This interdisciplinary research project focuses on the institutional conditions that shape the performance of local health systems in developing countries. The problem motivating the project is the inability of health systems in many countries to prevent extreme health disparities and human suffering. Decentralization reforms that operate on the premise that local institutional arrangements can provide public services better than central government agencies are a ubiquitous response to these disparities. The problem is that theoretical arguments for health-sector decentralization are underdeveloped, and empirical results assessing whether reformed systems produce healthier communities are mixed. The project will focus on explaining why some local health systems perform better than others. The researchers will address this question by developing and testing specific hypotheses about the ways governance structure affects the performance of local health systems. The project has three components. The researchers will draw on work in new institutionalism and polycentric governance to develop a theory linking decentralization, behavior patterns, and the performance of local health systems. They will collect time-series, cross-sectional, and social network data for 250 local health systems in Honduras, half of which have been decentralized to local organizations and the remainder managed by the central government. The researchers will combine existing longitudinal health data with socioeconomic and institutional data, and they will implement original social network mapping, survey data collection, and behavioral experiments with health system actors in the field. They will use these data to test several hypotheses about the ways governance structure affects health-system performance through changes in the behavior of local organizations and individuals.
This project will generate evidence about the local and institutional factors that affect disparities in the performance of health systems in developing countries. The questions examined are of theoretical significance, because they address how public policies affect societal outcomes through human institutions, as well as organizational and individual behavior. By building theory, implementing an innovative research design, constructing an original dataset, and employing quantitative and qualitative analyses to test theory, the researchers will contribute robust findings about the institutional conditions that drive differences in local health-system performance as well as the effectiveness of health-sector decentralization. The project will have immediate practical value as countries around the world struggle to create policies for effectively administering health systems and improving community health. Project findings will provide policy makers, analysts, and donors with a deeper understanding of the factors influencing health system performance, specific recommendations for improving that performance, and an innovative set of methods to evaluate the effectiveness of governance reforms. The results of this work will be relevant to numerous other sectors, such as education, agriculture, and the environment, where central governments have also transferred policy-making power to lower levels of government. This project is supported by the NSF Interdisciplinary Behavioral and Social Sciences Research (IBSS) competition.
