ABSTRACT
As Frederick W. Riggs noted in his seminal study, Administration in Developing Countries: The Theory of Prismatic Federalism (1964), the implementation of programmes and policies tends to be refracted by the history, institutions, and applicable technologies of discrete societies. This notion was further refined to describe federal/subnational relationships in various settings in Daniel Elazar’s study of Canadian federalism (1997), while Alain G. Gagnon and Raffaele Iacovino (2007) also utilised this concept in their discussion of the development of Quebec public policy within the Canadian context. In this volume, we have examined the development of health delivery in formal federal systems, the devolved ‘functional federal’ systems, such as those of Italy and China, and the quasi-federal systems of the United Kingdom and Spain, and found that this notion of prismatic federalism with refracted policies in different national and subnational contexts can be helpful in explaining health service delivery in ‘structural’ federal and ‘functional’ federal contexts. As Costa-Font and Greer concluded in their study of European health and social care, ‘few generalizations hold well because of the complexity of politics, institutions, powers, and finances in each country […] An observer who expects German federalism to make the Länder powerful actors in health policy, or French decentralization to produce territorial divergence, is inattentive to politics and institutional details and will be accordingly surprised’ (2013: 276). But is this all that can be said about the development of health policy in federal states? Beyond the recognition that federal and ‘functional’ federal systems tend to react to economic and political events in a manner determined by their specific cultural and institutional character, are there any more interesting convergences in the health policy of federal states that underscore either the advantages that federal states enjoy, or the complications that federal states confront, by virtue of their particular structures of governance?
