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Decentralised versus centralised governance of health services

  1. Chandrashekhar T Sreeramareddy1,*,
  2. TN Sathyanarayana2

Editorial Group: Cochrane Effective Practice and Organisation of Care Group

Published Online: 15 NOV 2013

DOI: 10.1002/14651858.CD010830


How to Cite

Sreeramareddy CT, Sathyanarayana TN. Decentralised versus centralised governance of health services (Protocol). Cochrane Database of Systematic Reviews 2013, Issue 11. Art. No.: CD010830. DOI: 10.1002/14651858.CD010830.

Author Information

  1. 1

    University Tunku Abdur Rahman, Faculty of Medicine and Health Sciences, Kajang, Selongor, Malaysia

  2. 2

    Public Health Foundation of India, Health Policy and Management, Hyderabad, Andhra Pradesh, India

*Chandrashekhar T Sreeramareddy, Faculty of Medicine and Health Sciences, University Tunku Abdur Rahman, Kajang, Selongor, 43000, Malaysia. chandrashekharats@yahoo.com.

Publication History

  1. Publication Status: New
  2. Published Online: 15 NOV 2013

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Table 1. A ‘decision space map’ for analysing the range of choices exercised by decentralised decision makers

Key functional areas

Financing- Sources of revenue - Allocation of expenditures - Income from fees and contracts

Service delivery and organisation- Hospital autonomy - Insurance plans - Payment mechanisms - Contracts with private providers - Required programs/norms

Health workforce- Salaries - Contracts - Civil service

Access rules- Targeting

Governance rules- Facility boards - Health offices - Community participation

 
Table 2. Subgroup analyses for differences in the effects of decentralised or centralised authority

Explanatory factorsCategories that will be considered for each factorPredicted interaction and its direction

Functional areas of health services governance for which authority was transferred
  1. Financing (sources of funds as disbursed centrally or locally raised and allocation for current activities)
  2. Service delivery and organisation (autonomy of local health systems/hospitals over implementation of activities, making decisions about insurance plans and payment mechanisms for health personnel, etc.)
  3. Health workforce (recruitment, postings, discipline and decisions on salaries of health personnel)
  1. The effects of decentralising the financing of health services only may be less than the effects of decentralisation that includes a wider range of functional areas. This is because locally raised funds alone may be insufficient for local needs (in the absence of central funding).
  2. Decentralisation that involves service delivery and organisation may be more effective than that involving other functional areas. This is because lower levels of the health system may then be able to better organise health services according to local priorities.
  3. The effects of decentralised governance for heath workforce issues only may be less than if decentralisation includes a wider range of functional areas. This is because staff salaries and health staff allocation may not match local needs if the funding of health programmes is still centrally decided.

Economic status of the country (World Bank definition)
  1. High-income countries
  2. Middle-income countries
  3. Low-income countries
The effects of decentralised governance of health services may be less in LMICs compared to HICs. This is because the infrastructure and resources to support decentralisation are inadequate or less developed in LMICs.