Social and Behavioral Effects of Decentralization on Health Services Delivery: Evidence from the Honduran Health Sector

Decentralization is widely promoted to improve local service delivery, yet evidence on frontline officials’ behavioral role remains limited. We study Honduras’ health-sector reform using lab-in-the-field experiments with 240 officials across 31 matched municipalities and administrative data on maternal health services, examining four behavioral mechanisms—motivation, cooperation, coordination, and trust—via linear regression and fuzzy-set qualitative comparative analysis. Decentralized settings show higher motivation and cooperation, and greater provision of prenatal, follow-up, and postpartum services. Decentralization acts as a necessary enabling condition across maternal-care stages, though mechanisms vary by outcome: early uptake aligns with motivation, later stages with multiple configurations, demonstrating equifinality. Decentralization thus operates less as a single causal lever than as a modifier of the institutional environment enabling behavioral pathways. Motivational gains stem primarily from new-hire selection, while cooperation benefits both new and existing staff. Institutional trust appears unaffected, suggesting it responds to longer time horizons than other mechanisms.