Table 4.

Summary of Findings on the Effects of Decentralization on Health System Performance

Author(s), (Year), Country	Study Design, Unit of Analysis, Data Year	Implementation of Decentralization	Decentralization Variables	Health Indicators	Effects, Magnitude
Faguet and Sánchez (2014)16 Colombia	Longitudinal ecological analysis Municipality 1993‐2004	Phase 1: Limited fiscal measures (1970s) Phase 2: Political and administrative matters (1980s) Phase 3: Public services provision and social investment; increased fiscal transfer (1990s) Phase 4: Extensive devolution of powers and responsibilities to municipal and departmental governments (2001)	Fiscal resource control: Local own revenue (local taxes and charges) as a share of total expenditure	Change in the poor population covered by public health insurance	Beneficial effect: An increase of health expenditure by 1 standard deviation is associated with the expansion of health insurance coverage by 2.33%‐14.07%
			Provincial/central control: A dummy variable indicating if a municipality is certified to receive transfers directly from central government		Beneficial effect: A municipality that has certification is more likely to expand its health insurance coverage by 8.4%‐12.6%
Hodge, Firth, Jimenez‐Soto, and Trisnantoro (2015)30 Indonesia	Repeated cross‐sectional, individual‐level analysis Individual 1991, 1994, 1997, 2002/2003, 2007/2008	Fiscal, administrative, and political administration were implemented starting in 2001 in all provinces and districts	The timing of decentralization: A dummy variable indicating if a birth delivery took place after the implementation of decentralization (2001)	Facility‐based delivery (a dummy variable indicating if a birth delivery took place in a medical facility)	Beneficial effect: The probability of delivering birth at a health facility in post‐decentralization era was 3.12 to 3.67 percentage points higher than before decentralization (increasing trend) Harmful effect: The probability of delivering at a health facility in post‐decentralization era and in non‐Java/Bali region was 5.7 to 7.3 percentage points lower compared to that in Java/Bali region before decentralization (widening regional disparity)
Kengia, Igarashi, and Kawabuchi (2013)32 Tanzania	Repeated cross‐sectional, individual‐level analysis Individual 1992, 1996, 1999, 2004/2005	1980s: Economic liberalization measures were adopted 1993: User fees were introduced in government health facilities 1996: Community Health Fund was implemented 2000: Decentralization by devolution (D‐by‐D)	The timing of decentralization: A set of dummy variables indicating if observation belongs to one of the decentralization periods	A dummy variable of whether a respondent utilized a skilled birth attendant	Harmful effect: After the implementation of D‐by‐D policy, the log‐odd of utilizing skilled birth attendants was 1.18 percentage points lower than before among wealthy population group Beneficial effect: After the implementation of D‐by‐D policy, the log‐odds of utilizing skilled birth attendants among the poor and poorest population groups were 1.15‐1.26 percentage points higher than the wealthiest group
Khaleghian (2004)33 Multiple countries (low‐ and middle‐income countries)	Longitudinal ecological analysis Country 1980‐1997	Varied from one country to another	The adoption of decentralization framework: A dummy variable indicating if a country adopted decentralization policy	Proportion of children immunized with DPT3 and measles at 1 year of age (coverage rates)	Beneficial effect: In countries implementing decentralization, the immunization coverage rates were 16.00‐19.06 and 13.4 ‐15.53 percentage points higher for DPT3 and measles, respectively (all samples) Harmful effect: Among middle‐income countries, the immunization coverage rates in countries adopting decentralization were 4.92‐17.41 and 5.51‐9.87 percentage points lower for DPT3 and measles, respectively
Maharani and Tampubolon (2015)34 Indonesia	Cross‐sectional, individual analysis Household 2011	Fiscal, administrative, and political administration were implemented starting in 2001 in all provinces and districts	Fiscal commitment to health sector: The ratio of local public expenditure on health to total local public expenditure	Complete immunization status among children aged 12‐23 months	No significant effect
Bustamante (2010)39 Mexico	Cross‐sectional, individual‐level analysis Household 2003	1982: Started decentralization of health care providers but halted in 1988‐1994 1995: Resumed the decentralization process 1998: Decentralized and centralized managed health providers coexist	The adoption of decentralization: A dummy variable indicating if the household is served by decentralized health providers (health care services providers managed by the state government)	Utilization of preventive services	Harmful effect: The marginal probability of an average household served by a decentralized health care provider was 3.6‐6.5 percentage points lower than an average household served by centralized health care providers
				Out‐of‐pocket health expenditures	Harmful effect: The average out‐of‐pocket health expenditure among households served by decentralized health care providers was 31.9‐39.9 percentage points higher than households served by centralized health care providers
Kruse, Pradhan, and Sparrow (2012)40 Indonesia	Longitudinal ecological analysis District 2001‐2006	Fiscal, administrative, and political administration were implemented starting in 2001 in all provinces and districts	Fiscal commitment to health sector: District per capita public health spending	Outpatient health care utilization rates	Beneficial effects: ‐Each additional 1% increase in district public health spending led to an increase of 0.016 outpatient visits to a health care provider per person per month ‐Each additional 1% increased in public health spending increased the utilization rate by 0.014 and 0.020 outpatient visits to a health care provider per person per month for the poorest and second wealth quartiles, respectively
				Household out‐of‐pocket health spending	No significant effect