The impacts of decentralisation on health-related equity: A systematic review of the evidence.
BACKGROUND
Decentralised 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.


OBJECTIVE
To conduct a systematic literature review of the implications of decentralised governance of health care on equity in health, health care and health financing.


METHODS
A 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.


RESULTS
Out 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.


CONCLUSIONS
The 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.
Ghana Health Service, Upper West Regional Health Directorate, P.O. Box 298, Wa, Ghana; University of Technology Sydney, Faculty of Health, Sydney, Australia. Electronic address: macsumah@yahoo.com.
Anthony Mwinkaara
AM
Sumah
Australian Catholic University, School of Allied and Public Health, Sydney, Australia. Electronic address: baatiemaleonard@gmail.com.
Leonard
L
Baatiema
University of Sydney, School of Public Health, Edward Ford Building A27, Sydney, NSW 2006, Australia. Electronic address: seyeabimbola@hotmail.com.
Seye
S
Abimbola
D003695:Delivery of Health Care / Q000379:methods; D000069576:Health Equity / Q000639:trends*; D006297:Health Services Accessibility / Q000191:economics / Q000592:standards*; D054625:Healthcare Disparities / Q000191:economics; D061889:Healthcare Financing; D006801:Humans; D011057:Politics
Decentralisation; Equity; Health care governance; Health outcomes; Health system; Health-related equity; Healthcare access; Heath financing