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Determining policy priorities in a devolved health system: an analytical framework

Novinskey, Christina (2015) Determining policy priorities in a devolved health system: an analytical framework. PhD thesis, London School of Economics and Political Science.

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Identification Number: 10.21953/lse.408mysp3usnu


This dissertation develops an analytical framework for studying the effects of health system devolution on the health policymaking process and policy choices made by subnational governments. It addresses two research questions: (1) How does devolution change the structure and agency of the health policymaking process? (2) What is the resulting impact on health policy priorities? A critical literature review covers decentralization, devolution, and interest-based approaches for analysing the policymaking process, structure and agency. An analytical framework for uppermiddle and high-income countries is constructed by integrating (i) a modified version of Bossert’s decision-space approach for decentralized health systems; (ii) BlomHansen’s combined policy network and rational-choice institutionalist approach, which analyses the intergovernmental relations within the national health policymaking environment; and (iii) an original conceptualisation and analysis of informal intergovernmental policymaking at the subnational government level. Empirical evaluation uses information on Spain’s 2001 health system devolution reform, focusing on the regional cases of Extremadura and Madrid. Primary data from stakeholder interviews and secondary data are analysed primarily using qualitative, case study and content analysis methods. The decision space granted to regional governments in Spain is examined before and after the reform, developing a decision-space map for Extremadura and Madrid and showing the shifts in the range of choice allowed for each health system function over time. Next, the compositions of the national and subnational health policy networks are determined for before and after devolution, and the policy priorities for each are estimated ex ante. Finally, the dissertation analyses the ex post priorities and results of health policy decisions made by Spain, Extremadura and Madrid in the period after devolution. Overall results show that the analytical framework is only partially successful in anticipating health policy priorities. Suggestions for improving the framework are proposed, and policy implications and lessons are drawn from the case studies.

Item Type: Thesis (PhD)
Additional Information: © 2015 Christina Marie Novinskey
Library of Congress subject classification: H Social Sciences > HN Social history and conditions. Social problems. Social reform
Supervisor: Mossialos, Elias and Fleckenstein, Timo and Costa-Font, Joan

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