Health care has been one of the most contested social policy responsibilities of governments in the early 21st century. Federalism and health system decentralization involves complex administrative and political structures, overlapping jurisdictions and uneven fiscal capacity. Yet, in most high-income countries and increasingly middle-income countries, health care constitutes the single largest category of government expenditure.
Federations must determine which order of government has constitutional and legal responsibility for health and healthcare and explicitly assign responsibilities to one or both government orders. Then, Federations must evaluate funding mechanisms and means of cooperation between levels of government to ensure equity, access, quality and efficiency of health care in federal systems.