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 Muñoz
  • Paloma Merino Amador
  • Laura Monzon Llamas
  • David Martinez Hernandez
  • Juana Maria Santos Sancho
Review

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.

Keywords

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

Notes

Acknowledgments

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)

References

  1. Abdullah A, Stoelwinder J (2008) Decentralization and health resource allocation: a case study at the district level in Indonesia. Healthc Quart 11:117–125CrossRefGoogle Scholar
  2. 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 PubMedGoogle Scholar
  3. 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 PubMedGoogle Scholar
  4. 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 CrossRefPubMedPubMedCentralGoogle Scholar
  5. 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
  6. 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
  7. 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):S4CrossRefPubMedPubMedCentralGoogle Scholar
  8. 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 CrossRefPubMedGoogle Scholar
  9. 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 CrossRefGoogle Scholar
  10. 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) 16:335–346CrossRefGoogle Scholar
  11. 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 CrossRefPubMedGoogle Scholar
  12. 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 82:822–827PubMedPubMedCentralGoogle Scholar
  13. Atun R (2012) Health systems, systems thinking and innovation. Health Policy Plan 27(Suppl 4):iv4–iv8. doi:10.1093/heapol/czs088 CrossRefPubMedGoogle Scholar
  14. 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 CrossRefPubMedGoogle Scholar
  15. 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
  16. 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 CrossRefPubMedGoogle Scholar
  17. 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
  18. 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 7:724–729PubMedGoogle Scholar
  19. 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 15:94–103CrossRefGoogle Scholar
  20. Blas E, Limbambala ME (2001) User-payment, decentralization and health service utilization in Zambia. Health Policy Plan 16:19–28CrossRefPubMedGoogle Scholar
  21. 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):68–78CrossRefGoogle Scholar
  22. 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
  23. 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 CrossRefPubMedGoogle Scholar
  24. 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 81:95–100PubMedPubMedCentralGoogle Scholar
  25. 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 CrossRefPubMedGoogle Scholar
  26. 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
  27. 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
  28. Brinkerhoff D, Leighton C (2002) Decentralization and health system reform, vol 1. Partners for Health Reformplus, BethesdaGoogle Scholar
  29. 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 CrossRefPubMedGoogle Scholar
  30. 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):138–148CrossRefGoogle Scholar
  31. Cassels A (1995) Health sector reform: key issues in less developed countries. J Int Dev 7:329–347CrossRefPubMedGoogle Scholar
  32. 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 CrossRefPubMedGoogle Scholar
  33. 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 CrossRefPubMedGoogle Scholar
  34. Critical Appraisal Skills Programme (CASP) (2014) CASP quality assessment tool for qualitative studies. http://media.wix.com/ugd/dded87_29c5b002d99342f788c6ac670e49f274.pdf. Accessed Feb 2014
  35. 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
  36. 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 7:445–450PubMedGoogle Scholar
  37. 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 CrossRefPubMedPubMedCentralGoogle Scholar
  38. European Observatory on Health Systems and Policies (2007) Decentralization in health care: strategies and outcomes. Open University Press, New YorkGoogle Scholar
  39. 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 CrossRefPubMedGoogle Scholar
  40. Fleury S, Ouverney A, Kronemberger T, Zani F (2010) Governança local no sistema descentralizado de saúde no Brasil Rev Panam Salud Publica 28Google Scholar
  41. 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
  42. Gilson L (ed) (2012) Health policy and systems research: a methodology reader. World Health Organization, GenevaGoogle Scholar
  43. Gilson L, Mills A (1995) Health sector reforms in sub-Saharan Africa: lessons of the last 10 years. Health Policy 32:215–243CrossRefPubMedGoogle Scholar
  44. 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 CrossRefGoogle Scholar
  45. 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 6:22274CrossRefGoogle Scholar
  46. Han W (2012) Health care system reforms in developing countries. J Public Health Res 1:199–207. doi:10.4081/jphr.2012.e31 CrossRefPubMedPubMedCentralGoogle Scholar
  47. Hatt L, Johns B, Connor C, Meline M, Kukla M, Moat K (2015) Impact of health systems strengthening on health. Abt Associates, BethesdaGoogle Scholar
  48. 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
  49. 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 17:210–220CrossRefGoogle Scholar
  50. Jaramillo I (2002) Evaluation of health system decentralization and reform of the social security system in Colombia [Spanish]. Gaceta sanitaria/SESPAS 16:48–53CrossRefGoogle Scholar
  51. 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
  52. 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 CrossRefGoogle Scholar
  53. 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–S13PubMedGoogle Scholar
  54. 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 CrossRefPubMedGoogle Scholar
  55. 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 CrossRefPubMedGoogle Scholar
  56. 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 CrossRefPubMedPubMedCentralGoogle Scholar
  57. 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
  58. Litvack JI, Ahmad J, Bird RM (1998) Rethinking decentralization in developing countries. World Bank Publications, Washington, D.CCrossRefGoogle Scholar
  59. 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 CrossRefPubMedGoogle Scholar
  60. 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
  61. Maharani A, Tampubolon G (2014) Has decentralisation affected child immunisation status in Indonesia? Glob Health Action 7:24913. doi:10.3402/gha.v7.24913 CrossRefPubMedGoogle Scholar
  62. 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 CrossRefPubMedGoogle Scholar
  63. 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 CrossRefPubMedPubMedCentralGoogle Scholar
  64. Mills A, Vaughan JP, Smith DL, Tabibzadeh I (1990) Health system decentralization: concepts, issues and country experience. WHO, GenevaGoogle Scholar
  65. 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
  66. Mills A, Gilson L, Hanson K, Palmer N, Lagarde M (2008) What do we mean by rigorous health-systems research? Lancet 372:1527–1529CrossRefPubMedGoogle Scholar
  67. 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
  68. 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 CrossRefPubMedPubMedCentralGoogle Scholar
  69. 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 CrossRefPubMedPubMedCentralGoogle Scholar
  70. 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
  71. 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
  72. 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 CrossRefPubMedPubMedCentralGoogle Scholar
  73. Phommasack B et al (2005) Decentralization and recentralization: effects on the health systems in Lao PDR. Southeast Asian J Trop Med Public Health 36:523–528PubMedGoogle Scholar
  74. 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
  75. 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 CrossRefGoogle Scholar
  76. 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 CrossRefGoogle Scholar
  77. 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 CrossRefGoogle Scholar
  78. Saly S, Onozaki I, Ishikawa N (2006) Decentralized DOTS shortens delay to TB treatment significantly in Cambodia Kekkaku. Tuberculosis 81:467–474PubMedGoogle Scholar
  79. 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 CrossRefGoogle Scholar
  80. 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 CrossRefPubMedGoogle Scholar
  81. Seshadri SR, Hebbare L, Kotte S (2012) Decentralisation and decision space in the health sector, Karnataka, India. In: BMC Proceedings, vol 6Google Scholar
  82. 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 62:28–32PubMedGoogle Scholar
  83. 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 CrossRefPubMedGoogle Scholar
  84. 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
  85. 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 CrossRefPubMedGoogle Scholar
  86. 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 12:538–547PubMedGoogle Scholar
  87. 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 CrossRefPubMedPubMedCentralGoogle Scholar
  88. WHO (1987) Declaration on strengthening district health systems based on primary health care. WHO, HarareGoogle Scholar
  89. WHO (2008) Everybody’ s business strengthening health systems to improve health outcomes. WHO, GenevaGoogle Scholar
  90. 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
  91. WHO (2010) Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies. WHO, GenevaGoogle Scholar
  92. WHO (2015) Health in 2015: from MDGs, millennium development goals to SDGs, sustainable development goals. WHO, Geneva. ISBN 978-92-4-156511-0Google Scholar
  93. 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 CrossRefGoogle Scholar
  94. World Bank (2016) Country and lending groups 2014. Accessed January 2016. http://data.worldbank.org/about/country-classifications/country-and-lending-groups

Copyright information

© Swiss School of Public Health (SSPH+) 2016

Authors and Affiliations

  • Daniel Cobos Muñoz
    • 1
    • 2
  • 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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