Table 5.

Summary of Findings on the Effects of Decentralization on Health Outcomes

Author(s), (Year), Country	Study Design, Unit of Analysis, Data Year	Implementation of Decentralization	Decentralization Variables	Health Indicators	Effects, Magnitude
Fritscher and Zamora (2016)27 Mexico	Longitudinal ecological analysis State 1993‐2003	Expenditure decentralization reform in health sector was announced in 1997 as part of the Health Sector Reform Program, 1995‐2000	Fiscal resource control: A dummy variable indicating if a state belongs to high Health Services Fund (FASSA) recipients	Infant mortality rate	No significant effect
			The timing of decentralization: A dummy variable indicating if the observation takes place in the period before or after the decentralization reform
Guanais and Macinko (2009)28 Brazil	Longitudinal ecological analysis Municipality 1998‐2006	The Family Health and Community Health Agents programs were expanded in 1996; responsibilities for managing primary care clinics, health centers, and health posts were transferred to municipal government control	Administrative control: The proportion of ambulatory care facilities directly under control of the municipal government	Postneonatal mortality	Beneficial effect: Municipalities with high administrative decentralization (municipal governments that control at least 85% of ambulatory care facilities) had about 0.80 fewer postneonatal deaths per 1,000 live births than municipalities that had low administrative decentralization
Habibi and colleagues (2003)29 Argentina	Longitudinal ecological analysis Province 1970‐2004	1930s: The Argentine revenue‐sharing system was introduced 1973: A new revenue‐sharing regime favorable to provinces was passed 1988: A new revenue‐sharing agreement between the federal and provincial administrations was signed	Fiscal resource control: The ratio of provincially controlled resources to total provincial resources	Infant mortality rate	Beneficial effect: Each additional 1% share of provincially controlled resources to total provincial resources was associated with 0.02‐0.11 fewer infant deaths per 1,000 live births
		1990s: The share of resources controlled by provincial governments was increased	Fiscal resource control: The ratio of provincial taxes to total provincially controlled resources		Beneficial effect: Each additional 1% share of provincially controlled taxes to total provincially controlled resources was associated with 0.12‐0.28 fewer infant deaths per 1,000 live births
Jin and Sun (2011)31 China	Longitudinal ecological analysis Province 1980, 1981, 1989, 1990, 2000, 2003	The systematic change to a decentralized fiscal system from a centralized one was started in 1994 by the passage of the 1994 Tax Sharing System (TSS)	Fiscal resource control: The ratio of per capita provincial budgetary expenditures to the sum of per capita central budgetary expenditures and per capita provincial budgetary expenditures	Infant mortality rate	Harmful effect: Each additional 1 standard deviation change of the share of per capita provincial budgetary expenditures to the sum of per capita central budgetary expenditures and per capita provincial budgetary expenditures was associated with an increase of 12.05 infant deaths per 1,000 live births
			Timing of decentralization: A dummy variable indicating if the observation was in the period after the 1994 TSS reform		Harmful effect: After the implementation of the 1994 TSS reform, the yearly provincial infant mortality rate increased by 13.09‐24.13 infant deaths per 1,000 live births
Rocha, Orellano, and Nishijima (2016)36 Brazil	Longitudinal ecological analysis Municipality 2000‐2007	1996: The Family Health and Community Health Agents programs were expanded 2000: Constitutional Amendment no. 29 (EC 29) was approved, which defined the share of federal, state, and local budgets that should be devoted to health actions and services	Fiscal resource control: The share of overall health expenditures financed by municipalities’ own resources	Infant mortality rates up to the age of 1 year and up to the age of 5 years	No significant effect
Soto, Farfan, and Lorant (2012)37 Colombia	Longitudinal ecological analysis Municipality 1998‐2007	The reassignment of government functions and responsibilities for providing health services across different levels of government began in 1993	Fiscal resource control: Locally controlled health expenditure as a proportion of total health expenditure	Infant mortality rate	Beneficial effects: ‐An increase of 1% of locally controlled health expenditure as a proportion of total health expenditure led to an overall reduction of 6.0%‐6.2% in infant mortality in all municipalities ‐An increase of 1% of locally controlled health expenditure as a proportion of total health expenditure led to a reduction of 7.5%‐8.1% in infant mortality in poor municipalities
Uchimura and Jütting (2009)38 China	Longitudinal ecological analysis Province 1995‐2001	The systematic change to a decentralized fiscal system from a centralized one was started in 1994 by the passage of the 1994 Tax Sharing System (TSS); fiscal transfer has played a substantial role in bridging fiscal gaps since then	Fiscal resource control: The ratio of total counties’ expenditure to total counties’ revenue within the province (vertical balance)	Infant mortality rate	Beneficial effect: An increase of 1% of the ratio of total counties’ expenditure to total counties’ revenue within the province led to a reduction of 0.23% in infant mortality
			Fiscal resource control: The ratio of counties’ expenditure to total provincial expenditure (fiscal capacity relative to other counties)		Beneficial effect: An increase of 1% of the ratio of counties’ expenditure to total provincial expenditure led to a reduction of 0.19% in infant mortality