Making social services work better for the poor: Evidence from a natural experiment with health sector decentralization in Honduras

Governments in many less developed countries have decentralized their social support systems over the last several decades. However, despite enthusiasm for these reforms, evidence remains limited and mixed as to whether they improve the delivery of basic social services. I take advantage of an unexpected pause in reform implementation in Honduras due to the country’s 2009 coup to investigate the effects of decentralization on local health services. Drawing on administrative data, an original survey of health workers, and qualitative interviews, my analysis shows that decentralization is credibly associated with increases in preventive care for women and that improved accountability and greater resilience to shocks are important mechanisms for this change. Moreover, my analysis highlights how regional organizations use decentralization to assert their own influence and deflect negative political consequences while pressuring for improvements in service delivery. These findings shed light both on the possibilities for improving local social services through governance reform and how national-level reforms can be leveraged by powerful actors at lower rungs of the governmental hierarchy.