Transfer of Primary Healthcare Service Provision to Local Governments: A Policy Capacity Analysis of Lessons from Eight Countries
Lessons from 8 Countries
Keywords:
primary healthcare decentralization, policy capacity, decision space, health system stewardship , universal health coverageAbstract
Health decentralization involves more than transferring budgets, personnel, facilities, and service-delivery responsibilities to local governments. This article applies Wu, Ramesh, and Howlett’s Policy Capacity framework and Bossert’s Decision Space framework to analyze the primary healthcare functions and authority transferred to local governments. The study systematically compares documentary evidence from eight countries selected through a Most Different Systems Design (MDSD): Portugal, Russia, Japan, the Philippines, Indonesia, Mexico, Brazil, and Chile. The analysis follows the READ framework and the transparency principles of PRISMA 2020 and PRISMA-S. The findings show that deficient systemic operational capacity is the most recurrent bottleneck in primary healthcare decentralization across the eight countries. Key challenges include intergovernmental grant systems, workforce preparedness, availability of medicines and medical supplies, referral systems, coordination among diverse service providers, and enforcement of the healthcare service standards. Analytical capacity at the individual, operational, and systemic levels is also essential to decentralization. This includes the ability of all actors in the local health systems to analyze data, plan services, and engage in policy learning. Meanwhile, political capacity helps build legitimacy and strengthen stewardship during the transition to decentralized governance. Among the dimensions of decision space, mechanisms for enforcing primary healthcare service standards emerge as a key factor in successful decentralization across the eight country cases. Two other important conditions are adequate government grants to local governments and a publicly funded universal health coverage system that provides a social safety net for vulnerable populations.
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