The conclusion synthesizes and reflects upon the case studies and comparative and theoretical contributions in the book. The cases are organized around three categories: first, relatively conventional decentralization initiatives in which reforms were adopted to improve governance; second, contexts in which decentralization has been contemplated as a framework for self-determination for the region’s stateless communities; and finally, decentralization initiatives undertaken in the shadow of conflict and state fragmentation. This concluding chapter develops theoretical insights drawn from the rich terrain for qualitative comparison across these three contexts. It offers reflections on key characteristics of the shared regional context and a typology of factors driving decentralization in the Middle East and North Africa (MENA) region. It argues that an important contribution of the volume lies in identifying a broader array of motivations for, and actors driving, decentralization than currently reflected in the scholarly literature and in parsing the implications for the institutional design of decentralized government. The chapter concludes by distilling patterns from the cases to identify distinct trajectories of decentralization that are evidenced in the MENA region and their entailments.

Morocco melded its advanced regionalization initiative into a constitutional reform process launched to head off local Arab Spring protests. The literature has approached these reforms from a governance perspective. The initiative has enhanced the democratic legitimacy of regional councils and modestly increased their powers and resources, but without disturbing the state’s established administrative structure, wherein appointed governors shadow elected officials at every level. This chapter examines advanced regionalization with particular focus on its implications for the fate of Western Sahara. Internationally, Morocco has sold advanced regionalization as evidence that it remains committed to a political resolution based on its Autonomy Plan, which offered a special status of asymmetrical autonomy for Western Sahara in its constitutional order. The chapter argues that advanced regionalization instead underpins Morocco’s two-pronged strategy: a hardening external position on Western Sahara coupled with internal efforts to minoritize and folklorize Sahrawi identity. The goal of this strategy is to disassociate the question of Western Sahara from the decolonization/self-determination paradigm and reframe it as a matter of Sahrawi linguistic-minority rights and cultural preservation.

Health services are organized in remarkably diverse ways and yet manage to produce comparable outcomes. Countries should build on the strengths of their own systems, rather than feel pressure to adopt health service organization models imported from elsewhere. Most countries have centralized and decentralized elements that coexist and generally are embedded in a wider governance and political economy context. Efforts to use decentralization to improve health outcomes succeed when they build organizational capacity to exercise newfound decision rights and ensure robust accountability systems. The private sector encompasses a diverse set of actors that play a critical role in delivering health services but that are often inappropriately neglected in public policy and planning efforts. There is no one perfect model of care, the best ones are adaptable and evolve to address shifting epidemiological patterns, emerging threats such as pandemics, and climate change. Addressing the organization and management of health services inevitably involves a focus on supply-side factors, but demand-side considerations play a critical role in improving health outcomes and cannot be ignored.

Regulated industries increasingly look like multi-product monopolies or oligopolies, which necessitates adaptations in the design of regulation. An oligopolistic market structure will be preferred if it allows information rents to be cut and shared and if these gains offset lost scale economies. Rent cuts come from sampling effects, yardstick competition and complementarity effects. In mixed oligopolies, differences in the objectives and constraints of public and private competitors make the regulation tasks more complex and limit the possibility of implementing yardstick competition. If the costs are relatively well known (standardized technologies), a monopoly may be a better choice as there is no variance in production costs and so dual sourcing is inefficient. Otherwise, when the firms’ costs are correlated, a duopoly leads to lower marginal costs despite the need to duplicate the R&D costs. In mixed oligopolies, regulation must be adapted to the differences in the objectives and institutional constraints of private and public operators. In oligopolistic industries, self-regulation and regulation by contract offer alternatives to regulation by a specialized regulatory agency. For a multi-product monopolist, the regulatory challenge is to decide whether to set a rate of return for each product sold by the regulated firm or for its overall business.