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Health care based on priorities is lost in decentralisation

BMJ 2005; 331 doi: (Published 21 July 2005) Cite this as: BMJ 2005;331:235
  1. Aleksandar Dzakula, research fellow (adzakula{at}
  1. Andrija Stampar School of Public Health, Rockefellerova 4, Zagreb, Croatia

    EDITOR—Decentralisation of the health system was applied in all transition countries in the 1990s.13 In most countries it was encouraged by the necessity to reform the inherited model of health organisation and to achieve the final goal—an efficient and fair health system. Croatia has special experience in decentralisation, primarily because of its geographical, political, and administrative circumstances but also because of its decentralised health system during the socialist regime in the 1980s.

    Firstly, Croatia is a country with extreme differences between its regions. The income per head in the richest region is 10 times that in the poorest region.

    Secondly, decentralisation reforms were not based on analyses of the problems and assessment of resources but on maintaining the framework within which they were implemented. Such implementation of the changes resulted in a complete change of the essence of the local health system, whereas the given framework imposed limitations on the development and changes, instead of fostering them.

    Thirdly, decentralisation was implemented without having organised a local network of professionals that would work on the local level and would be able to manage local health needs.

    Decentralisation is always a challenge in any health system and is mostly looked at as a series of political and organisational measures. Unfortunately, the expectation that decentralisation will ensure successful professional activities is often overlooked in the analyses. Furthermore, the measures and the purpose of decentralisation are often not recognised as important elements of political culture. The primary purpose of decentralisation—health care based on the real priorities and resources—therefore remains marginal.


    • Competing interests None declared.


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