Vertical Competition in the Spanish National Health System (NHS)

In unitary states, competitive decentralisation structures can take place by increasing the visibility of politically accountable jurisdictions in certain policy responsibilities such as health care. Drawing from the Spanish decentralisation process we examine the mechanisms (and determinants) of vertical competition in the development of health policies in the Spanish National Health System. The Spanish example provides qualitative evidence of vertical competition that assimilates government outcomes of unitary states to that of federal structures. The Spanish experience indicates that the specific vertical competition mechanisms in place until 2002 are likely to be responsible for significant policy innovation and welfare state development.