{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,4]],"date-time":"2026-09-04T08:04:31Z","timestamp":1788509071680,"version":"build-2803163510"},"reference-count":44,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2024,11,8]],"date-time":"2024-11-08T00:00:00Z","timestamp":1731024000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Public Health"],"abstract":"<jats:sec><jats:title>Background<\/jats:title><jats:p>Health system reform initiatives have increasingly embraced decentralization as a key trend. The implementation process and its outcomes are influenced by a myriad of factors, including economic forces, political dynamics, and ideological factors. Comprehending and carefully examining the implementation phase of decentralization and its consequences to achieve desired outcomes is crucial. Notably, this phase is often considered the weakest aspect of policy reforms, especially in developing countries. Therefore, this study aimed to explore and analyze the implementation phase of decentralization and its implications as essentials for achieving intended goals. The study objectives evolved around examining the entire decentralization as a multifaceted social and political process in Khartoum State, Sudan, from its early stages of decision-making, policy formulation, and implementation process and the influencing contextual factors.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>This study was an exploratory qualitative study that employed in-depth interviews to gather perspectives of healthcare providers and policymakers, semi-structured observations, and thematic analysis. The study utilized Grindle\u2019s framework for analysis.<\/jats:p><\/jats:sec><jats:sec><jats:title>Findings<\/jats:title><jats:p>This study revealed a political nature of decision-making, with a top\u2013down approach to the implementation, which also lacked stakeholder involvement. It showed a lack of transparency, official documentation, and proper handover procedures from the Ministry of Health to the devolved hospitals during the implementation process. A conflict of interest between the federal and the state level was also reported. It is important to note that this process occurred within the context of structural adjustment program (SAP) schemes, which had already empowered the private sector in Sudan.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>This study documented the implementation process of decentralization of health services and its influencing factors. The study recommended reforming the decentralization policy through consultative stakeholder involvement and by implementing a concurrent responsibility paradigm that divides authority between the federal and state levels.<\/jats:p><\/jats:sec>","DOI":"10.3389\/fpubh.2024.1439219","type":"journal-article","created":{"date-parts":[[2024,11,8]],"date-time":"2024-11-08T04:28:14Z","timestamp":1731040094000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":3,"title":["The implementation process of decentralization of health services: a qualitative perspective from Sudan"],"prefix":"10.3389","volume":"12","author":[{"given":"Bandar","family":"Noory","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sara","family":"Hassanain","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kassem","family":"Kassak","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2024,11,8]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"445","DOI":"10.5588\/pha.18.0070","article-title":"The effect of decentralization on tuberculosis services in three states of Sudan","volume":"7","author":"El-Sony","year":"2003","journal-title":"Int J Tuberc Lung Dis"},{"key":"ref2","author":"Saltman","year":"2006"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"e073669","DOI":"10.1136\/bmjopen-2023-073669","article-title":"Impact of health system governance on healthcare quality in low-income and middle-income countries: a scoping review","volume":"13","author":"George","year":"2023","journal-title":"BMJ Open"},{"key":"ref4","author":"Kolehmainen-Aitken","year":"1999"},{"key":"ref5","author":"Kolehmainen","year":"1996"},{"key":"ref6","author":"Perez","year":"1995"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"561","DOI":"10.1186\/s12913-016-1784-9","article-title":"Decentralization and health system performance \u2013 a focused review of dimensions, difficulties, and derivatives in India","volume":"16","author":"Panda","year":"2016","journal-title":"BMC Health Serv Res"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"e013317","DOI":"10.1136\/bmjgh-2023-013317","article-title":"The impact of decentralisation on health systems: a systematic review of reviews","volume":"8","author":"Sapkota","year":"2023","journal-title":"BMJ Glob Health"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"605","DOI":"10.1093\/heapol\/czz055","article-title":"The impacts of decentralization on health system equity, efficiency and resilience: a realist synthesis of the evidence","volume":"34","author":"Abimbola","year":"2019","journal-title":"Health Policy Plan"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"323","DOI":"10.1111\/1468-0009.12327","article-title":"Does decentralization improve health system performance and outcomes in low- and middle-income countries? 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