Area of Research and Definitions

The stated aim of this study is to analyse reforms that have occurred over the past decade (2012-2021) in CEMR member countries and that have affected the shape, numbers and structures of local and regional governments (territorial reforms) as well as their competencies, their ability to self-govern, and local autonomy in general. For the purpose of this study, they are broadly referred to as “territorial reforms” and include “governance reforms” and any other type of reform considered to have had an impact on territories.


Therefore, any numbers pertaining to local governments refer exclusively to “decentralised governments” or “self-government”, which are also political entities with decision-making bodies, in addition to being an administrative-territorial unit, that are constituted through elections. Infranational governments, subnational governments, etc. are all generally categorised as “Local and Regional Governments” (LRGs) and are thus used interchangeably in this study.


Deconcentrated governments, territorial units or administrative representatives of the central government, such as the “prefectures” (préfectures) in France or the administrative regions (mkhare) in Georgia, are not covered by this study, neither in the analysis nor in the country sheets. Sometimes, certain systems co-exist (capital cities or large metropolitan areas), in which case their particular structure of local self-government generally functions alongside the state administration; but these exceptions are not addressed here.


Geographical Scope

The main figures and graphics used in this study have been put together based on the responses received from national associations of LRGs covering 40 countries, including 26 EU Member States.[1] In total, these 40 countries encompass more than 115,000 local and regional governments, nearly 678 million people,[2] and the national associations represent 94% of these countries’ populations.[3]


Data Sources

The data for this study was primarily compiled through a survey conducted in the first quarter of 2021 as well as from phone interviews. Our analysis also relied on desk research to complement the information provided by CEMR’s member national associations of local and regional governments, and to deepen our knowledge on the relevant topics.[4] The statistical data were primarily obtained from experts from associations of towns, municipalities and regions.


For the statistics concerning population, land area or the like, Eurostat was the main source used. For the population data, the figures for 2021 were up-to-date for all the countries with six exceptions. For Bosnia and Herzegovina, Georgia, Kosovo, Moldova, Israel and the United Kingdom, we resorted to data from the World Bank.



In order to collect primary data and pick up on any trends relating to territorial reforms in Europe, we used a template similar to what was used for previous editions of the study,[5] namely a description of the local systems in each country, including a comprehensive list of local competences and general facts

particular to that country. The country sheets presented in this study are based on this template.[6] It should also be noted that, for this edition of the TERRI report, a decision was taken to narrow the focus of our analysis to look specifically at the public health competence and how governance systems adapted to manage responses to the COVID-19 pandemic. Building on this foundation, we broadened our enquiry by adding a section to the questionnaire regarding the impact of the COVID-19 crisis on governance as well as on public health systems and functions.


The purpose of the questionnaire was to learn about territorial reforms, irrespective of whether they occurred because of a governmental decision or specific situations stemming from COVID-19 crisis management. The survey was divided into several parts and drafted so as to assess any changes in the numbers of local and regional governments, the date and nature of territorial and health reforms, the result of the reforms, i.e. whether they pointed to more decentralisation, re-centralisation, or enhanced collaboration between governments and/or more responsibilities for LRGs, as well as the impact of the COVID-19 crisis response on the governance-in-partnership and the role of national associations of LRGs.


The questionnaire was made up of 32 questions, five of which were open-ended, divided up into four sections. One question in the health section was a comprehensive table listing 21 preselected health functions. The European Committee of the Regions’ reports on the role of local and regional authorities in managing health systems across the EU,[7]. Using the country profiles presented in these reports, we identified a set of 21 health functions (Box 3) covering LRGs’ likely roles in the area of public health, allowing us to conduct an in-depth analysis of the position as well as the remit and responsibilities of LRGs and their national associations in the health sector.


It is important to note that even though additional desk research was carried out regarding certain points, the main data used in our analysis comes from survey responses, which may of course be subject to individual points of view.


Financial Data

Examining local competencies and trends also calls for a look at the state of local finances. The sources for this data were Eurostat, the World Bank, and the World Observatory on Subnational Finance and Investment. When needed, we used the European Commission’s currency converter, InforEuro, to obtain the official monthly accounting rate.


In Part 2 on the local health systems, we looked at the overall expenditure of LRGs, compared it against the national GDP, and then calculated how much LRG expenditure went specifically to health. To make it easier to screen the data and determine the LRG heavyweights in terms of health care spending, the respondent countries were broken down into four groups (Groups 1 to 4, always ranked respectively lowest to highest) based on three indicators:

  • national GDP,
  • LRG expenditure as a percentage of national GDP,
  • LRG expenditure on health.

The aim of this clustering exercise was to help us assess whether there was any correlation between the LRGs coming from the wealthiest countries and the level of their expenditure on health. The results are presented in part 2 of the study in Figure 5.[8]


Scientific Revision

To corroborate the conclusions reached from our data collection and desk research, we arranged to have two experts, with specialised knowledge in, respectively, decentralisation trends and local health systems in Europe, partner with us and scientifically scrutinise our analysis.


Stéphane Guérard, Associate Professor of Public Law at the University of Lille in France, is the founder and head of the network, the “Observatory of Local Autonomy” (OLA), made up of academics from 43 European states and 12 non-European states. It is organised into 71 European teams and 12 non-European teams of researchers from 100 universities. Mr Guérard is a specialist on local autonomy and decentralisation trends and reforms in Europe and worldwide.

Rossella Soldi is the Managing Director of Progress Consulting S.r.l., a private consultancy on sustainable development that specialises in analysing the impact of European policies from the perspective of local and regional governments. Ms Soldi has also authored a number of studies commissioned by the European Committee of the Regions on public health management at the subnational level, and her latest work focused on ‘Regional differences in COVID-19 response: exposure and strategy’.


Lastly, this analysis has been proofread several times and validated by experts from the LRG national associations involved in the study.

Using this research approach, we compiled an overview covering the evolution of local governments and governance over the past decade (2012-2021) and the state of local public health systems and recent reforms (Parts 1 and 2). The research then analysed implications for the management of governance arrangements in general, and the affects of managing local public health in particular (Part 3).


[1] All the EU Member states except Ireland

[2] Source (population of the 29 countries): Eurostat (September 2021) and Worldometer (population in Israel)

[3] Source (representativeness of the associations): CEMR Study National Associations of Local and Regional Governments in Europe, January 2019.

[4] See Bibliography

[5] 2016: CEMR Structures and Competences 2016; 2013:; 2005:

[6] See Country Profiles


[8] Clusters are presented in Annex 1.