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The impacts of decentralization on health system equity, efficiency and resilience: a realist synthesis of the evidence.

Abstract

One constant refrain in evaluations and reviews of decentralization is that the results are mixed. But given that decentralization is a complex intervention or phenomenon, what is more important is to generate evidence to inform implementation strategies. We therefore synthesized evidence from the literature to understand why, how and under what circumstances decentralization influences health system equity, efficiency and resilience. In doing this, we adopted the realist approach to evidence synthesis and included quantitative and qualitative studies in high-, low- and middle-income countries that assessed the the impact of decentralization on health systems. We searched the Medline and Embase databases via Ovid, and the Cochrane library of systematic reviews and included 51 studies with data from 25 countries. We identified three mechanisms through which decentralization impacts on health system equity, efficiency and resilience: 'Voting with feet' (reflecting how decentralization either exacerbates or assuages the existing patterns of inequities in the distribution of people, resources and outcomes in a jurisdiction); 'Close to ground' (reflecting how bringing governance closer to the people allows for use of local initiative, information, feedback, input and control); and 'Watching the watchers' (reflecting mutual accountability and support relations between multiple centres of governance which are multiplied by decentralization, involving governments at different levels and also community health committees and health boards). We also identified institutional, socio-economic and geographic contextual factors that influence each of these mechanisms. By moving beyond findings that the effects of decentralization on health systems and outcomes are mixed, this review presents mechanisms and contextual factors to which policymakers and implementers need to pay attention in their efforts to maximize the positive and minimize the negative impact of decentralized governance.

Authors+Show Affiliations

School of Public Health, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia. National Primary Health Care Development Agency, Abuja, FCT 900247, Nigeria. The George Institute for Global Health, Sydney, NSW 2042, Australia. Health Systems Governance Collaborative, Department of Health Systems Governance and Financing, World Health Organization, Avenue Appia 20, 1211 Geneva, Switzerland.Noguchi Memorial Institute for Medical Research, University of Ghana, P.O. Box LG 581 Legon, Accra, Ghana.Health Systems Governance Collaborative, Department of Health Systems Governance and Financing, World Health Organization, Avenue Appia 20, 1211 Geneva, Switzerland. World Health Organization, 3 Avenue S.A.R. Sidi Mohamed, Rabat, Morocco.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

31378811

Citation

Abimbola, Seye, et al. "The Impacts of Decentralization On Health System Equity, Efficiency and Resilience: a Realist Synthesis of the Evidence." Health Policy and Planning, 2019.
Abimbola S, Baatiema L, Bigdeli M. The impacts of decentralization on health system equity, efficiency and resilience: a realist synthesis of the evidence. Health Policy Plan. 2019.
Abimbola, S., Baatiema, L., & Bigdeli, M. (2019). The impacts of decentralization on health system equity, efficiency and resilience: a realist synthesis of the evidence. Health Policy and Planning, doi:10.1093/heapol/czz055.
Abimbola S, Baatiema L, Bigdeli M. The Impacts of Decentralization On Health System Equity, Efficiency and Resilience: a Realist Synthesis of the Evidence. Health Policy Plan. 2019 Aug 5; PubMed PMID: 31378811.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - The impacts of decentralization on health system equity, efficiency and resilience: a realist synthesis of the evidence. AU - Abimbola,Seye, AU - Baatiema,Leonard, AU - Bigdeli,Maryam, Y1 - 2019/08/05/ PY - 2019/05/27/accepted PY - 2019/8/6/entrez KW - Decentralization KW - community KW - efficiency KW - equity KW - health system KW - realist KW - resilience JF - Health policy and planning JO - Health Policy Plan N2 - One constant refrain in evaluations and reviews of decentralization is that the results are mixed. But given that decentralization is a complex intervention or phenomenon, what is more important is to generate evidence to inform implementation strategies. We therefore synthesized evidence from the literature to understand why, how and under what circumstances decentralization influences health system equity, efficiency and resilience. In doing this, we adopted the realist approach to evidence synthesis and included quantitative and qualitative studies in high-, low- and middle-income countries that assessed the the impact of decentralization on health systems. We searched the Medline and Embase databases via Ovid, and the Cochrane library of systematic reviews and included 51 studies with data from 25 countries. We identified three mechanisms through which decentralization impacts on health system equity, efficiency and resilience: 'Voting with feet' (reflecting how decentralization either exacerbates or assuages the existing patterns of inequities in the distribution of people, resources and outcomes in a jurisdiction); 'Close to ground' (reflecting how bringing governance closer to the people allows for use of local initiative, information, feedback, input and control); and 'Watching the watchers' (reflecting mutual accountability and support relations between multiple centres of governance which are multiplied by decentralization, involving governments at different levels and also community health committees and health boards). We also identified institutional, socio-economic and geographic contextual factors that influence each of these mechanisms. By moving beyond findings that the effects of decentralization on health systems and outcomes are mixed, this review presents mechanisms and contextual factors to which policymakers and implementers need to pay attention in their efforts to maximize the positive and minimize the negative impact of decentralized governance. SN - 1460-2237 UR - https://www.unboundmedicine.com/medline/citation/31378811/The_impacts_of_decentralization_on_health_system_equity,_efficiency_and_resilience:_a_realist_synthesis_of_the_evidence L2 - https://academic.oup.com/heapol/article-lookup/doi/10.1093/heapol/czz055 DB - PRIME DP - Unbound Medicine ER -