European-wide policymaking at the urban level: A qualitative study

Background
Inter-urban area (UA) health inequalities can be as dramatic as those between high and low-income countries. Policies need to focus on the determinants of health specific to UAs to effect change. This study therefore aimed to determine the degree to which policymakers from different countries could make autonomous health and wellbeing policy decisions for their urban jurisdiction area.
Methods
We conducted a cross-sectional, qualitative interview study with policymakers recruited from 8 European countries (N=37).
Results
The reported autonomy among policymakers varied considerably between countries, from little or no autonomy and strict adherence to national directives (e.g. Slovak Republic) to a high degree of autonomy and ability to interpret national guidelines to local context (e.g. Norway). The main perceived barriers to implementation of local policies were political, and the importance of regular and effective communication with stakeholders, especially politicians, was emphasised. Having qualified health professionals in positions of influence within the UA was cited as a strong driver of the public health agenda at the UA level.
Conclusion
Local-level policy development and implementation depends strongly on the degree of autonomy and independence of policymakers, which in turn depends on the organisation, structure and financial budget allocation of public health services. While high levels of centralisation in small, relatively homogenous countries may enhance efficient use of resources, larger, more diverse countries may benefit from devolution to smaller geographical regions.