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.
Milbank Q. 2018 Jun;96(2):323-368. doi: 10.1111/1468-0009.12327.
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.
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.
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.
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.
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.
政策要点：30 多年来，国际发展机构一直倡导卫生系统权力下放，以改善中低收入国家的卫生系统绩效。我们发现，几乎没有严格的证据证明权力下放进程对卫生系统绩效或结果的影响，部分原因是难以衡量如此深远和多方面的系统层面变化。我们提出了一个新的研究议程，重点关注权力下放的明确定义，以及体制因素和机制如何在权力下放治理结构的总体背景下影响卫生系统绩效和结果。
尽管自 20 世纪 80 年代以来，发展中国家将权力下放改革作为改善公共服务提供的一种手段广泛采用，但权力下放对卫生系统改善作用的经验证据仍然有限且不确定。本研究回顾了 2000 年至 2016 年期间发表的具有充分研究设计的同行评议期刊文章，以确定权力下放进程是否以及如何影响卫生系统的证据。
我们对公共卫生和社会科学文献中的同行评议期刊文章进行了系统回顾。我们使用反映权力下放和卫生系统结构的预定义搜索词，在 9 个数据库中搜索文章。纳入标准是原始研究文章、中低收入国家背景、可量化的结果衡量指标以及使用比较或统计调整的研究设计。我们排除了高收入国家背景的研究和/或用非英语发表的研究。
16 项研究符合我们预先规定的纳入和排除标准，并根据所测量的结果进行分组：卫生系统投入（n=3）、绩效（n=7）和健康结果（n=7）。许多涉及权力下放相关概念问题但没有进行任何实证估计的研究被排除在外。总体而言，我们发现权力下放对卫生系统指标的影响结果喜忧参半，似乎对卫生系统绩效和健康结果有有益影响。只有 10 项研究被认为具有相对较低的偏倚风险。
本研究揭示了权力下放对卫生系统绩效影响的有限经验知识。权力下放对卫生系统绩效和结果的作用的混合实证结果突出了权力下放进程的复杂性及其对整个系统的影响。因此，我们提出了一个新的研究议程，重点关注权力下放的明确定义，以及体制因素和机制如何在权力下放治理结构的总体背景下影响卫生系统绩效和结果。
