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      Does Decentralization Improve Health System Performance and Outcomes in Low- and Middle-Income Countries? A Systematic Review of Evidence From Quantitative Studies : Decentralization and Health System Performance and Outcomes

      1 , 2 , 1
      The Milbank Quarterly
      Wiley

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          Abstract

          <div class="section"> <a class="named-anchor" id="milq12327-sec-0010"> <!-- named anchor --> </a> <p class="first" id="d350123e153"> <div class="boxed-text panel" id="d350123e155"> <a class="named-anchor" id="d350123e155"> <!-- named anchor --> </a> <div class="panel-content"> <div class="caption" id="d350123e156"> <strong> <span class="fig-title">Policy Points:</span> </strong> </div> <p id="d350123e159"> <div class="list"> <a class="named-anchor" id="milq12327-list-0001"> <!-- named anchor --> </a> <ul class="so-custom-list"> <li id="d350123e162"> <div class="so-custom-list-content so-ol"> <p class="first" id="d350123e163">For more than 3 decades, international development agencies have advocated health system decentralization to improve health system performance in low‐ and middle‐income countries. </p> </div> </li> <li id="d350123e165"> <div class="so-custom-list-content so-ol"> <p class="first" id="d350123e166">We found little rigorous evidence documenting the impact of decentralization processes on health system performance or outcomes in part due to challenges in measuring such far‐reaching and multifaceted system‐level changes. </p> </div> </li> <li id="d350123e168"> <div class="so-custom-list-content so-ol"> <p class="first" id="d350123e169">We propose a renewed research agenda that focuses on discrete definitions of decentralization and how institutional factors and mechanisms affect health system performance and outcomes within the general context of decentralized governance structures. </p> </div> </li> </ul> </div> </p> </div> </div> </p> </div><div class="section"> <a class="named-anchor" id="milq12327-sec-0020"> <!-- named anchor --> </a> <h5 class="section-title" id="d350123e174">Context</h5> <p id="d350123e176">Despite the widespread adoption of decentralization reforms as a means to improve public service delivery in developing countries since the 1980s, empirical evidence of the role of decentralization on health system improvement is still limited and inconclusive. This study reviewed studies published from 2000 to 2016 with adequate research designs to identify evidence on whether and how decentralization processes have impacted health systems. </p> </div><div class="section"> <a class="named-anchor" id="milq12327-sec-0030"> <!-- named anchor --> </a> <h5 class="section-title" id="d350123e179">Methods</h5> <p id="d350123e181">We conducted a systematic review of peer‐reviewed journal articles from the public health and social science literature. We searched for articles within 9 databases using predefined search terms reflecting decentralization and health system constructs. Inclusion criteria were original research articles, low‐ and middle‐income country settings, quantifiable outcome measures, and study designs that use comparisons or statistical adjustments. We excluded studies in high‐income country settings and/or published in a non‐English language. </p> </div><div class="section"> <a class="named-anchor" id="milq12327-sec-0040"> <!-- named anchor --> </a> <h5 class="section-title" id="d350123e184">Findings</h5> <p id="d350123e186">Sixteen studies met our prespecified inclusion and exclusion criteria and were grouped based on outcomes measured: health system inputs ( <i>n</i> = 3), performance ( <i>n</i> = 7), and health outcomes ( <i>n</i> = 7). Numerous studies addressing conceptual issues related to decentralization but without any attempt at empirical estimation were excluded. Overall, we found mixed results regarding the effects of decentralization on health system indicators with seemingly beneficial effects on health system performance and health outcomes. Only 10 studies were considered to have relatively low risks of bias. </p> </div><div class="section"> <a class="named-anchor" id="milq12327-sec-0050"> <!-- named anchor --> </a> <h5 class="section-title" id="d350123e198">Conclusions</h5> <p id="d350123e200">This study reveals the limited empirical knowledge of the impact of decentralization on health system performance. Mixed empirical findings on the role of decentralization on health system performance and outcomes highlight the complexity of decentralization processes and their systemwide effects. Thus, we propose a renewed research agenda that focuses on discrete definitions of decentralization and how institutional factors and mechanisms affect health system performance and outcomes within the general context of decentralized governance structures. </p> </div>

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          Analyzing the decentralization of health systems in developing countries: decision space, innovation and performance.

          T Bossert (1998)
          Decentralization has long been advocated as a desirable process for improving health systems. Nevertheless, we still lack a sufficient analytical framework for systematically studying how decentralization can achieve this objective. We do not have adequate means of analyzing the three key elements of decentralization: (1) the amount of choice that is transferred from central institutions to institutions at the periphery of health systems, (2) what choices local officials make with their increased discretion and (3) what effect these choices have on the performance of the health system. This article proposes a framework of analysis that can be used to design and evaluate the decentralization of health systems. It starts from the assumption that decentralization is not an end in itself but rather should be designed and evaluated for its ability to achieve broader objectives of health reform: equity, efficiency, quality and financial soundness. Using a "principal agent" approach as the basic framework, but incorporating insights from public administration, local public choice and social capital approaches, the article presents a decision space approach which defines decentralization in terms of the set of functions and degrees of choice that formally are transferred to local officials. The approach also evaluates the incentives that central government can offer to local decision-makers to encourage them to achieve health objectives. It evaluates the local government characteristics that also influence decision-making and implementation at the local level. Then it determines whether local officials innovate by making choices that are different from those directed by central authorities. Finally, it evaluates whether the local choices have improved the performance of the local health system in achieving the broader health objectives. Examples from Colombia are used to illustrate the approach. The framework will be used to analyze the experience of decentralization in a series of empirical studies in Latin America. The results of these studies should suggest policy recommendations for adjusting decision space and incentives so that localities make decisions that achieve the objectives of health reform.
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                Author and article information

                Journal
                The Milbank Quarterly
                The Milbank Quarterly
                Wiley
                0887378X
                June 2018
                June 2018
                June 04 2018
                : 96
                : 2
                : 323-368
                Affiliations
                [1 ]Rockefeller College of Public Affairs and Policy; University at Albany-State University of New York
                [2 ]School of Architecture, Planning, and Policy Development; Institut Teknologi Bandung; Indonesia
                Article
                10.1111/1468-0009.12327
                5987820
                29870116
                fc1e6b50-3e31-46b7-a5df-d6dc4f5960ea
                © 2018

                http://doi.wiley.com/10.1002/tdm_license_1.1

                http://onlinelibrary.wiley.com/termsAndConditions#vor

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