The Impacts of Health Decentralization on Equity, Efficiency, and Effectiveness: A Scoping Review

Rafaela Oliveira, Gonçalo Santinha () and Teresa Sá Marques
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Rafaela Oliveira: Governance, Competitiveness and Public Policies Research Unit (GOVCOPP), Department of Social, Political and Territorial Sciences, University of Aveiro, 3810-193 Aveiro, Portugal
Gonçalo Santinha: Governance, Competitiveness and Public Policies Research Unit (GOVCOPP), Department of Social, Political and Territorial Sciences, University of Aveiro, 3810-193 Aveiro, Portugal
Teresa Sá Marques: Geography and Spatial Planning Research Centre (CEGOT), Department of Geography, Faculty of Arts and Humanities, University of Porto, 4150-564 Porto, Portugal

Sustainability, 2023, vol. 16, issue 1, 1-32

Abstract: Decentralization is considered an important component of participatory democracy. However, despite its widespread implementation in the healthcare sector, its impact on health systems’ performance remains unclear. Using a theoretical framework based on the World Health Organization’s five decentralization variables—geography and sociodemographics, organization of political processes, functions and economic weight, steering, and control—we conducted a scoping review to unveil causal mechanisms linking each feature to equity, efficiency, and effectiveness. Following the PRISMA protocol, 1627 articles were screened, and 63 were selected for data analysis, with a focus on middle- and high-income countries. The findings show that the most frequently discussed forms of decentralization are fiscal and administrative, with a primary focus on how governance mechanisms affect equity and efficiency. The effects of decentralized healthcare governance on equity, efficiency, and effectiveness are diverse and contingent on contextual factors and the implementation processes. The spatial context (geography) of decentralization negatively impacts equity, and steering strongly affects effectiveness. Functions and economic weight significantly influence efficiency, albeit with variability. Overall, decentralization falls short of delivering substantial healthcare system benefits, although this depends on contextual factors.

Keywords: decentralization; health systems; scoping review; equity; efficiency; effectiveness (search for similar items in EconPapers)
JEL-codes: O13 Q Q0 Q2 Q3 Q5 Q56 (search for similar items in EconPapers)
Date: 2023
References: View references in EconPapers View complete reference list from CitEc
Citations: View citations in EconPapers (1)

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Persistent link: https://EconPapers.repec.org/RePEc:gam:jsusta:v:16:y:2023:i:1:p:386-:d:1311528

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