Eri Witcahyo Witcahyo, Asobat Gani, I Made Suwandi

The Role of Decentralized Health Systems in Shaping Service Quality: A Systematic Review in Low- and Middle-Income Countries

Introduction

The role of decentralized health systems in shaping service quality: a systematic review in low- and middle-income countries. Systematic review explores decentralized health systems' impact on service quality in low- and middle-income countries (LMICs). Finds mixed outcomes, offering policy insights.

Abstract

Decentralization has emerged as a prominent strategy for health sector reform in low- and middle-income countries (LMICs), aiming to enhance service quality, efficiency, equity, and responsiveness. This study systematically reviews literature published between 2021 and 2025 to explore the role of decentralized health systems in shaping healthcare service quality across LMICs. Using PRISMA 2020 guidelines, 20 eligible studies were identified and analyzed from databases including PubMed, Scopus, Web of Science, and Google Scholar. Thematic synthesis of findings reveals mixed outcomes: while decentralization improves local responsiveness, enhances community engagement, and strengthens health system performance in some settings, it also exacerbates disparities in others due to uneven institutional capacity, limited fiscal resources, and fragmented coordination. Key performance areas identified include human resource deployment, financing, access to services, and equity in service delivery. The study emphasizes the significance of local capacity-building, efficient resource allocation, and integrated planning in attaining sustainable and equitable healthcare improvements within decentralized systems. This review provides practical insights for policymakers aiming to align decentralization strategies with health equity and service quality objectives.

Review

This systematic review addresses a highly pertinent and complex topic: the role of decentralized health systems in shaping service quality within low- and middle-income countries (LMICs). The authors effectively highlight decentralization as a significant health sector reform strategy aimed at improving critical outcomes such as efficiency, equity, and responsiveness. Utilizing PRISMA 2020 guidelines, the study rigorously synthesizes findings from 20 eligible studies published between 2021 and 2025, drawing from a comprehensive set of academic databases including PubMed, Scopus, Web of Science, and Google Scholar. This focused approach on very recent literature ensures the review’s findings are timely and reflect contemporary understanding and challenges in the field. The review's thematic synthesis reveals a nuanced and often contradictory picture of decentralization's impact. While it demonstrates clear benefits in certain contexts, such as enhanced local responsiveness, increased community engagement, and strengthened overall health system performance, it concurrently exposes significant drawbacks. Notably, the study identifies instances where decentralization exacerbates existing disparities, a critical concern attributed to uneven institutional capacity, limited fiscal resources, and fragmented coordination across different levels of the health system. Key performance areas—including human resource deployment, financing mechanisms, access to essential services, and equity in service delivery—are thoroughly examined, providing a robust framework for understanding where decentralized systems succeed or falter. The findings offer valuable practical insights for policymakers and practitioners grappling with health system reforms. By underscoring the critical importance of local capacity-building, efficient resource allocation, and integrated planning, the review provides actionable recommendations for mitigating the negative consequences of decentralization while maximizing its potential benefits. This work serves as an essential guide for aligning decentralization strategies with the overarching objectives of health equity and improved service quality in LMICs, making a significant contribution to both scholarly discourse and evidence-based policy development in global health.

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