Quality of care in decentralized primary care clinics: a conceptual framework

In an attempt to provide high quality medical care, despite limited resources, health care providers in various countries have introduced decentralization into their health care services. It has been assumed that the delegation of authority to the local levels of the organization will enhance their ability to respond to local needs, and improve cost containment without compromising the quality of care. However, to date, few empirical studies have explored the relationship between decentralization and such projected outcomes. In this article we present a conceptual framework for analyzing possible consequences of decentralization on dimensions of quality of primary health care. We also suggest a framework for defining decentralization programs by their key components, and employ these frameworks to analyze a specific decentralization program being implemented in Israel's largest health maintenance organization (HMO). While we identify the dimensions most likely to be affected, we also conclude that data presently available do not permit a definitive prediction of whether the overall effect of decentralization on quality of care will be positive or negative. The potential reaction of a unit to the elements of change introduced by a decentralization program is influenced by the structural, cultural and management characteristics of that unit. Therefore, future attempts to decentralize health care organizations should be accompanied by close monitoring.