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The Independent Evaluation Group (IEG) assessed the effectiveness of Bank support for decentralization between fiscal 1990 and 2007 in 20 countries, seeking to inform the design and implementation of future support. Given the difficulties of measuring the results of decentralization, the evaluation used intermediate outcome indicators—such as strengthened legal and regulatory frameworks for intergovernmental relations, improved administrative capacity, and increased accountability of sub national governments and functionaries to higher levels of government and to citizens—to assess the results of Bank support in these 20 countries. To examine potential lessons at a sectoral level, the evaluation also assessed whether Bank support for decentralization improved intermediate outcomes for service delivery in the education sector in 6 of the 20 countries.

This article describes the local government system established in the 2001 Devolution Plan and its evolution over the period 2002-07, with a focus on two essential public services, education and health. We believe that the devolution of service delivery functions, delegation of financial powers, decentralization of authority, and deconcentration of executive powers can, together, lead to better accountability of results and, hence, to improved public service delivery to the poor and marginalized.The Devolution Plan made inroads toward these goals, particularly in education, but their achievement was incomplete due to a number of factors, including incomplete fiscal decentralization, limited targeting of backward areas, and centralizing tendencies of the provincial departments and civil service. Recommendations are offered on how to further develop the local government system more generally, with an eye towards increasing accountability and improving coordination both across local governments and between tiers.For this, complementary reforms to simplify business processes and revamp human resource management policies are needed; introducing a district level civil service is among the suggested changes. The article concludes with detailed recommendations on improving the decentralized delivery of education and health services.

Abstract One constant refrain in evaluations and reviews of decentralization is that the results are mixed. But given that decentralization is a complex intervention or phenomenon, what is more important is to generate evidence to inform implementation strategies. We therefore synthesized evidence from the literature to understand why, how and under what circumstances decentralization influences health system equity, efficiency and resilience. In doing this, we adopted the realist approach to evidence synthesis and included quantitative and qualitative studies in high-, low- and middle-income countries that assessed the the impact of decentralization on health systems. We searched the Medline and Embase databases via Ovid, and the Cochrane library of systematic reviews and included 51 studies with data from 25 countries. We identified three mechanisms through which decentralization impacts on health system equity, efficiency and resilience: ‘Voting with feet’ (reflecting how decentralization either exacerbates or assuages the existing patterns of inequities in the distribution of people, resources and outcomes in a jurisdiction); ‘Close to ground’ (reflecting how bringing governance closer to the people allows for use of local initiative, information, feedback, input and control); and ‘Watching the watchers’ (reflecting mutual accountability and support relations between multiple centres of governance which are multiplied by decentralization, involving governments at different levels and also community health committees and health boards). We also identified institutional, socio-economic and geographic contextual factors that influence each of these mechanisms. By moving beyond findings that the effects of decentralization on health systems and outcomes are mixed, this review presents mechanisms and contextual factors to which policymakers and implementers need to pay attention in their efforts to maximize the positive and minimize the negative impact of decentralized governance.

Background Experts suggest that Non-Communicable Disease (NCD) care is best delivered at the primary level, including in humanitarian crisis settings. In many crisis-affected countries, NCD care is predominantly delivered by specialists at secondary care level, and there is limited evidence on decentralising NCD care in such settings. We aimed to explore health actor and patient experiences of decentralising diabetes and hypertension (DM/HTN) care from a hospital to primary care clinics in the humanitarian setting of Duhok, Kurdistan Region of Iraq. Methods and results We conducted a qualitative study including 30 semi-structured interviews with a purposive sample of patients ( n  = 16), healthcare providers ( n  = 7), and key stakeholders ( n  = 7) involved in the decentralisation project. Guided by a conceptual framework, data were analysed thematically using deductive and inductive approaches. The decentralisation project achieved its stated goals of (a) increasing patients’ access to DM/HTN care, by reducing cost and distance, and (b) decreasing workload at secondary care level. The approach appeared acceptable from patient, provider and stakeholder perspectives. Key health system inputs were put in place to support the decentralisation project, including medicines, equipment and health workforce training, but gaps remained. While access and quality seemed to improve, integration, continuity and sustainability were more challenging to achieve. Key systemic challenges to sustainability included a lack of health financing, and weak national supply chains and information systems. Patients’ trust in the service was important and was closely linked to having access to a continuous supply of trusted medications. Conclusions While it is possible to decentralise diabetes and hypertension care from secondary to primary level in a humanitarian setting, multiple contextual factors must be considered, including supply chain strengthening and adaptation to existing workforce capacity. Our study findings may inform other actors exploring the decentralisation of NCD care elsewhere in Iraq and in other humanitarian settings.

Background We wanted to better understand whether and how agility can be achieved in a decentralised service delivery organisation in Sweden. The pandemic outbreak of SARS-Cov-2 (Covid-19) provided an opportunity to assess decentralisation as a strategy to improve the responsiveness of healthcare and at the same time handle an unpredictable and unexpected event. Methods Data from in-depth interviews with a crisis management team ( n  = 23) and free text answers in a weekly survey to subordinated clinical directors, i.e. unit managers, ( n  = 108) were scrutinised in a directed content analysis. Dynamic capabilities as a prerequisite for dynamic effectiveness, understood as reaching strategic and operative effectiveness simultaneously, were explored by using three frameworks for dynamic effectiveness, dynamic capabilities and delegated authority in a decentralised organisation. Results Unpredictable events, such as the pandemic Covid-19 outbreak, demand a high grade of ability to be flexible. We find that a high degree of operational effectiveness, which is imperative in an emergency situation, also is a driver of seeking new strategic positions to even better meet new demands. The characteristics of the dynamic capabilities evolving from this process are described and discussed in relation to decentralisation, defined by decision space, organisational and individual capacity as well as accountability. We present arguments supporting that a decentralised management model can facilitate the agility required in an emergency. Conclusions This study is, to our knowledge, the first of its kind where a decentralised management model in a service delivery organisation in healthcare is studied in relation to crisis management. Although stemming from one organisation, our findings indicating the value of decentralisation in situations of crisis are corroborated by theory, suggesting that they could be relevant in other organisational settings also.

Although health care delivery is becoming increasingly digitized, driven by the pursuit of improved access, equity, efficiency, and effectiveness, progress does not appear to be equally distributed across therapeutic areas. Oncology is renowned for leading innovation in research and in care; digital pathology, digital radiology, real-world data, next-generation sequencing, patient-reported outcomes, and precision approaches driven by complex data and biomarkers are hallmarks of the field. However, remote patient monitoring, decentralized approaches to care and research, “hospital at home,” and machine learning techniques have yet to be broadly deployed to improve cancer care. In response, the Digital Medicine Society and Moffitt Cancer Center convened a multistakeholder roundtable discussion to bring together leading experts in cancer care and digital innovation. This viewpoint highlights the findings from these discussions, in which experts agreed that digital innovation is lagging in oncology relative to other therapeutic areas. It reports that this lag is most likely attributed to poor articulation of the challenges in cancer care and research best suited to digital solutions, lack of incentives and support, and missing standardized infrastructure to implement digital innovations. It concludes with suggestions for actions needed to bring the promise of digitization to cancer care to improve lives.

Background Community health worker (CHW) programs are an important resource in the implementation of universal health coverage (UHC) in many low- and middle-income countries (LMICs). However, in countries with decentralized health systems like the Philippines, the quality and effectiveness of CHW programs may differ across settings due to variations in resource allocation and local politics. In the context of health system decentralization and the push toward UHC in the Philippines, the objective of this study was to explore how the experiences of CHWs across different settings were shaped by the governance and administration of CHW programs. Methods We conducted 85 semi-structured interviews with CHWs ( n  = 74) and CHW administrators ( n  = 11) in six cities across two provinces (Negros Occidental and Negros Oriental) in the Philippines. Thematic analysis was used to analyze the qualitative data with specific attention to how the experiences of participants differed within and across geographic settings. Results Health system decentralization contributed to a number of variations across settings including differences in the quality of human resources and the amount of financial resources allocated to CHW programs. In addition, the quality and provider of CHW training differed across settings, with implications for the capacity of CHWs to address specific health needs in their community. Local politics influenced the governance of CHW programs, with CHWs often feeling pressure to align themselves politically with local leaders in order to maintain their employment. Conclusions The functioning of CHW programs can be challenged by health system decentralization through the uneven operationalization of national health priorities at the local level. Building capacity within local governments to adequately resource CHWs and CHW programs will enhance the potential of these programs to act as a bridge between the local health needs of communities and the public health system.

Background Enhancing primary health care (PHC) is considered a policy priority for health systems strengthening due to PHC’s ability to provide accessible and continuous care and manage multimorbidity. Research in PHC often focuses on the effects of specific interventions (e.g. physicians’ contracts) in health care outcomes. This informs narrowly designed policies that disregard the interactions between the health functions (e.g. financing and regulation) and actors involved (i.e. public, professional, private), and their impact in care delivery and outcomes. The purpose of this study is to analyse the interactions between PHC functions and their impact in PHC delivery, particularly in providers’ behaviour and practice organisation. Methods Following a systems thinking approach with data obtained through a three-round European Delphi process, we developed a framework that captures (1) the interactions between PHC functions by analysing correlations between PHC characteristics of participating countries, (2) how actors involved shaped these interactions by identifying the actor and level of devolution (or fragmentation) in the analysis, and (3) their potential effect on care delivery by exploring panellists’ opinions. Results A total of 59 panellists from 24 countries participated in the first round and 76% of the initial panellists (22 countries) completed the last round. Findings show correlations between governance, financing and regulation based on their degree of decentralisation. This is supported by panellists, who agreed that the actors involved in health system governance determine the type of PHC financing (e.g. ownership or payment mechanisms) and regulation (e.g. competences or gatekeeping), and this may impact care delivery and outcomes. Governance in our framework is an overarching function whose impact in PHC delivery is mediated through the degree of decentralisation (both delegation and devolution) of PHC financing and regulation. Conclusions The application of this approach in policy implementation assessment intends to uncover limitations due to poor accountability and commitment to shared objectives. Its application in the design of health strategies helps foresee (and prevent) undesired or unexpected effects of narrow interventions. This approach will assist in the development of the realistic and long-term policies required for health systems strengthening.

Strong primary care systems are often viewed as the bedrock of health care systems that provide high-quality care, but the evidence supporting this view is somewhat limited. We analyzed comparative primary care data collected in 2009-10 as part of a European Union- funded project, the Primary Health Care Activity Monitor for Europe. Our analysis showed that strong primary care was associated with better population health; lower rates of unnecessary hospitalizations; and relatively lower socioeconomic inequality, as measured by an indicator linking education levels to self-rated health. Overall health expenditures were higher in countries with stronger primary care structures, perhaps because maintaining strong primary care structures is costly and promotes developments such as decentralization of services delivery. Comprehensive primary care was also associated with slower growth in health care spending. More research is needed to explore these associations further, even as the evidence grows that strong primary care in Europe is conducive to reaching important health system goals. [PUBLICATION ABSTRACT]

Decentralization is promoted as a strategy to improve health system performance by bringing decision-making closer to service delivery. Some studies have investigated if decentralization actually improves the health system. However, few have explored the conditions that enable it to be effective. To determine these conditions, we have analyzed the perspectives of decision-makers in the Philippines where devolution, one form of decentralization, was introduced 25 years ago. Drawing from the \"decision space\" approach, we interviewed 27 decision-makers with an average of 23.6 years of working across different levels of the Philippine government health sector and representing various local settings. Qualitative analysis followed the \"Framework Method.\" Conditions that either enable or hinder the effectiveness of decentralization were identified by exploring decision-making in five health sector functions. These conditions include: for planning, having a multi-stakeholder approach and monitoring implementation; for financing and budget allocation, capacities to raise revenues at local levels and pooling of funds at central level; for resource management, having a central level capable of augmenting resource needs at local levels and a good working relationship between the local health officer and the elected local official; for program implementation and service delivery, promoting innovation at local levels while maintaining fidelity to national objectives; and for monitoring and data management, a central level capable of ensuring that data collection from local levels is performed in a timely and accurate manner. The Philippine experience suggests that decentralization is a long and complex journey and not an automatic solution for enhancing service delivery. The role of the central decision-maker (e.g. Ministry of Health) remains important to assist local levels unable to perform their functions well. It is policy-relevant to analyze the conditions that make decentralization work and the optimal combination of decentralized and centralized functions that enhance the health system.