Policy interdependence and the models of health care devolution: “systems or federacies”?

A number of European countries have devolved health care services to subnational units. This is especially the case in unitary states that organise the health system as a national health service (NHS), where choice is not “build in” the system. This policy note argues that, in such settings, there are two distinct models of devolving authority to subnational jurisdictions: a “federacy model” where only a few territories obtain health care responsibilities (such as in the United Kingdom), and a “systems model” where the whole health system is devolved to a full set of subnational units (such as in Spain). The choice of one, or the other, influences the spatial diversity of health care activity and the extent of policy interdependence across regions. Drawing on evidence from the UK and Spain, we show that a “system model” gives rise to significant policy interdependence and lower regional dispersion than a “federacy model.”.