Decentralization and primary health care in the 21st century : A view from Latin America and the Caribbean

Decentralization remains as a major policy development to implement more accessible and equitable health systems around the world. Recent reports of the World Health Organization propose decentralization as a key policy to advance in the restructuring of health systems and services. However, there is no consensus about the consequences, advantages and pitfalls of decentralization. Despite the fact that decentralization has been a major topic in recent years, there is a lack of systematic assessments about the role and implications of this policy.

 The paper is a systematic review of the design, implementation and impacts of decentralization in the specific case of Latin American and the Caribbean. The review was performed utilizing major databases of published literature in peer-review journals. The period of the review was 1994- September 2008. A total of 200 articles and documents were identified in Medline and Virtual Health Library. A fraction of them (approximately 15%) was finally selected in terms of the search criteria which were related to evaluation or assessments of the following issues: policy design, implementation and policy impacts.

 The paper presents the major conclusions of the systematic review. In general, evaluation of decentralization is an incipient area of research especially at country and subnational levels of government. A vast majority of the published research is concentrated on description of policy designs and implementation processes. In the few cases of evaluations, however, it is possible to enunciate some important lessons: (1) decentralization represents a window of opportunity for other major policies, such as increases in coverage, (2) there is a tendency in subnational and local institutions to depend from the allocations received from the center, (3) there are specific cases of equity improvements and increases in coverage of health services, (4) analysis of efficiency and quality are practically nonexistent.