euro.who (August 018) Hospitals with greater autonomy are perceived to be more flexible in meeting the needs of the local population. However, there is a tension between the potential to improve responsiveness and flexibility via greater decentralization and the potential efficiency gains and geographical equity derived from centralization. This policy brief explores the experience with decentralized hospital governance in 10 European countries (Denmark, England, Finland, France, Germany, Italy, Netherlands, Scotland, Spain and Sweden) and finds that there are interesting examples of authorities in systems with decentralized hospital governance collaborating to overcome equity and efficiency concerns, but that the specific institutional and political contexts make it difficult to transfer successful models from one country to another.