Understanding the Dynamics of Local Health Systems in Developing Countries

This 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, premised on the idea 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 on whether reformed systems produce healthier communities are extremely mixed.  This project’s guiding question is:  why do 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.  First, 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.  Second, researchers will collect time-series, cross-sectional, and social network data for 250 local health systems in Honduras, half that have been decentralized to local organizations and the remainder managed by the central government.  The researchers will combine existing longitudinal health data with socio-economic and institutional data, as well as implementing original social network mapping, survey data collection, and behavioral experiments with health system actors in the field.  Third, using these data the researchers will test several hypotheses about the ways governance structure affects health system performance through changes in the behavior of local organizations and individuals.

This research will generate evidence on the local and institutional factors that affect disparities in the performance of health systems in developing countries.  The questions examined are of theoretical significance as 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 on the institutional conditions that drive differences in local health system performance as well as the effectiveness of health sector decentralization.  Moreover, this research is of immediate practical value as countries around the world struggle to create policies for effectively administering health systems and improving community health.  The study will provide policymakers, 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.  Finally, the results of this work will be relevant to numerous other sectors – like education, agriculture, and the environment – where central governments have also transferred policy-making power to lower levels of government.

This project is in collaboration with:
Krister Andersson (Political Science & IBS, CU Boulder)
Jane Menken (Sociology & IBS, CU Boulder)

NSF Interdisciplinary Behavioral and Social Sciences Research (IBSS) competition, 2013-2017