Policy implementation in the health sector of the federal state of Belgium: An ethnographic approach

When analysing public policies, an implementation gap is often attributed to unclear or irrelevant goals, implementers’ disobedience and/or the numerous layers of government involved. This paper focuses on the multi-layer problem, wondering whether aspects other than the number of layers have an influence on the implementation gap in federal contexts, for example, the layers’ degree of autonomy or the competencies ‘allocation. It addresses the following research question: from an organizational point of view, to what extent does federalism, as a specific institutional configuration, influence the constitution of an implementation gap as part of a public policy implementation process? This research focuses on the implementation of public policy in the Belgian health sector intended to integrate care for chronic patients. It highlights the blockages that may occur in a multi-layer federal country like Belgium, showing that federalism can become dysfunctional if the allocation of competencies was made in an incoherent manner.