International Journal of Public Health

, Volume 62, Issue 2, pp 219–229 | Cite as

Decentralization of health systems in low and middle income countries: a systematic review

  • Daniel Cobos MuñozEmail author
  • Paloma Merino Amador
  • Laura Monzon Llamas
  • David Martinez Hernandez
  • Juana Maria Santos Sancho



A substantial number of low and middle income countries (LMICs) have implemented health sector reforms in the last 40 years, and the majority of them have included some degree of decentralization of the health system as part of the wider reform. This review will provide an updated and comprehensive assessment of the effects of decentralization in LMICs.


We conducted a systematic review of published and grey literature till May 2015, following standard methods.


54 qualitative, quantitative and mixed methods studies conducted in 26 countries were included in the review. We found positive and negative effects of decentralization of health systems in LMICs. Whereas decentralization of governance, financing and service delivery, have been shown to have positive effects on the system; decentralization of resource management has been challenging in several settings.


Overall, lessons learned from LMICs suggest that factors such as adequate mix of technical skills at the local level to perform decentralized tasks, effective decentralization of decision-making to the periphery, and political leadership are key factors for a successful decentralization.


Systematic review Decentralization District health system Universal health coverage Health sector reform UHC Governance LMIC 



The authors would like to thank Gay Bronson and Ana Martinez Santos for their support with language editing.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Supplementary material

38_2016_872_MOESM1_ESM.docx (99 kb)
Supplementary material 1 (DOCX 112 kb)


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Copyright information

© Swiss School of Public Health (SSPH+) 2016

Authors and Affiliations

  • Daniel Cobos Muñoz
    • 1
    • 2
    Email author
  • Paloma Merino Amador
    • 3
  • Laura Monzon Llamas
    • 1
    • 2
  • David Martinez Hernandez
    • 4
  • Juana Maria Santos Sancho
    • 4
  1. 1.Swiss Tropical and Public Health InstituteBaselSwitzerland
  2. 2.University of BaselBaselSwitzerland
  3. 3.Department of MicrobiologyHospital Clínico San CarlosMadridSpain
  4. 4.Department of Public Health and Preventive MedicineComplutense UniversityMadridSpain

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