Why is it so hard to know whether decentralization is a good policy for health systems? Many observers have made unsubstantiated claims for decentralization and federalism in part because there are many different ways to design and implement decentralization and federal policies. It is also very difficult to evaluate the impact of these policies because of the importance of different contexts and of simultaneous policies of funding, payment and service delivery changes in the health sector. We have applied a consistent approach, called “decision space”, to show the complex arrangements of decentralization and federal policies in 8 different countries and begin the process of evaluation in the hopes of providing recommendations for policy makers.

Thomas J. Bossert

Senior Lecturer and the Director of the International Health Systems Program of the Harvard T. H. Chan School of Public Health