Community Health Sciences, The Aga Khan University, Karachi, Pakistan.
NOVA National School of Public Health, Public Health Research Centre, Comprehensive Health Research Center (CHRC), NOVA University Lisbon, Lisbon, Portugal.
Health Res Policy Syst. 2024 May 27;22(1):61. doi: 10.1186/s12961-024-01145-3.
Decentralization of a health system is a complex and multidimensional phenomenon that demands thorough investigation of its process logistics, predisposing factors and implementation mechanisms, within the broader socio-political environment of each nation. Despite its wide adoption across both high-income countries (HICs) and low-and-middle-income countries (LMICs), empirical evidence of whether decentralization actually translates into improved health system performance remains inconclusive and controversial. This paper aims to provide a comprehensive description of the decentralization processes in three countries at different stages of their decentralization strategies - Pakistan, Brazil and Portugal.
This study employed a systematic analysis of peer-reviewed academic journals, official government reports, policy documents and publications from international organizations related to health system decentralization. A comprehensive search was conducted using reputable databases such as PubMed, Google Scholar, the WHO repository and other relevant databases, covering the period up to the knowledge cutoff date in June 2023. Information was systematically extracted and organized into the determinants, process mechanics and challenges encountered during the planning, implementation and post-decentralization phases. Although decentralization reforms have achieved some success, challenges persist in their implementation. Comparing all three countries, it was evident that all three have prioritized health in their decentralization reforms and aimed to enhance local decision-making power. Brazil has made significant progress in implementing decentralization reforms, while Portugal and Pakistan are still in the process. Pakistan has faced significant implementation challenges, including capacity-building, resource allocation, resistance to change and inequity in access to care. Brazil and Portugal have also faced challenges, but to a lesser extent. The extent, progress and challenges in the decentralization processes vary among the three countries, each requiring ongoing evaluation and improvement to achieve the desired outcomes.
Notable differences exist in the extent of decentralization, the challenges faced during implementation and inequality in access to care between the three countries. It is important for Portugal, Brazil and Pakistan to address these through reinforcing implementation strategies, tackling inequalities in access to care and enhancing monitoring and evaluation mechanism. Additionally, fostering knowledge sharing among these different countries will be instrumental in facilitating mutual learning.
卫生系统的权力下放是一个复杂的多维度现象，需要在每个国家更广泛的社会政治环境中，彻底调查其过程物流、前置因素和实施机制。尽管高收入国家（HICs）和中低收入国家（LMICs）都广泛采用了权力下放，但权力下放是否确实能转化为改善卫生系统绩效的实证证据仍不确定且存在争议。本文旨在全面描述三个处于不同权力下放战略阶段的国家的权力下放过程，即巴基斯坦、巴西和葡萄牙。
本研究采用系统分析同行评议的学术期刊、政府官方报告、与卫生系统权力下放相关的政策文件和国际组织出版物。使用 PubMed、Google Scholar、世卫组织资料库和其他相关资料库等知名资料库进行了全面搜索，涵盖截至 2023 年 6 月知识截止日期的时期。系统地提取信息并将其组织到规划、实施和权力下放后阶段中遇到的决定因素、过程机制和挑战中。尽管权力下放改革取得了一些成功，但在实施过程中仍存在挑战。将所有三个国家进行比较后，明显发现所有三个国家都将卫生作为其权力下放改革的重点，并旨在增强地方决策能力。巴西在实施权力下放改革方面取得了重大进展，而葡萄牙和巴基斯坦仍在进行中。巴基斯坦在实施方面面临重大挑战，包括能力建设、资源分配、对变革的抵制以及获得医疗服务的不平等。巴西和葡萄牙也面临挑战，但程度较轻。这三个国家的权力下放进程的程度、进展和挑战各不相同，需要不断评估和改进以实现预期结果。
这三个国家在权力下放的程度、实施过程中面临的挑战以及获得医疗服务的不平等方面存在显著差异。巴西、葡萄牙和巴基斯坦都需要通过加强实施战略、解决获得医疗服务的不平等问题以及加强监测和评估机制来应对这些问题。此外，促进这些不同国家之间的知识共享将有助于促进相互学习。
