Un Federalismo Saludable? Health System Decentralization and Performance in Mexico Open Access

Serrano, Ray (2017)

Permanent URL: https://etd.library.emory.edu/concern/etds/3197xm993?locale=en


This dissertation is prepared in light of ongoing debates on the merits of health system decentralization and its ties to universal access, quality, and equity. Across the world, low-and-middle income countries continue to enact reforms that transfer functions (fiscal, administrative, political, and regulatory) from national to subnational agents, and vice versa. This dissertation provides a nuanced understanding of decentralization from the standpoint of one middle income country, i.e., Mexico, and its complex, deeply-fragmented health system. The dissertation's initial chapters seek to conceptualize decentralization as a reform process. They provide a framework to better understand decentralization's specific links to quality measures. The dissertation then assesses the performance of Mexico's safety-net healthcare facilities in light of Donabedian measures of quality.

The first chapter of the dissertation explores key dimensions of Mexico's health system decentralization, specifically the actors, functions, and historical interactions that characterize the current system. Relying on a myriad of consultancy reports, peer-reviewed articles, and government documents, I account for the various actors and functions of Mexico's brand of health system decentralization. I then account for decision space of key actors in the areas of administration, financing, and policymaking. The second chapter focuses on the intermediary mechanisms that are involved in decentralized policies and quality measures. I provide a framework that highlights the specific dimensions of decentralization and quality. I contend that the proposed framework could benefit future scholars and policymakers who seek to identify policy levers that can reconcile local needs/preferences with improved service delivery.

The third chapter moves the literature beyond mere conceptualization of decentralization to actual uses of decentralization components towards health services utilization and health system performance. It reveals key findings on patients seeking care/treatment at centralized and decentralized healthcare facilities. It notes that while patients seeking care/treatment at decentralized facilities may find lower travel times and wait times, their counterparts at centralized facilities may benefit from a greater availability of medications and better explanations of medications and treatment plans. Combined, the three chapters provide a foundation by which future research can explore the impact of decentralization. The dissertation can guide scholars in assessing this impact as a collective of micro-dynamic processes that can ultimately affect overall health system performance. Moreover, it allows us to understand how decentralization efforts in a resource-limited setting can affect similar populations at the same time.

Table of Contents

Table of Contents

List of Tables

List of Figures



Gaps in Current Literature

Dissertation Chapters

Chapter 1: Health System Decentralization: A Case Study of Mexico

Competing Models of Health Systems

Decentralization and Health Systems Frameworks

The Benefits and Challenges of Health System Decentralization in Low- and Middle-Income Countries:

The Architecture of Mexico's Healthcare Delivery Systems

A History of Health System Decentralization in Mexico

Healthcare Delivery: Centralized vs. Decentralized Providers

Conceptualizing Mexico's Health System Decentralization

Assessing the Dimensions of Mexico's Health System Decentralization


Chapter 2: Connecting Mexico's Health System Decentralization with Quality Assessment: A Conceptual Framework

Dimensions for Assessing Healthcare Quality

The Relationship between Decentralization and Healthcare Quality

Intermediary Mechanisms

Linking Mexico's Health System Decentralization to Quality of Care


Chapter 3: Patient Assessment of Quality for Centralized and Decentralized Providers in Mexico Providers in Mexico


Methods and Data

Theoretical Framework




Policy Implications


About this Dissertation

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