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

Dwicaksono, Adenantera; Fox, Ashley

doi:10.1111/1468-0009.12327

Cited by 45 publications

(58 citation statements)

References 44 publications

(124 reference statements)

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“…Keywords: Decentralization, Decision making, Health policy, Mixed methods, Philippines, Public health administration Background Decentralization of health services, particularly in the form of devolution of authority to local governments [1], has been implemented in many countries motivated by the expectation that it will empower local decisionmakers to oversee and steer their own health services [2]. Yet beyond a few studies of selected disease-specific programs where decentralization resulted in better health outcomes [3,4], decentralization's effectiveness in improving outcomes related to the broader dimension of health system performance is uncertain based on the limited number of reviews that examined the global evidence [5][6][7]. On the other hand, the fact that local decision-makers are granted the "decision space" [8,9], which provides an idea of the extent of choices available to them, and are able to make decisions for the functions of local health services because of decentralization may already be a desired outcome in itself.…”

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confidence: 99%

Who should decide for local health services? A mixed methods study of preferences for decision-making in the decentralized Philippine health system

Liwanag

Wyss

2020

BMC Health Serv Res

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Background: The Philippines decentralized government health services through devolution to local governments in 1992. Over the years, opinions varied on the impact of devolved governance to decision-making for local health services. The objective of this study was to analyze decision-makers' perspectives on who should be making decisions for local health services and on their preferred structure of health service governance should they be able to change the situation. Methods: We employed a mixed methods approach that included an online survey in one region and in-depth interviews with purposively-selected decision-makers in the Philippine health system. Study participants were asked about their perspectives on decision-making in the functions of planning, health financing, resource management, human resources for health, health service delivery, and data management and monitoring. Analysis of survey results through visualization of data on charts was complemented by the themes that emerged from the qualitative analysis of in-depth interviews based on the Framework Method. Results: We received 24 online survey responses and interviewed 27 other decision-makers. Survey respondents expressed a preference to shift decision-making away from the local politician in favor of the local health officer in five functions. Most survey participants also preferred re-centralization. Analysis of the interviews suggested that the preferences expressed were likely driven by an expectation that re-centralization would provide a solution to the perceived politicization in decision-making and the reliance of local governments on central support.

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confidence: 99%

Who should decide for local health services? A mixed methods study of preferences for decision-making in the decentralized Philippine health system

Liwanag

Wyss

2020

BMC Health Serv Res

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“…These three health system goals (equity, efficiency and resilience) were selected because of their conceptual richness, the extensive (and unresolved) literature on the relationship between them and decentralization, and their emerging currency as major goals to which health systems need to aspire globally (see Sumah et al , 2016; Dwicaksono and Fox, 2018; Aligica and Tarko, 2014). While the literature on the definition of these terms is extensive and often contested (see Braveman and Gruskin, 2003; Cylus et al , 2016; and Barasa et al , 2017), for the purposes of this review, we adopted basic and broad definitions.…”

Section: Introductionmentioning

confidence: 99%

“…These sources of complexity are neither sufficiently explored (nor, indeed, explorable) in approaches to systematic review which focus on whether specific desired outcomes are generated or not. Hence, previous systematic reviews sought to identify generalizable and conclusive evidence on whether the impact of decentralization on health systems is positive or negative (Sreeramareddy and Sathyanarayana, 2013; Sumah et al , 2016; Cobos Muñoz et al , 2017; Liwanag and Wyss, 2017; Dwicaksono and Fox, 2018), with the outcomes of interest defined in specific, quantitative terms, thus limiting the range of evidence to review (Sreeramareddy and Sathyanarayana, 2013; Sumah et al , 2016; Dwicaksono and Fox, 2018), with limited potential for transferring insights and lessons from one setting to another.…”

Section: Introductionmentioning

confidence: 99%

The impacts of decentralization on health system equity, efficiency and resilience: a realist synthesis of the evidence

Abimbola

Baatiema

Bigdeli

2019

Health Policy and Planning

154

207

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One constant refrain in evaluations and reviews of decentralization is that the results are mixed. But given that decentralization is a complex intervention or phenomenon, what is more important is to generate evidence to inform implementation strategies. We therefore synthesized evidence from the literature to understand why, how and under what circumstances decentralization influences health system equity, efficiency and resilience. In doing this, we adopted the realist approach to evidence synthesis and included quantitative and qualitative studies in high-, low- and middle-income countries that assessed the the impact of decentralization on health systems. We searched the Medline and Embase databases via Ovid, and the Cochrane library of systematic reviews and included 51 studies with data from 25 countries. We identified three mechanisms through which decentralization impacts on health system equity, efficiency and resilience: ‘Voting with feet’ (reflecting how decentralization either exacerbates or assuages the existing patterns of inequities in the distribution of people, resources and outcomes in a jurisdiction); ‘Close to ground’ (reflecting how bringing governance closer to the people allows for use of local initiative, information, feedback, input and control); and ‘Watching the watchers’ (reflecting mutual accountability and support relations between multiple centres of governance which are multiplied by decentralization, involving governments at different levels and also community health committees and health boards). We also identified institutional, socio-economic and geographic contextual factors that influence each of these mechanisms. By moving beyond findings that the effects of decentralization on health systems and outcomes are mixed, this review presents mechanisms and contextual factors to which policymakers and implementers need to pay attention in their efforts to maximize the positive and minimize the negative impact of decentralized governance.

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“…Besides that, decentralization should accelerate service delivery in each area. Although the outcome effect varied, decentralization can improve health outcomes such as infant mortality rates, maternal mortality rates, and life expectancy (26).…”

Section: Discussionmentioning

confidence: 99%

Scaling Up Public Health Interventions: A Case Study of the Polio Immunization Program in Indonesia

Cintyamena

Azizatunnisa

Ahmad

et al. 2020

Preprint

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Background: The scaling up of public health interventions has received greater attention in recent years; however, there remains paucity of systematic investigations of the scaling up processes. We aim to investigate the overall process, actors and contexts of polio immunization scaling up in Indonesia from 1988 until 2018. Methods: A mixed method study with sequential explanatory design was conducted. We carried out a quantitative survey of 323 actors involved in the polio program at national and sub-national levels, followed by Key Informant Interviews (KII)s. Document review was also carried out to construct a timeline of the polio eradication program with milestones. We carried out descriptive statistical analysis of quantitative data and thematic analysis of qualitative data.Results: The scaling up of polio immunization in Indonesia started as a vertical expansion approach led by the Ministry of Health within a centralized health system. The coverage of immunization increased drastically from 5% in the earlier 80s to 67.5% in 1987; incremental increases followed until achieving Universal Coverage Immunization (UCI) in 1990 and subsequently 95% coverage in 1995. Engagement of stakeholders and funding made the scaling up of polio immunization a priority. There was also substantial multisector involvement, including institutions and communities. Local area monitoring (LAM) and integrated health posts (Posyandu) were key to the polio immunization implementation strategy. Challenges for scaling up during this centralized period included cold chain infrastructure and limited experience in carrying out mass campaigns. Scaling up during the decentralized era was slower due to expansion in the number of provinces and districts. Moreover, there were challenges such as the negative perception of immunization side-effects, staff turnover, and the unsmooth transition of centralization towards decentralization.Conclusion: Vertical scaling up of polio immunization program intervention was successful during the centralized era, with involvement of the president as a role model and the engine of multi sector actors. Posyandu (integrated health posts) played an important role, yet its revitalization after the reform-decentralization era has not been optimum.

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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

Cited by 45 publications

References 44 publications

Who should decide for local health services? A mixed methods study of preferences for decision-making in the decentralized Philippine health system

Who should decide for local health services? A mixed methods study of preferences for decision-making in the decentralized Philippine health system

The impacts of decentralization on health system equity, efficiency and resilience: a realist synthesis of the evidence

Scaling Up Public Health Interventions: A Case Study of the Polio Immunization Program in Indonesia

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