Decentralization and Regionalization: Redesigning Health Systems for High Quality Maternity Care; Comment on “Decentralization and Regionalization of Surgical Care: A Review of Evidence for the Optimal Distribution of Surgical Services in Low- and Middle-Income Countries”

Document Type : Commentary


UNICEF, Health Section, Dar es Salaam, Tanzania


The question of how to optimally design health systems in low- and middle-income countries (LMICs) for high quality care and survival requires context-specific evidence on which level of the health system is best positioned to deliver services. Given documented poor quality of care for surgical conditions in LMICs, evidence to support intentional health system design is urgently needed. Iverson and colleagues address this very important question. This commentary explores their findings with particular attention to how they apply to maternity care. Though surgical maternity care is a common healthcare need, maternal complications are often unpredictable and require immediate surgical attention in order to avert serious morbidity or mortality. A discussion of decentralization for maternity services must grapple with this tension and differentiate between facilities that can provide emergency surgical care and those that can not.


  1. Iverson KR, Svensson E, Sonderman K, et al. Decentralization and regionalization of surgical care: a review of evidence for the optimal distribution of surgical services in low- and middle-income countries. Int J Health Policy Manag. 2019;8(9):521-537. doi:10.15171/ijhpm.2019.43
  2. Juran S, Broer PN, Klug SJ, et al. Geospatial mapping of access to timely essential surgery in sub-Saharan Africa. BMJ Glob Health. 2018;3(4):e000875. doi:10.1136/bmjgh-2018-000875
  3. Meara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569-624. doi:10.1016/s0140-6736(15)60160-x
  4. Kruk ME, Gage AD, Arsenault C, et al. High-quality health systems in the Sustainable Development Goals era: time for a revolution. Lancet Glob Health. 2018;6(11):e1196-e1252. doi:10.1016/s2214-109x(18)30386-3
  5. Gage AD, Carnes F, Blossom J, et al. In low- and middle-income countries, is delivery in high-quality obstetric facilities geographically feasible? Health Aff (Millwood). 2019;38(9):1576-1584. doi:10.1377/hlthaff.2018.05397
  6. Bitton A, Ratcliffe HL, Veillard JH, et al. Primary health care as a foundation for strengthening health systems in low- and middle-income countries. J Gen Intern Med. 2017;32(5):566-571. doi:10.1007/s11606-016-3898-5
  7. Bygbjerg IC. Double burden of noncommunicable and infectious diseases in developing countries. Science. 2012;337(6101):1499-1501. doi:10.1126/science.1223466
  8. World Health Organization, World Bank Group, OECD. Delivering Quality Health Services: A Global Imperative for Universal Health Coverage. Geneva: WHO; 2018.
  9. Souza JP, Gülmezoglu AM, Vogel J, et al. Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study. Lancet. 2013;381(9879):1747-1755. doi:10.1016/s0140-6736(13)60686-8
  10. Leslie HH, Fink G, Nsona H, Kruk ME. Obstetric facility quality and newborn mortality in Malawi: a cross-sectional study. PLoS Med. 2016;13(10):e1002151. doi:10.1371/journal.pmed.1002151
  11. Kruk ME, Gage AD, Joseph NT, Danaei G, García-Saisó S, Salomon JA. Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries. Lancet. 2018;392(10160):2203-2212. doi:10.1016/s0140-6736(18)31668-4
  12. Danilack VA, Nunes AP, Phipps MG. Unexpected complications of low-risk pregnancies in the United States. Am J Obstet Gynecol. 2015;212(6):809.e801-806. doi:10.1016/j.ajog.2015.03.038
  13. Aoyama K, D'Souza R, Pinto R, et al. Risk prediction models for maternal mortality: a systematic review and meta-analysis. PLoS One. 2018;13(12):e0208563. doi:10.1371/journal.pone.0208563
  14. Kruk ME, Leslie HH, Verguet S, Mbaruku GM, Adanu RMK, Langer A. Quality of basic maternal care functions in health facilities of five African countries: an analysis of national health system surveys. Lancet Glob Health. 2016;4(11):e845-e855. doi:10.1016/s2214-109x(16)30180-2
  15. Gabrysch S, Nesbitt RC, Schoeps A, et al. Does facility birth reduce maternal and perinatal mortality in Brong Ahafo, Ghana? a secondary analysis using data on 119 244 pregnancies from two cluster-randomised controlled trials. Lancet Glob Health. 2019;7(8):e1074-e1087. doi:10.1016/s2214-109x(19)30165-2
  16. Lewis TP, Roder-DeWan S, Malata A, Ndiaye Y, Kruk ME. Clinical performance among recent graduates in nine low- and middle-income countries. Trop Med Int Health. 2019;24(5):620-635. doi:10.1111/tmi.13224
  17. Miller S, Abalos E, Chamillard M, et al. Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. Lancet. 2016;388(10056):2176-2192. doi:10.1016/s0140-6736(16)31472-6
Volume 10, Issue 4
April 2021
Pages 215-217
  • Receive Date: 07 December 2019
  • Revise Date: 22 February 2020
  • Accept Date: 23 February 2020
  • First Publish Date: 01 April 2021