TY - JOUR
T1 - The impact of decentralisation on health systems
T2 - A systematic review of reviews
AU - Nepal Federal Health System Team
AU - Sapkota, Sujata
AU - Dhakal, Amshu
AU - Rushton, Simon
AU - van Teijlingen, Edwin
AU - Marahatta, Sujan B.
AU - Balen, Julie
AU - Lee, Andrew C.K.
AU - Adhikary, P.
AU - Balen, Julie
AU - Bajracharya, Bikesh
AU - Bhandari, S.
AU - Gautam, S.
AU - Karki, A.
AU - Karki, J. K.
AU - Koirala, B.
AU - Neupane, R.
AU - Panday, S.
AU - Paudel, Sudarshan
AU - Pohl, G.
AU - Simkhada, P. P.
AU - Subedi, M.
AU - Vaidya, A.
AU - Wasti, S. P.
N1 - Funding Information:
The review was conducted as part of a broader research project ( https://www.nepalfederalhealthsystem.com/ ) funded by the Medical Research Council, Economic and Social Research Council, Foreign Commonwealth and Development Office, and Wellcome Trust under the Health System Research Initiative Round 6 (grant ref. MR/T023554/1).
Publisher Copyright:
© Author(s) (or their employer(s)) 2023.
PY - 2023/12/21
Y1 - 2023/12/21
N2 - Background Decentralisation is a common mechanism for health system reform; yet, evidence of how it impacts health systems remains fragmented. Despite published findings from primary and secondary research illustrating range of impacts, a comprehensive and clear understanding is currently lacking. This review synthesised the existing evidence to assess how decentralisation (by devolution) impacts each of the six WHO building blocks, and the health system. Method We systematically searched five electronic databases for reviews exploring impact of decentralisation on health systems, globally. Reviews, both systematic and non-systematic, published in the English language from January 1990 to February 2022 were included. Data were synthesised across each of six building blocks. Quality assessment of the reviews was conducted using Critical Appraisal Skills Program for systematic and Scale for Assessment of Narrative Review Articles for non-systematic reviews. Results Nine reviews, each addressing somewhat different questions, contexts and issues, were included. A range of positive and negative impacts of decentralisation on health system building blocks were identified; yet, overall, the impacts were more negative. Although inconclusive, evidence suggested that the impacts on leadership and governance and financing components in particular shape the impact on overall health system. Assessment of how the impact on building blocks translates to the broader impact on health systems is challenged by the dynamic complexities related to contexts, process and the health system itself. Conclusions Decentralisation, even if well intentioned, can have unintended consequences. Despite the difficulty of reaching universally applicable conclusions about the pros and cons of decentralisation, this review highlights some of the common potential issues to consider in advance. PROSPERO registration number CRD42022302013.
AB - Background Decentralisation is a common mechanism for health system reform; yet, evidence of how it impacts health systems remains fragmented. Despite published findings from primary and secondary research illustrating range of impacts, a comprehensive and clear understanding is currently lacking. This review synthesised the existing evidence to assess how decentralisation (by devolution) impacts each of the six WHO building blocks, and the health system. Method We systematically searched five electronic databases for reviews exploring impact of decentralisation on health systems, globally. Reviews, both systematic and non-systematic, published in the English language from January 1990 to February 2022 were included. Data were synthesised across each of six building blocks. Quality assessment of the reviews was conducted using Critical Appraisal Skills Program for systematic and Scale for Assessment of Narrative Review Articles for non-systematic reviews. Results Nine reviews, each addressing somewhat different questions, contexts and issues, were included. A range of positive and negative impacts of decentralisation on health system building blocks were identified; yet, overall, the impacts were more negative. Although inconclusive, evidence suggested that the impacts on leadership and governance and financing components in particular shape the impact on overall health system. Assessment of how the impact on building blocks translates to the broader impact on health systems is challenged by the dynamic complexities related to contexts, process and the health system itself. Conclusions Decentralisation, even if well intentioned, can have unintended consequences. Despite the difficulty of reaching universally applicable conclusions about the pros and cons of decentralisation, this review highlights some of the common potential issues to consider in advance. PROSPERO registration number CRD42022302013.
KW - Health systems
KW - Systematic review
UR - http://www.scopus.com/inward/record.url?scp=85181850529&partnerID=8YFLogxK
U2 - 10.1136/bmjgh-2023-013317
DO - 10.1136/bmjgh-2023-013317
M3 - Review article
AN - SCOPUS:85181850529
VL - 8
JO - BMJ Global Health
JF - BMJ Global Health
SN - 2059-7908
IS - 12
M1 - e013317
ER -