France, Germany, Italy, Netherlands, Norway, Portugal, Serbia, Spain, Sweden, Ukraine, United Kingdom (LGA)

[4] Law No. 2009-879 of 21 July 2009