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Dissatisfied with Decentralisation: Explaining Citizens' Evaluations of Poland's 1999 Health Care Reforms

Abstract Decentralisation of public policy from national to sub-national governments occurs in 80% of developing and transitioning economies worldwide (Manor, 1999), and is advocated by the International Monetary Fund, World Bank, and European Union. Proponents argue that decentralisation disperses political power, involves citizens in the political process, and allows sub-national officials to craft efficient policies. After suffering under centralised state policymaking (1945–1989), citizens of Central and Eastern Europe should be avid supporters of decentralisation. Yet 80% of the Polish populace was dissatisfied with decentralisation of health care services by 2000. This article uses public opinion, interview, and elite survey data to examine the critical case of Poland's 1999 health decentralisation, answering two questions about public opinion on decentralisation. First, why were Polish citizens displeased with decentralisation? Second, what factors make or break public evaluations of decentralisation? The article demonstrates that Poles were more dissatisfied with their health care during health decentralisation (1999–2001) than when it was centralised (1994–1998, and 2002–2007). Aggregate public opinion data suggests support for decentralisation dwindles when it becomes synonymous with offloading state responsibilities to private citizens. However, surveys of health care consumers, providers, and administrators in four Polish provinces show the important role political parties play in managing expectations and support for decentralisation.