BU Research Blog

Today we received notice that our paper ‘The impacts of decentralisation on health systems: a systematic review of reviews’ has been accepted by the international journal BMJ Global Health. [1]  This review of reviews was produced as part of the Nepal Federal Health System Project, examining the consequences for the health system of Nepal’s move to a federal government structure.  This is a joint project (2020-2024) led by the University of Sheffield and in collaboration with Bournemouth University, the University of Huddersfield, Manmohan Memorial Institute of Health Sciences (MMIHS) and PHASE Nepal.  This longitudinal interdisciplinary study is funded by the UK Health Systems Research Initiative [Grant ref. MR/T023554/1] and has resulted in four previous publications. [2-5]

The latest paper is a review which synthesizes evidence generated by previous reviews on the impact of decentralising health system governance on the six WHO (World Health Organization) health system building blocks.   We systematically searched for reviews exploring the impact of decentralisation on the health system from five databases. Reviews, both systematic and non-systematic, published in the English language from 1990 to February 2022 were included.  Nine reviews, each addressing slightly different questions, contexts and health system issues, were synthesised.  They showed that devolution can have positive or negative impacts on the health system and its components. Moreover, impact assessments are significantly affected by complexities surrounding decentralisation and health system concepts: their dynamic mechanisms, inconsistent and often differently operationalized health system and health system component variables, and methodological challenges. For the WHO health system components, more negative than positive impacts were reported. The reviews highlight the importance of closely assessing (pre-)existing (political and non-political) characteristics of countries and their health systems to better understand impacts. This review of reviews concludes that decentralisation can have a negative or a positive impact on the health system and its components; the impacts are shaped by pre-existing country contexts. Generating conclusive and generalisable evidence of the impacts of decentralisation on health systems is challenging. Whilst decentralisation may seek to enhance community engagement and improve the responsiveness of decision-making, it has the potential to create serious challenges to the health system, the manifestations of which are likely to be context-specific.

Prof. Edwin van Teijlingen

CMWH

1. Sapkota, S., Dhakal, A., Rushton, S., van Teijlingen, E., Marahatta, S.B., Balen, J., Lee, A. for the Nepal Federal Health System Team (2023) The impacts of decentralisation on health systems: a systematic review of reviews, BMJ Global Health (forthcoming)
2. Wasti, S.P., van Teijlingen, E.,Rushton, S., Subedi, M., Simkhada, P., Balen, J. for the Nepal Federal Health System Team (2023) Overcoming the Challenges Facing Nepal’s Health System During Federalisation: An Analysis of Health System Building Blocks, Health Research Policy & Systems 21(117) https://doi.org/10.1186/s12961-023-01033-2
3. Sapkota, S., Panday, S., Wasti, S.P., Lee, A., Balen, J., van Teijlingen, E., Rushton, S., Subedi, M., Gautam, S., Karki., J., Adhikary, P., Marahatta, S., Simkhada, P., for the Nepal Federal Health System Team (2022) Health System Strengthening: The Role of Public Health in Federal Nepal, Journal of the Nepal Public Health Association 7(1):36-42.
4. Adhikary, P., Balen, J., Gautam, S., Ghimire, S., Karki, J., Lee, A.C.K., Marahatta, S.B., Panday, S., Pohl, G., Rushton, S., Sapkota, S., Simkhada, P.P., Subedi, M., van Teijlingen, E. for the Nepal Federal Health System team (2020) The COVID-19 pandemic in Nepal: Emerging evidence on the effectiveness of action by, and cooperation between, different levels of government in a federal system, Journal of Karnali Academy of Health Sciences 3 (3): 1-11.
5. Rushton, S., Pandey, S., van Teijlingen, E., Subedi, M., Balen, J., Karki, J., Simkhada, P. on behalf of the Nepal Federal Health System Team (2021) An Investigation into the Impact of Decentralization on the Health System of Nepal. Journal of Manmohan Memorial Institute of Health Sciences, 7(1): 3–14. https://doi.org/10.3126/jmmihs.v7i1.43146