{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,16]],"date-time":"2026-04-16T16:27:36Z","timestamp":1776356856707,"version":"3.51.2"},"reference-count":84,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2023,12,31]],"date-time":"2023-12-31T00:00:00Z","timestamp":1703980800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100001871","name":"Funda\u00e7\u00e3o para a Ci\u00eancia e Tecnologia","doi-asserted-by":"publisher","award":["2022.13288.BD"],"award-info":[{"award-number":["2022.13288.BD"]}],"id":[{"id":"10.13039\/501100001871","id-type":"DOI","asserted-by":"publisher"}]},{"name":"Programa Operacional Centro 2020","award":["2022.13288.BD"],"award-info":[{"award-number":["2022.13288.BD"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Sustainability"],"abstract":"<jats:p>Decentralization is considered an important component of participatory democracy. However, despite its widespread implementation in the healthcare sector, its impact on health systems\u2019 performance remains unclear. Using a theoretical framework based on the World Health Organization\u2019s five decentralization variables\u2014geography and sociodemographics, organization of political processes, functions and economic weight, steering, and control\u2014we conducted a scoping review to unveil causal mechanisms linking each feature to equity, efficiency, and effectiveness. Following the PRISMA protocol, 1627 articles were screened, and 63 were selected for data analysis, with a focus on middle- and high-income countries. The findings show that the most frequently discussed forms of decentralization are fiscal and administrative, with a primary focus on how governance mechanisms affect equity and efficiency. The effects of decentralized healthcare governance on equity, efficiency, and effectiveness are diverse and contingent on contextual factors and the implementation processes. The spatial context (geography) of decentralization negatively impacts equity, and steering strongly affects effectiveness. Functions and economic weight significantly influence efficiency, albeit with variability. Overall, decentralization falls short of delivering substantial healthcare system benefits, although this depends on contextual factors.<\/jats:p>","DOI":"10.3390\/su16010386","type":"journal-article","created":{"date-parts":[[2023,12,31]],"date-time":"2023-12-31T10:01:06Z","timestamp":1704016866000},"page":"386","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":16,"title":["The Impacts of Health Decentralization on Equity, Efficiency, and Effectiveness: A Scoping Review"],"prefix":"10.3390","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4568-8884","authenticated-orcid":false,"given":"Rafaela","family":"Oliveira","sequence":"first","affiliation":[{"name":"Governance, Competitiveness and Public Policies Research Unit (GOVCOPP), Department of Social, Political and Territorial Sciences, University of Aveiro, 3810-193 Aveiro, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4732-5959","authenticated-orcid":false,"given":"Gon\u00e7alo","family":"Santinha","sequence":"additional","affiliation":[{"name":"Governance, Competitiveness and Public Policies Research Unit (GOVCOPP), Department of Social, Political and Territorial Sciences, University of Aveiro, 3810-193 Aveiro, Portugal"}]},{"given":"Teresa","family":"S\u00e1 Marques","sequence":"additional","affiliation":[{"name":"Geography and Spatial Planning Research Centre (CEGOT), Department of Geography, Faculty of Arts and Humanities, University of Porto, 4150-564 Porto, Portugal"}]}],"member":"1968","published-online":{"date-parts":[[2023,12,31]]},"reference":[{"key":"ref_1","unstructured":"Saltman, R.B., Bankauskaite, V., and Vrangb\u00e6k, K. 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