Decentralization and equitable service delivery: Access and satisfaction under health sector governance reform

Administrative reforms implemented in the Global South are often designed to improve health service delivery for rural communities. Decentralization is one of the most popular strategies, with contemporary versions combining devolution and performance-based management. Our study draws on the experience of health sector reform in Honduras where the government decentralized health service delivery in a third of its municipalities.

This study aims to assess the consequences of decentralization for equitable health service delivery. Focusing on access to healthcare and satisfaction, we collected and analyzed data for about 9,000 households in a matched sample of 65 municipalities, 23 centrally-administered and 42 decentralized. Indicators of access include individual- and facility-level barriers to receiving care, satisfaction indicators focus on the consultation and overall health system, and indicators of household wealth, gender, education, and race and ethnicity are considered as potential moderators.

Relative to centralized administration, our main analysis shows that facility-level barriers to accessing healthcare were lower, satisfaction was higher, and wealth-based disparities were attenuated under decentralization. Exploratory analyses show key differences among three types of intermediary organizations under decentralization: access improvements were most pronounced with associations and municipal governments, satisfaction improvements were greatest with NGOs and associations, and wealth-based disparities attenuated most under NGOs.

Contrary to several previous studies, we find that decentralization can support the improvement of not only outputs and outcomes, but also key aspects related to equitable health service delivery. However, these improvements may be less consistent and depend on the type of organization that manages local health service delivery.