Territorial Governance, Powers and Reforms in Europe

2021 Edition: Focus on Local Health Care Systems

Territorial and governance reforms are well underway in Europe, a development that can be viewed as an indication of democracy in motion. These reforms have encouraged greater decentralization and a more effectual share of responsibility between the different spheres of government. Now, the unparalleled challenges that have arisen since the start of the pandemic have moved the issue of effective coordinated actions by governments center stage and the efforts of local and regional governments (LRGs) and their national associations into the spotlight.

In this context, the Council of European Municipalities and Regions (CEMR) has prepared the first edition of the TERRI Report, a publication that builds on the foundations of the CEMR’s earlier studies entitled, ‘Local and Regional governments in Europe – Structures and Competences’.

The TERRI report examines territorial and governance reforms undertaken in recent years and the evolving nature of relationships between central and subnational governments, as seen through the eyes of CEMR’s national associations, using information compiled every five years.

The report is accompanied by detailed country profiles of the subnational governance structure for each of the 40 CEMR countries covered by the study.

General comparative trends

Amongst the 40 CEMR countries covered by the study, there are 36 unitary countries (including regional states like Spain and Italy), four with federal systems and eight countries have an intermediary tier of governance, e.g. provinces or counties, and more than half have a regional government.

One major development that stood out was the fact that territorial reforms have been introduced in a sizeable majority of the 40 countries covered by the study. A quarter however experienced no change in the number of territorial governments during the period studied.

The second trend that was noteworthy shows the majority of changes taking place at the local or municipal tier. A large number of territorial reforms that took place over the past decade seem mainly focused on reducing the number of local governments in order to establish larger units. In the case of Finland for example, there were 23 municipal amalgamations from 2013 to 2021, with a decrease in the number of municipalities from 336 to 309, and an increase in the size of local governments. In Albania, 12 regions were created even as municipalities were reduced from 373 to 61. In Malta, five regional councils were established in 2021 (previously called “Regional Committees”), following the Local Government Reform Process and the publication of Act No. XIV of 2019. Their legal basis was strengthened and the powers of these regional councils were boosted. Many of the examples listed below confirm this pattern of a decrease in the number of municipalities and/or an increase in amalgamations over the years.

Local Public Healthcare Responsibilities: Mapping local and regional health tasks by country

Healthcare is an essential public service and its provision has undergone substantial changes in recent years. Decision-making in healthcare often tends to be the prerogative of central governments, given their role in ensuring that health services are delivered efficiently and equitably across territories. Nonetheless, decentralization is also a fundamental characteristic of many healthcare systems, given the key role played by local and regional governments with respect to the inputs and outputs from the health sector, not to mention their capacity to closely monitor actual delivery of healthcare services.

The next section of the study analyses local and regional governments’ powers and responsibilities specifically in the field of health, using primary data shared by CEMR’s members. The report provides an in-depth look at local and regional governments’ responsibilities which, due to the differing structures of health systems across Europe, vary enormously from country to country. What’s more, the current reality of the COVID-19 pandemic has made it possible to gain important insights, through the experiences of regional and local governments, into how an unparalleled health emergency is being managed across Europe.

This analysis includes a review of local competences relating to health care, including details regarding a number of health tasks and whether they fall under the planning and /or implementation level. Recent reforms and trends in the domain of health and their implications for local powers and finances are discussed as well.

Impact of health reforms on local and regional governments’ pandemic preparedness

As is well documented by now, the COVID-19 pandemic has caused a crisis of unparalleled proportions since its onset in Europe in 2020. While all tiers of government were faced with extraordinary challenges, the heavy reliance by central governments on LRG leadership in providing support to citizens, businesses and communities apace, during an acute health and economic crisis, is undisputed. The pressure exerted by COVID-19 on health systems across the globe has been enormous, and the worsening pandemic was quick to reveal any shortcomings and weaknesses, as well as existing problems in countries’ health systems. In countries all over, wide-ranging reflections are already underway on what can be done to strengthen public health systems and how to better govern-in-partnership, so as to improve preparedness for future crises.  

The final section of the report focuses on whether the introduction of health reforms had any impact on local and regional government capacity to deal with the COVID-19 pandemic. The section also chronicles the different experiences of local and regional governments, as recounted by CEMR’s national associations, in managing the crisis. It should be stressed that since the data was primarily collected during the first quarter of 2021, this information represents a snapshot in time. Given the fast-moving pace of managing such events, it is highly likely that the results presented in the following section have since evolved, but what follows seeks to document the ongoing changes faced by local and regional governments during the past months.

Read the full report

Council of European Municipalities and Regions (CEMR). 2022. TERRI Report: Territorial, Governance, Powers and Reforms in Europe, 2021 Edition: Focus on Local Health Care Systems.