Back to Basics: Does Decentralization Improve Health System Performance? Evidence from Ceará in North-East Brazil

The objective was to examine whether decentralization has improved health system performance in the State of Ceara, north-east Brazil. Decentralization was associated with improved performance, but only for 5 of our 22 performance indicators. Moreover, in the multiple regression, decentralization explained the variance in only one performance indicator; indicators for informal management and political culture appeared to be more important influences. However, some indicators for informal management were themselves associated with decentralization but not any of the political culture indicators. Good management practices in the study led to decentralized local health systems rather than vice versa. [from abstract]