ReviewThe impacts of decentralisation on health-related equity: A systematic review of the evidence

- Decentralisation is widely implemented in both developed and developing countries.
- Decentralisation has both enhanced and exacerbated health-related equity.
- The effect of decentralisation is dependent on context and associated complementary mechanisms.
- Central coordination, fiscal transfers and other equalisation schemes can enhance health-related equity.
- There's no golden standard of decentralisation that particularly can enhance health-related equity.

BackgroundDecentralised governance of health care has been widely adopted globally over the past three decades. But despite being implemented as a management strategy across many health systems, its impact on health equity is yet unclear.ObjectiveTo conduct a systematic literature review of the implications of decentralised governance of health care on equity in health, health care and health financing.MethodsA systematic search of CINAHL, EconLit, Embase, MEDLINE, PsycINFO, PubMed, Scopus, and Cochrane database of systematic reviews was conducted. Articles that met the inclusion criteria examined entire health systems and the relationship between implementing decentralised governance and health-related equity. The quality of reporting of the included studies was assessed using a 10-point quality rating tool.ResultsOut of 808 articles identified, 9 met the inclusion criteria. The included studies were mostly explorative and used a range of quantitative techniques to analyse the relationship between variables of interest. The review found that depending on context, decentralisation could either lead to equity gains or exacerbate inequities. The impact of decentralisation on inequities in health and health care depends on pre-existing socio-economic disparities and financial barriers to access. While decentralisation can lead to inequities in health financing between sub-national jurisdictions, this is minimised with substantial central government transfers and cross subsidisation.ConclusionThe implications of decentralised governance of health systems on health-related equity are varied and depend on pre-existing socio-economic and organisational context, the form of decentralisation implemented and the complementary mechanisms implemented alongside decentralisation.