Planes de prestación de servicios para los sistemas de salud en países de bajos ingresos: un resumen de revisiones sistemáticas
Información
- DOI:
- https://doi.org/10.1002/14651858.CD011083.pub2Copiar DOI
- Base de datos:
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- Cochrane Database of Systematic Reviews
- Versión publicada:
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- 13 septiembre 2017see what's new
- Tipo:
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- Overview
- Etapa:
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- Review
- Grupo Editorial Cochrane:
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Grupo Cochrane de Práctica y organización sanitaria efectivas
- Copyright:
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- Copyright © 2017 The Authors. Cochrane Database of Systematic Reviews published by John Wiley & Sons, Ltd. on behalf of The Cochrane Collaboration.
- This is an open access article under the terms of the Creative Commons Attribution‐Non‐Commercial Licence, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.
Cifras del artículo
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Autores
Contributions of authors
All of the authors contributed to drafting and revising the overview.
Sources of support
Internal sources
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Department of Family Medicine, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.
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Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina.
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Norwegian Knowledge Centre for the Health Services, Oslo, Norway.
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University of Cape Town, Cape Town, South Africa.
External sources
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Norwegian Agency for Development Cooperation (Norad), Oslo, Norway.
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Effective Health Care Research Consortium, UK.
The Effective Health Care Research Consortium which is funded by UK aid from the UK Government for the benefit of developing countries.
Declarations of interest
Simon Lewin, Cristian A Herrera, Newton Opiyo, Tomas Pantoja, Elizabeth Paulsen, Gabriel Rada, Claire Glenton, Signe Flottorp, and Andrew D Oxman are editors of the Cochrane Effective Practice and Organisation of Care (EPOC) Group. Simon Lewin, Andrew D Oxman, Charles S Wiysonge, Charles I Okwundu, and Lilian Dudley are authors of some of the included reviews. Agustín Ciapponi, Gabriel Bastías, Marie‐Pierre Gagnon, Sebastian Garcia Marti, Blanca Peñaloza, and Fatima Suleman have no relevant conflicts to declare.
Acknowledgements
We would like to thank the following editors and peer referees who provided comments to improve the overview: Sasha Shepperd (editor), Jane Goudge, George Pariyo and to Meggan Harris for copy‐editing the overview.
We would also like to acknowledge the following colleagues who helped to produce the SUPPORT Summaries upon which this overview is based: Cristián Mansilla, Peter Steinmann, Atif Riaz, Hossein Joudaki, Taryn Young, Karumbi Jamlick, Natalia Zamorano, Celeste Naude, Andrea Basagoitia and Nadja van Ginneken.
We would also like to thank Susan Munabi‐Babigumira, Atle Fretheim, Simon Goudie and Hanna Bergman for editing some of the SUPPORT Summaries, as well as the review authors and others who provided feedback on them.
Charles S Wiysonge's work is supported by the South African Medical Research Council and the National Research Foundation of South Africa (Grant Numbers: 106035 and 108571).
The Norwegian Satellite of the Effective Practice and Organisation of Care (EPOC) Group receives funding from the Norwegian Agency for Development Co‐operation (Norad), via the Norwegian Institute of Public Health to support review authors in the production of their reviews.
This overview is a product of the Effective Health Care Research Consortium, which provided funding to make this overview open access. The Consortium is funded by UK aid from the UK Government for the benefit of developing countries (Grant: 5242). The views expressed in this overview do not necessarily reflect UK government policy.
Version history
| Published | Title | Stage | Authors | Version |
| 2017 Sep 13 | Delivery arrangements for health systems in low‐income countries: an overview of systematic reviews | Review | Agustín Ciapponi, Simon Lewin, Cristian A Herrera, Newton Opiyo, Tomas Pantoja, Elizabeth Paulsen, Gabriel Rada, Charles S Wiysonge, Gabriel Bastías, Lilian Dudley, Signe Flottorp, Marie‐Pierre Gagnon, Sebastian Garcia Marti, Claire Glenton, Charles I Okwundu, Blanca Peñaloza, Fatima Suleman, Andrew D Oxman | |
| 2014 May 05 | Delivery arrangements for health systems in low‐income countries: an overview of systematic reviews | Protocol | Agustín Ciapponi, Simon Lewin, Gabriel Bastías, Lilian Dudley, Signe Flottorp, Marie‐Pierre Gagnon, Sebastian Garcia Marti, Claire Glenton, Cristian A Herrera, Charles I Okwundu, Newton Opiyo, Andrew D Oxman, Tomas Pantoja, Elizabeth Paulsen, Blanca Peñaloza, Gabriel Rada, Fatima Suleman, Charles Shey Wiysonge | |
Keywords
MeSH
Medical Subject Headings (MeSH) Keywords
Medical Subject Headings Check Words
Humans;
| Delivery arrangement | Included Review | No studies | Certainty of evidence | |
| Very low | Low | |||
| Who receives care and when | ||||
| Queuing strategies | Patient outcomes, coverage, utilisation | — | — | |
| Care received by groups vs individual care | Access, coverage, utilisation | — | — | |
| Who provides care | ||||
| Pre‐licensure education | — | — | Access, coverage, utilisation | |
| Recruitment and retention strategies | — | — | Patient outcomes; access, coverage, utilisation | |
| Role extension or task shifting ‐ Lay health workers: hypertension | — | — | Patient outcomes; access, coverage, utilisation; quality of care; resource use | |
| Role extension or task shifting ‐ Lay health workers: delivery of community‐based neonatal care packages | — | Patient outcomes | Patient outcomes, access, coverage, utilisation | |
| Role expansion or task shifting ‐ Lay health workers: maternal and child care and infectious diseases | — | — | Patient outcomes; access, coverage, utilisation | |
| Role expansion or task shifting ‐ Healthcare providers giving additional social support to pregnant women vs usual care | — | — | Patient outcomes | |
| Role expansion or task shifting – Physician‐nurse substitution | Access, coverage, utilisation | — | — | |
| Role expansion or task shifting ‐ Midlevel health professionals: midwife‐led care in pregnancy | — | — | Patient outcomes; access, coverage, utilisation | |
| Role expansion or task shifting ‐ Clinical officers/non‐physician clinicians/Associate clinicians vs physician for caesarean section | — | Patient outcomes; access, coverage, utilisation | — | |
| Role expansion or task shifting ‐ Non‐specialist providers vs. specialist providers for mental health | — | Patient outcomes | Patient outcomes | |
| Role expansion or task shifting ‐ Specialist nursing post added to hospital nurse staffing | — | — | Patient outcomes | |
| ‐ Dietary assistants added to hospital nurse staffing | — | — | Patient outcomes | |
| Role expansion or task shifting ‐ Pharmacists delivering non‐dispensing services to patients | — | Resource use | — | |
| Role expansion or task shifting ‐ Skilled birth attendant | — | — | Patient outcomes | |
| Role expansion or task shifting ‐ Dental care by dental therapists | Resource use | Patient outcomes | — | |
| Coordination of care | ||||
| Care pathways ‐ Improved pre‐hospital trauma systems vs no systems | — | — | Patient outcomes; access, coverage, utilisation | |
| Care pathways ‐ Rapid response systems in hospitals vs no systems | — | Patient outcomes; access, coverage, utilisation | — | |
| Care pathways ‐ Hospital clinical pathways vs usual care | — | Patient outcomes; resource use | Patient outcomes; access, coverage, utilisation | |
| Case management ‐ Children with pneumonia ‐ Community‐based with antibiotics | — | — | Patient outcomes | |
| ‐ Hospital‐based with oxygen or Vitamin | — | Patient outcomes | — | |
| Case management ‐ People living with HIV/AIDS | — | — | Patient outcomes; access, coverage, utilisation; quality of care | |
| Coordination of care to reduce rehospitalisation ‐ Pre‐/postdischarge interventions vs usual care | — | — | Access, coverage, utilisation | |
| ‐ Transition interventions vs usual care | — | — | Access, coverage, utilisation | |
| Discharge planning ‐ Hospital discharge planning vs usual care | Patient outcomes | — | — | |
| Integration ‐ Adding a service to an existing service vs services with no addition ‐ Integrated vs vertical delivery models | Resource use | Quality of care | — | |
| — | — | Access, coverage, utilisation | ||
| Referral systems ‐ Healthcare delivery of organisational interventions vs no intervention for referral from primary to secondary care | Patient outcomes | — | — | |
| Referral systems ‐ Nurse vs physician triage systems in emergency departments | — | — | Quality of care | |
| Teams ‐ Practice‐based interventions to promote collaboration vs no intervention | — | Patient outcomes; access, coverage, utilisation; resource use | — | |
| Where care is provided | ||||
| Site of service delivery ‐ HIV voluntary counselling and testing (VCT) at an optional location vs VCT at clinic | — | — | Access, coverage, utilisation | |
| Site of service delivery ‐ Units dedicated to care for people living with HIV/AIDS ‐ Institutions managing a high volume of people living with HIV/AIDS | — | — | Patient outcomes; quality of care | |
| Patient outcomes; quality of care | — | — | ||
| Site of service delivery ‐ Home care (different models) vs facility | Access, coverage, utilisation; quality of care; resource use | Patient outcomes adverse, effects | — | |
| Site of service delivery ‐ Maternity waiting home vs no waiting homes | Patient outcomes; access, coverage, utilisation; quality of care; resource use | — | — | |
| Site of service delivery ‐ Strategies for increasing ownership and use of insecticide treated bednets | Patient outcomes; access, coverage, utilisation; quality of care; resource use | — | — | |
| Site of service delivery ‐ Home‐based care for people living with HIV/AIDS ‐ Home‐based care by multidisciplinary team care for people living with HIV/AIDS vs no team | — | Patient outcomes | Resource use | |
| Resource use | — | Patient outcomes | ||
| Site of service delivery ‐ Early discharge from hospital for mothers and infants born at term vs standard discharge | — | Resource use | Patient outcomes; access, coverage, utilisation | |
| Site of service delivery ‐ Out‐of‐facility vs facility‐based HIV and reproductive health services for youth | — | Quality of care | Quality of care | |
| Site of service delivery ‐ Decentralised vs centralised HIV care for initiation and maintenance of anti‐retroviral therapy | — | Patient outcomes | Patient outcomes; access, coverage, utilisation | |
| Information and communication technology | ||||
| E‐Health ‐ Mobile phone messaging for long‐term illnesses vs usual care | — | Access, coverage, utilisation | — | |
| E‐Health ‐ Mobile phone messaging reminders for attendance at healthcare appointments vs various other interventions | — | — | Access, coverage, utilisation | |
| E‐Health ‐ Decision support to improve healthcare process and health outcomes for people living with HIV/AIDS ‐ Clinical information systems to improve healthcare process and health outcomes for people living with HIV/AIDS | — | Patient outcomes; access, coverage, utilisation | Quality of care | |
| — | — | Quality of care | ||
| Health information systems ‐ Women carrying their own case notes in pregnancy vs less detailed health cards | Access, coverage, utilisation | Patient outcomes | Patient outcomes; access, coverage, utilisation; quality of care; resource use | |
| E‐Health ‐ Mobile phone messaging to promote adherence to antiretroviral therapy vs usual care | — | — | — | |
| Patient reminder and recall systems ‐ Reminders for routine childhood vaccination vs usual care | Patient outcomes | — | — | |
| Quality and safety systems | ||||
| Quality monitoring and improvement systems ‐ Medication review for hospitalised adult patients vs standard care | — | — | Patient outcomes; access, coverage, utilisation | |
| Quality monitoring and improvement systems ‐ Interventions to improve antibiotic prescribing to hospital inpatients | — | Access, coverage, utilisation | Patient outcomes; quality of care | |
| Quality monitoring and improvement systems ‐ Decision support to improve healthcare process and health outcomes for people living with HIV/AIDS ‐ Decision support with clinical information systems to improve healthcare process and health outcomes for people living with HIV/AIDS | — | Patient outcomes; Access, coverage, utilisation | Quality of care | |
| — | — | Quality of care | ||
| Working conditions of health workers | ||||
| Staff support ‐ Managerial supervision to improve quality of primary health care | — | Quality of care | Quality of care | |
| Complex interventions cutting across delivery categories and across the other overviews | ||||
| Package of multiple interventions ‐ Emergency obstetric referral interventions | Quality of care | Patient outcomes | Patient outcomes | |
| 1Priorities for primary research based on the absence of evidence or low‐certainty of evidence for important outcomes: patient outcomes; access, coverage, utilisation; quality of care; and resource use. | ||||
| Delivery arrangement | Systematic reviews needed* |
| Who provides care | |
| · Role expansion or task shifting General practice | Only supplementary review identified (Engstrom 2001) |
| · Role expansion or task shifting Professional groups than physician anaesthesiologists administering anaesthesia | 10 years of most recent search 10 years |
| · Role expansion or task shifting ‐ Interventions for increasing health promotion practices in dental healthcare settings | Review in progress: Kengne 2014 |
| . Role expansion or task shifting ‐ Allied health professionals (paramedics, physiotherapists, occupational therapists, language therapists, radiographers) | No review identified |
| . Role expansion or task shifting ‐ Dental health promotion | No review identified |
| · Self‐management ‐ Family support for reducing morbidity and mortality in people with HIV/AIDS | Only supplementary review identified (Mohanan 2009) |
| ‐ Movement of health workers between public and private care | No review identified |
| Coordination of care | |
| · Disease management | No review identified |
| · Packages of care | Only supplementary reviews (Dowswell 2010; Haws 2007) |
| Where care is provided | |
| · Facilities and equipment | No review identified |
| · Generalist outreach | No review identified |
| · Intermediate care | No review identified |
| · Mobile units ‐ mobile clinics for women's and children's health | Review in progress Abdel‐Aleem 2012 |
| · Site of service delivery ‐ Facility‐based deliveries in reducing maternal and infant morbidity and mortality in low‐ and middle‐income countries | Review in progress: Dudley 2009 |
| · Size of organisations | No review identified |
| · Specialist outreach | No review identified |
| · Transportation services | No review identified |
| Information and communication technology | |
| · E‐Health ‐ telemedicine vs face‐to‐face patient care: effects on professional practice and healthcare outcomes | Review update in progress: Currell 2000 |
| Quality and safety systems | |
| · Quality monitoring and improvement systems ‐ Organisational and professional interventions to promote the uptake of evidence in emergency care | Review in progress: Curran 2007 |
| · Quality monitoring and improvement systems ‐ Interventions for reducing medication errors in hospitalised adults | Review in progress: Lopez 2012 |
| · Quality monitoring and improvement systems ‐ Interventions for reducing medication errors in children in hospital | Review in progress: Soe 2013 |
| Working conditions of health workers | |
| · Workload | No review identified |
| · Health and safety systems | No review identified |
| · Staff‐support interventions for health workers | No review identified |
| 1Priorities for systematic reviews on supporting the delivery arrangement interventions in low‐income countries, * Based on key areas in the taxonomy of delivery arrangements (Table 1) for which we did not find a finished systematic review meeting our inclusion criteria. | |
| Delivery arrangement | Definition |
| Who receives care and when | |
| Queuing strategies | Different ways of managing waiting lists |
| Group vs individual care | Providing care to groups vs individual patients |
| Who provides care | |
| Pre‐licensure education | How health professionals are educated |
| Recruitment and retention strategies | Strategies for recruiting to and retaining health workers in specific areas or types of work |
| Movement of health workers between public and private care | Strategies for managing the movement of health workers between public and private organisations |
| Role expansion or task shifting | Expanding tasks undertaken by a cadre of health workers or shifting tasks from one cadre to another |
| Self‐management | Shifting the provision of care to patients or their families |
| Co‐ordination of care | |
| Integration | Integration of the delivery of different type of services |
| Packages of care | Integrated packages of care such as the Integrated Management of Childhood Illness (IMCI) |
| Case management | Use of individuals, often specially trained nurses, to coordinate care for patients with multiple or complex needs |
| Disease management | Programmes designed to manage or prevent a chronic condition using a systematic approach to care and potentially employing multiple ways of influencing patients, providers or the process of care |
| Care pathways | Strategies to link evidence to practice for specific health conditions. These strategies detail the local structure, systems and time frames to address recommendations |
| Teams | Care provided by teams or interdisciplinary collaboration |
| Communication between providers | Systems1 or strategies for communication between healthcare providers |
| Referral systems | Systems1 for managing referrals of patients between healthcare providers |
| Discharge planning | Systems1 for planning the discharge of patients from facilities |
| Where care is provided | |
| Site of service delivery | Changes in where care is provided including home vs facility, inpatient vs outpatient, specialised vs non‐specialised facility |
| Intermediate care | Services designed to facilitate the transition from hospital to home |
| Specialist outreach | Regular visits by specialist providers to primary care or rural hospital settings |
| Generalist outreach | Regular visits by generalist doctors to primary care or rural hospital settings |
| Transportation services | Arrangements for transporting patients from one site to another |
| Mobile units | Mobile facilities that visit and deliver services on a regular basis |
| Facilities and equipment | Changes in healthcare facilities or equipment |
| Size of organisations | Consequences of differences in the size of health service provider organisations |
| Procurement and distribution of supplies | Systems1 for procuring and distributing medicines or other supplies |
| Information and communication technology | |
| Health information systems | Health record and health management systems |
| Patient reminder and recall systems | Systems1 for recalling patients for follow‐up or prevention |
| E‐Health | The combined use of electronic communication and information technology in the health sector. This includes the use of digital data – transmitted, stored and retrieved electronically – for clinical, educational and administrative purposes |
| Quality and safety systems | |
| Quality monitoring and improvement systems | Systems1 for monitoring and improving the quality of health care |
| Safety monitoring and improvement systems | Systems1 for monitoring and improving the safety of health care |
| Working conditions of health workers | |
| Workload | Changes in the workload of health workers |
| Work environment | Changes in the working environment of health workers |
| Staff support | Provision of staff support to health workers |
| Health and safety systems | Systems* for protecting or promoting the health and safety of health workers |
| 1Systems include structures or organisational arrangements. | |
| Delivery arrangement | How this might work |
| Who receives care and when | |
| Queuing strategies | Strategies such as increasing capacity or productivity might reduce waiting times by increasing the supply of services. Strategies such as co‐payments, explicit referral criteria or clinical priority scores might decrease waiting times by reducing or managing demand. |
| Group vs individual care | Group care might expand coverage by increasing the numbers of patients health workers can see and might improve effectiveness through peer support. |
| Who provides care | |
| Pre‐licensure education | Strategies that help to ensure that students complete their education might improve access to care by increasing the supply of health professionals. |
| Recruitment and retention strategies | Strategies that help to recruit health professionals to underserved areas or keep them there might improve access to care and equity. |
| Movement of health workers between public and private care | Strategies that attract or keep health workers in the public sector might improve access to care, equity and sustainability. |
| Role expansion or task shifting | Role expansion or task shifting form more to less specialised health workers might improve access, coverage and equity. |
| Self‐management | Shifting responsibility for care from health workers to patients might improve access for other patients, empower patients and reduce resource use. |
| Coordination of care | |
| Integration | Bringing together several service functions might increase service coherence and reduce fragmentation, thereby improving access, utilisation and efficiency. On the other hand, vertical (non‐integrated programmes) might improve the delivery of effective interventions, thereby improving health outcomes. |
| Packages of care | Packages of care, such as the Integrated Management of Childhood Illnesses, might improve coverage, delivery quality and utilisation of effective interventions and thereby improve health outcomes. |
| Case management | Case management might improve quality of care and patient compliance and efficiency by ensuring that patients are followed up and reducing fragmentation. |
| Disease management | Disease management might improve the quality of care and efficiency by reducing fragmentation. |
| Care pathways | An evidence‐based plan of care that aims to promote organised and efficient multidisciplinary patient care might improve the quality of care and efficiency. |
| Teams | Multidisciplinary teams of health professionals might improve the quality of care, reduce delays and fragmentation and thereby improve health outcomes. |
| Communication between providers | Improved communication between providers might improve the quality of care and efficiency. |
| Referral systems | Effective referral systems might improve the quality of care by helping ensure that patients who need specialised care receive it and improve efficiency by reducing inappropriate referrals. |
| Discharge planning | Strategies that help to ensure that patients are discharged as soon as they are ready might improve efficiency by reducing unnecessary hospital utilisation. Strategies that help to ensure that patients are managed appropriately following discharge might improve the quality of care and efficiency by reducing re‐hospitalisation. |
| Where care is provided | |
| Site of service delivery | Providing services closer to patients (e.g. in rural areas) might improve access and utilisation. |
| Intermediate care | Facilities that offer a transition between hospital care and home care might improve efficiency by reducing the length of hospital stays and might improve the quality of care following discharge from the hospital |
| Specialist outreach | Providing specialist services closer to patients (e.g. in rural areas) might improve access. |
| Generalist outreach | Providing generalist services closer to patients (e.g. in rural areas) might improve access. |
| Transportation services | Strategies that make it easier for patients to travel to and from health facilities might improve access and utilisation |
| Mobile units | Mobile units might improve utilisation by making it easier for patients to access services. |
| Facilities and equipment | Strategies that improve the availability of facilities and equipment might improve access and utilisation. |
| Size of organisations | Larger organisations might improve efficiency because of economies of scale. They might also improve the quality of care for procedures where there are better outcomes with a high volume. On the other hand changing the size of organisations (e.g. mergers) might reduce efficiency and quality of care during a transition period because of the need to integrate different systems. Also, very large organisations may be difficult to manage, increase administrative costs and have communication problems that might reduce efficiency and quality of care. |
| Procurement and distribution of supplies | Strategies that improve the procurement and distribution of supplies might reduce resource use and improve the quality of care by ensuring that necessary supplies are available. |
| Information and communication technology | |
| Health information systems | Health information systems might improve the quality of care and efficiency by improving communication, coordination and decision‐making. |
| Patient reminder and recall systems | Patient reminder and recall systems might increase utilisation and the quality of care by helping to ensure that patients receive effective interventions. |
| E‐Health | Electronic communication of health information might improve access to care by making it easier for patients and generalists to consult with specialists and for information to be shared between patients, providers and the health system. |
| Quality and safety systems | |
| Quality monitoring and improvement systems | Monitoring systems might help to ensure that problems with the quality of care are identified and addressed. Routine, structured processes to address problems might help to improve the quality of care. |
| Safety monitoring and improvement systems | Monitoring systems might help to ensure that problems with safety are identified and addressed. Routine, structured processes to address problems might help to improve safety. |
| Working conditions of health workers | |
| Workload | Strategies to manage workloads might improve efficiency by helping to ensure health workers have an optimal amount of work. They might improve access to care by reducing burnout, absenteeism and loss of health workers. |
| Work environment | Improvements to the work environment might improve the quality of care and efficiency by improving working conditions. They might improve access to care by helping to attract and retain health workers. |
| Staff support | Staff support might reduce burnout, absenteeism and loss of health workers and thereby improve access to care. |
| Health and safety systems | Health and safety systems might reduce injuries and illness among health workers and thereby improve access to care and reduce resource use needed to care for injured or ill health workers. |
| Delivery arrangement | Included reviews |
| Who receives care and when | |
| Queuing strategies | Interventions to reduce waiting times for elective procedures (Ballini 2015) |
| Care received by groups vs individual care | Group versus conventional antenatal care for women (Catling 2015) |
| Who provides care | |
| Pre‐licensure education | Effects of changes in the pre‐licensure education of health workers on health‐worker supply (Pariyo 2009) |
| Recruitment and retention strategies | Interventions for increasing the proportion of health professionals practising in rural and other underserved areas (Grobler 2015) |
| Movement of health workers between public and private care | No relevant systematic review found |
| Role expansion or task shifting ‐ Lay health workers: hypertension | Effectiveness of community health workers in the care of people with hypertension (Brownstein 2007) |
| Role expansion or task shifting ‐ Lay health workers: delivery of community‐based neonatal care packages | Community‐based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes (Lassi 2015) |
| Role expansion or task shifting ‐ Lay health workers: maternal and child health and infectious diseases | Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases (Lewin 2010) |
| Role expansion or task shifting ‐ Midlevel health professionals: non‐doctor providers for abortion care | Safety and effectiveness of termination services performed by doctors versus midlevel providers: a systematic review and analysis (Ngo 2013) |
| Role expansion or task shifting ‐ Healthcare providers giving additional social support to pregnant women vs usual care | Support during pregnancy for women at increased risk of low birthweight babies (Hodnett 2010) |
| Role expansion or task shifting ‐ Midlevel health professionals: midwife‐led care in pregnancy | Midwife‐led continuity models versus other models of care for childbearing women (Sandall 2013) |
| Role expansion or task shifting ‐ Allied health professionals (paramedics, physiotherapists, occupational therapists, language therapists, radiographers) | No relevant systematic review found |
| Role expansion or task shifting ‐ Clinical officers/non‐physician clinicians/associate clinicians vs physician for caesarean section | A comparison of clinical officers with medical doctors on outcomes of caesarean section in the developing world: meta‐analysis of controlled studies (Wilson 2011) |
| Role expansion or task shifting ‐ General practice | No relevant systematic review found |
| Role expansion or task shifting ‐ Non‐specialist vs specialist providers for mental health | Non‐specialist health worker interventions for the care of mental, neurological and substance‐abuse disorders in low‐ and middle‐income countries (Van Ginneken 2013) |
| Role expansion or task shifting ‐ Specialist nursing post added to hospital nurse staffing/dietary assistants added to hospital nurse staffing | Hospital nurse staffing models and patient‐ and staff‐related outcomes (Butler 2011) |
| Role expansion or task shifting ‐ Physician‐nurse substitution | Effects of physician‐nurse substitution on clinical parameters: a systematic review and meta‐analysis (Martínez‐González 2014) |
| Role expansion or task shifting ‐ Professional groups vs physician anaesthesiologists administering anaesthesia | No relevant systematic review found |
| Role expansion or task shifting ‐ Pharmacists delivering non‐dispensing services to patients | The effect of pharmacist‐provided non‐dispensing services on patient outcomes, health service utilisation and costs in low‐ and middle‐income countries (Pande 2013) |
| Role expansion or task shifting ‐ Skilled birth attendants | The effect of providing skilled birth attendance and emergency obstetric care in preventing stillbirths (Yakoob 2011) |
| Role expansion or task shifting ‐ Dental health promotion | No relevant systematic review found |
| Role expansion or task shifting ‐ Dental care by dental therapists | A systematic review of oral health outcomes produced by dental teams incorporating midlevel providers (Wright 2013) |
| Self‐management | No relevant systematic review found |
| Coordination of care | |
| Care pathways ‐ Improved pre‐hospital trauma systems vs no systems | Prehospital trauma systems reduce mortality in developing countries: a systematic review and meta‐analysis (Henry 2012) |
| Care pathways ‐ Rapid response systems in hospitals vs no systems | () Rapid response systems: a systematic review and meta‐analysis (Maharaj 2015) |
| Care pathways ‐ Hospital clinical pathways vs usual care | Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs (Rotter 2010) |
| Case management ‐ Children with pneumonia/community‐based with antibiotics/hospital‐based with oxygen or vitamins | The effect of case management on childhood pneumonia mortality in developing countries (Theodoratou 2010) |
| Case management ‐ People living with HIV/AIDS | Setting and organisation of care for persons living with HIV/AIDS (Handford 2006) |
| Communication between providers ‐ Interactive communication between primary care doctors and specialists vs usual care | Meta‐analysis: effect of interactive communication between collaborating primary care physicians and specialists (Foy 2010) |
| Coordination of care to reduce rehospitalisation ‐ Pre‐/post discharge interventions vs usual care/transition interventions vs usual care | Interventions to reduce 30‐day rehospitalisation: a systematic review (Hansen 2011) |
| Discharge planning ‐ Hospital discharge planning vs usual care | Discharge planning from hospital (Gonçalves‐Bradley 2016) |
| Disease management | No relevant systematic review found |
| Integration ‐ Adding a service to an existing service vs services with no addition/integrated vs vertical delivery models | Strategies for integrating primary health services in middle‐ and low‐income countries at the point of delivery (Dudley 2011) |
| Packages of care | No relevant systematic review found |
| Referral systems ‐ Healthcare delivery of organisational interventions vs no intervention for referral from primary to secondary care | Interventions to improve outpatient referrals from primary care to secondary care (Akbari 2008) |
| Referral systems ‐ Nurse vs physician triage systems in emergency departments | The role of triage liaison physicians on mitigating overcrowding in emergency departments: a systematic review (Rowe 2011) |
| Teams ‐ Team midwifery vs standard care | Hospital nurse staffing models and patient‐ and staff‐related outcomes (Butler 2011) |
| Teams ‐ Multidisciplinary team care for people living with HIV/AIDS vs no team | Home‐based care for reducing morbidity and mortality in people infected with HIV/AIDS (Young 2010) |
| Teams ‐ Practice based interventions to promote collaboration vs no intervention | Interprofessional collaboration to improve professional practice and healthcare outcomes (Reeves 2017) |
| Where care is provided | |
| Facilities and equipment | No relevant systematic review found |
| Generalist outreach | No relevant systematic review found |
| Intermediate care | No relevant systematic review found |
| Mobile units | No relevant systematic review found |
| Site of service delivery ‐ HIV voluntary counselling and testing (VCT) at an optional location vs VCT at clinic | Home‐based HIV voluntary counselling and testing (VCT) for improving uptake of HIV testing (Bateganya 2010) |
| Site of service delivery ‐ Units dedicated to care for people living with HIV/AIDS/institutions managing a high volume of people living with HIV/AIDS | Setting and organisation of care for persons living with HIV/AIDS (Handford 2006) |
| Site of service delivery ‐ Home‐base care for people living with HIV/AIDS ‐ Home‐based care with multidisciplinary team care for people living with HIV/AIDS vs other delivery options | Home‐based care for reducing morbidity and mortality in people infected with HIV/AIDS (Young 2010) |
| Site of service delivery Facility vs home | No relevant systematic review found |
| Site of service delivery ‐ Home‐based management of malaria (presumptive treatment of children with symptoms) vs usual care | Home‐ or community‐based programmes for treating malaria (Okwundu 2013) |
| Site of service delivery ‐ Strategies for increasing ownership and use of insecticide‐treated bednets | Strategies to increase the ownership and use of insecticide‐treated bednets to prevent malaria (Augustincic 2015) |
| Site of service delivery ‐ Home care (different models) vs facility | Systematic review of international evidence on the effectiveness and costs of paediatric home care for children and young people who are ill (Parker 2013) |
| Site of service delivery ‐ Maternity waiting home vs no waiting homes | Maternity waiting facilities for improving maternal and neonatal outcome in low‐resource countries (Van Lonkhuijzen 2012) |
| Site of service delivery ‐ Generalist outreach | No relevant systematic review found |
| Site of service delivery ‐ Community‐based interventions for childhood diarrhoea and pneumonia versus routine care | Effect of community based interventions on childhood diarrhoea and pneumonia: uptake of treatment modalities and impact on mortality (Das 2013) |
| Site of service delivery ‐ Early discharge from hospital for mothers and infants born at term versus standard discharge | Early postnatal discharge from hospital for healthy mothers and term infants (Brown 2007) |
| Site of service delivery ‐ Out‐of‐facility vs facility‐based HIV and reproductive health services for young people | Reaching youth with out‐of‐facility HIV and reproductive health services: a systematic review (Denno 2012) |
| Site of service delivery ‐ Decentralised vs centralised HIV care for initiating and maintaining anti‐retroviral therapy | Decentralising HIV treatment in lower‐ and middle‐income countries (Kredo 2013) |
| Site of service delivery ‐ Workplace programmes for HIV and tuberculosis vs no programme | Workplace programmes for HIV and tuberculosis: a systematic review to support development of international guidelines for the health workforce (Yassi 2013) |
| Size of organisations | No relevant systematic review found |
| Specialist outreach | No relevant systematic review found |
| Information and communication technology | |
| E‐Health ‐ Mobile phone messaging for long‐term illnesses vs usual care | Mobile phone messaging for facilitating self‐management of long‐term illnesses (De Jongh 2012) |
| E‐Health ‐ Mobile phone messaging reminders for attendance at healthcare appointments vs various other interventions | Mobile phone messaging reminders for attendance at healthcare appointments (Gurol‐Urganci 2013) |
| E‐Health ‐ Mobile phone messaging to promote adherence to antiretroviral therapy vs usual care | Mobile phone text messages for improving adherence to antiretroviral therapy (ART): an individual patient data meta‐analysis of randomised trials (Mbuagbaw 2013) |
| E‐Health ‐ Telemedicine vs face‐to‐face patient care | No relevant systematic review found |
| Health information systems ‐ Women carrying their own case notes in pregnancy vs less detailed health cards | Giving women their own case notes to carry during pregnancy (Brown 2011) |
| Patient reminder and recall systems ‐ Reminders for routine childhood vaccination vs usual care | Interventions for improving coverage of child immunisation in low‐income and middle‐income countries (Oyo‐Ita 2016) Patient reminder and recall systems to improve immunisation rates (Jacobson Vann 2005) |
| Quality and safety systems | |
| Quality/safety monitoring and improvement systems ‐ Medication review for hospitalised adult patients vs standard care | Medication review in hospitalised patients to reduce morbidity and mortality (Christensen 2016) |
| Quality monitoring and improvement systems ‐ Interventions to improve antibiotic prescribing to hospital inpatients | Interventions to improve antibiotic prescribing practices for hospital inpatients (Davey 2013) |
| Quality monitoring and improvement systems ‐ Decision support to improve healthcare process and health outcomes for people living with HIV/AIDS ‐ Decision support with clinical information system to improve healthcare process and health outcomes for people living with HIV/AIDS | Chronic care model decision support and clinical information systems interventions for people living with HIV: a systematic review (Pasricha 2012) |
| Working conditions of health workers | |
| Workload | No relevant systematic review found |
| Staff support ‐ Managerial supervision to improve quality of primary health care | Managerial supervision to improve primary health care in low‐ and middle‐income countries (Bosch‐Capblanch 2011) |
| Staff support ‐ Staff‐support interventions for health workers | No relevant systematic review found |
| Work environment ‐ Improvements to nursing work environment vs no intervention | No relevant systematic review found |
| Health and safety systems | No relevant systematic review found |
| Complex interventions cutting across delivery categories and across the other overviews | |
| Package of multiple interventions ‐ Emergency obstetric referral interventions | The effectiveness of emergency obstetric referral interventions in developing country settings: a systematic review (Hussein 2012.) |
| Review ID | Excluded reviews | Reasons for exclusion |
| Interventions to improve antibiotic prescribing practices in ambulatory care | Search out of date | |
| The impact of ehealth on the quality and safety of health care: a systematic overview | Addressed by De Jongh 2012, and Pasricha 2012 | |
| Effect of community pharmacy‐based interventions on patient health outcomes: a systematic review | Addressed by Pande 2013 | |
| Does continuity of care improve patient outcomes? | Major limitations | |
| A systematic review of task‐shifting for HIV treatment and care in Africa | Addressed by Kredo 2013 | |
| WHO systematic review of randomized controlled trials of routine antenatal care | Search out of date | |
| 60 Million non‐facility births: who can deliver in community settings to reduce intrapartum‐related deaths? | Major limitations | |
| SMS for disease control in developing countries: a systematic review of mobile health applications | Major limitations | |
| Evaluated strategies to increase attraction and retention of health workers in remote and rural areas | Addressed by Grobler 2015 | |
| Antenatal day care units versus hospital admission for women with complicated pregnancy | Limited relevance to low‐income countries | |
| Alternative versus standard packages of antenatal care for low‐risk pregnancy | Addressed by Lassi 2015 | |
| Is general practice effective? A systematic literature review | Search out of date | |
| A systematic review of the effect of primary care‐based service innovations on quality and patterns of referral to specialist secondary care | Search out of date | |
| Services for reducing duration of hospital care for acute stroke patients | Limited relevance to low‐income countries | |
| Models of care in nursing: a systematic review | Addressed by Butler 2011 | |
| Safety of task‐shifting for male medical circumcision: a systematic review and meta‐analysis | Major limitations | |
| Implementing electronic medical record systems in developing countries | Limited relevance to low‐income countries | |
| Information systems for patient follow‐up and chronic management of HIV and tuberculosis: a life‐saving technology in resource‐poor areas | Major limitations | |
| Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review | Limited relevance to low‐income countries | |
| Effectiveness of intermediate care in nursing‐led in‐patient units | Limited relevance to low‐income countries | |
| Specialist outreach clinics in primary care and rural hospital settings | Search out of date | |
| Mobile phone messaging for communicating results of medical investigations | Limited relevance to low‐income countries | |
| Do triage systems in healthcare improve patient flow? A systematic review of the literature | Addressed by Rowe 2011 | |
| Midwife‐led versus other models of care for childbearing women | Addressed by Sandall 2013 | |
| Impact of packaged interventions on neonatal health: a review of the evidence | Addressed by Lassi 2015 | |
| What do community‐based dengue control programmes achieve? A systematic review of published evaluations | Govenance arrangement | |
| Improving patient handovers from hospital to primary care: a systematic review | Limited relevance to low‐income countries | |
| Outpatient Case Management for Adults With Medical Illness and Complex Care Needs | Limited relevance to low‐income countries | |
| Impact of home‐based management of malaria on health outcomes in Africa: a systematic review of the evidence | Addressed by Okwundu 2013 | |
| Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors | Search out of date | |
| Mobile phone text messaging for promoting adherence to antiretroviral therapy in patients with HIV infection | Addressed by Mbuagbaw 2013 | |
| Are birth kits a good idea? A systematic review of the evidence | Implementation strategies | |
| What kinds of policy and programme interventions contribute to reductions in maternal mortality? The effectiveness of primary level referral systems for emergency maternity care in developing countries | Addressed by Hussein 2012 | |
| Evidence on interventions to reduce medical errors: an overview and recommendations for future research | Search out of date | |
| The impact of health information technology on the quality of medical and health care: a systematic review | Major limitations | |
| Tuberculosis among health‐care workers in low‐ and middle‐income countries: a systematic review | Major limitations | |
| Clinical pharmacists and inpatient medical care: a systematic review | Limited relevance to low‐income countries | |
| Linking sexual and reproductive health and HIV interventions: a systematic review | Addressed by Dudley 2011 | |
| Systematic review of effect of community‐level interventions to reduce maternal mortality | Addressed by Lewin 2010 | |
| Patient‐held medical records for patients with chronic disease: a systematic review | Major limitations | |
| Pharmacist care of patients with heart failure: a systematic review of randomized trials | Addressed by Pande 2013 | |
| Economic effectiveness of disease management programs: a meta‐analysis | Major limitations | |
| Healthcare via cell phones: a systematic review | Addressed by De Jongh 2012 | |
| Nurse versus physician‐led care for the management of asthma | Addressed by Martinez‐Gonzalez 2014 | |
| The integration of family planning with other health services: a literature review | Addressed by Dudley 2011 | |
| Linking families and facilities for care at birth: what works to avert intrapartum‐related deaths? | Major limitations | |
| Integrating tuberculosis and HIV services in low‐ and middle‐income countries: a systematic review | Limited relevance to low‐income countries | |
| Effect of mobile phone intervention for diabetes on glycaemic control: a meta‐analysis | Addressed by De Jongh 2012 | |
| A systematic review of the literature comparing the practices of dispensing and non‐dispensing doctors | Major limitations | |
| Integration of HIV/AIDS services with maternal, neonatal and child health, nutrition, and family planning services | Addressed by Dudley 2011, but it addresses a subset of types of integration that is highly relevant. | |
| The impact of primary healthcare on population health in low‐ and middle‐income countries | Major limitations | |
| Provision of DMPA by community health workers: what the evidence shows | Addressed by Lewin 2010 | |
| Community strategies that improve care and retention along the prevention of mother‐to‐child transmission of HIV cascade: a review | Major limitations | |
| Preventing occupational stress in healthcare workers | Outside of the scope of the overviews – focus on occupational health | |
| Evidence for the effect of disease management: is $1 billion a year a good investment? | Major limitations | |
| Outreach and Early Warning Systems (EWS) for the prevention of intensive care admission and death of critically ill adult patients on general hospital wards | Addressed by Maharaj 2015. | |
| Do either early warning systems or emergency response teams improve hospital patient survival? A systematic review | Addressed by Maharaj 2015. | |
| A systematic review of evidence about extended roles for allied health professionals | Search out of date | |
| The effectiveness and cost implications of task‐shifting in the delivery of antiretroviral therapy to HIV‐infected patients: a systematic review | Addressed by Kredo 2013 | |
| Self‐management education programs for people living with HIV/AIDS: a systematic review | Limited relevance to low‐income countries | |
| Performance improvement based on integrated quality management models: what evidence do we have? A systematic literature review | Limited relevance to low‐income countries | |
| Multidisciplinary care planning and teamwork in primary care | Not a systematic review of interventions | |
| Family support for reducing morbidity and mortality in people with HIV/AIDS | Uninformative empty review | |
| Can paraprofessionals deliver cognitive‐behavioral therapy to treat anxiety and depressive symptoms? | Addressed by Van Ginneken 2013 | |
| Free‐standing midwife‐led maternity units: a safe and effective alternative to hospital delivery for low‐risk women? | Addressed by Sandall 2013 | |
| Effectiveness of community health workers in the care of persons with diabetes | Major limitations | |
| Maternal health interventions in resource limited countries: a systematic review of packages, impacts and factors for change | Major limitations | |
| Unit‐dose packaged medicines for treating malaria | Implementation strategies | |
| Systematic review of interventions to improve prescribing | Major limitations | |
| Effectiveness of training of non‐mental health care providers in mental health in low‐ and middle‐income countries: a systematic review | Addressed by Van Ginneken 2013 | |
| Email for clinical communication between healthcare professionals | Implementation strategies | |
| Evaluating models of care closer to home for children and young people who are ill: a systematic review | Addressed by Parker 2013 | |
| Interventions to increase clinical incident reporting in health care | Major limitations | |
| Do specialized centers and specialists produce better outcomes for patients with chronic diseases than primary care generalists? A systematic review | Limited relevance to low‐income countries | |
| Childbirth attendance strategies and their impact on maternal mortality and morbidity in low‐income settings: a systematic review | Addressed by Yakoob 2011 | |
| Effects of rapid response systems on clinical outcomes: systematic review and meta‐analysis | Addressed by Maharaj 2015 | |
| Interventions to reduce unnecessary antibiotic prescribing: a systematic review and quantitative analysis | Implementation strategies | |
| Interprofessional education: effects on professional practice and healthcare outcomes | Implementation strategies | |
| Who can provide effective and safe termination of pregnancy care? A systematic review | Addressed by Ngo 2013 | |
| Patient support and education for promoting adherence to highly active antiretroviral therapy for HIV/AIDS | Major limitations | |
| The impact of HIV clinical pharmacists on HIV treatment outcomes: a systematic review | Addressed by Pande 2013 | |
| Effect of pneumonia case management on mortality in neonates, infants, and preschool children: a meta‐analysis of community‐based trials | Not a systematic review of interventions | |
| Nurse‐led clinics as an effective service for cardiac patients: results from a systematic review | Major limitations. | |
| Interventions aimed at improving the nursing work environment: a systematic review | Search out of date | |
| The effects of on‐screen, point of care computer reminders on processes and outcomes of care | Implementation strategies. Limited relevance to low‐income countries. | |
| Shifting care from hospitals to the community: a review of the evidence on quality and efficiency | Major limitations | |
| Comparative effectiveness and safety of physician and nurse anaesthetists: a narrative systematic review | Search out of date | |
| Private local pharmacies in low‐ and middle‐income countries: a review of interventions to enhance their role in public health | Major limitations | |
| Linking family planning with HIV/AIDS interventions: a systematic review of the evidence | Major limitations | |
| Health information technology in primary health care in developing countries: a literature review | Major limitations | |
| A meta‐analysis of interventions to improve care for chronic illnesses | Major limitations | |
| Integrating prevention of mother‐to‐child HIV transmission (PMTCT) programmes with other health services for preventing HIV infection and improving HIV outcomes in developing countries | Addressed by Dudley 2011 | |
| Telephone communication of HIV testing results for improving knowledge of HIV infection status | Addressed by De Jongh 2012; Gurol‐Urganci 2013; Mbuagbaw 2013 | |
| The effect of health facility delivery on neonatal mortality: systematic review and meta‐analysis | Major limitations | |
| Integrated delivery of HIV and tuberculosis services in sub‐Saharan Africa: a systematic review | Major limitations | |
| A systematic review of the effectiveness of community‐based mental health outreach services for older adults | Limited relevance to low‐income countries | |
| Scope and effectiveness of mobile phone messaging for HIV/AIDS care: a systematic review | Addressed by Mbuagbaw 2013 | |
| The association between continuity of care and outcomes: a systematic and critical review | Limited relevance to low‐income countries | |
| Preventive staff‐support interventions for health workers | Outside of the scope of the overviews – focuses largely on occupational health | |
| Patterns of routine antenatal care for low‐risk pregnancy | Search out of date | |
| Outcomes of free‐standing, midwife‐led birth centers: a structured review | Addressed by Sandall 2013 | |
| Delivery systems for insecticide treated and untreated mosquito nets in Africa: categorization and outcomes achieved | Major limitations | |
| Evaluations of community mental health care in low‐ and middle‐income countries: a 10‐year review of the literature | Addressed by Van Ginneken 2013 | |
| Strategies for delivering insecticide‐treated nets at scale for malaria control: a systematic review | Addressed by Augustincic 2015 | |
| A critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas | Addressed by Grobler 2015 | |
| Rapid response systems: a systematic review | Addressed by Maharaj 2015 | |
| Comparative effectiveness of collaborative chronic care models for mental health conditions across primary, specialty, and behavioral health care settings: systematic review and meta‐analysis | Limited relevance to low‐income countries | |
| Impact of community‐based support services on antiretroviral treatment programme delivery and outcomes in resource‐limited countries: a synthetic review | Major limitations | |
| Effects of clinical communication interventions in hospitals: a systematic review of information and communication technology adoptions for improved communication between clinicians | Limited relevance to low‐income countries | |
| Reducing needle stick injuries in healthcare occupations: an integrative review of the literature | Not a systematic review of interventions | |
| The effectiveness of youth centers in increasing use of sexual and reproductive health services: a systematic review | Addressed by Denno 2012 | |
| A systematic review of chronic disease management | Major limitations |
| Review | A. Identification, selection and critical appraisal of studies1 | B. Analysis2 | C. Overall3 | |||||||||||
| 1. Selection criteria | 2. Search | 3. Up‐to‐date | 4. Study selection | 5. Risk of bias | 6. Overall | 1. Study characteristics | 2. Analytic methods | 3. Heterogeneity | 4. Appropriate synthesis | 5. Exploratory factors | 6. Overall | 1. Other considerations | 2. Reliability of the review | |
| + | + | + | + | + | + | + | + | NA | + | + | + | + | + | |
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| + | + | + | + | + | + | ? | + | NA | + | NA | + | + | + | |
| + | + | + | + | + | + | + | + | + | + | NA | + | + | + | |
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| + | + | + | + | + | + | NA | NA | NA | NA | NA | NA | + | + | |
| + | ? | + | ? | ? | − | ? | + | + | + | ? | − | + | − | |
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| Total + | 51 | 32 | 47 | 42 | 43 | 46 | 40 | 50 | 43 | 45 | 35 | 45 | 47 | 45 |
| Total − | 0 | 1 | 0 | 0 | 1 | 3 | 0 | 0 | 0 | 0 | 1 | 3 | 1 | 6 |
| Total NA | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 3 | 1 | 3 | 2 | 0 | 0 |
| Total ? | 0 | 18 | 4 | 9 | 7 | 2 | 10 | 0 | 5 | 5 | 12 | 1 | 3 | 0 |
| 1A. Identification, selection and critical appraisal of studies 1. Selection criteria: were the criteria used for deciding which studies to include in the review reported? (+ yes; ? can't tell/partially; − no) 2. Search: was the search for evidence reasonably comprehensive? (+ yes; ? can't tell/partially; − no) 3. Up‐to‐date: is the review reasonably up‐to‐date? (+ yes; ? can't tell/partially; − no) 4. Study selection: was bias in the selection of articles avoided? (+ yes; ? can't tell/partially; − no) 5. Risk of bias: did the authors use appropriate criteria to assess the risk for bias in analysing the studies that are included? (+ yes; ? can't tell/partially; − no) 6. Overall: how would you rate the methods used to identify, include and critically appraise studies? (+ only minor limitations, − important limitations) 2B. Analysis 1. Study characteristics: were the characteristics and results of the included studies reliably reported? (+ yes; ? can't tell/partially; − no, NA not applicable; e.g. no studies or data) 2. Analytic methods: were the methods used by the review authors to analyse the findings of the included studies reported? (+ yes; ? can't tell/partially; − no, NA not applicable; e.g. no studies or data) 3. Heterogeneity: did the review describe the extent of heterogeneity? (+ yes; ? can't tell/partially; − no, NA not applicable; e.g. no studies or data) 4. Appropriate synthesis: were the findings of the relevant studies combined (or not combined) appropriately relative to the primary question the review addresses and the available data? (+ yes; ? can't tell/partially; − no, NA not applicable; e.g. no studies or data) 5. Exploratory factors: did the review examine the extent to which specific factors might explain differences in the results of the included studies? (+ yes; ? can't tell/partially; − no, NA not applicable; e.g. no studies or data) 6. Overall: how would you rate the methods used to analyse the findings relative to the primary question addressed in the review? (+ only minor limitations, − important limitations) 3C. Overall 1. Other considerations: are there any other aspects of the review not mentioned before which lead you to question the results? (+ yes; ? can't tell/partially; − no) 2. Reliability of the review: based on the above assessments of the methods how would you rate the reliability of the review? (+ only minor limitations, − important limitations) | ||||||||||||||
| Delivery arrangement | Key messages |
| Who receives care and when | |
| Queuing strategies | ➡ Direct/open access and direct booking systems probably slightly decrease median waiting times and may decrease mean waiting times in hospital settings.
➡ The effects of other interventions to reduce waiting times, including increasing the supply of services, are uncertain. ➡ The included studies were from high‐income countries. |
| Group vs individual care | ➡ In high‐income countries, group compared to individual antenatal care probably reduces the number of preterm births, while having little or no effect on the number of low birthweight and small for gestational age newborns; and it may have little or no effect on perinatal mortality. ➡ The applicability of the findings of this review to low‐income countries is uncertain. ➡ The effects, costs and cost‐effectiveness of group antenatal care should be evaluated in large randomised trials in low‐income countries. |
| Who provides care | |
| Pre‐licensure education | ➡ There is little evidence of the effects of interventions to increase the capacity of health professional training institutions, reduce student dropout rates or increase the number of students recruited from other countries into health professional training institutions. ➡ Academic advising programmes for minority groups may:
➡ No studies were found of the effects of other pre‐licensure measures to increase health worker supply. |
| Recruitment and retention strategies | ➡ It is uncertain whether any of the following types of interventions to recruit or retain health professionals increase the number of health professionals practising in underserved areas.
|
| Role expansion or task shifting ‐ Lay health workers: hypertension | In people with hypertension: ➡ Community health workers (CHWs) probably improve behavioural changes (such as appointment keeping and adherence to medication), blood pressure control, and the 5‐year mortality rate. ➡ CHWs may slightly improve healthcare utilisation and health systems outcomes (such as reduced hospital admissions). ➡ All the included studies took place in a high‐income country but mainly in poor communities. |
| Role expansion or task shifting ‐ Lay health workers: delivery of community‐based neonatal care packages | ➡ Community mobilisation and antenatal and postnatal home visitation decreases neonatal mortality. ➡ The following community‐based intervention packages probably reduce neonatal mortality.
➡ The following community‐based intervention packages may reduce neonatal mortality.
➡ The following community‐based intervention packages may reduce maternal mortality.
|
| Role expansion or task shifting ‐ Lay health workers: maternal and child health and infectious diseases | ➡ The use of lay health workers in maternal and child health programmes:
➡ The use of lay health workers in tuberculosis programmes:
➡ Little evidence is available regarding the effectiveness of substituting lay health workers for health professionals or the effectiveness of alternative strategies for training, supporting and sustaining lay health workers. ➡ Factors that need to be considered when assessing whether intervention effects are likely to be transferable to other settings include:
|
| Role expansion or task shifting ‐ Midlevel health professionals: non‐doctor providers for abortion care | ➡ Surgical aspiration abortion procedures administered by midlevel providers probably lead to little or no difference in incomplete and failed abortions, compared to doctors. ➡ Surgical aspiration abortion procedures administered by midlevel providers probably lead to slightly more complications, compared to doctors. ➡ Medical abortion procedures administered by midlevel providers probably lead to slightly less incomplete and failed abortions, compared to doctors. ➡ Factors that need to be considered when assessing the transferability of the findings to a low‐income setting include the availability of doctors to perform abortion procedures, the availability and training of midlevel providers to perform surgical and medical abortions and the abortion rates and incidence of unsafe abortion procedures. |
| Role expansion or task shifting ‐ Healthcare providers giving additional social support to pregnant women vs usual care | ➡ Compared to usual care, providing additional social support during an at‐risk pregnancy probably leads to fewer caesarean births and may lead to fewer antenatal hospital admissions. ➡ Compared to usual care, providing additional social support during an at‐risk pregnancy probably has little or no effect on the incidence of low birth weight, preterm births, or perinatal deaths. ➡ The studies included in this review were conducted among socially disadvantaged groups in middle‐ and high‐income countries. Disadvantaged groups in some high‐ and middle‐income countries may share similar characteristics to disadvantaged groups in low‐income countries, and the results of these studies may therefore be transferable to low‐income country settings. |
| Role expansion or task shifting ‐ Midlevel health professionals: midwife‐led care in pregnancy | ➡ In high‐income countries, midwife‐led care compared to other models of care for childbearing women and their infants:
➡ In addition, midwife‐led care compared to other models of care probably reduces caesarean births and increases the number of women with an intact perineum. ➡ None of the included studies took place in a low‐income country, and the transferability of this evidence is uncertain. |
| Role expansion or task shifting ‐ Clinical officers vs physician for caesarean section | ➡ It is uncertain whether there are any differences in maternal or perinatal mortality between caesarean sections performed by non‐physician clinicians and by doctors. ➡ Non‐physician clinicians performing caesarean sections may lead to slightly more wound infections and occurrences of wound dehiscence than doctors. ➡ All six studies included in this systematic review were from low‐income countries. |
| Role expansion or task shifting ‐ Non specialists vs specialists providers for mental health | ➡ The use of non‐specialist health workers in the care of adults with depression, anxiety or both:
➡ The use of non‐specialist health workers in the care of adults with dementia:
➡ The use of non‐specialist health workers may decrease the quantity of alcohol consumed in problem drinkers. ➡The use of non‐specialist health workers or teachers may reduce the symptoms in adults with post‐traumatic stress disorder. ➡ It is uncertain whether lay health workers or teachers reduce post‐traumatic stress disorder symptoms among children. ➡ Most of the included studies took place in low‐resource settings. |
| Role expansion or task shifting ‐ Specialist nursing post added to hospital nurse staffing ‐ Dietary assistants added to hospital nurse staffing | ➡ The addition of a specialist nursing post to staffing may decrease patient length of stay; and may lead to little or no difference in in‐hospital mortality, readmissions, attendance at emergency departments within 30 days, or postdischarge adverse events. ➡ Adding support staff (dietary assistants) to nurse staffing may decrease mortality in trauma units, in hospital, and at 4 months after discharge. ➡ Team midwifery shortens the length of stay in special care nurseries for infants, slightly shortens the length of stay in hospital for women giving birth, and probably leads to little or no difference in perinatal deaths. ➡ None of the included studies took place in a low‐income country. |
| Role expansion or task shifting ‐ Physician‐nurse substitution | ➡ Nurse‐led care probably leads to a lower systolic blood pressure and lower CD4 cell counts in HIV/AIDs patients compared to physician‐led care. ➡ Nurse‐led care compared to physician‐led care probably leads to little or no difference in other clinical parameters, such as diastolic blood pressure, total cholesterol level, and glycosylated haemoglobin concentrations. ➡ Most of the studies took place in high‐income countries.
|
| Role expansion or task shifting ‐ Pharmacists delivering non‐dispensing services to patients | ➡ The provision of additional services by pharmacists targeted at patients, such as patient health education and follow‐up, may lead to:
➡ The provision of additional services by pharmacists targeted at healthcare professionals, such as educational outreach visits, may improve patient outcomes ➡ The applicability of the findings to low‐income countries may be limited by pharmacist numbers, patients and physicians' attitudes to pharmacists, pharmacists' training, and laws governing pharmaceutical practice |
| Role expansion or task shifting ‐ Skilled birth attendants | ➡ Skilled birth attendance may reduce stillbirths and perinatal mortality. ➡ It is uncertain what the effects of alternative ways of providing emergency obstetric care are on stillbirths or perinatal mortality. |
| Role expansion or task shifting ‐ Dental care by dental therapists | ➡ It is uncertain whether midlevel providers decrease the incidence, prevalence or severity of dental caries, or increase treatment of caries. ➡ None of the included studies took place in a low‐income country. |
| Coordination of care | |
| Care pathways ‐ Improved pre‐hospital trauma systems vs no systems | ➡ Pre‐hospital trauma systems may reduce mortality. ➡ Pre‐hospital trauma systems may reduce the response time from injury to first medical contact in the field. ➡ Most of the included studies took place in middle‐income countries. |
| Care pathways ‐ Rapid response systems in hospitals vs no systems | ➡ Rapid‐response systems for hospitalised adults may slightly reduce hospital mortality and cardiopulmonary arrests outside of intensive care units; and may lead to little or no difference in admissions to intensive care units. ➡ Rapid‐response systems for hospitalised children may slightly reduce cardiopulmonary arrests outside of intensive care units, and the effects on hospital mortality and admissions to intensive care units are uncertain. ➡ None of the included studies took place in a low‐income country. |
| Care pathways ‐ Hospital clinical pathways vs usual care | ➡ Clinical pathways compared to usual care in hospitals probably decrease the length of stay and may decrease complications and hospital readmissions. ➡ It is uncertain whether clinical pathways reduce in‐hospital mortality or hospital costs. ➡ Multifaceted interventions that include a clinical pathway probably lead to little or no difference in hospital mortality and may lead to little or no difference in length of stay or hospital costs. ➡ It is uncertain whether multifaceted interventions that include a clinical pathway decrease hospital complication or readmissions. ➡ Almost all the evaluations of clinical pathways have been conducted in high‐income economies. |
| Case management ‐ Children with pneumonia ‐ Community‐based with antibiotics ‐ Hospital‐based with oxygen or Vitamin | ➡ Community case management of pneumonia may reduce all‐cause mortality and mortality due to acute lower respiratory infection. ➡ All studies took place in low‐ and middle‐income countries. |
| Case management ‐ People living with HIV/AIDS | ➡ Case management may reduce mortality and the number of emergency department visits among people living with HIV/AIDS. Other effects of case management are uncertain. ➡ Computer prompts probably hasten initiation of recommended treatments for patients with HIV/AIDS. Other effects of computer prompts and information systems are uncertain. ➡ The effects of multidisciplinary or multifaceted interventions are uncertain. All the studies reviewed took place in high‐income countries. |
| Communication between providers ‐ Interactive communication between primary care doctors and specialists vs usual care | ➡ Interactive communication between primary care physicians and specialists probably leads to substantial improvements in patient outcomes. ➡ Although the population samples in the included studies were patients with diabetes and psychiatric conditions in high‐income countries, the consistency of effects suggests the potential of interactive communication to improve the effectiveness of primary care/specialist collaboration across other conditions and settings. ➡ When assessing the transferability of these findings to low‐income country settings, the availability and accessibility of specialist care in these settings should be considered as well as the technology required for interactive communication. |
| Coordination of care to reduce rehospitalisation ‐ Pre, post discharge interventions vs usual care ‐ Transition interventions vs usual care | ➡ It is uncertain whether pre‐discharge interventions reduce rehospitalisation. ➡ Postdischarge interventions may lead to little if any difference in rehospitalisation. ➡ It is uncertain whether patient‐centred discharge instructions reduce rehospitalisation. ➡ Inpatient–outpatient provider continuity may slightly reduce rehospitalisation. ➡ It is uncertain whether interactions between patients and nurses before and after discharge to support patient self‐care reduce rehospitalisation. ➡ No studies conducted in low‐income countries were identified. |
| Discharge planning ‐ Hospital discharge planning vs usual care | ➡ In high‐income countries:
➡ The effects of discharge planning in low‐income countries are uncertain since no studies took place in these settings.
|
| Integration ‐ Adding a service to an existing service vs services with no addition ‐ Integrated vs vertical delivery models | ➡ Adding family planning to other services probably increases the utilisation of family planning; but probably results in little or no difference in the number of new pregnancies. ➡ Adding provider‐initiated HIV counselling and testing to sexually transmitted infection services and to TB services probably increases the number of people receiving HIV testing. ➡ Integrating sexually transmitted infection services for female sexual partners of truck drivers into routine primary care may reduce women's utilisation of these services and their attendance following referral. ➡ Integrated community and facility provision of HIV prevention and control improves the proportion of STIs treated effectively in males but leads to little or no difference in the proportion treated effectively in females. ➡ Integrated community and facility provision of HIV prevention and control results in little or no difference in sexually transmitted disease incidence or HIV incidence in the population. ➡ 'Integration' is a complex intervention and is understood in different ways in different settings. Evaluations need to clearly describe the interventions being compared, including how services are integrated in practice. |
| Integration | ➡ Integrating vaccination with other healthcare services may increase DTP3 and measles vaccine coverage and may have little or no effect on BCG coverage. |
| Referral systems ‐ Healthcare delivery of organisational interventions vs no intervention for referral from primary to secondary care | ➡ Professional education that includes guidelines, checklists, video materials and educational outreach by specialists probably improves the quantity and quality of referrals. ➡ Joint primary care practitioner and consultant sessions probably result in improved patient outcomes. ➡ Organisational interventions that may improve referral rates and referral appropriateness include:
➡ Professional education that only includes the passive dissemination of referral guidelines probably leads to little or no difference in both the quantity and quality of referrals. ➡ The effects of financial incentives on referral rates are uncertain. |
| Referral systems ‐ Nurse vs physician triage systems in emergency departments | ➡ Physician‐led triage compared to nurse‐led triage probably reduces emergency department length of stay, physician's initial assessment time, and the proportion of patients leaving without being seen. ➡ It may lead to little or no difference in the proportion of patients leaving the emergency department against medical advice. ➡ None of the included studies took place in a low‐income country. |
| Teams ‐ Team midwifery vs standard care | ➡ Team midwifery shortens the length of stay in special care nurseries for infants, slightly shortens the length of stay in hospital for women giving birth, and probably leads to little or no difference in perinatal deaths. ➡ None of the included studies took place in a low‐income country. |
| Teams ‐ Multidisciplinary team care for people living with HIV/AIDS vs no team | ➡ Intensive home‐based care delivered by nurses to people living with HIV and AIDS:
➡ Multi‐professional team care in the home, compared with usual care by primary care nurses, may lead to little or no difference in the quality of life, time in care or survival of people living with HIV and AIDS. ➡ Information, communication and decision support via a computer in the homes of people living with AIDS may lead to little or no difference in health status or decision‐making skills and confidence but may slightly reduce people's social isolation and improve their quality of life. ➡ It is uncertain whether exercise at home improves the physical functioning, well‐being, body composition measures or biochemical measures of people living with HIV and AIDS. ➡ Home‐based safe water systems probably reduce the frequency and severity of diarrhoea among people living with HIV and AIDS. |
| Teams ‐ Practice‐based interventions to promote collaboration vs no intervention | ➡ The review identified 4 types of interprofessional collaboration interventions: externally facilitated interprofessional activities, interprofessional meetings, interprofessional checklists and interprofessional rounds. ➡ It is uncertain if externally facilitated interprofessional activities improve collaborative working, team communication, co‐ordination, patient‐assessed quality of care or continuity of care. ➡ The use of externally facilitated interprofessional activities or interprofessional meetings may slightly improve adherence to recommended practices and prescription of medicines. ➡ None of the included studies assessed outcomes related to patient mortality, morbidity or complication rates. ➡ Interprofessional checklists, interprofessional rounds and externally facilitated interprofessional activities may slightly improve overall use of resources and slightly decrease length of hospital stay and costs. ➡ The studies included in the review were very varied in terms of the types of professionals included, the tasks performed, the degree of interaction, and the populations and health issues considered. In addition, all of the studies took place in high‐income countries. |
| Where care is provided | |
| Site of service delivery ‐ HIV voluntary counselling and testing (VCT) at an optional location | ➡ Offering people a choice of settings in which to receive VCT, including at home, may increase
➡ People's preferred location for HIV VCT is uncertain. This outcome was not reported. ➡ The review findings come from one setting in a low‐income country and may not be relevant to all settings. |
| Site of service delivery ‐ Units dedicated to care for people living with HIV/AIDS ‐ Institutions managing a high volume of people living with HIV/AIDS | ➡ Units dedicated to AIDS care and high‐volume institutions may reduce mortality among people living with HIV/AIDS. ➡ High volume institutions probably reduce the number of emergency department visits and the length of hospital stays among people living with HIV/AIDS. ➡ The effects of other interventions related to the setting of care, such as outreach or interventions to reduce travel time to providers, are uncertain. |
| Site of service delivery ‐ Home‐based care for people living with HIV/AIDS ‐ Home‐based care with multidisciplinary team care for people living with HIV/AIDS vs other delivery options | ➡ Intensive home‐based care delivered by nurses to people living with HIV and AIDS:
➡ Multi‐professional team care in the home, compared with usual care by primary care nurses, may lead to little or no difference in the quality of life, time in care or survival of people living with HIV and AIDS. ➡ Information, communication and decision support via a computer in the homes of people living with AIDS may lead to little or no difference in health status or decision‐making skills and confidence but may slightly reduce people's social isolation and improve their quality of life. ➡ It is uncertain whether exercise at home improves the physical functioning, well‐being, body composition measures or biochemical measures of people living with HIV and AIDS. ➡ Home‐based safe water systems probably reduce the frequency and severity of diarrhoea among people living with HIV and AIDS. |
| Site of service delivery ‐ Home‐based management of malaria (presumptive treatment of children with symptoms) vs usual care | ➡ Home‐ or community‐based programmes for treating malaria:
➡ The effects of home‐ or community‐based programmes for treating malaria on hospitalisations, severe malaria, the prevalence of parasitaemia, and adverse effects are uncertain. ➡ The use of rapid diagnostic tests in home‐ or community‐based programmes for treating malaria, compared to clinical diagnosis:
➡ The effects of using rapid diagnostic tests in home‐ or community‐based programmes for treating malaria on treatment failures, severe malaria, the prevalence of parasitaemia, anaemia, and adverse effects are uncertain. |
| Site of service delivery ‐ Strategies for increasing ownership and use of insecticide‐treated bednets | ➡ Providing free insecticide‐treated bednets compared to providing subsidised or full market price bednets probably increases the number of pregnant women, adults and children who possess insecticide‐treated bednets but probably leads to little or no difference in appropriate use of bednets. ➡ Education about appropriate use of insecticide‐treated bednets may increase the number of adults and children under five sleeping under bednets. ➡ Providing incentives to encourage the use of insecticide‐treated bednets may lead to little or no difference in use. ➡ The included studies took place in rural communities in Africa, India and Iran. |
| Site of service delivery ‐ Home care (different models) vs facility | ➡ Compared with hospital care, home care may lead to little or no difference in re‐admissions or the time spent by families caring for children with acute physical conditions. Home care for children with acute physical conditions probably increases healthcare costs but decreases costs incurred by families in the UK. ➡ For children with traumatic brain injury, home rehabilitation compared with clinic‐based rehabilitation may slightly improve mental functioning. The effects on adverse events, family and caregivers, and costs were not reported. ➡ For children with acute lymphoblastic leukaemia, home chemotherapy compared with hospital chemotherapy may slightly improve their quality of life and may lead to little or no difference in adverse events or family costs. The impact on family and caregivers is uncertain. ➡ None of the studies included in the review took place in low‐income countries and none reported effects on mortality. |
| Site of service delivery ‐ Maternity waiting home vs no waiting homes | ➡ The effects of maternity waiting homes on perinatal and maternal mortality and morbidity in low‐resource settings are uncertain.
➡ Related literature suggests that:
|
| Site of service delivery ‐ Community‐based interventions for childhood diarrhoea and pneumonia vs routine care | ➡ Community‐based interventions probably increase care seeking for diarrhoea in children, increase use of oral rehydration solution, and reduce mortality due to diarrhoea among children age 0‐4 years. ➡ Community‐based interventions probably increase care seeking for pneumonia in children, increase use of antibiotics, and reduce mortality due to acute pneumonia among children age 0‐4 years. |
| Site of service delivery ‐ Early discharge from hospital for mothers and infants born at term vs standard discharge | ➡ Early discharge may lead to little or no difference in the number of infant or maternal readmissions.
➡ Early discharge may lead to little or no difference in breastfeeding rates at two months. ➡ The effect of early discharge on the cost of care is uncertain.
➡ All the included studies took place in high‐income countries.
|
| Site of service delivery ‐ Out‐of‐facility vs facility‐based HIV and reproductive health services for youth | ➡ Few studies that included data comparing out‐of‐facility services with facility‐based services took place in low‐ and middle‐income countries. ➡ Improved access to self‐test kits probably leads to more young people being screened for chlamydia compared to clinic‐based testing. ➡ Access to emergency contraception through pharmacies without a doctor's prescription ('over‐the‐counter' access) may increase non‐prescription emergency contraception use, but may have mixed effects on overall use of emergency contraception with increases in some settings but not others. ➡ The distribution of condoms and health education messages by street outreach workers may increase condom use. ➡ It is uncertain whether street and youth centre‐based outreach improves follow through on HIV referral for homeless or street‐based youth. ➡ It is uncertain whether the use of community youth programme promoters and integrated youth centres increase the use of contraceptives. ➡ It is uncertain whether members of the poorest households are more likely to use home‐based counselling and testing for HIV, compared to those living in wealthier households. |
| Site of service delivery ‐ Decentralised vs centralised HIV care for initiation and maintenance of anti‐retroviral therapy | ➡ Partial decentralisation of HIV treatment (starting care at hospital and then moving to health centre care) probably reduces the combined number of people who die or are lost to care at one year and may reduce the costs of travel for patients. ➡ Full decentralisation of HIV treatment (starting and continuing care at a health centre) probably reduces the number of people lost to care but it is uncertain if it reduces deaths at one year. ➡ Decentralisation of HIV treatment from facility to community probably leads to little or no difference in the number of people who die or are lost to care at one year. ➡ Decentralisation of HIV treatment from facility to community may reduce total costs to people living with HIV and AIDS and to the health service. ➡ Most of the included studies took place in low‐income countries. |
| Site of service delivery ‐ Workplace programmes for HIV and tuberculosis vs no programme | ➡ Workplace programmes for health workers may increase the uptake of HIV testing. ➡ Workplace programmes for health workers may increase awareness of post‐exposure prophylaxis to prevent HIV infection. ➡ Onsite compared with offsite rapid HIV testing may increases the uptake of voluntary counselling and testing among workers in sectors other than health. ➡ Workplace programmes offering free antiretroviral therapy may improve markers of effective antiretroviral therapy among workers living with HIV and AIDS in sectors other than health. ➡ All studies included in this review took place in low‐ and middle‐income countries. |
| Information and communication technology | |
| E‐Health ‐ Mobile phone messaging for long‐term illnesses vs usual care | ➡ Mobile phone messaging support probably leads to little or no difference in people's knowledge about their diabetes but may improve people's self‐efficacy in relation to their diabetes. ➡ Mobile phone messaging support probably leads to little or no difference in adherence to diabetes medication in young people with diabetes or care plan adherence in people with asthma but probably improves medication adherence in people with hypertension. ➡ Mobile phone messaging support for people living with diabetes probably leads to little or no difference in glycaemic control and may lead to little or no difference in diabetes complications. ➡ Mobile phone messaging support for people living with asthma or hypertension may lead to little or no difference in control of these conditions. ➡ It is uncertain whether mobile phone messaging support changes health service utilisation by people living with diabetes and asthma. ➡ All of the studies took place in high‐income countries and the applicability of the findings to low‐income countries is likely to vary, depending on the availability of the technological infrastructure required and factors such as levels of patient literacy and the acceptability of this intervention among different groups. |
| E‐Health ‐ Mobile phone messaging reminders for attendance at healthcare appointments vs various other interventions | ➡ Mobile phone text message reminders compared with no reminders probably lead to an increase in attendance at healthcare appointments. ➡ Mobile phone text message reminders probably lead to little or no difference in attendance at healthcare appointments compared to phone call reminders. However, the cost per text message per attendance may be lower compared to the cost of mobile phone call reminders. ➡ Mobile phone text message reminders plus postal reminders may lead to improved attendance at healthcare appointments compared to postal reminders alone. |
| E‐Health ‐ Mobile phone messaging to promote adherence to antiretroviral therapy vs usual care | ➡ Mobile phone text messages compared to standard care improve adherence to ART for up to 12 months. ➡ Mobile phone text messages compared to standard care may lead to little or no difference in mortality or loss to follow‐up after up to 12 months. ➡ Weekly text messages probably improve adherence compared to daily text messages, and interactive text messages probably improve adherence compared to non‐interactive text messages. ➡ All studies took place in low‐income countries in Africa. |
| Health information systems ‐ Women carrying their own case notes in pregnancy vs less detailed health cards | ➡ Women carrying their own case notes:
➡ These findings are based on a few small trials in high‐income countries. Factors that should be considered in applying the findings of this review to low‐income country settings include:
|
| Patient reminder and recall systems ‐ Interventions to improve childhood vaccination vs usual care | ➡ Health education combined with reminders may increase DTP3 coverage. ➡ Reminders and recall strategies probably increase routine childhood vaccination uptake. Related findings: ➡ Community‐based health education probably improves coverage of three doses of diphtheria‐tetanus‐pertussis vaccine (DTP3). However, the impacts of facility‐based health education on coverage of DPT3 may vary from little or no effect to potentially important benefits. ➡ Household monetary incentives may have little or no effect on achieving full vaccination coverage. ➡ Home visits may improve OPV3 and measles coverage. |
| Quality and safety systems | |
| Quality/safety monitoring and improvement system ‐ Medication review for hospitalised adult patients vs standard care | ➡ Medication review may lead to little or no difference in mortality or hospital readmissions. ➡ Medication review may reduce hospital emergency department contacts. ➡ None of the studies took place in a low‐ or middle‐income country. |
| Quality monitoring and improvement systems ‐ Interventions to improve antibiotic prescribing to hospital inpatients | ➡ Restrictive interventions may improve antibiotic prescribing at one month but may lead to little or no difference in antibiotic prescribing at longer follow‐up compared with persuasive interventions. ➡ Interventions intended to decrease unnecessary antibiotic prescribing probably lead to little or no difference in all‐cause mortality. ➡ It is uncertain whether interventions intended to decrease unnecessary antibiotic prescribing affect the length of stay or readmissions. ➡ Interventions intended to increase effective antibiotic prescribing for pneumonia may decrease mortality. ➡ None of the included studies took place in a low‐income country. |
| Quality monitoring and improvement systems ‐ Decision support to improve healthcare process and health outcomes for people living with HIV/AIDS ‐ Decision support with clinical information system to improve healthcare process and health outcomes for people living with HIV/AIDS | ➡ Decision support may improve adherence to recommended practice by health professionals and adherence to treatment by patients. It is uncertain if it improves health outcomes or healthcare utilisation. ➡ Clinical information systems probably increase the proportion of patients with a suppressed HIV load, and may increase adherence to recommended practice by health professionals and adherence to treatment by patients. It is uncertain whether they improve healthcare utilisation. ➡ Combinations of decision support and clinical information systems may improve adherence to recommended practice by health professionals and adherence to treatment by patients. It is uncertain if they change at‐risk behaviours, health outcomes or healthcare utilisation. ➡ Few studies took place in low‐income countries. |
| Working conditions of health workers | |
| Staff support ‐ Managerial supervision to improve quality of primary health care | ➡ Managerial supervision may improve provider practices and knowledge compared with no supervision. ➡ It is uncertain whether managerial supervision improves medicine stock management. ➡ It is uncertain whether ‘'enhanced' managerial supervision (e.g. increased supervision, the use of tools such as checklists) improves the performance of lay or community health workers or midwives; the proportion of children receiving adequate care; or patient and health worker satisfaction. ➡ ‘'Less intensive' managerial supervision (e.g. fewer visits) may lead to little or no difference in the number of new family planning client visits or the number of clients that re‐visit. ➡ The need for additional resources for managerial supervision needs to be addressed when developing policies for and implementing supervision strategies. ➡ When implementing managerial supervision, other factors such as whether the healthcare system and organisational culture of healthcare teams are centralised or decentralised should also be considered. |
| Staff support | ➡ Training vaccination managers to provide supportive supervision for healthcare provider may have little or no effect on coverage of DTP, oral polio vaccine (OPV) and hepatitis B virus (HBV) vaccine. |
| Complex interventions cutting across delivery categories and across the other overviews | |
| Package of multiple interventions ‐ Emergency obstetric referral interventions | ➡ Emergency referral interventions may lead to a reduction in maternal mortality. ➡ Emergency referrals probably lead to a reduction in neonatal mortality. ➡ The effect of emergency referral interventions on stillbirths is uncertain. ➡ None of the included studies reported cost outcomes; the cost implications of emergency referral interventions are therefore uncertain. ➡ The included studies took place in low‐ and middle‐income countries and are likely applicable to other low‐income country settings. |
| Delivery arrangement | Patient outcome | Access, coverage, utilisation | Quality of care | Resource use | Social outcomes | Impacts on equity | Health care provider outcomes | Adverse effects | Other |
| Who receives care and when | |||||||||
| Queuing strategies | NR | NR | ✔㊉㊉㊉㊀1 ✔㊉㊉㊀㊀2 ?㊉㊀㊀㊀ 3 | NR | NR | NR | NR | NR | NR |
| Group vs individual care | ✔㊉㊉㊉㊀4 ∅ ㊉㊉㊉㊀5 ∅ ㊉㊉㊀㊀6 | NR | NR | NR | NR | NR | NR | NR | NR |
| Who provides care | |||||||||
| Pre‐licensure education | NR | ✔㊉㊉㊀㊀7 | NR | NR | NR | ✔㊉㊉㊀㊀8 | NR | NR | NR |
| Recruitment and retention strategies | NR | ?㊉㊀㊀㊀9 | NR | NR | NR | NR | NR | NR | NR |
| Role expansion or task shifting ‐ Lay health workers: hypertension | ✔㊉㊉㊉㊀10 | ✔㊉㊉㊉㊀10 | ✔㊉㊉㊀㊀11 | ✔㊉㊉㊀㊀11 | NR | NR | NR | NR | NR |
| Role expansion or task shifting ‐ Community‐based intervention packages that include additional training of outreach workers | ✔㊉㊉㊉㊀12 ✔㊉㊉㊀㊀13 ✔㊉㊉㊉㊉14 ✔㊉㊉㊀㊀15 | NR | NS | NR | NR | NR | NR | NR | NR |
| Role expansion or task shifting ‐ Lay health workers: maternal and child care and infectious diseases | ✔㊉㊉㊀㊀16 ✔㊉㊉㊀㊀17 ✔㊉㊉㊉㊀18 | ✔㊉㊉㊀㊀19 ✔㊉㊉㊉㊀20 ∅㊉㊉㊉㊀21 | NR | NR | NR | NR | NR | NR | NR |
| Role expansion or task shifting ‐ Midlevel health professionals: non‐doctor providers for abortion care | ✕㊉㊉㊉㊀22 ✔㊉㊉㊉㊀23 | NR | NR | NR | NR | NR | NR | NR | NR |
| Role expansion or task shifting ‐ Healthcare providers giving additional social support to pregnant women vs usual care | ✔㊉㊉㊉㊀24 ∅㊉㊉㊀㊀25 ∅㊉㊉㊉㊀26 | NR | NR | NR | NR | NR | NR | NR | NR |
| Role expansion or task shifting ‐ Physician‐nurse substitution | ✔㊉㊉㊉㊀27 ∅ ㊉㊉㊉㊀ 28 | NR | NR | NR | NR | NR | NR | NR | NR |
| Role expansion or task shifting ‐ Midlevel health professionals: midwife‐led care in pregnancy | ✔㊉㊉㊉㊉29 ✔㊉㊉㊉㊀30 | ✔㊉㊉㊉㊀31 | NR | NR | NR | NR | NR | NR | NR |
| Role expansion or task shifting ‐ Clinical officers/non‐physician clinicians/associate clinicians vs physician for caesarean section | ?㊉㊀㊀㊀ 32 ✕㊉㊉㊀㊀ 33 | NR | NR | NR | NR | NR | NR | NR | NR |
| Role expansion or task shifting ‐ Non‐specialist providers vs specialist providers for mental health | ?㊉㊀㊀㊀ 34 ✔㊉㊉㊀㊀ 35 ✔㊉㊉㊉㊀ 36 | NR | NR | NR | NR | NR | NR | NR | NR |
| Role expansion or task shifting ‐ Specialist nursing post added to hospital nurse staffing | ∅㊉㊉㊀㊀ 37 | ✔㊉㊉㊀㊀38 ∅㊉㊉㊀㊀ 39 | NR | NR | NR | NR | NR | NR | NR |
| ‐ Dietary assistants added to hospital nurse staffing | ∅㊉㊉㊀㊀ 40 ✔㊉㊉㊀㊀41 | NR | NR | NR | NR | NR | NR | NR | NR |
| Role expansion or task shifting ‐ Pharmacists delivering non‐dispensing services to patients | ✔㊉㊉㊀㊀42 | ✔㊉㊉㊀㊀43 | NR | ✔㊉㊉㊀㊀44 ?㊉㊀㊀㊀45 | NR | NR | NR | NR | NR |
| Role expansion or task shifting‐ Skilled birth attendant | ✔㊉㊉㊀㊀ 46 ?㊉㊀㊀㊀47 | NR | NR | NR | NR | NR | NR | NR | NR |
| Role expansion or task shifting ‐ Dental care by dental therapists | ?㊉㊀㊀㊀48 | ?㊉㊀㊀㊀49 | NR | NS | NR | NR | NR | NR | NR |
| Coordination of care | |||||||||
| Care pathways ‐ Improved pre‐hospital trauma systems vs no systems | ✔㊉㊉㊀㊀50 | ✔㊉㊉㊀㊀51 | NR | NR | NR | NR | NR | NR | NR |
| Care pathways ‐ Rapid response systems in hospitals vs no systems | ✔㊉㊉㊀㊀52 ✔㊉㊉㊀㊀53 ?㊉㊀㊀㊀54 | ∅ ㊉㊉㊀㊀55 ?㊉㊀㊀㊀56 | NR | NR | NR | NR | NR | NR | NR |
| Care pathways ‐ Hospital clinical pathways vs usual care | ?㊉㊀㊀㊀57 ✔㊉㊉㊀㊀ 58 | ∅ ✔㊉㊉㊀㊀59 ✔㊉㊉㊉㊀60 | NR | ? ㊉㊀㊀㊀61 | NR | NR | NR | NR | NR |
| Case management ‐ Children with pneumonia | ✔㊉㊉㊀㊀62 ✔㊉㊉㊀㊀63 | NR | NR | NR | NR | NR | NR | NR | NR |
| Case management ‐ People living with HIV/AIDS | ✔㊉㊉㊀㊀ 64 | ✔㊉㊉㊀㊀65 ?㊉㊀㊀㊀66 | NR | NR | NR | NR | NR | NR | |
| Communication between providers ‐ Interactive communication between primary care doctors and specialists vs usual care | ✔㊉㊉㊉㊀67 | NR | NR | NR | NR | NR | NR | NR | NR |
| Coordination of care to reduce rehospitalisation ‐ Pre‐/postdischarge interventions vs usual care | NR | ?㊉㊀㊀㊀68 ∅ ㊉㊉㊀㊀69 | NR | NR | NR | NR | NR | NR | NR |
| ‐ Transition interventions vs usual care | NR | ✔㊉㊉㊀㊀70 ?㊉㊀㊀㊀71 ?㊉㊀㊀㊀72 | NR | NR | NR | NR | NR | NR | NR |
| Discharge planning ‐ Hospital discharge planning vs usual care | NR | ✔㊉㊉㊉㊀73 ✔㊉㊉㊉㊀74 | NR | ? ㊉㊀㊀㊀75 | NR | NR | NR | NR | ✔㊉㊉㊀㊀76 |
| Integration ‐ Adding a service to an existing service vs services with no addition | ∅㊉㊉㊉㊀ 77 | ✔㊉㊉㊉㊀78 | NR | NR | NR | NR | NR | NR | ✔㊉㊉㊀㊀79 |
| ‐ Integrated vs vertical delivery models | ∅㊉㊉㊉㊉ 80 | ✕ ㊉㊉㊀㊀81 ✔㊉㊉㊉㊀82 ✔㊉㊉㊉㊉ 83 | ✔㊉㊉㊉㊉84 ∅㊉㊉㊉㊉85 | NR | NR | NR | NR | NR | NR |
| Referral systems ‐ Organisational interventions vs no intervention for referral from primary to secondary care | NR | NR | ✔㊉㊉㊀㊀86 ✔㊉㊉㊀㊀87 | NR | NR | NR | NR | NR | NR |
| Referral systems ‐ Nurse vs physician triage systems in emergency departments | NR | ✔㊉㊉㊉㊀88 | ∅ ㊉㊉㊀㊀89 ✔㊉㊉㊉㊀90 ✔㊉㊉㊉㊀91 | NR | NR | NR | NR | NR | NR |
| Teams ‐ Team midwifery vs standard care | ∅ ㊉㊉㊉㊀92 | ✔㊉㊉㊉㊉93 ✔㊉㊉㊉㊉94 | NR | NR | NR | NR | NR | NR | NR |
| Teams ‐ Practice‐based interventions to promote collaboration vs no intervention | NR | ✔㊉㊉㊀㊀95 | ?㊉㊀㊀㊀96 ?㊉㊀㊀㊀97 | ✔㊉㊉㊀㊀98 | NR | NR | ?㊉㊀㊀㊀99 | NR | NR |
| Where care is provided | |||||||||
| Site of service delivery ‐ HIV voluntary counselling and testing (VCT) at an optional location vs VCT at clinic | NR | NR | NR | NR | NR | NR | NR | NR | ✔㊉㊉㊀㊀100 |
| Site of service delivery ‐ Units dedicated to care for people living with HIV/AIDS | ✔㊉㊉㊀㊀ 101 | NR | NR | NR | NR | NR | NR | NR | NR |
| ‐ Institutions managing a high volume of people living with HIV/AIDS | ✔㊉㊉㊀㊀ 102 | ✔㊉㊉㊉㊀103 | NR | NR | NR | NR | NR | NR | NR |
| Site of service delivery ‐ Intensive home‐based care delivered by nurses for people living with HIV/AIDS vs other delivery options | ∅㊉㊉㊉㊀ 104 ∅㊉㊉㊉㊀ 105 ✔㊉㊉㊀㊀ 106 ✔㊉㊉㊀㊀ 107 ∅㊉㊉㊀㊀108 | NR | NR | NR | NR | NR | NR | NR | ✔㊉㊉㊉㊀ 109 |
| Site of service delivery ‐ Multi‐professional team care in the home for people living with HIV/AIDS vs usual care by primary care nurses | ∅㊉㊉㊀㊀ 110 ∅㊉㊉㊀㊀ 111 ∅㊉㊉㊀㊀ 112 | NR | NR | NR | NR | NR | NR | NR | NR |
| Site of service delivery ‐ Exercise at home for people living with HIV/AIDS vs no exercise at home | ?㊉㊀㊀㊀113 | NR | NR | NR | NR | NR | NR | NR | NR |
| Site of service delivery ‐ Strategies for increasing ownership and use of insecticide‐treated bednets | NR | NR | NR | NS | NS | NR | NR | NR | ✔㊉㊉㊉㊀114 ∅㊉㊉㊉㊀115 ✔㊉㊉㊀㊀116 ∅㊉㊉㊀㊀117 |
| Site of service delivery ‐ Home‐ or community‐based management of malaria (presumptive treatment of children with symptoms) vs usual care | ✔㊉㊉㊉㊀118 ?㊉㊀㊀㊀119 ∅㊉㊉㊀㊀ 120 | ?㊉㊀㊀㊀121 ✔㊉㊉㊉㊀122 | NR | NR | NR | NR | NR | ?㊉㊀㊀㊀123 | NR |
| Site of service delivery ‐ Use of rapid diagnostic tests in home‐ or community‐based programmes for treating malaria vs clinical diagnosis | ∅㊉㊉㊀㊀ 124 ?㊉㊀㊀㊀125 | ✔㊉㊉㊉㊀126 ∅㊉㊉㊀㊀ 127 | NR | NR | NR | NR | NR | ?㊉㊀㊀㊀128 | NR |
| Site of service delivery ‐ Home (different models) vs facility care for children with acute physical conditions | ✔㊉㊉㊀㊀129 ✔㊉㊉㊀㊀130 | ∅㊉㊉㊀㊀131 | NR | ✔✕㊉㊉㊉㊀ 132 ∅㊉㊉㊀㊀133 | ∅㊉㊉㊀㊀134 | NR | NR | ∅㊉㊉㊀㊀135 | |
| Site of service delivery ‐ Maternity waiting home vs no waiting homes for pregnant women | NS | NS | NS | NS | NS | NS | NS | NS | NS |
| Site of service delivery ‐ Community‐based interventions for childhood diarrhoea and pneumonia vs routine care | ✔㊉㊉㊉㊀136 ✔㊉㊉㊉㊀137 | ✔㊉㊉㊉㊀138 ✔㊉㊉㊉㊀139 | NR | NR | NR | NR | NR | NR | NR |
| Site of service delivery ‐ Early discharge from hospital for mothers and infants born at term vs standard discharge | ∅㊉㊉㊀㊀140 | ∅㊉㊉㊀㊀141 | NR | ? ㊉㊀㊀㊀142 | NR | NR | NR | NR | NR |
| Site of service delivery ‐ Out‐of‐facility vs facility‐based HIV and reproductive health services for youth | NR | ✔㊉㊉㊉㊀143 ✔㊉㊉㊀㊀ 144 ∅㊉㊉㊀㊀ 145 ✔㊉㊉㊀㊀ 146 ?㊉㊀㊀㊀ 147 | ?㊉㊀㊀㊀ 148 | NR | NR | ?㊉㊀㊀㊀ 149 | NR | NR | NR |
| Site of service delivery ‐ Decentralised vs centralised HIV care for initiation and maintenance of anti‐retroviral therapy | ✔㊉㊉㊀㊀ 150 ✔㊉㊉㊉㊀151 ∅㊉㊉㊉㊀ 152 ?㊉㊀㊀㊀ 153 | ✔㊉㊉㊀㊀154 ✔㊉㊉㊉㊀155 ∅㊉㊉㊉㊀156 | NR | ✔㊉㊉㊀㊀157 ✔㊉㊉㊀㊀158 | NR | NR | NR | NR | NR |
| Site of service delivery ‐ Workplace programmes for HIV and tuberculosis diagnosis and treatment vs no programme | ✔㊉㊉㊀㊀159 | ✔㊉㊉㊀㊀160 ✔㊉㊉㊀㊀161 | NR | NR | NR | NR | NS | NR | ✔㊉㊉㊀㊀162 |
| Information and communication technology | |||||||||
| E‐Health ‐ Mobile phone messaging for long‐term illnesses vs usual care | ∅㊉㊉㊉㊀163 ∅㊉㊉㊀㊀164 ∅㊉㊉㊀㊀165 | ∅㊉㊉㊉㊀166 ∅㊉㊉㊉㊀167 ✔ ㊉㊉㊉㊀168 ?㊉㊀㊀㊀ 169 | NR | NR | NR | NR | NR | NR | ✔㊉㊉㊀㊀170 ∅㊉㊉㊉㊀ 171 |
| E‐Health ‐ Mobile phone messaging reminders for attendance at healthcare appointments vs various other interventions | NR | ✔㊉㊉㊉㊀172 ✔㊉㊉㊀㊀173 ∅ ㊉㊉㊉㊀174 | NR | ✔㊉㊉㊀㊀175 | NR | NR | NR | NR | NR |
| E‐Health ‐ Mobile phone messaging to promote adherence to antiretroviral therapy vs usual care | 0㊉㊉㊀㊀ 176 | NR | ✔㊉㊉㊉㊉177 ∅㊉㊉㊀㊀ 178 | NR | NR | NR | NR | NR | NR |
| Health information systems ‐ Women carrying their own case notes in pregnancy vs less detailed health cards | ∅㊉㊉㊀㊀179 | ∅㊉㊉㊀㊀180 ✔㊉㊉㊀㊀181 ✔X㊉㊉㊀㊀182 | NR | NR | NR | NR | NR | NR | ∅㊉㊉㊀㊀183 ∅㊉㊉㊀㊀184 ✔㊉㊉㊉㊀ 185✔㊉㊉㊀㊀186 |
| Patient reminder and recall systems ‐ Interventions to improve childhood vaccination including reminders for routine childhood vaccination vs usual care | NR | ✔㊉㊉㊉㊀187 ✔X㊉㊉㊀㊀188 ✔㊉㊉㊀㊀189 ∅㊉㊉㊀㊀190✔㊉㊉㊀㊀191 ∅㊉㊉㊀㊀192 ∅㊉㊉㊀㊀193 ✔㊉㊉㊀㊀194 ✔㊉㊉㊉㊀195 | NR | NR | NR | NR | NR | NR | NR |
| Quality and safety systems | |||||||||
| Quality/safety monitoring and improvement systems ‐ Medication review for hospitalised adult patients vs standard care | ∅㊉㊉㊀㊀ 196 | ∅㊉㊉㊀㊀197 ∅㊉㊉㊀㊀198 | NR | NR | NR | NR | NR | NR | NR |
| Quality monitoring and improvement systems ‐ Interventions to improve antibiotic prescribing to hospital inpatients | ✔㊉㊉㊀㊀ 199 ∅㊉㊉㊉㊀ 200 | ? ㊉㊀㊀㊀201 | ✔㊉㊉㊀㊀202 ∅㊉㊉㊀㊀ 203 | NR | NR | NR | NR | NR | NR |
| Quality monitoring and improvement systems ‐ Decision support to improve healthcare process and health outcomes for people living with HIV/AIDS | ? ㊉㊀㊀㊀204 | ? ㊉㊀㊀㊀205 ✔㊉㊉㊀㊀206 | ✔㊉㊉㊀㊀ 207 | NR | NR | NR | NR | NR | NR |
| ‐ Decision support with clinical information system to improve healthcare process and health outcomes for people living with HIV/AIDS | ? ㊉㊀㊀㊀208 | ? ㊉㊀㊀㊀209 ✔㊉㊉㊀㊀ 210 | ✔㊉㊉㊀㊀ 211 | NR | NR | NR | NR | NR | ?㊉㊀㊀㊀ 212 |
| Clinical information systems to improve healthcare process and health outcomes for people living with HIV/AIDS | ✔㊉㊉㊉㊀ 213 | ✔㊉㊉㊀㊀ 214 ? ㊉㊀㊀㊀215 | ✔㊉㊉㊀㊀ 216 | ||||||
| Working conditions of health workers | |||||||||
| Staff support ‐ Managerial supervision to improve quality of primary health care | NR | ? ㊉㊀㊀㊀ 217 | ✔㊉㊉㊀㊀ 218 ? ㊉㊀㊀㊀ 219 ∅ ㊉㊉㊀㊀ 220 | NR | NR | NR | ?㊉㊀㊀㊀ 221 | NR | ✔㊉㊉㊀㊀ 222 ?㊉㊀㊀㊀ 223 ?㊉㊀㊀㊀ 224 |
| Complex interventions cutting across delivery categories and across the other overviews | |||||||||
| Package of multiple interventions ‐ Emergency obstetric referral interventions112 | ∅㊉㊉㊀㊀ 225 ?㊉㊀㊀㊀ 226 ✔㊉㊉㊉㊀ 227 ?㊉㊀㊀㊀ 228 ✔㊉㊉㊀㊀ 229 | NR | NS | NR | NR | NR | NR | NR | NR |
| ✔: a desirable effect, ∅: little or no effect, ?: an uncertain effect, ✕: an undesirable effect, NS: no included studies, NR: not reported. | |||||||||
| 1Ballini 2015: median waiting times in hospital settings. 115Augustincic 2015: appropriate use of bednets 116Augustincic 2015: may increase the number of adults and children under five sleeping under bednets 117Augustincic 2015: use of insecticide‐treated bednets 118Okwundu 2013: all cause mortality 119Okwundu 2013: severe malaria; the prevalence of parasitaemia 120Okwundu 2013: prevalence of anaemia 121Okwundu 2013: hospitalisations 122Okwundu 2013: number of children treated promptly with an effective antimalaria medicine 123Okwundu 2013: adverse effects 124Okwundu 2013: all‐cause mortality 125Okwundu 2013: treatment failure; severe malaria; prevalence of parasitaemia; anaemia 126Okwundu 2013: number of children treated with antimalarials 127Okwundu 2013: hospitalisations 128Okwundu 2013: adverse effects 129Parker 2013: for children with traumatic brain injury ‐ mental functioning 130Parker 2013: for children with acute lymphoblastic leukeamia ‐ quality of life 131Parker 2013: re‐admissions for children with acute physical conditions 132Parker 2013: for children with acute physical conditions ‐ increases in healthcare costs; decreases in costs incurred by families (in the UK) 133Parker 2013: for children with acute lymphoblastic leukeamia ‐ costs incurred by families 134Parker 2013: time spent by family caring for children with acute physical conditions 135Parker 2013: for children with acute lymphoblastic leukeamia ‐ adverse events 136Das 2013: mortality due to diarrhoea among children aged 0‐4 years 137Das 2013: mortality due to acute pneumonia among children aged 0‐4 years 138Das 2013: care seeking and use of oral rehydration solution for children aged 0‐4 years with diarrhoea 139Das 2013: care seeking and use of antibiotics for children aged 0‐4 years with acute pneumonia 140Brown 2011: breastfeeding rates at two months 141Brown 2011: number of infant or maternal readmissions 142Brown 2011: costs of care 143Denno 2012: self test kits ‐ youth being screened for chlamydia 144Denno 2012: access to emergency contraception through pharmacies without a doctor's prescription ‐ non‐prescription emergency contraception use 145Denno 2012: access to emergency contraception through pharmacies without a doctor's prescription ‐ overall use of emergency contraception 146Denno 2012: distribution of condoms and health education messages by street outreach workers ‐ condom use 147Denno 2012: community youth promoters and integrated youth centres ‐ use of contraceptives 148Denno 2012: street and youth centre‐based outreach ‐ HIV referral for homeless or street‐based youth 149Denno 2012: whether the poorest households are more likely to use home‐based counselling and testing for HIV, compared to those in wealthier households 150Kredo 2013: partial decentralisation ‐ death at one year 151Kredo 2013: partial decentralisation ‐ combined number of people who die or are lost to care at one year 152Kredo 2013: decentralisation of HIV treatment from facility to community ‐ deaths at one year; combined number of people who die or are lost to care at one year 153Kredo 2013: full decentralisation ‐ deaths at one year; combined number of people who die or are lost to care at one year 154Kredo 2013: partial decentralisation ‐ number of people lost to care at one year 155Kredo 2013: full decentralisation ‐ number of people lost to care at one year 156Kredo 2013: decentralisation of HIV treatment from facility to community ‐ number of people lost to care at one year 157Kredo 2013: partial decentralisation ‐ costs of travel for patients 158Kredo 2013: decentralisation of HIV treatment from facility to community ‐ total costs to people living with HIV and AIDS and to the health service 159Yassi 2013: workplace programmes offering free antiretroviral therapy ‐ markers of effective antiretroviral therapy among workers living with HIV and IADS in sectors other than health 160Yassi 2013: workplace programmes for health workers ‐ uptake of HIV testing 161Yassi 2013: onsite compared with offsite rapid HIV testing ‐ uptake of voluntary counselling and testing among workers in sectors other than health 162Yassi 2013: workplace programmes for health workers ‐ awareness of post‐exposure prophylaxis to prevent HIV infection 163De Jongh 2012: people living with diabetes ‐ glycaemic control 164De Jongh 2012: people living with diabetes ‐ diabetes complications 165De Jongh 2012: people living with asthma or hypertension ‐ control of these conditions 166De Jongh 2012: people living with diabetes ‐ adherence to diabetes medication in young people 167De Jongh 2012: people living with asthma ‐ care plan adherence 168De Jongh 2012: people living with hypertension ‐ medication adherence 169De Jongh 2012: people living with diabetes and asthma ‐ health service utilisation 170De Jongh 2012: people's self‐efficacy in relation to their diabetes 171De Jongh 2012: people's knowledge about their diabetes 172Gurol‐Urganci 2013: mobile phone text message reminders compared with no reminders ‐ attendance at healthcare appointments 173Gurol‐Urganci 2013: mobile phone text message reminders plus postal reminders compared to postal reminders alone ‐ attendance at healthcare appointments 174Gurol‐Urganci 2013: mobile phone text message reminders compared to phone call reminders ‐ attendance at healthcare appointments 175Gurol‐Urganci 2013: mobile phone text message reminders compared to phone call reminders ‐ cost per message 176Mbuagbaw 2013: mortality up to 12 months 177Mbuagbaw 2013: adherence to antiretroviral therapy at 12 months 178Mbuagbaw 2013: loss to follow‐up at 12 months 179Brown 2007: miscarriages, stillbirths and neonatal deaths 180Brown 2007: breastfeeding initiation 181Brown 2007: epidural anaesthesia 182Brown 2007: increase in assisted deliveries 183Brown 2007: smoking cessation 184Brown 2007: availability of complete antenatal records at the time of delivery; loss of case notes 185Brown 2007: women who carry their own clinical case notes probably feel more in control and involved in decision making about their care and probably want to do so again in subsequent pregnancies 186Brown 2007: women's satisfaction with antenatal care 187Oyo‐Ita 2016: community‐based health education ‐ coverage of three doses of Diphtheria‐Tetanus‐Pertussis vaccine (DTP3) 188Oyo‐Ita 2016: facility‐based health education ‐ coverage of three doses of Diphtheria‐Tetanus‐Pertussis vaccine (DTP3) 189Oyo‐Ita 2016: health education combined with reminders ‐ DTP3 coverage 190Oyo‐Ita 2016: training vaccination managers ‐ coverage of DTP3, oral polio vaccine, hepatitis B vaccine 191Oyo‐Ita 2016: integrating vaccination with other healthcare services ‐ DTP3 coverage; measles vaccine coverage 192Oyo‐Ita 2016: integrating vaccination with other healthcare services ‐ BCG coverage 193Oyo‐Ita 2016: household monetary incentives ‐ full vaccination coverage 194Oyo‐Ita 2016: home visits ‐ oral polio vaccine coverage; measles coverage 195Oyo‐Ita 2016: reminders and recall strategies ‐ routine childhood vaccination uptake 196Christensen 2016: all cause mortality 197Christensen 2016: hospital readmissions 198Christensen 2016: hospital emergency department contacts 199Davey 2013: interventions intended to increase effective antibiotic prescribing for pneumonia ‐ mortality 200Davey 2013: interventions intended to decrease unnecessary antibiotic prescribing ‐ mortality. 201Davey 2013: interventions intended to decrease unnecessary antibiotic prescribing ‐ the length of stay; readmissions 202Davey 2013: restrictive interventions compared with persuasive interventions ‐ antibiotic prescribing at one month 203Davey 2013: restrictive interventions compared with persuasive interventions ‐ antibiotic prescribing at longer follow‐up 204Pasricha 2012: health outcomes 205Pasricha 2012: healthcare utilisation 206Pasricha 2012: adherence to treatment by patients 207Pasricha 2012: adherence to recommended practice by health professionals 208Pasricha 2012: health outcomes 209Pasricha 2012: health care utilisation 210Pasricha 2012: adherence to treatment by patients 211Pasricha 2012: adherence to recommended practice by health professionals 212Pasricha 2012: at‐risk behaviours 213Pasricha 2012: suppressed HIV load 214Pasricha 2012: adherence to treatment by patients 215Pasricha 2012: healthcare utilisation 216Pasricha 2012: adherence to recommended practice by health professionals 217Bosch‐Capblanch 2011: enhanced managerial supervision ‐ proportion of children receiving adequate care 218Bosch‐Capblanch 2011: managerial supervision ‐ provider practices 219Bosch‐Capblanch 2011: enhanced managerial supervision ‐ performance of lay health workers; performance of midwives 220Bosch‐Capblanch 2011: less intensive managerial supervision ‐ number of new family planning visits; number of clients that re‐visit 221Bosch‐Capblanch 2011: enhanced managerial supervision ‐ health worker satisfaction 222Bosch‐Capblanch 2011: managerial supervision ‐ provider knowledge 223Bosch‐Capblanch 2011: managerial supervision ‐ medicine stock management 224Bosch‐Capblanch 2011: enhanced managerial supervision ‐ patient satisfaction 225Hussein 2012: organisational interventions to improve emergency obstetric referral ‐ maternal mortality 226Hussein 2012: organisational interventions to improve emergency obstetric referral ‐ stillbirths 227Hussein 2012: organisational interventions to improve emergency obstetric referral ‐ neonatal mortality 228Hussein 2012: structural interventions to improve emergency obstetric referral ‐ maternal mortality; stillbirths 229Hussein 2012: structural interventions to improve emergency obstetric referral ‐ neonatal mortality | |||||||||
| Delivery arrangement | Systematic review | Applicability limitations | |
| Findings | Interpretation | ||
| Who receives care and when | |||
| Queuing strategies | All included studies took place in high‐income countries. | The effect of the interventions included in the review would likely depend on several factors, including:
| |
| Care received by groups vs individual care | 3 out of 4 studies included in the systematic review took place in a high‐income country (USA, Sweden). | Local availability of resources and maternal/care providers acceptability should be considered before applying the intervention. | |
| Who provides care | |||
| Pre‐licensure education | All included studies took place in high‐income countries. | The challenges faced in healthcare worker education in high‐ and low‐income countries are qualitatively and quantitatively different (e.g. the availability of funds, laws regarding equity and awareness of these, job prospects including remuneration, and curricula). Appropriate interventions could be expected to have a comparatively higher impact in low‐income countries where alternatives and opportunities are generally more limited than in high‐income countries. However, there is no evidence regarding the effects of such interventions. | |
| Recruitment and retention strategies | No randomised trial was identified. The observational or questionnaire‐based studies discussed in the reviews were carried out in various settings, including high‐, middle‐ and low‐income countries. The results suggest that some interventions could have positive effects on the recruitment and retention of health workers in under‐served areas. However, these findings require further rigorous evaluation. | Economic and cultural differences, differences between health system structures, and differences in state and educational institutional capacity to regulate and manage various types of interventions may limit the applicability of findings to low‐ and middle‐income countries. | |
| Role expansion or task shifting ‐ Physician‐nurse substitution | Most of the studies took place in high‐income countries. | The applicability of the findings may be affected by cultural and economic differences, patient populations, services provided in primary care settings, and the availability and level of nurses' skills. | |
| Role expansion or task shifting ‐ Midlevel health professionals: midwife‐led care in pregnancy | All trials included in the review took place in high‐income countries. However, midwives are the primary providers of antenatal and postpartum care in most low‐ and middle‐income countries. | When assessing the transferability of these findings, the following factors should be considered: the availability and training of midwives; accessibility to each healthcare model for childbearing women; cost implications of other models of care compared to midwife‐led care and local epidemiology of maternal and perinatal mortality. | |
| Role expansion or task shifting ‐ Specialist nursing post added to hospital nurse staffing ‐ Dietary assistants added to hospital nurse staffing | The trials included in the review took place in high‐income countries. | When assessing the transferability of these findings to low‐income countries the following factors should be considered: the availability and training of nurses; the acceptability, feasibility and costs of different nurse staffing models. In particular, nurse and other health professional associations may need to be consulted and the ability of the health system and hospitals to support the implementation of new nurse staffing models. | |
| Coordination of care | |||
| Care pathways ‐ Rapid response systems in hospitals | Almost all the studies took place in high‐income countries and were before‐after studies with no contemporaneous control group | The organisational culture, the resources needed for applying the process should be considered when implementing interventions in middle‐ or low‐income settings. | |
| Care pathways ‐ Clinical pathways | Almost all the studies took place in high‐income countries. | There are many ways in which healthcare teams in high‐income and low‐ or middle‐ income countries may differ. The organisational culture, the commitment to quality and safety, the resources needed for documenting the process (e.g. electronic health records), are among the issues that need to be considered, particularly when implementing interventions in middle‐ or low‐income settings. | |
| Communication between providers ‐ Interactive communication between primary care doctors and specialists | The studies included in the review took place in high‐income countries. | When assessing the transferability of these findings to low‐income country settings, one needs to consider the organisation of the health system as well as the availability and accessibility of specialist care in such settings. | |
| Coordination of care to reduce rehospitalisation ‐Pre‐/postdischarge interventions vs usual care ‐Transition interventions vs usual care | All studies took place in high‐income countries. | The applicability of the available evidence to low income countries is uncertain because the effects of interventions might depend on the capacity and type of health professionals available in the hospital to apply the interventions, the availability of community care, and the skills of the patient/family to accomplish instructions. Some of the interventions rely on a high level of communication between the hospital and the providers of services outside the hospital. This is not always available or possible in low‐income settings. | |
| Discharge planning | Almost all the studies took place in high‐income countries | The applicability of the available evidence to low‐income countries is uncertain because the effects of discharge planning might depend on the availability of community care. It may also depend on the capacity and type of health professionals available in the hospital (for example, doctors, nurses or lay health workers) to prepare and implement discharge plans based on individual patient needs. A high level of communication between the discharge planner and the providers of services outside the hospital is not always available in low‐income settings. | |
| Referral systems ‐Healthcare delivery of organisational interventions for referral from primary to secondary care | Most of the included studies took place in high‐income countries and within particular health systems. These systems included, for example, the publicly funded National Health System in the UK, and Medicaid in the USA. | The studies were based in well‐resourced environments in which primary care services were provided by an adequate number of practitioners, and relatively easy access was available to specialist services. Such scenarios are not necessarily available or possible in many low‐income countries. The study findings therefore need to be interpreted with caution when applied to low‐income countries. | |
| Teams ‐ Team midwifery vs standard care | The same considerations described in Butler 2011 ‐ role expansion or task shifting | ||
| Teams ‐ Dental care by dental therapists | Most studies evaluated schoolchildren from urban or rural areas of high‐income countries. | The provision of oral health care requires a complicated infrastructure besides workforce such as appropriate supervision, dental offices and a financing system. Therefore, the findings may not be directly applicable to low‐income countries. | |
| Teams ‐ Practice based interventions to promote collaboration | All the studies took place in high‐income countries. | Healthcare teams are a multidimensional construct, and team structures and processes can vary widely according to membership, scope of work, tasks, and interactions. Some interventions, such as video and audio conferencing that have been used by some teams, may not be available in some settings. Carefully designed and rigorously conducted randomised studies of healthcare teams, measuring Patient/client or healthcare process outcomes are needed before being implemented on a large scale in low income countries. | |
| Where care is provided | |||
| Site of service delivery ‐ Units dedicated to care for people living with HIV/AIDS ‐ Institutions managing a high volume of people living with HIV/AIDS | All the studies took place in high income countries. None of the studies in this review took place in resource‐poor settings. | It may be difficult for policymakers to replicate the study settings and/or organisation of care in low‐income countries. | |
| Quality and safety systems | |||
| Quality monitoring and improvement systems ‐ Medication review for hospitalised adult patients vs standard care | None of the trials took place in a low‐ or middle‐income country. | In addition to considering the uncertainty about the benefits of medication review found in these trials, in low‐income countries the availability of resources, including pharmacists with appropriate training, and the cost of the intervention (including training) should be considered. | |
| 1Priorities for primary research based on applicability limitations to low‐income countries of delivery arrangement interventions identified by the included reviews. We did not search for additional primary studies. | |||
