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

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  • Published:
International Journal of Public Health

Abstract

Objectives

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.

Methods

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

Results

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.

Conclusions

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.

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References

  • Abdullah A, Stoelwinder J (2008) Decentralization and health resource allocation: a case study at the district level in Indonesia. Healthc Quart 11:117–125

    Article  Google Scholar 

  • Adam T, de Savigny D (2012) Systems thinking for strengthening health systems in LMICs: need for a paradigm shift. Health Policy Plan 27(Suppl 4):iv1–iv3. doi:10.1093/heapol/czs084

    PubMed  Google Scholar 

  • Adam T, Hsu J, de Savigny D, Lavis JN, Rottingen JA, Bennett S (2012) Evaluating health systems strengthening interventions in low-income and middle-income countries: are we asking the right questions? Health Policy Plan 27(Suppl 4):iv9–iv19. doi:10.1093/heapol/czs086

    PubMed  Google Scholar 

  • Ali Jadoo SA, Aljunid SM, Sulku SN, Nur AM (2014) Turkish health system reform from the people’s perspective: a cross sectional study. BMC Health Serv Res 14:30. doi:10.1186/1472-6963-14-30

    Article  PubMed  PubMed Central  Google Scholar 

  • 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–S7

    Google 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–S11

  • Ansari U, Cockcroft A, Omer K, Ansari NM, Khan A, Chaudhry UU, Andersson N (2011) Devolution and public perceptions and experience of health services in Pakistan: linked cross sectional surveys in 2002 and 2004. BMC Health Serv Res 11(Suppl 2):S4

    Article  PubMed  PubMed Central  Google Scholar 

  • Arredondo A, Orozco E (2006) Effects of health decentralization, financing and governance in Mexico. Rev Saude Publica 40:152–160. doi:10.1590/S0034-89102006000100023

    Article  PubMed  Google Scholar 

  • Arredondo A, Orozco E (2008) Equity, governance and financing after health care reform: lessons from Mexico. Int J Health Plan Manag 23:37–49. doi:10.1002/hpm.913

    Article  Google Scholar 

  • Arredondo-Lopez A, Orozco-Nunez E (2014) Health governance and social protection indicators in Latin-America: strengths, weaknesses and lessons-learned from six Mexican states. Rev Salud Publica (Bogota) 16:335–346

    Article  Google Scholar 

  • Arrieta A (2011) Health reform and cesarean sections in the private sector: the experience of Peru. Health Policy 99:124–130. doi:10.1016/j.healthpol.2010.07.016

    Article  PubMed  Google Scholar 

  • Atkinson S, Haran D (2004) Back to basics: does decentralization improve health system performance? Evidence from Ceará in north-east Brazil. Bull World Health Organ 82:822–827

    PubMed  PubMed Central  Google Scholar 

  • Atun R (2012) Health systems, systems thinking and innovation. Health Policy Plan 27(Suppl 4):iv4–iv8. doi:10.1093/heapol/czs088

    Article  PubMed  Google Scholar 

  • Atun R, de Jongh T, Secci F, Ohiri K, Adeyi O (2010) A systematic review of the evidence on integration of targeted health interventions into health systems. Health Policy Plan 25:1–14. doi:10.1093/heapol/czp053

    Article  PubMed  Google 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 18:1771–1781

    Google Scholar 

  • Bedelu M, Ford N, Hilderbrand K, Reuter H (2007) Implementing antiretroviral therapy in rural communities: the Lusikisiki model of decentralized HIV/AIDS care. J Infect Dis 196:S464–S468. doi:10.1086/521114

    Article  PubMed  Google 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, DC

  • Bernatas JJ, Ali IM, Ismael HA, Matan AB, Aboubakar IH (2003) Decentralisation of directly observed treatment in a large African city: evaluation of the experience of Djibouti. Int J Tuberc Lung Dis 7:724–729

    CAS  PubMed  Google Scholar 

  • Bixby LR (2004) Assessing the impact of health sector reform in Costa Rica through a quasi-experimental study [Spanish]. Revista Panamericana de Salud Publica/Pan Am J Public Health 15:94–103

    Article  Google Scholar 

  • Blas E, Limbambala ME (2001) User-payment, decentralization and health service utilization in Zambia. Health Policy Plan 16:19–28

    Article  PubMed  Google Scholar 

  • Borrero E, Carrasquilla G, Alexander N (2012) Decentralization and health system reform: what is their impact on malaria incidence in Colombian municipalities? [Spanish]. Biomedica: revista del Instituto Nacional de Salud 32(Suppl 1):68–78

    Article  Google 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 30

  • Bossert T, Chitah MB, Bowser D (2003a) Decentralization in Zambia: resource allocation and district performance. Health Policy Plan 18:357–369. doi:10.1093/heapol/czg044

    Article  PubMed  Google Scholar 

  • Bossert TJ, Larranaga O, Giedion U, Arbelaez JJ, Bowser DM (2003b) Decentralization and equity of resource allocation: evidence from Colombia and Chile. Bull World Health Organ 81:95–100

    PubMed  PubMed Central  Google Scholar 

  • Boyer S, Eboko F, Camara M, Abe C, Nguini MEO, Koulla-Shiro S, Moatti JP (2010) Scaling up access to antiretroviral treatment for HIV infection: the impact of decentralization of healthcare delivery in Cameroon. Aids 24:S5–S15. doi:10.1097/01.aids.0000366078.45451.46

    Article  PubMed  Google 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

    Article  PubMed  PubMed Central  Google 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

    Article  PubMed  Google Scholar 

  • Brinkerhoff D, Leighton C (2002) Decentralization and health system reform, vol 1. Partners for Health Reformplus, Bethesda

  • Campos-Outcalt D, Kewa K, Thomason J (1995) Decentralization of health services in Western Highlands Province, Papua New Guinea: an attempt to administer health service at the subdistrict level. Soc Sci Med 40:1091–1098. doi:10.1016/0277-9536(94)00222-f

    Article  CAS  PubMed  Google Scholar 

  • Carvajal R, Cabrera GA, Mateus JC (2004) Effects of the health sector reform upon tuberculosis control interventions in Valle del Cauca, Colombia [Spanish]. Biomedica: revista del Instituto Nacional de Salud 24(Supp 1):138–148

    Article  Google Scholar 

  • Cassels A (1995) Health sector reform: key issues in less developed countries. J Int Dev 7:329–347

    Article  CAS  PubMed  Google Scholar 

  • Chan AK et al (2010) Outcome assessment of decentralization of antiretroviral therapy provision in a rural district of Malawi using an integrated primary care model. Trop Med Int Health 15:90–97. doi:10.1111/j.1365-3156.2010.02503.x

    Article  PubMed  Google Scholar 

  • Ciccone DK, Vian T, Maurer L, Bradley EH (2014) Linking governance mechanisms to health outcomes: a review of the literature in low- and middle-income countries. Soc Sci Med 117:86–95. doi:10.1016/j.socscimed.2014.07.010

    Article  PubMed  Google 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, Geneva

  • El-Sony AI, Mustafa SA, Khamis AH, Enarson DA, Baraka OZ, Bjunett G (2003) The effect of decentralisation on tuberculosis services in three states of Sudan. Int J Tuberc Lung Dis 7:445–450

    CAS  PubMed  Google Scholar 

  • English M, Irimu G, Wamae A, Were F, Wasunna A, Fegan G, Peshu N (2008) Health systems research in a low-income country: easier said than done. Arch Dis Child 93:540–544. doi:10.1136/adc.2007.126466

    Article  PubMed  PubMed Central  Google Scholar 

  • European Observatory on Health Systems and Policies (2007) Decentralization in health care: strategies and outcomes. Open University Press, New York

  • Fayorsey RN et al (2013) Decentralization of pediatric HIV care and treatment in five sub-Saharan African countries. J Acquir Immune Defic Syndr 62:e124–e130. doi:10.1097/QAI.0b013e3182869558

    Article  PubMed  Google Scholar 

  • Fleury S, Ouverney A, Kronemberger T, Zani F (2010) Governança local no sistema descentralizado de saúde no Brasil Rev Panam Salud Publica 28

  • 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

    Article  PubMed  PubMed Central  Google Scholar 

  • Gilson L (ed) (2012) Health policy and systems research: a methodology reader. World Health Organization, Geneva

  • Gilson L, Mills A (1995) Health sector reforms in sub-Saharan Africa: lessons of the last 10 years. Health Policy 32:215–243

    Article  CAS  PubMed  Google Scholar 

  • Guanais FC, Macinko J (2009) The health effects of decentralizing primary care in Brazil. Health Aff (Millwood) 28:1127–1135. doi:10.1377/hlthaff.28.4.1127

    Article  Google Scholar 

  • Hagstromer O, Lundstedt L, Balcha TT, Bjorkman P (2013) Decentralised paediatric HIV care in Ethiopia: a comparison between outcomes of patients managed in health centres and in a hospital clinic. Glob Health Action 6:22274

    Article  Google Scholar 

  • Han W (2012) Health care system reforms in developing countries. J Public Health Res 1:199–207. doi:10.4081/jphr.2012.e31

    Article  PubMed  PubMed Central  Google Scholar 

  • Hatt L, Johns B, Connor C, Meline M, Kukla M, Moat K (2015) Impact of health systems strengthening on health. Abt Associates, Bethesda

    Google 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

  • Homedes N, Ugalde A (2005) Las reformas de salud neoliberales en América Latina: una visión crítica a través de dos estudios de caso. Pan Am J Public Health 17:210–220

    Article  Google Scholar 

  • Jaramillo I (2002) Evaluation of health system decentralization and reform of the social security system in Colombia [Spanish]. Gaceta sanitaria/SESPAS 16:48–53

    Article  CAS  Google Scholar 

  • Jimenez MM, Hinestroza Y, Gomez RD (2007) Health reform and malaria control in two endemic areas of Colombia, 1982–2004 [Spanish]. Colombia Medica 38:113–131

    Google Scholar 

  • Kamuzora P, Maluka S, Ndawi B, Byskov J, Hurtig AK (2013) Promoting community participation in priority setting in district health systems: experiences from Mbarali district. Tanzania Glob Health Action 6:22669. doi:10.3402/gha.v6i0.22669

    Article  Google Scholar 

  • Kangangi JK et al (2003) Decentralisation of tuberculosis treatment from the main hospitals to the peripheral health units and in the community within Machakos District. Kenya Int J Tuberc Lung Dis 7:S5–S13

    CAS  PubMed  Google Scholar 

  • Khaleghian P (2004) Decentralization and public services: the case of immunization. Soc Sci Med 59:163–183. doi:10.1016/j.socscimed.2003.10.013

    Article  PubMed  Google Scholar 

  • Kroeger A, Ordonez-Gonzalez J, Avina AI (2002) Malaria control reinvented: health sector reform and strategy development in Colombia. Trop Med Int Health 7:450–458. doi:10.1046/j.1365-3156.2002.00876.x

    Article  PubMed  Google Scholar 

  • La Vincente S, Aldaba B, Firth S, Kraft A, Jimenez-Soto E, Clark A (2013) Supporting local planning and budgeting for maternal, neonatal and child health in the Philippines. Health Res Policy Syst 11:3. doi:10.1186/1478-4505-11-3

    Article  PubMed  PubMed Central  Google 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, York

  • Litvack JI, Ahmad J, Bird RM (1998) Rethinking decentralization in developing countries. World Bank Publications, Washington, D.C

    Book  Google Scholar 

  • Liu X, Martineau T, Chen L, Zhan S, Tang S (2006) Does decentralisation improve human resource management in the health sector? A case study from China. Soc Sci Med 63:1836–1845. doi:10.1016/j.socscimed.2006.05.011

    Article  PubMed  Google 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

    Article  PubMed  Google Scholar 

  • Maharani A, Tampubolon G (2014) Has decentralisation affected child immunisation status in Indonesia? Glob Health Action 7:24913. doi:10.3402/gha.v7.24913

    Article  PubMed  Google Scholar 

  • McPake B, Yepes FJ, Lake S, Sanchez LH (2003) Is the Colombian health system reform improving the performance of public hospitals in Bogota? Health Policy Plan 18:182–194. doi:10.1093/heapol/czg023

    Article  PubMed  Google Scholar 

  • Meessen B, Malanda B, Community of Practice “Health Service D” (2014) No universal health coverage without strong local health systems. Bull World Health Organ 92:78–78A. doi:10.2471/BLT.14.135228

    Article  PubMed  PubMed Central  Google Scholar 

  • Mills A, Vaughan JP, Smith DL, Tabibzadeh I (1990) Health system decentralization: concepts, issues and country experience. WHO, Geneva

    Google 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

    Article  CAS  PubMed  Google Scholar 

  • Mills A, Gilson L, Hanson K, Palmer N, Lagarde M (2008) What do we mean by rigorous health-systems research? Lancet 372:1527–1529

    Article  PubMed  Google 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:e1000097

    Google Scholar 

  • Mshelia C et al (2013) Can action research strengthen district health management and improve health workforce performance? A research protocol. BMJ Open 3:e003625. doi:10.1136/bmjopen-2013-003625

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Munga MA, Songstad NG, Blystad A, Maestad O (2009) The decentralisation-centralisation dilemma: recruitment and distribution of health workers in remote districts of Tanzania. BMC Int Health Hum Rights 9:9. doi:10.1186/1472-698X-9-9

    Article  PubMed  PubMed Central  Google 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

    Article  PubMed  PubMed Central  Google 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 York

    Google Scholar 

  • Perks C, Toole MJ, Phouthonsy K (2006) District health programmes and health-sector reform: case study in the Lao People’s Democratic Republic. Bull World Health Organ 84:132–138. doi:10.2471/BLT.05.025403

    Article  PubMed  PubMed Central  Google Scholar 

  • Phommasack B et al (2005) Decentralization and recentralization: effects on the health systems in Lao PDR. Southeast Asian J Trop Med Public Health 36:523–528

    PubMed  Google 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

    Article  PubMed  PubMed Central  Google Scholar 

  • Regmi K, Naidoo J, Pilkington PA, Greer A (2010) Decentralization and district health services in Nepal: understanding the views of service users and service providers. J Public Health 32:406–417. doi:10.1093/pubmed/fdp116

    Article  Google Scholar 

  • Reidy WJ et al (2014) Decentralization of HIV care and treatment services in central Province, Kenya. J Acquir Immune Defic Syndromes 67:e34–e40. doi:10.1097/QAI.0000000000000264

    Article  Google Scholar 

  • Saide MAO, Stewart DE (2001) Decentralization and human resource management in the health sector: a case study (1996–1998) from Nampula province. Mozamb Int J Health Plan Manag 16:155–168. doi:10.1002/hpm.620

    Article  CAS  Google Scholar 

  • Saly S, Onozaki I, Ishikawa N (2006) Decentralized DOTS shortens delay to TB treatment significantly in Cambodia Kekkaku. Tuberculosis 81:467–474

    PubMed  Google Scholar 

  • Segall M (2003) District health systems in a neoliberal world: a review of key policy areas. Int J Health Plan Manag 18:S5–S26. doi:10.1002/hpm.719

    Article  Google Scholar 

  • Senkubuge F, Modisenyane M, Bishaw T (2014) Strengthening health systems by health sector reforms. Glob Health Action 7:23568. doi:10.3402/gha.v7.23568

    Article  PubMed  Google Scholar 

  • Seshadri SR, Hebbare L, Kotte S (2012) Decentralisation and decision space in the health sector, Karnataka, India. In: BMC Proceedings, vol 6

  • Shaikh S, Naeem I, Nafees A, Zahidie A, Fatmi Z, Kazi A (2012) Experience of devolution in district health system of Pakistan: perspectives regarding needed reforms. J Pak Med Assoc 62:28–32

    PubMed  Google Scholar 

  • Thomas BH, Ciliska D, Dobbins M, Micucci S (2004) A process for systematically reviewing the literature: providing the research evidence for public health nursing interventions. Worldviews Evid Based Nurs 1:176–184. doi:10.1111/j.1524-475X.2004.04006.x

    Article  CAS  PubMed  Google 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

  • Vargas Bustamante A (2010) The tradeoff between centralized and decentralized health services: evidence from rural areas in Mexico. Soc Sci Med 71:925–934. doi:10.1016/j.socscimed.2010.05.022

    Article  PubMed  Google Scholar 

  • Wei X, Liang X, Liu F, Walley JD, Dong B (2008) Decentralising tuberculosis services from county tuberculosis dispensaries to township hospitals in China: an intervention study. Int J Tuberc Lung Dis 12:538–547

    CAS  PubMed  Google Scholar 

  • Wei X et al (2011) Evaluating the impact of decentralising tuberculosis microscopy services to rural township hospitals in Gansu Province, China. BMC Public Health 11:103. doi:10.1186/1471-2458-11-103

    Article  PubMed  PubMed Central  Google Scholar 

  • WHO (1987) Declaration on strengthening district health systems based on primary health care. WHO, Harare

    Google Scholar 

  • WHO (2008) Everybody’ s business strengthening health systems to improve health outcomes. WHO, Geneva

    Google Scholar 

  • WHO (2009) Ouagadougou Declaration on primary health care and health systems in Africa: achieving better health for Africa in the new millennium. WHO, Ouagadougou

    Google Scholar 

  • WHO (2010) Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies. WHO, Geneva

    Google Scholar 

  • WHO (2015) Health in 2015: from MDGs, millennium development goals to SDGs, sustainable development goals. WHO, Geneva. ISBN 978-92-4-156511-0

    Google Scholar 

  • Willis K, Khan S (2009) Health Reform in Latin America and Africa: decentralisation, participation and inequalities. Third World Quart 30:991–1005. doi:10.1080/01436590902969742

    Article  Google Scholar 

  • World Bank (2016) Country and lending groups 2014. Accessed January 2016. http://data.worldbank.org/about/country-classifications/country-and-lending-groups

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Acknowledgments

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

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Authors and Affiliations

  1. Swiss Tropical and Public Health Institute, Socinstrasse 57, PO Box 4002, Basel, Switzerland

    Daniel Cobos Muñoz & Laura Monzon Llamas

  2. University of Basel, Basel, Switzerland

    Daniel Cobos Muñoz & Laura Monzon Llamas

  3. Department of Microbiology, Hospital Clínico San Carlos, Madrid, Spain

    Paloma Merino Amador

  4. Department of Public Health and Preventive Medicine, Complutense University, Madrid, Spain

    David Martinez Hernandez & Juana Maria Santos Sancho

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  1. Daniel Cobos Muñoz
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  2. Paloma Merino Amador
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  3. Laura Monzon Llamas
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Correspondence to Daniel Cobos Muñoz.

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Cobos Muñoz, D., Merino Amador, P., Monzon Llamas, L. et al. Decentralization of health systems in low and middle income countries: a systematic review. Int J Public Health 62, 219–229 (2017). https://doi.org/10.1007/s00038-016-0872-2

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