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A substantial number of low and middle income countries (LMICs) have implemented health sector reforms in the last 40 years, and the majority of them have included some degree of decentralization of the health system as part of the wider reform. This review will provide an updated and comprehensive assessment of the effects of decentralization in LMICs. We conducted a systematic review of published and grey literature till May 2015, following standard methods. 54 qualitative, quantitative and mixed methods studies conducted in 26 countries were included in the review. We found positive and negative effects of decentralization of health systems in LMICs. Whereas decentralization of governance, financing and service delivery, have been shown to have positive effects on the system; decentralization of resource management has been challenging in several settings. Overall, lessons learned from LMICs suggest that factors such as adequate mix of technical skills at the local level to perform decentralized tasks, effective decentralization of decision-making to the periphery, and political leadership are key factors for a successful decentralization.

Objective To estimate the effect of unimproved household water and toilet facilities on pregnancy-related mortality in Afghanistan. Methods The data source was a population-based cross-sectional study, the Afghan Mortality Survey 2010. Descriptive, univariate and multivariate logistic regression analyses were carried out, comparing 69 pregnancy-related deaths (cases) and 15386 surviving women (non-cases) who had a live birth or stillbirth between 2007 and 2010. Results After adjusting for confounders, households with unimproved water access had 1.91 the odds of pregnancy-related mortality [95% confidence interval (CI) 1.11–3.30] compared to households with improved water access. We also found an association between unimproved toilet facilities and pregnancy-related mortality (OR = 2.25; 95% CI 0.71–7.19; P-value = 0.169), but it was not statistically significant. Conclusions Unimproved household water access was an important risk factor for pregnancy-related mortality in Afghanistan. However, we were unable to discern whether unimproved water source is a marker of unhygienic environments or socio-economic position. There was weak evidence for the association between unimproved toilet facilities and pregnancy-related mortality; this association requires confirmation from larger studies. Objectif Estimer l'effet des installations d'eau et de toilettes non ameliorees dans les menages sur la mortalite liee a la grossesse en Afghanistan. Methodes La source des donnees est une etude transversale basee sur la population, l'Enquete Afghane de 2010 sur la Mortalite. Des analyses de regression logistique descriptives, univariees et multivariees ont ete effectuees, en comparant 69 deces lies a la grossesse (cas) et 15 356 femmes survivantes (non-cas) qui avaient eu une naissance vivante ou une mortinaissance entre 2007 et 2010. Resultats Apres ajustement pour les facteurs confusionnels, les menages ayant acces a l'eau non amelioree avaient 1,91 fois de chance de mortalite liee a la grossesse (intervalle de confiance [IC] 95%: 1,11 a 3,30) compares aux menages ayant acces a l'eau amelioree. Nous avons egalement trouve une association entre les installations de toilettes non ameliorees et la mortalite liee a la grossesse (OR = 2,25; IC 95%: 7,19 a 0,71; P = 0,169), mais qui n’etait pas statistiquement significative. Conclusions L'acces des menages a l'eau non ameliorees etait un important facteur de risque pour la mortalite liee a la grossesse en Afghanistan. Cependant, sur base des informations disponibles, nous etions incapables de discerner si la source d'eau non amelioree etait un marqueur de mauvaises conditions d'hygiene ou de la situation socioeconomique. Il y avait de faibles preuves pour l'association entre les installations de toilettes non ameliorees et la mortalite liee a la grossesse; cette association requiert une confirmation par des etudes plus larges. Objetivo Calcular el efecto del acceso en los hogares al agua no segura y a instalaciones sanitarias inadecuadas sobre la mortalidad materna relacionada con el embarazo en Afganistan. Metodos La fuente de datos es un estudio croseccional basado en la poblacion, la Encuesta de Mortalidad de Afganistan del 2010. Se realizaron analisis descriptivos y regresiones logisticas simples y multiples, comparando 69 muertes maternas relacionados con el embarazo (casos) y 15,356 mujeres vivas (controles) que habian tenido un parto, con feto vivo o de mortinato, entre el 2007 y 2010. Resultados Despues de ajustar para posibles factores de confusion, los hogares con acceso a agua no segura tenian una mayor probabilidad de mortalidad materna relacionada con el embarazo (1.91, [IC] 95% 1.11–3.30) que los hogares con un acceso a agua potable. Tambien encontramos una asociacion entre el uso de instalaciones sanitarias inadecuadas y la mortalidad materna relacionada con el embarazo (OR = 2.25; IC 95% 0.71–7.19; P = 0.169), pero no era estadisticamente significativa. Conclusiones El acceso de los hogares a agua no segura era un importante factor de riesgo para la mortalidad materna relacionada con el embarazo en Afganistan. Sin embargo, con la informacion disponible, no pudimos discernir si el acceso a agua no potable es un marcador de ambientes poco higienicos o de posicion socio-economica. Habia una evidencia debil sobre la asociacion entre el uso de instalaciones sanitarias inadecuadas y la mortalidad materna relacionada con el embarazo; esta asociacion requiere de confirmacion a traves de estudios mas grandes.