Result card

  • ORG5: How does de-centralisation or centralization requirements influence the implementation of FIT?

How does de-centralisation or centralization requirements influence the implementation of FIT?

Authors: Principal investigators: Valentina Prevolnik Rupel, Nika Berlic Investigators: Dominika Novak Mlakar, Taja Čokl, Plamen Dimitrov, Marta López de Argumedo

Internal reviewers: Americo Cicchetti, Daniela D'Angela, Marco Marchetti

Acknowledgments: /

Analysis of selected studies extracted from the basic literature search. Four articles were found to be relevant to this question and one publication. We found additional information by an internet search of grey literature performed on 16 May 2013 via the search engine Google. It was performed by investigator using key words specific to this question (“impact of centralization/ dencetralization on colorectal cancer screening”, “centralized vs. decentralized health care environments”, “centralized vs. decentralized health care system”, “centralized or decentralized health services”, “impact of centralization/ decentralization on health preventive programmes”). One grey literature source is referred to in these results.


The factors that speak in favor of centralized services are the following {21}:

a) development of teams of different disciplines are easily to arrange in larger establishments,

b) large units achieve economies of scale and can make most efficient use of a scarce resource and

c) better outcomes for patients under the care of more specialized professionals.


Although the organizational theory includes several disadvantages of decentralization: (a) the risk of sub-optimality as decentralized entities focus on their own performance rather than the entire organization, b) lack of coordination, c) inappropriate diversity in practices and standards especially in personnel management and d) reduced comparability and predictability at the system level) {22}, there is still a significant advantage for the basic interventions as screening. Decentralized clinics and activities provide better access to health campaigns, which offer more information and knowledge to the participants {23}. Regarding implementation of  FIT and participation in screening, centralization might reduce participation in screening, especially in countries with practices like in France {24}, where the individuals from the target population are first invited to consult their family physician before they receive the screening test by mail. Centralization might also reduce the awareness of screening meaning for health, because the access to information is not as good as in decentralized system. There is consistent evidence that centralisation of cancer screening services increased patient travel costs, time and distance {25}. The negative impact is mostly felt by those with low incomes, poor access to transport, by elderly and disabled {21}. Centralization impact that is related to access of the information about the screening could easily be overcome with mobile screening vans, which can be used for more distant areas.

Survey, implemented among 11 European countries, has shown that countries have its health system organized in a different way. Austria, Italy (i.e. decentralized in regional level) and Spain have decentralised health system. In Spain, every single region has its own organization. The Spain also indicated that they don’t have information about the influence of each Regional Health System on the screening phases. The Russian healthcare system is a mixture of centralized and decentralized features. The decision making regarding health policy issues, key national health and reimbursement programs is centralized and supported by significant federal budget funds. Implementation of important health programs is the obligation of regional and municipal health authorities. Centralization of the healthcare system affects all CRC screening phases. Lithuania has semi-centralized health-care system. Lithuania indicated that there is a national legislation act, concerning the CRC screening programme, defining screening services and implementation procedures. The implementation results of this programme are provided by the Colon Cancer Early Detection Program Funding Coordination Group. The Coordination Group indicates results of the programme at least once a year. Programme implementation reports are provided to the Ministry of Health and to the National Health Insurance Fund under the Ministry of Health. Scotland indicated that the advice on screening programmes is provided to all devolved administrations by the UK National Screening Committee. Screening policy is set by the Scottish Government Health Directorates. Romania has stated that National Unit for the Management of Screening Programmes under Ministry of Health is responsible for the planning, implementation and monitoring. The tests are performed by Accredited Laboratories. National screening programme in France is organized around departmental management structures that coordinate all activities, provide training to general practitioners, manage invitations based on data of the national health insurance, track results and assure transmission of data to the In VS (Institute national de Veille Sanitaire - French Institute for Public Health Surveillance). Slovenia has a centrally organized program. Preparations started in 2006, when the Ministry of Health has approved the national program and has been granted funding of public funds through the Health Insurance (Health Insurance Institute of Rep. Slovenia). In 2008 a pilot study was made and in 2009 the program became operational at the state level. The Central Unit, at the Institute of Public Health of Slovenia, is responsible for the planning, organization, implementation, tracking, monitoring and data collection. The colonoscopy preparation and implementation is performed by clinics/health centres and colonoscopy authorized centres (this is decentralized).

Program organization in Croatia is related to their country division into 20 counties plus the capital city of Zagreb. There is one public health institute in each county and city. In each local public health institute there is a coordinator nominated for the National Screening Program. At the national level, a coordinator from the Croatian National Public Health Institute has been nominated, and all 22 coordinators are members of the Committee for Program Performance. An Expert Committee has also been nominated by the Minister of Health and Social Welfare with the main task to evaluate professional qualification of colonoscopists included in the National Program and to attend to other issues during the program performance {26}.

Literature provides little information on the impact of de-centralisation or centralisation on implementation of FIT.

Rupel P et al. Result Card ORG5 In: Rupel P et al. Organisational aspects In: Jefferson T, Cerbo M, Vicari N [eds.]. Fecal Immunochemical Test (FIT ) versus guaiac-based fecal occult blood test (FOBT) for colorectal cancer screening [Core HTA], Agenas - Agenzia nazionale per i servizi sanitari regionali; 2014. [cited 3 December 2022]. Available from: