Decentralization of health systems in low and middle income countries: a systematic 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: Decentralization; District health system; Governance; Health sector reform; LMIC; Systematic review; UHC; Universal health coverage.