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

Health Policy and Planning
Seye AbimbolaMaryam Bigdeli

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 initiativ...Continue Reading

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Citations

Feb 27, 2020·Health Policy and Planning·Nancy KagwanjaEdwine Barasa
Feb 27, 2020·Health Systems and Reform·Ken HashimotoSunil Rajkumar
Aug 14, 2020·BMJ Global Health·Seye Abimbola
Nov 29, 2020·International Journal for Equity in Health·Qian LiWanjin Hu
Dec 29, 2020·Health Policy·Ana Belén Espinosa-GonzálezAra Darzi
Jan 28, 2021·International Health·Nuzulul Kusuma PutriKaren A Grépin
Nov 6, 2020·International Journal of Environmental Research and Public Health·Eva GlaeserSteffen Flessa
Apr 7, 2021·BMJ Global Health·Seye Abimbola
May 27, 2021·Biosensors & Bioelectronics·Jun Jie OngAbdul W Basit
Jul 10, 2021·Health Policy and Planning·Henry ZakumumpaFreddie Ssengooba
Aug 5, 2021·Health Policy and Planning·Vanessa T Siy VanValerie Gilbert T Ulep
Oct 15, 2021·BMC Health Services Research·Angela KairuEdwine Barasa

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