title: Back to basics: does decentralization improve health system performance? Evidence from Ceara in north-east Brazil.
abstract: OBJECTIVE
  To examine whether decentralization has improved health system performance in the State of Ceara, north-east Brazil.
  
  
  METHODS
  Ceara is strongly committed to decentralization. A survey across 45 local (municipio) health systems collected data on performance and formal organization, including decentralization, informal management and local political culture. The indicators for informal management and local political culture were based on prior ethnographic research. Data were analysed using analysis of variance, Duncan's post-hoc test and multiple regression.
  
  
  RESULTS
  Decentralization was associated with improved performance, but only for 5 of our 22 performance indicators. Moreover, in the multiple regression, decentralization explained the variance in only one performance indicator; indicators for informal management and political culture appeared to be more important influences. However, some indicators for informal management were themselves associated with decentralization but not any of the political culture indicators.
  
  
  CONCLUSIONS
  Good management practices in the study led to decentralized local health systems rather than vice versa. Any apparent association between decentralization and performance seems to be an artefact of the informal management, and the wider political culture in which a local health system is embedded strongly influences the performance of local health systems.
authors.affiliation: Health Systems Development Programme, University of Manchester, M13 9PL England. Sarah.Atkinson@man.ac.uk
authors.forename: Sarah
authors.initials: S
authors.lastname: Atkinson
authors.forename: Dave
authors.initials: D
authors.lastname: Haran
mesh_terms: D001938:Brazil; D018672:Community Health Planning / Q000458:organization & administration*; D003695:Delivery of Health Care / Q000458:organization & administration* / Q000592:standards; D003906:Developing Countries; D018166:Health Care Reform / Q000458:organization & administration*; D006801:Humans; D009111:Local Government; D017146:Models, Organizational; D011057:Politics; D011635:Public Health Administration / Q000592:standards*; D019984:Quality Indicators, Health Care; D011795:Surveys and Questionnaires; D017749:Total Quality Management / Q000379:methods