Decentralization of Health Systems: Challenges and Global Issues of the Twenty-First Century

Abstract

Decentralization of health systems is a growing trend in most nations. However, there are a series of new challenges that face these processes of decentralization. To assess these challenges, this chapter first starts with a definition of decentralization that defines who gets more choice (deconcentration or devolution) and how much choice they get over what functions, which we call “decision space.” It is also important to assess the capacities of those who receive more choice and the accountability they have toward the national authorities and the local population of beneficiaries. The major new challenges to the processes of decentralization reviewed in this chapter are national health insurance and universal coverage, growth of the private sector, epidemiological and demographic changes, and new structures of governance and accountability. It concludes with policy recommendations which suggest the need to balance “decision space” for local authorities with realistic development of their capacities, reserving some key functions to the national authorities. It is also important to push forward a research agenda to assess the best mix of the elements of decentralization that are most likely to achieve better health system performance.