Decentralization of health systems in low and middle income countries: a systematic review
- 863 Downloads
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.
KeywordsSystematic 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.
This article does not contain any studies with human participants or animals performed by any of the authors.
- Anokbonggo WW, Ogwal-Okeng JW, Obua C, Aupont O, Ross-Degnan D (2004a) Impact of decentralization on health services in Uganda: a look at facility utilization, prescribing and availability of essential drugs. East Afr Med J 81(12):S2–S7Google Scholar
- Anokbonggo WW, Ogwal-Okeng JW, Ross-Degnan D, Aupont O (2004b) Attitudes and perceptions of stakeholders on decentralization of health services in Uganda: the case of Lira and Apac districts. East Afr Med J Suppl S8–S11Google Scholar
- Ayala Cerna C, Kroeger A (2002) Health sector reform in Colombia and its effects on tuberculosis control and immunization programs [Spanish]. Cadernos de saude publica/Ministerio da Saude Fundacao Oswaldo Cruz, Escola Nacional de Saude Publica 18:1771–1781Google Scholar
- Berman PA, Bossert TJ (2000) A Decade of Health Sector Reform in developing countries: what have we learned? Paper presented at the appraising a decade of health sector reform in developing countries, Washington, DCGoogle Scholar
- Bossert T (2000) Guidelines for promoting decentralization of health systems in Latin America. Latin America and caribbean health sector reform initiative - LAC HSR - No 30Google Scholar
- Boyer S, Abu-Zaineh M, Blanche J, Loubiere S, Bonono RC, Moatti JP, Ventelou B (2011) Does HIV services decentralization protect against the risk of catastrophic health expenditures? Some lessons from Cameroon. Health Serv Res 46:2029–2056. doi: 10.1111/j.1475-6773.2011.01312.x CrossRefPubMedPubMedCentralGoogle Scholar
- Boyer S, Protopopescu C, Marcellin F, Carrieri MP, Koulla-Shiro S, Moatti J-P, Spire B (2012) Performance of HIV care decentralization from the patient’s perspective: health-related quality of life and perceived quality of services in Cameroon. Health Policy Plan 27:301–315. doi: 10.1093/heapol/czr039 CrossRefPubMedGoogle Scholar
- Brinkerhoff D, Leighton C (2002) Decentralization and health system reform, vol 1. Partners for Health Reformplus, BethesdaGoogle Scholar
- Critical Appraisal Skills Programme (CASP) (2014) CASP quality assessment tool for qualitative studies. http://media.wix.com/ugd/dded87_29c5b002d99342f788c6ac670e49f274.pdf. Accessed Feb 2014
- Egger D, Ollier E, Tumusiime P, Bataringaya J (2007) Strengthening management in low-income countries: lessons from Uganda, vol 11. World Health Organization, GenevaGoogle Scholar
- European Observatory on Health Systems and Policies (2007) Decentralization in health care: strategies and outcomes. Open University Press, New YorkGoogle Scholar
- Fleury S, Ouverney A, Kronemberger T, Zani F (2010) Governança local no sistema descentralizado de saúde no Brasil Rev Panam Salud Publica 28Google Scholar
- Frumence G, Nyamhanga T, Mwangu M, Hurtig AK (2014) The dependency on central government funding of decentralised health systems: experiences of the challenges and coping strategies in the Kongwa District, Tanzania. BMC Health Serv Res 14:39. doi: 10.1186/1472-6963-14-39 CrossRefPubMedPubMedCentralGoogle Scholar
- Gilson L (ed) (2012) Health policy and systems research: a methodology reader. World Health Organization, GenevaGoogle Scholar
- Hatt L, Johns B, Connor C, Meline M, Kukla M, Moat K (2015) Impact of health systems strengthening on health. Abt Associates, BethesdaGoogle Scholar
- Higgins JPT, Green S (2011) Cochrane handbook for systematic reviews of interventions version 5.1.0 [updated March 2011]. The Cochrane Collaboration. Available from http://handbook.cochrane.org
- Jimenez MM, Hinestroza Y, Gomez RD (2007) Health reform and malaria control in two endemic areas of Colombia, 1982–2004 [Spanish]. Colombia Medica 38:113–131Google Scholar
- Levaggi R, Smith P (2003) Decentralization in health care: lessons from public economics. Paper presented at the conference on economics and health policy centre for health economics, YorkGoogle Scholar
- Loubiere S, Boyer S, Protopopescu C, Bonono CR, Abega S-C, Spire B, Moatti J-P (2009) Decentralization of HIV care in Cameroon: increased access to antiretroviral treatment and associated persistent barriers. Health Policy 92:165–173. doi: 10.1016/j.healthpol.2009.03.006 CrossRefPubMedGoogle Scholar
- Mills A, Vaughan JP, Smith DL, Tabibzadeh I (1990) Health system decentralization: concepts, issues and country experience. WHO, GenevaGoogle Scholar
- Mills A, Antonius R, Daniel J, Gray H, Haqq E, Rutten F (2002) The distribution of health planning and management responsibilities between centre and periphery: historical patterns and reform trends in four Caribbean territories. Health Policy 62:65–84. doi: 10.1016/S0168-8510%2801%2900230-5 CrossRefPubMedGoogle Scholar
- Moher D, Liberati A, Tetzlaff J, Altman DG (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 15:e1000097Google Scholar
- Mutevedzi PC, Lessells RJ, Heller T, Banighausen T, Cooke GS, Newell ML (2010) Scale-up of a decentralized HIV treatment programme in rural Kwazulu-Natal, South Africa: does rapid expansion affect patient outcomes? [Spanish]. Bull World Health Organ 88:593–600. doi: 10.2471/BLT.09.069419 CrossRefPubMedPubMedCentralGoogle Scholar
- O’Connell T, Sharkey A (2013) Reaching universal health coverage through district health system strengthening: using a modified Tanahashi model sub-nationally to attain equitable and effective coverage. UNICEF, New YorkGoogle Scholar
- Rashidian A, Joudaki H, Khodayari-Moez E, Omranikhoo H, Geraili B, Arab M (2013) The impact of rural health system reform on hospitalization rates in the Islamic Republic of Iran: an interrupted time series. Bull World Health Organ 91:942–949. doi: 10.2471/BLT.12.111708 CrossRefPubMedPubMedCentralGoogle Scholar
- Seshadri SR, Hebbare L, Kotte S (2012) Decentralisation and decision space in the health sector, Karnataka, India. In: BMC Proceedings, vol 6Google Scholar
- United Nations (2015) Transforming our world: the 2030 agenda for sustainable development. http://www.un.org/ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=E
- WHO (1987) Declaration on strengthening district health systems based on primary health care. WHO, HarareGoogle Scholar
- WHO (2008) Everybody’ s business strengthening health systems to improve health outcomes. WHO, GenevaGoogle Scholar
- WHO (2009) Ouagadougou Declaration on primary health care and health systems in Africa: achieving better health for Africa in the new millennium. WHO, OuagadougouGoogle Scholar
- WHO (2010) Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies. WHO, GenevaGoogle Scholar
- WHO (2015) Health in 2015: from MDGs, millennium development goals to SDGs, sustainable development goals. WHO, Geneva. ISBN 978-92-4-156511-0Google Scholar
- World Bank (2016) Country and lending groups 2014. Accessed January 2016. http://data.worldbank.org/about/country-classifications/country-and-lending-groups