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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.
Milbank Q 2018; 96(2):323-368MQ

Abstract

Policy Points: For more than 3 decades, international development agencies have advocated health system decentralization to improve health system performance in low- and middle-income countries. We found little rigorous evidence documenting the impact of decentralization processes on health system performance or outcomes in part due to challenges in measuring such far-reaching and multifaceted system-level changes. We propose a renewed research agenda that focuses on discrete definitions of decentralization and how institutional factors and mechanisms affect health system performance and outcomes within the general context of decentralized governance structures.

CONTEXT

Despite the widespread adoption of decentralization reforms as a means to improve public service delivery in developing countries since the 1980s, empirical evidence of the role of decentralization on health system improvement is still limited and inconclusive. This study reviewed studies published from 2000 to 2016 with adequate research designs to identify evidence on whether and how decentralization processes have impacted health systems.

METHODS

We conducted a systematic review of peer-reviewed journal articles from the public health and social science literature. We searched for articles within 9 databases using predefined search terms reflecting decentralization and health system constructs. Inclusion criteria were original research articles, low- and middle-income country settings, quantifiable outcome measures, and study designs that use comparisons or statistical adjustments. We excluded studies in high-income country settings and/or published in a non-English language.

FINDINGS

Sixteen studies met our prespecified inclusion and exclusion criteria and were grouped based on outcomes measured: health system inputs (n = 3), performance (n = 7), and health outcomes (n = 7). Numerous studies addressing conceptual issues related to decentralization but without any attempt at empirical estimation were excluded. Overall, we found mixed results regarding the effects of decentralization on health system indicators with seemingly beneficial effects on health system performance and health outcomes. Only 10 studies were considered to have relatively low risks of bias.

CONCLUSIONS

This study reveals the limited empirical knowledge of the impact of decentralization on health system performance. Mixed empirical findings on the role of decentralization on health system performance and outcomes highlight the complexity of decentralization processes and their systemwide effects. Thus, we propose a renewed research agenda that focuses on discrete definitions of decentralization and how institutional factors and mechanisms affect health system performance and outcomes within the general context of decentralized governance structures.

Authors+Show Affiliations

Rockefeller College of Public Affairs and Policy, University at Albany-State University of New York. School of Architecture, Planning, and Policy Development, Institut Teknologi Bandung, Indonesia.Rockefeller College of Public Affairs and Policy, University at Albany-State University of New York.

Pub Type(s)

Journal Article
Research Support, Non-U.S. Gov't
Review
Systematic Review

Language

eng

PubMed ID

29870116

Citation

Dwicaksono, Adenantera, and Ashley M. Fox. "Does Decentralization Improve Health System Performance and Outcomes in Low- and Middle-Income Countries? a Systematic Review of Evidence From Quantitative Studies." The Milbank Quarterly, vol. 96, no. 2, 2018, pp. 323-368.
Dwicaksono A, Fox AM. Does Decentralization Improve Health System Performance and Outcomes in Low- and Middle-Income Countries? A Systematic Review of Evidence From Quantitative Studies. Milbank Q. 2018;96(2):323-368.
Dwicaksono, A., & Fox, A. M. (2018). Does Decentralization Improve Health System Performance and Outcomes in Low- and Middle-Income Countries? A Systematic Review of Evidence From Quantitative Studies. The Milbank Quarterly, 96(2), pp. 323-368. doi:10.1111/1468-0009.12327.
Dwicaksono A, Fox AM. Does Decentralization Improve Health System Performance and Outcomes in Low- and Middle-Income Countries? a Systematic Review of Evidence From Quantitative Studies. Milbank Q. 2018;96(2):323-368. PubMed PMID: 29870116.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Does Decentralization Improve Health System Performance and Outcomes in Low- and Middle-Income Countries? A Systematic Review of Evidence From Quantitative Studies. AU - Dwicaksono,Adenantera, AU - Fox,Ashley M, PY - 2018/6/6/entrez PY - 2018/6/6/pubmed PY - 2018/8/7/medline KW - decentralization KW - developing countries KW - health reform SP - 323 EP - 368 JF - The Milbank quarterly JO - Milbank Q VL - 96 IS - 2 N2 - : Policy Points: For more than 3 decades, international development agencies have advocated health system decentralization to improve health system performance in low- and middle-income countries. We found little rigorous evidence documenting the impact of decentralization processes on health system performance or outcomes in part due to challenges in measuring such far-reaching and multifaceted system-level changes. We propose a renewed research agenda that focuses on discrete definitions of decentralization and how institutional factors and mechanisms affect health system performance and outcomes within the general context of decentralized governance structures. CONTEXT: Despite the widespread adoption of decentralization reforms as a means to improve public service delivery in developing countries since the 1980s, empirical evidence of the role of decentralization on health system improvement is still limited and inconclusive. This study reviewed studies published from 2000 to 2016 with adequate research designs to identify evidence on whether and how decentralization processes have impacted health systems. METHODS: We conducted a systematic review of peer-reviewed journal articles from the public health and social science literature. We searched for articles within 9 databases using predefined search terms reflecting decentralization and health system constructs. Inclusion criteria were original research articles, low- and middle-income country settings, quantifiable outcome measures, and study designs that use comparisons or statistical adjustments. We excluded studies in high-income country settings and/or published in a non-English language. FINDINGS: Sixteen studies met our prespecified inclusion and exclusion criteria and were grouped based on outcomes measured: health system inputs (n = 3), performance (n = 7), and health outcomes (n = 7). Numerous studies addressing conceptual issues related to decentralization but without any attempt at empirical estimation were excluded. Overall, we found mixed results regarding the effects of decentralization on health system indicators with seemingly beneficial effects on health system performance and health outcomes. Only 10 studies were considered to have relatively low risks of bias. CONCLUSIONS: This study reveals the limited empirical knowledge of the impact of decentralization on health system performance. Mixed empirical findings on the role of decentralization on health system performance and outcomes highlight the complexity of decentralization processes and their systemwide effects. Thus, we propose a renewed research agenda that focuses on discrete definitions of decentralization and how institutional factors and mechanisms affect health system performance and outcomes within the general context of decentralized governance structures. SN - 1468-0009 UR - https://www.unboundmedicine.com/medline/citation/29870116/Does_Decentralization_Improve_Health_System_Performance_and_Outcomes_in_Low__and_Middle_Income_Countries_A_Systematic_Review_of_Evidence_From_Quantitative_Studies_ L2 - https://doi.org/10.1111/1468-0009.12327 DB - PRIME DP - Unbound Medicine ER -