Having and eating the cake? The centralisation paradox in decentralised healthcare governance: a scoping review

BACKGROUND: Decentralisation in healthcare governance is widely promoted to enhance managerial autonomy, responsiveness, and performance. However, empirical evidence suggests that managers operating in decentralised systems continue to rely on centrally coordinated organisational structures. This interdependence remains insufficiently conceptualised in existing research. METHODS: A scoping review was conducted to synthesise empirical studies examining how central coordination in organisational systems shapes managers' effective decision space in decentralised healthcare organisations. Searches were performed in PubMed and CINAHL, complemented by snowballing. The review followed PRISMA-ScR guidelines. Data were analysed using a conceptual synthesis approach informed by paradox theory and the decision space framework. FINDINGS: Four interrelated themes were identified: (1) delegated authority and experienced autonomy, (2) the role of organisational capacity in enabling decision space, (3) persistent central coordination within decentralised systems, and (4) autonomy dependent on coordination. The findings show that while decentralisation expands formal decision-making authority, the effective exercise of this authority depends on centrally coordinated enabling systems, including digital infrastructure, administrative support, and financial management. This interdependence reflects a consistent pattern across contexts. CONCLUSIONS: The study proposes the concept of a centralisation paradox, demonstrating that managerial autonomy in decentralised healthcare governance is contingent upon central coordination. By extending the decision space model, the study proposes a dual-domain conceptualisation distinguishing between professional decision-making and enabling systems. This reframing advances theoretical understanding of decentralised governance and offers practical insights for designing healthcare organisations that balance local autonomy with system-wide coordination.