The impacts of decentralisation on health systems: a systematic review of reviews.

Abstract

Background: Despite decentralisation being a common mechanism through which health systems around the world have been reformed, a clear understanding of how decentralisation impacts health systems is lacking. Although both primary and secondary research exists, the evidence remains scattered. This review collected and synthesised evidence generated by previous reviews on the impact of decentralising health system governance on the six WHO (World Health Organization) health system building blocks. Methods: We systematically searched for reviews exploring the impact of decentralisation on the health system from five databases. Reviews, both systematic and non-systematic, published in the English language from 1990 to February 2022 were included. Quality assessment of the reviews was conducted using CASP for systematic reviews and SANRA for non-systematic reviews. Results: Nine reviews, each addressing slightly different questions, contexts and health system issues, were synthesised. They showed that devolution can have positive or negative impacts on the health system and its components. Moreover, impact assessments are significantly affected by complexities surrounding decentralisation and health system concepts: their dynamic mechanisms, inconsistent and often differently operationalized health system and health system component variables, and methodological challenges. For the WHO health system components, more negative than positive impacts were reported. The reviews highlight the importance of closely assessing (pre-)existing (political and non-political) characteristics of countries and their health systems to better understand impacts. Conclusions: Decentralisation can have a negative or a positive impact on the health system and its components; the impacts are shaped by pre-existing country contexts. Generating conclusive and generalisable evidence of the impacts of decentralisation on health systems is challenging. Whilst decentralisation may seek to enhance community engagement and improve the responsiveness of decision-making, it has the potential to create serious challenges to the health system, the manifestations of which are likely to be context-specific. Protocol Registration: PROSPERO CRD42022302013