Zarządzenie systemami opieki zdrowotnej w krajach o niskich dochodach: przegląd przeglądów systematycznych
Abstract
Background
Governance arrangements include changes in rules or processes that determine authority and accountability for health policies, organisations, commercial products and health professionals, as well as the involvement of stakeholders in decision‐making. Changes in governance arrangements can affect health and related goals in numerous ways, generally through changes in authority, accountability, openness, participation and coherence. A broad overview of the findings of systematic reviews can help policymakers, their technical support staff and other stakeholders to identify strategies for addressing problems and improving the governance of their health systems.
Objectives
To provide an overview of the available evidence from up‐to‐date systematic reviews about the effects of governance arrangements for health systems in low‐income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on governance arrangements and informing refinements of the framework for governance arrangements outlined in the overview.
Methods
We searched Health Systems Evidence in November 2010 and PDQ Evidence up to 17 December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well‐conducted systematic reviews of studies that assessed the effects of governance arrangements on patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use (health expenditures, healthcare provider costs, out‐of‐pocket payments, cost‐effectiveness), healthcare provider outcomes (such as sick leave), or social outcomes (such as poverty, employment) and that were published after April 2005. We excluded reviews with limitations that were important enough to compromise the reliability of the findings of the review. Two overview authors independently screened reviews, extracted data and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence) and assessments of the relevance of findings to low‐income countries.
Main results
We identified 7272 systematic reviews and included 21 of them in this overview (19 primary reviews and 2 supplementary reviews). We focus here on the results of the 19 primary reviews, one of which had important methodological limitations. The other 18 were reliable (with only minor limitations).
We grouped the governance arrangements addressed in the reviews into five categories: authority and accountability for health policies (three reviews); authority and accountability for organisations (two reviews); authority and accountability for commercial products (three reviews); authority and accountability for health professionals (seven reviews); and stakeholder involvement (four reviews).
Overall, we found desirable effects for the following interventions on at least one outcome, with moderate‐ or high‐certainty evidence and no moderate‐ or high‐certainty evidence of undesirable effects.
Decision‐making about what is covered by health insurance
‐ Placing restrictions on the medicines reimbursed by health insurance systems probably decreases the use of and spending on these medicines (moderate‐certainty evidence).
Stakeholder participation in policy and organisational decisions
‐ Participatory learning and action groups for women probably improve newborn survival (moderate‐certainty evidence).
‐ Consumer involvement in preparing patient information probably improves the quality of the information and patient knowledge (moderate‐certainty evidence).
Disclosing performance information to patients and the public
‐ Disclosing performance data on hospital quality to the public probably encourages hospitals to implement quality improvement activities (moderate‐certainty evidence).
‐ Disclosing performance data on individual healthcare providers to the public probably leads people to select providers that have better quality ratings (moderate‐certainty evidence).
Authors' conclusions
Investigators have evaluated a wide range of governance arrangements that are relevant for low‐income countries using sound systematic review methods. These strategies have been targeted at different levels in health systems, and studies have assessed a range of outcomes. Moderate‐certainty evidence shows desirable effects (with no undesirable effects) for some interventions. However, there are important gaps in the availability of systematic reviews and primary studies for the all of the main categories of governance arrangements.
Streszczenie prostym językiem
Efekty zarządzania systemami opieki zdrowotnej w krajach o niskich dochodach
Jaki jest cel tego przeglądu?
Celem niniejszego przeglądu Cochrane jest zapewnienie pełnego podsumowania informacji na temat skutków wdrażania różnych strategii zarządzania systemami opieki zdrowotnej w krajach o niskich dochodach.
Do przeglądu włączono 19 istotnych przeglądów systematycznych. W przeglądach tych oceniano różne strategie zarządzania systemami opieki zdrowotnej. Łącznie włączono do nich 172 badania.
Niniejszy przegląd jest jednym z czterech przeglądów tego typu (Cochrane Overview), którego celem była ocena organizacji systemów opieki zdrowotnej.
Główne wyniki
Jakie są efekty stosowania różnych strategii organizacji zarządzania i odpowiedzialności za politykę zdrowotną?
Do analizy włączono trzy przeglądy, na podstawie których wyciągnięto następujące wnioski:
‐ współpraca między placówkami służby zdrowia na poziomie lokalnym i innymi organami samorządu terytorialnego może prowadzić do niewielkiej lub żadnej różnicy w zakresie poprawy zdrowia fizycznego oraz jakości życia pacjentów (dane naukowe o niskiej pewności co do ich wiarygodności);
‐ wprowadzanie maksymalnej kwoty refundacji leków przez systemy ubezpieczeń zdrowotnych prawdopodobnie wpływa na zmniejszenie spożycia leków oraz związanych z tym wydatków (dane naukowe o umiarkowanej pewności co do ich wiarygodności).
‐ nie ma pewności czy działania, których celem jest zapobieganie, wykrywanie i reagowanie na oszustwa w opiece zdrowotnej są skuteczne w ograniczeniu nadużyć i związanych z nimi wydatków (dane naukowe o bardzo niskiej pewności co do ich wiarygodności).
Jakie są efekty stosowania różnych strategii organizacji zarządzania i odpowiedzialności w organizacjach zajmujących się opieką zdrowotną?
Do analizy włączono dwa przeglądy, na podstawie których wyciągnięto następujące wnioski:
‐ Zawieranie umów na świadczenie usług zdrowotnych z niepublicznymi dostawcami opieki zdrowotnej lub organizacjami typu non‐profit może poprawić dostęp do świadczeń i wyniki zdrowotne pacjentów oraz obniżyć wydatki gospodarstwa domowego na zdrowie (dane naukowe o niskiej pewności co do ich wiarygodności). Nie odnaleziono danych naukowych, które pozwoliłyby ocenić, czy zlecanie świadczeń zewnętrznym dostawcom było bardziej skuteczne niż wykorzystanie tych samych środków w sektorze państwowym.
Jakie są efekty stosowania różnych strategii organizacji zarządzania i odpowiedzialności w przypadku produktów komercyjnych, takich jak leki i wyroby medyczne?
Do analizy włączono trzy przeglądy, na podstawie których wyciągnięto następujące wnioski:
‐ systemy opieki zdrowotnej, w których Światowa Organizacja Zdrowia (WHO) zatwierdza rejestrację (wstępna kwalifikacja) producentów oraz leków (tj. w których organy regulacyjne prowadzą kontrolę producentów leków w celu zapewnienia spełnienia międzynarodowych standardów) mogą wpływać na zmniejszenie odsetka leków, które nie spełniają norm lub są podrabiane (dane naukowe o niskiej pewności co do ich wiarygodności);
‐ ustanowienie maksymalnej kwoty refundacji dla leków dostępnych w aptece w ramach ubezpieczenia zdrowotnego, może wpłynąć na zwiększenie zużycia leków generycznych oraz zmniejszenie zużycia leków oryginalnych (dane naukowe o niskiej pewności co do ich wiarygodności); odnalezione dowody nie pozwalają ocenić czy podejście to wpływa na całkowitą kwotę wydatków na leki (dane naukowe o bardzo niskiej pewności co do ich wiarygodności);
‐ reklama bezpośrednia, skierowana do pacjentów wpływa na zwiększenie liczby próśb pacjentów o przepisanie leku oraz zwiększenie liczby wydawanych recept (dane naukowe o dużej pewności co do ich wiarygodności).
Jakie są efekty stosowania różnych strategii organizacji zarządzania i odpowiedzialności wśród podmiotów świadczących opiekę zdrowotną?
Do analizy włączono siedem przeglądów, na podstawie których wyciągnięto następujące wnioski:
‐ szkolenia dla managerów opieki zdrowotnej mogą poszerzyć ich wiedzę dotyczącą planowania procesów oraz rozwinąć umiejętności z zakresu ich monitorowania i ewaluacji (dane naukowe o niskiej pewności co do ich wiarygodności);
‐ zmniejszenie ograniczeń imigracyjnych w krajach o wysokich dochodach prawdopodobnie zwiększa do nich migrację pielęgniarek z krajów o niskich i średnich dochodach (dane naukowe o umiarkowanej pewności co do ich wiarygodności);
‐ nie ma pewności czy kontrola prowadzona przez instytucje zewnętrzne, oceniająca przestrzeganie standardów jakości, poprawia stosowanie się do zaleceń (standardów), jakość świadczenia opieki zdrowotnej oraz wskaźniki zakażeń szpitalnych (dane naukowe o bardzo niskiej pewności co do ich wiarygodności).
Jakie są efekty stosowania różnych strategii organizacji zaangażowania uczestników systemu w zarządzanie opieką zdrowotną?
Do analizy włączono cztery przeglądy, na podstawie których wyciągnięto następujące wnioski:
‐ szkolenia bezpośrednie oraz grupy działania dla kobiet prawdopodobnie wpływają na poprawę przeżycia noworodków (dane naukowe o umiarkowanej pewności co do ich wiarygodności) i mogą wydłużać przeżycie wśród matek (dane naukowe o niskiej pewności co do ich wiarygodności);
‐ upublicznianie danych dotyczących jakości systemów ubezpieczenia zdrowotnego może prowadzić do wybierania przez pacjentów ubezpieczeń zdrowotnych posiadających wyższe oceny jakości oraz unikania ubezpieczeń charakteryzujących się gorszymi ocenami; rozwiązanie to może prowadzić do nieznacznej poprawy wyników zdrowotnych ubezpieczyciela (dane naukowe o niskiej pewności co do ich wiarygodności);
‐ upublicznianie danych dotyczących jakości opieki szpitalnej może w niewielkim lub żadnym stopniu wpływać na wybór szpitala przez pacjentów (dane naukowe o niskiej pewności co do ich wiarygodności); strategia ta prawdopodobnie zachęca szpitale do wdrażania działań mających na celu poprawę jakości świadczonych usług (dane naukowe o umiarkowanej pewności co do ich wiarygodności) i może prowadzić do nieznacznej poprawy wyników zdrowotnych w danym szpitalu (dane naukowe o niskiej pewności co do ich wiarygodności);
‐ upublicznianie danych dotyczących wydajności poszczególnych świadczeniodawców prawdopodobnie wpływa na wybór przez pacjenta świadczeniodawcy o wyższej ocenie jakości usług medycznych (dane naukowe o umiarkowanej pewności co do ich wiarygodności).
Nie odnaleziono badań, w których oceniano skutki udziału uczestników systemu opieki zdrowotnej w podejmowaniu decyzji dotyczących polityki zdrowotnej i organizacji służby zdrowia.
Jak aktualny jest ten przegląd ?
Autorzy przeglądu przeszukali przeglądy systematyczne opublikowane do 17 grudnia 2016 r.
Authors' conclusions
Background
This is one of four overviews of systematic reviews of strategies for improving health systems in low‐income countries (Ciapponi 2014; Pantoja 2014; Wiysonge 2014). The aim is to provide broad overviews of the evidence about the effects of delivery, financial and governance arrangements, and implementation strategies. This overview addresses governance arrangements.
We summarise the scope of each of the four overviews below.
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Delivery arrangements include changes in who receives care and when, who provides care, the working conditions of those who provide care, coordination of care amongst different providers, where care is provided, the use of information and communication technology to deliver care, and quality and safety systems (Ciapponi 2014).
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Financial arrangements include changes in how funds are collected, insurance schemes, how services are purchased, and the use of targeted financial incentives or disincentives (Wiysonge 2014).
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Governance arrangements include changes in rules or processes that determine authority and accountability for health policies, organisations, commercial products and health professionals, and the involvement of stakeholders in decision‐making.
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Implementation strategies include interventions designed to bring about changes in healthcare organisations, the behaviour of healthcare professionals or the use of health services by healthcare recipients (Pantoja 2014).
The term 'governance' has been defined in several ways, as illustrated in Table 1. Although these definitions overlap, they may create confusion. We have defined governance here as rules or processes that affect the way in which powers are exercised, particularly with regard to authority, accountability, openness, participation, and coherence. Governance includes processes and institutions through which individuals and groups "articulate their interests, mediate their differences and exercise their legal rights and obligations" (Siddiqi 2009). Our focus accordingly is on the effects of governance arrangements to achieve health and related goals, such as efficiency, equity, human rights, responsiveness and fairness (Murray 2000). Attributes such as accountability, openness and participation can also be goals in and of themselves. For example, the World Health Organization (WHO)'s Declaration of Alma‐Ata states that "The people have a right and duty to participate individually and collectively in the planning and implementation of their health care" (WHO 1978). Governance arrangements can potentially affect patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use, healthcare provider outcomes (such as sick leave) and social outcomes (such as poverty or employment) (EPOC 2017). Impacts on these outcomes can be intended and desirable, or unintended and undesirable. In addition, the effects of delivery arrangements on these outcomes can either reduce or increase inequities. Health systems in low‐income countries differ from those in high‐income countries in terms of the availability of resources and access to services. Thus, some problems in high‐income countries are not relevant to low‐income countries, such as governance arrangements that rely on expensive technologies that are not available in low‐income countries. Similarly, some problems in low‐income countries are not relevant to high‐income countries, such as policies that regulate emigration of health workers. Our focus in this overview is specifically on governance arrangements in low‐income countries, by which we mean countries that the World Bank classifies as low‐ or lower‐middle‐income (World Bank Group 2016). Because upper‐middle‐income countries often have a mixture of health systems with problems similar to both those in low‐income countries and high‐income countries, our focus is relevant to middle‐income countries but excludes consideration of conditions that are not relevant in low‐income countries and are relevant in middle‐income countries.
| Governance: definitions |
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| Stewardhip: definitions and features distinguishing it from governance |
| Stewardship is similar to the concept of public governance but, as envisaged by the WHO, is more specifically focused on the state's role in taking responsibility for the health and well‐being of the population, and guiding the health system as a whole (Travis 2003). Stewardship has been described as one of the four basic functions of health system organisations (Murray 2000). The other three functions in this model are financing, provision, and resource generation. Definitions of stewardship include the following.
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Description of the interventions
It is possible to categorise alternative governance arrangements in a number of ways. For example, Health Systems Evidence (Lavis 2015) uses the following categories: policy authority, organisational authority, commercial authority, professional authority, and consumer and stakeholder involvement. Frenk 2013 and Murray 2000, as noted in Table 1, have described six sub‐functions of stewardship (a particular type of governance): overall system design, performance assessment, priority setting, intersectoral advocacy, regulation and consumer protection. Furthermore, WHO has identified three basic tasks of stewardship (WHO 2000): formulating health policy (defining the vision and direction), exerting influence (approaches to regulation), and collecting and using intelligence. The types of interventions that we include in this overview are listed in Table 2 using a structure derived from the taxonomy developed by Lavis 2015. We used this framework as our starting point because it is not limited to stewardship, and it is comprehensive and detailed. We adapted the framework in order to clarify the classification of interventions where this was ambiguous.
| Governance arrangement | Definition |
| Authority and accountability for health policies | |
| Interagency collaboration | Collaboration and partnerships for health and social development between the health sector and other different sectors |
| Centralisation and decentralisation | Policies to regulate the degree of which managerial responsibilities are transferred to regional or local authorities in contrast to having them at the central level |
| District management | Policies that regulate the management of district health systems |
| Decision‐making about what or who is covered by health insurance | Processes for deciding what is reimbursed and who is covered by health insurance |
| Policies to reduce corruption | Policies for reducing corruption in the health sector |
| Policies to manage absenteeism | Regulations for managing absenteeism of health professionals |
| Requirements for monitoring or evaluation | Policies that regulate programme monitoring and evaluation |
| Authority and accountability for organisations | |
| Ownership | Policies that regulate who can own health service organisations |
| Stewardship of private health services | Policies that regulate health services provided by the private sector |
| Insurance | Policies that regulate the provision of insurance (e.g. who can provide insurance, mandatory open enrolment, coverage of essential drugs) |
| Accreditation | Processes for accrediting healthcare providers |
| Multi‐institutional arrangements | Policies for how multiple organisations work together |
| Authority and accountability for commercial products | |
| Registration | Procedures for registering or licensing commercial products (e.g. drugs) |
| Patents and profits | Policies that regulate patents and profits |
| Pricing and purchasing policies | Policies that determine the price that is paid or how commercial products are purchased |
| Marketing regulations | Policies that regulate marketing of commercial products |
| Sales and dispensing | Policies that regulate the sale and dispensing of drugs or other healthcare products |
| Liability for commercial products | Policies that regulate liability for commercial products |
| Authority and accountability for health professionals | |
| Training and licensing | Policies that regulate training and licensure requirements for health professionals |
| Scope of practice | Policies that regulate what health professionals can do |
| Recruitment and retention strategies | Policies that regulate where health professionals work (e.g. restrictions on where they can work or requirements to work in rural areas) |
| Emigration and immigration policies | Policies that regulate emigration and immigration of health professionals |
| Dual practice | Policies that regulate dual practice, in which health workers hold two or more jobs, for example in both the public or private sectors |
| Quality of practice | Policies or systems for assuring quality of care |
| Professional competence | Policies or procedures for assuring professional competence |
| Policies to manage absenteeism | Policies for managing absenteeism of health professionals |
| Professional liability | Policies that regulate liability for health professionals |
| Stakeholder involvement | |
| Stakeholder participation in policy and organisational decisions | Policies and procedures for involving stakeholders in decision‐making |
| Community mobilisation | Processes that enable people to organise themselves |
| Community monitoring | Monitoring of health services by individuals or community organisations |
| Patient information | Policies that regulate what information is provided to patients |
| Patients' rights | Policies that regulate patients' rights, including access to care and information |
How the intervention might work
Changes in governance arrangements can affect health and related goals in multiple ways. Generally, this is likely to occur through changes in authority, accountability, openness, participation, and coherence (promotion of mutually reinforcing policy actions). Table 3 presents examples of how changes in different types of governance arrangements might lead to better healthcare outcomes.
| Governance arrangement | Definition |
| Authority and accountability for health policies | |
| Interagency collaboration | Policies to facilitate interagency collaboration, for instance, between local government and local health authorities in order to address social determinants of health, can contribute to improve health of the population. |
| Decentralisation and centralisation | Shifting authority closer to those who are affected might improve accountability, openness and participation, which might in turn lead to more appropriate priorities, more efficiency and less corruption, and in turn better health outcomes. |
| District management | Regulations that lead to improvements in the management of district health systems can improve access to and the quality of care, and in turn better health outcomes. |
| Decision‐making about what or who is covered by health insurance | Changes in processes used to decide what is reimbursed or who is covered by health insurance might improve access to cost‐effective interventions, and in turn lead to better health outcomes. |
| Policies to reduce corruption | Regulations that reduce corruption can increase the availability of resources for care, and in turn improve health outcomes. |
| Requirements for monitoring or evaluation | Policies that improve decisions about when and how healthcare programmes are monitored or evaluated can lead to better‐informed decisions, and in turn better health outcomes. |
| Authority and accountability for organisations | |
| Ownership | For‐profit health services might limit access for people who cannot afford to pay or divert funds from care to profits and taxes, which might result in poorer quality care and worse health outcomes. |
| Stewardship of private health services | Regulations that increase the accountability of the private sector might improve the quality of care, and in turn lead to better health outcomes. |
| Insurance | Changes in regulations that determine who can provide insurance, who receives it, who pays for it, and who makes decisions about reimbursement might affect coverage and access to care, and in turn health outcomes. |
| Accreditation | Changes in provider accreditation might improve the quality of care, and in turn health outcomes. |
| Multi‐institutional arrangements | Changes in how donors and governments work together might result in more effective and efficient use of resources, and in turn lead to better health outcomes. |
| Authority and accountability for commercial products | |
| Registration | Changes in how drugs or other health technologies are licensed might improve safety, and in turn health outcomes, |
| Patents and profits | Changes in patent regulations might affect the development and availability of drugs or other health technologies, and in turn health outcomes. |
| Pricing and purchasing policies | Regulations that reduce the price that is paid or how drugs or services are purchased might improve access to care, and in turn health outcomes. |
| Marketing regulations | Regulations that limit inappropriate marketing of drugs, other technologies or services might reduce inappropriate use and increase the availability of resources for cost‐effective care, and in turn improve health outcomes. |
| Sales and dispensing | Changes in who can sell drugs or other healthcare products might improve access or improve quality, and in turn health outcomes. |
| Liability for commercial products | Changes in liability for drugs, other technologies or services might improve safety, and in turn health outcomes. |
| Authority and accountability for health professionals | |
| Training and licensing | Regulations that improve training or licensure of health professionals might improve the safety and quality of care, and in turn health outcomes. |
| Scope of practice | Regulations that determine what health professionals can do might improve access to care or safety, and in turn health outcomes. |
| Recruitment and retention strategies | Regulations that determine where health professionals can work might improve access to care, and in turn health outcomes. |
| Emigration and immigration policies | Regulations that determine emigration or immigration of health professionals might improve access to care, and in turn health outcomes. |
| Dual practice | Regulations that affect the extent of dual practice might improve access to care, and in turn health outcomes. |
| Quality of practice | Policies or systems for assuring quality of care might improve the quality of care, and in turn health outcomes. |
| Professional competence | Policies or procedures for assuring professional competence might improve the safety and quality of care, and in turn health outcomes. |
| Policies to manage absenteeism | Regulations that reduce absenteeism can improve access to care, and in turn health outcomes. |
| Professional liability | Changes in liability for health professionals might improve safety or remove impediments to evidence‐based care, and in turn improve health outcomes. |
| Stakeholder involvement | |
| Stakeholder participation in policy and organisational decisions | Involving stakeholders in decision‐making might improve the overall decision‐making about how to use resources and organise care, and in turn lead to better health outcomes. |
| Community mobilisation | Processes that enable people to organise themselves might raise awareness, change behaviours and lead to improvements in access and utilisation of health services, and in turn improve health outcomes. |
| Community monitoring | Monitoring of health services by individuals or community organisations might help to ensure quality, improve access to care, and reduce corruption, and in turn improve health outcomes. |
| Patient information | Regulations that improve the extent to which patients are well‐informed might lead to better informed decisions, and in turn improve health outcomes. |
| Patients' rights | Policies that regulate patients' rights, such as access to care and information, might improve access and utilisation of health services and improve the quality of health services, and in turn improve health outcomes. |
Why it is important to do this overview
Our objective is to provide a broad overview of current evidence from systematic reviews evaluating the effects of alternative governance arrangements for health systems in low‐income countries. We recognise that there is a paucity of research that has evaluated the effects of governance arrangements (Bennington 2010; Frenk 2013). Nonetheless, a broad overview of the findings of systematic reviews can help policymakers, their technical support staff and other stakeholders to identify strategies for addressing problems with the governance of their health systems. It can also help to identify needs and priorities for evaluations of governance arrangements, as well as priorities for systematic reviews of the effects of governance arrangements. The overview also helps to refine the framework outlined in Table 2 for considering alternative health system arrangements for allocating authority and ensuring accountability, openness, participation and coherence.
Our focus is specifically on low‐income countries in this overview because there are structural differences in health systems and country contexts compared to middle‐ and high‐income countries. These differences make it difficult to select, analyse and summarise the evidence for low‐, middle‐ and high‐income countries in a single overview. By focusing on low‐income countries, we were able to exclude reviews that are not relevant to those countries and to consistently address the relevance of the evidence in included reviews for those countries. This makes the overview more helpful for people making decisions about governance arrangements in low‐income countries.
Changes in health systems are complex. They may be difficult to evaluate, the applicability of the findings of evaluations from one setting to another may be uncertain, and synthesising the findings of evaluations may be difficult. However, the alternative to well‐designed evaluations is poorly designed evaluations; the alternative to systematic reviews is non‐systematic reviews; and the alternative to using the findings of systematic reviews to inform decisions is making decisions without the support of this rigorous evidence. Policymakers still need other types of information, including context specific information and judgments (e.g. judgments about the applicability of the findings of systematic reviews in a specific context) when making decisions about governance arrangements.
This overview can help people making decisions about governance arrangements by summarising the findings of available systematic reviews, including estimates of the effects of changes in governance arrangements and the certainty of those estimates, by identifying important uncertainties identified by those systematic reviews and by identifying where new or updated systematic reviews are needed. The overview can also help to inform judgments about the relevance of the available evidence in a specific context (Rosenbaum 2011).
Objectives
To provide an overview of the available evidence from up‐to‐date systematic reviews about the effects of governance arrangements for health systems in low‐income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on governance arrangements and informing refinements of the framework for governance arrangements outlined in the overview (Table 2).
Methods
We used the methods described below in all four overviews of health system arrangements and implementation strategies in low‐income countries (Ciapponi 2014; Pantoja 2014; Wiysonge 2014).
Criteria for considering reviews for inclusion
We included systematic reviews that:
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assessed the effects of governance arrangements (as defined in the Background);
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had a Methods section with explicit selection criteria;
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reported at least one of the following types of outcomes: patient outcomes (health and health behaviors), the quality or utilisation of healthcare services, resource use (health expenditures, healthcare provider costs, out‐of‐pocket payments, cost‐effectiveness), healthcare provider outcomes (such as sick leave, burnout), or social outcomes (such as poverty, employment);
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were relevant to low‐income countries as classified by the World Bank (World Bank Group 2016);
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were published after April 2005.
Judgments about relevance to low‐income countries are sometimes difficult to make, and we are aware that evidence from high‐income countries is not directly generalisable to low‐income countries. We based our judgments on an assessment of the likelihood that the governance arrangements considered in a review address a problem that is important in low‐income countries, would be feasible, and would be of interest to decision‐makers in low‐income countries, regardless of where the included studies took place. So, for example, we excluded arrangements that require technology that is not widely available in low‐income countries. At least two of the overview authors made judgments about the relevance to low‐income countries and discussed with the other authors whenever there was uncertainty. Reviews that only included studies from a single high‐income country were not eligible due to concerns about the wider applicability of the findings of such reviews. However, we did consider reviews that only included studies from high‐income countries if the interventions were relevant for low‐income countries.
We excluded reviews published before April 2005 as these were highly unlikely to be up‐to‐date. We also excluded reviews that had methodological limitations that were important enough to compromise the reliability of the review findings (Appendix 1).
Search methods for identification of reviews
We searched Health Systems Evidence in November 2010 using the following filters.
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Health system topics = governance arrangements.
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Type of synthesis = systematic review or Cochrane Review.
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Type of question = effectiveness.
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Publication date range = 2000 to 2010.
We conducted subsequent searches using PDQ ('pretty darn quick')‐Evidence, which was launched in 2012. We searched PDQ up to 17 December 2016, using the filter 'Systematic Reviews' with no other restrictions. We updated that search, excluding records that were entered into PDQ‐Evidence prior to the date of the last previous search.
PDQ‐Evidence is a database of evidence for decisions about health systems, which is derived from the Epistemonikos database of systematic reviews (Rada 2013). It includes systematic reviews, overviews of reviews (including evidence‐based policy briefs) and studies included in systematic reviews. Epistemonikos and PDQ‐Evidence incorporate searches from the following databases with no language or publication status restrictions.
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Cochrane Database of Systematic Reviews (CDSR).
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PubMed.
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Embase.
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Database of Abstracts of Reviews of Effectiveness (DARE).
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Health Technology Assessment Database.
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CINAHL.
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LILACS.
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PsycINFO.
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Evidence for Policy and Practice Information and Co‐ordinating Centre (EPPI‐Centre) Evidence Library.
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3ie Systematic Reviews and Policy Briefs.
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World Health Organization (WHO) Database.
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Campbell Library.
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Supporting the Use of Research Evidence (SURE) Guides for Preparing and Using Evidence‐Based Policy Briefs.
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European Observatory on Health Systems and Policies.
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UK Department for International Development (DFID).
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National Institute for Health and Care Excellence (NICE) public health guidelines and systematic reviews.
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Guide to Community Preventive Services.
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Canadian Agency for Drugs and Technologies in Health (CADTH) Rx for Change.
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McMaster Plus KT+.
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McMaster Health Forum Evidence Briefs.
Appendix 2 presents the detailed search strategies for PubMed, LILACS, Embase, CINAHL and PsycINFO. We screened all records in the other databases. PDQ staff and volunteers update these searches weekly for Pubmed and monthly for the other databases, screening records continually, and adding new reviews to the database daily.
In addition, we screened all of the Cochrane Effective Practice and Organisation of Care (EPOC) Group reviews in Archie (i.e. Cochrane's central server for managing documents) and the reference lists of relevant policy briefs and overviews of reviews.
Data collection and analysis
Selection of reviews
Two of the overview authors (CH and SL) independently screened the titles and abstracts found in PDQ‐Evidence to identify reviews that appeared to meet the inclusion criteria. Two other authors (AO and SL) screened all of the titles and abstracts that we could not confidently include or exclude after the first screening to identify any additional eligible reviews. One of the overview authors screened the reference lists (CH).
One of the overview authors applied the selection criteria to the full text of potentially eligible reviews and assessed the reliability of reviews that met all of the other selection criteria (CH) (Appendix 1). Two other authors (AO or SL) independently checked these judgments.
Data extraction and management
We summarised each included review using the approach developed by the SUPPORT collaboration (Rosenbaum 2011). We used standardised data extraction forms to extract data on the background of the review: interventions, participants, settings and outcomes; key findings; and considerations of applicability, equity, economic considerations, and monitoring and evaluation. We assessed the certainty of the evidence for the main comparisons using the GRADE approach (Guyatt 2008; Schünemann 2011a; Schünemann 2011b; EPOC 2016).
Each completed SUPPORT Summary underwent peer‐review and was published on the SUPPORT Summaries website, where we provide details about how we prepared the summaries and how we assessed the applicability of the findings, impacts on equity, economic considerations, and the need for monitoring and evaluation. We describe the rationale for the criteria that we used for these assessments in the SUPPORT Tools for evidence‐informed health policymaking (Fretheim 2009; Lavis 2009; Oxman 2009a; Oxman 2009b). As noted there, "a local applicability assessment must be done by individuals with a very good understanding of on‐the‐ground realities and constraints, health system arrangements, and the baseline conditions in the specific setting" (Lavis 2009). In this overview we have made broad assessments of the applicability of findings from studies in high‐income countries to low‐income countries using the criteria described in the SUPPORT summaries database, with input from people with relevant experience and expertise in low‐income countries.
Assessment of methodological quality of included reviews
We assessed the reliability of systematic reviews that met our inclusion criteria using criteria developed by the SUPPORT and SURE collaborations (Appendix 2; SUPPORT 2009, SURE 2011). Based on these criteria, we categorised each review as having:
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only minor limitations;
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limitations that are important enough that it would be worthwhile to search for another systematic review and to interpret the results of this review cautiously, if no better review is available;
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limitations that are important enough to compromise the reliability of the review and prompt its exclusion from the overview.
Data synthesis
We describe the methods used to prepare a SUPPORT Summary of each review in detail on the SUPPORT Summaries website. Briefly, for each included systematic review, we prepared a table summarising what the review authors searched for and what they found (Appendix 3), we prepared 'Summary of findings' tables for each main comparison, and we assessed the relevance of the findings for low‐income countries. The SUPPORT Summaries include key messages, important background information, a summary of the findings of the review and structured assessments of the relevance of the review for low‐income countries. We subjected the SUPPORT Summaries to review by the lead author of each review, at least one content area expert, people with practical experience in low‐income settings, and a Cochrane EPOC Group editor (AO or SL). The authors of the SUPPORT Summaries responded to each comment and made appropriate revisions, and the summaries underwent copy‐editing. The editor determined whether the comments had been adequately addressed and whether the summary was ready for publication on the SUPPORT Summary website.
We organised the review by modifying the taxonomy for health systems arrangements used by Health Systems Evidence (Lavis 2015), adjusting this framework iteratively to ensure that we appropriately categorised all of the included reviews and that we included and logically organised all relevant health system governance arrangements. We prepared a table listing the included reviews as well as the types of governance arrangements for which we were not able to identify a reliable, up‐to‐date review (Table 4). We also prepared a table of excluded reviews (Table 5), describing reviews that addressed a question for which another (more up‐to‐date or reliable) review was available, reviews that were published before April 2005 (for which a SUPPORT Summary was available), reviews with results that we did not consider transferable to low‐income countries, and reviews with limitations that were important enough to compromise the reliability of the review findings.
| Governance arrangement | Included reviews |
| Authority and accountability for health policies | |
| Interagency collaboration | Collaboration between local health and local government agencies for health improvement (Hayes 2012) |
| Decentralisation and centralisation | No eligible systematic review found |
| District management | No eligible systematic review found |
| Decision‐making about what or who is covered by health insurance | |
| Policies that regulate what drugs are reimbursed | No eligible systematic review found |
| Policies that regulate what services are reimbursed | No eligible systematic review found |
| Restrictions on drug reimbursement | Pharmaceutical policies: effects of restrictions on reimbursement (Green 2010) |
| Restrictions on reimbursement for health insurance | No eligible systematic review found |
| Strategies for expanding health insurance coverage | No eligible systematic review found |
| Policies to reduce corruption | No evidence of the effect of the interventions to combat health care fraud and abuse: a systematic review of literature (Rashidian 2012) |
| Policies to manage absenteeism | No eligible systematic review found |
| Requirements for monitoring or evaluation | No eligible systematic review found |
| Authority and accountability for organisations | |
| Ownership | No eligible systematic review found |
| Stewardship of private health services | No eligible systematic review found |
| Contracting out | The impact of contracting out on health outcomes and use of health services in low and middle income countries (Lagarde 2009) |
| Accreditation | No eligible systematic review found |
| Regulation of insurance provision | |
| Provision of drug insurance | No eligible systematic review found |
| Provision of health insurance | No eligible systematic review found |
| Multi‐institutional arrangements | |
| Policies that regulate interactions between donors and governments | No eligible systematic review found |
| Social franchising | The effect of social franchising on access to and quality of health services in low‐ and middle‐income countries (Koehlmoos 2009) |
| Governance arrangements for coordinating care across multiple providers | No eligible systematic review found |
| Mergers | No eligible systematic review found |
| Authority and accountability for commercial products | |
| Registration | |
| Drugs | Interventions to combat or prevent drug counterfeiting: a systematic review (El‐Jardali 2015) |
| Health technology | No eligible systematic review found |
| Patents and profits | |
| Drugs | No eligible systematic review found |
| Health technology | No eligible systematic review found |
| Pricing and purchasing policies | |
| Drugs | Pharmaceutical policies: effects of reference pricing, other pricing, and purchasing policies (Acosta 2014) |
| Health technology and services | No eligible systematic review found |
| Marketing regulations | |
| Drugs | Benefits and harms of direct to consumer advertising: a systematic review (Gilbody 2005) |
| Health technology and services | No eligible systematic review found |
| Sales and dispensing | |
| Drugs | No eligible systematic review found |
| Health technology | No eligible systematic review found |
| Liability for commercial products | No eligible systematic review found |
| Authority and accountability for health professionals | |
| Training and licensing | |
| Pre‐licensure education | Effects of changes in the pre‐licensure education of health workers on health‐worker supply (Pariyo 2009) |
| Training district health system managers | Interventions for hiring, retaining and training district health system managers in low‐ and middle‐income countries (Rockers 2013) |
| Licensure | No eligible systematic review found |
| Specialty certification | No eligible systematic review found |
| Scope of practice | No eligible systematic review found |
| Recruitment and retention strategies | Interventions for increasing the proportion of health professionals practising in underserved communities (Grobler 2015) |
| Recruitment and retention strategies | Interventions for hiring, retaining and training district health system managers in low‐ and middle‐income countries (Rockers 2013) |
| Movement of health workers between public and private organisations | Financial interventions and movement restrictions for managing the movement of health workers between public and private organizations in low‐ and middle‐income countries (Rutebemberwa 2014) |
| Emigration and immigration policies | Interventions for controlling emigration of health professionals from low‐ and middle‐income countries (Peñaloza 2011) |
| Dual practice | Interventions to manage dual practice among health workers (Kiwanuka 2011) |
| Authority and accountability for quality of practice | |
| Authority and accountability for quality of outpatient care | External inspection versus external standards for improving healthcare organisation behaviour, healthcare professional behaviour or patient outcomes (Flodgren 2011) |
| Authority and accountability for quality assurance of hospital (inpatient) care | External inspection versus external standards for improving healthcare organisation behaviour, healthcare professional behaviour or patient outcomes (Flodgren 2011) |
| Professional competence | No eligible systematic review found |
| Professional liability | No eligible systematic review found |
| Stakeholder involvement | |
| Stakeholder participation in policy and organisational decisions | Methods of consumer involvement in developing healthcare policy and research, clinical practice guidelines and patient information material (Nilsen 2010) |
| Community mobilisation | Women's groups practicing participatory learning and action to improve maternal and newborn health in low‐resource settings: a systematic review and meta‐analysis (Prost 2013) |
| What do community‐based dengue control programmes achieve? A systematic review of published evaluations (Heintze 2007) | |
| Community monitoring | No eligible systematic review found |
| Patient information | |
| Drug information | No eligible systematic review found |
| Public disclosure of performance data | Systematic review: the evidence that publishing patient care performance data improves quality of care (Fung 2008) |
| Patients’ rights | No eligible systematic review found |
| Review ID | Excluded reviews | Reasons for exclusion |
| Financial incentives for return of service in underserved areas: a systematic review | Addressed by Grobler 2015 | |
| Quality of private and public ambulatory health care in low and middle income countries: systematic review of comparative studies | Addressed by upcoming Herrera 2013 | |
| Consumer involvement in health research: a review and research agenda | More than 10 years out of date | |
| Quality of care in for‐profit and not‐for‐profit nursing homes: systematic review and meta‐analysis | Not transferable to low‐income countries | |
| Systematic review of involving patients in the planning and development of health care | Addressed by Nilsen 2010 | |
| A systematic review and meta‐analysis of studies comparing mortality rates of private for‐profit and private not‐for‐profit hospitals. | More than 10 years out of date | |
| Comparison of mortality between private for‐profit and private not‐for‐profit hemodialysis centers | More than 10 years out of date | |
| Payments for care at private for‐profit and private not‐for‐profit hospitals: a systematic review and meta‐analysis | Not transferable to low‐income countries | |
| Community‐based health insurance in low‐income countries: a systematic review of the evidence | Addressed by Meng 2010 | |
| Public reporting in health care: how do consumers use quality‐of‐care information? A systematic review | Addressed by Fung 2008 | |
| Active pharmaceutical management strategies of health insurance systems to improve cost‐effective use of medicines in low‐ and middle‐income countries: a systematic review of current evidence. | Major limitations | |
| Health sector accreditation research: a systematic review | Major limitations | |
| The standard of healthcare accreditation standards: a review of empirical research underpinning their development and impact | Major limitations | |
| Effectiveness of intermediate care in nursing‐led in‐patient units | Not transferable to low‐income countries | |
| Provision of a surgeon’s performance data for people considering elective surgery | Addressed by Fung 2008 | |
| Strategies for expanding health insurance coverage in vulnerable populations | Scope of the Implementation overview | |
| Evidence from systematic reviews to inform decision making regarding financing mechanisms that improve access to health services for poor people. A policy brief prepared for the International Dialogue on Evidence‐Informed Action to Achieve Health Goals in Developing Countries IDEAHealth | Addressed by Lagarde 2009 | |
| Linking families and facilities for care at birth: what works to avert intrapartum‐related deaths? | Major limitations | |
| Staffing remote rural areas in middle‐ and low‐income countries: a literature review of attraction and retention | Addressed by Grobler 2015 | |
| The effectiveness of contracting‐out primary health care services in developing countries: a review of the evidence | Addressed by Lagarde 2009 | |
| Contracting for the delivery of community health services: a review of global experience | Addressed by Lagarde 2009 | |
| The public release of performance data: what do we expect to gain? A review of the evidence | More than 10 years out of date | |
| Expanding health insurance coverage in vulnerable groups: a systematic review of options | Addressed by Jia 2014 | |
| Community accountability at peripheral health facilities: a review of the empirical literature and development of a conceptual framework | Major limitations | |
| Private versus public strategies for health service provision for improving health outcomes in resource‐limited settings | Major limitations | |
| Comparison of tiered formularies and reference pricing policies: a systematic review | Addressed by Acosta 2014 | |
| Rural retention of human resources for health | Addressed by Grobler 2015 | |
| Can working with the private for‐profit sector improve utilization of quality health services by the poor? A systematic review of the literature | Major limitations | |
| Systematic review of the links between human resource management practices and performance | Major limitations | |
| Strategies for engaging the private sector in sexual and reproductive health: how effective are they? | More than 10 years out of date | |
| Can clinical governance deliver quality improvement in Australian general practice and primary care? A systematic review of the evidence | Addressed by Flodgren 2011 | |
| Community participation in rural primary health care: intervention or approach? | Addressed by Nilsen 2010 | |
| Impact of pharmaceutical prior authorisation policies: a systematic review of the literature | Addressed by Green 2010 | |
| Ranji 2007 | Effects of rapid response systems on clinical outcomes: systematic review and meta‐analysis | Scope of the Delivery overview |
| Nurse‐led clinics as an effective service for cardiac patients: results from a systematic review | Major limitations | |
| Can interventions improve health services from informal private providers in low and middle‐income countries? A comprehensive review of the literature | Major limitations | |
| Specialty board certification and clinical outcomes: the missing link | More than 10 years out of date | |
| Hospital ownership and financial performance: a quantitative research review | Not transferable to low‐income countries | |
| Physician dual practice: a review of literature | Addressed by Kiwanuka 2011 | |
| Improving antibiotic selection: a systematic review and quantitative analysis of quality improvement strategies | Addressed by New Reference | |
| Clinical governance in primary care: a literature review | Addressed by Phillips 2010 | |
| Examining characteristics, knowledge and regulatory practices of specialised drug shops in Sub‐Saharan Africa: a systematic review of the literature | Not a review of effects of interventions | |
| Working with the private sector for child health | More than 10 years out of date | |
| Motivation and retention of health workers in developing countries: a systematic review | Not a review of effects of interventions | |
| A critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas | Addressed by Grobler 2015 |
We described the characteristics of the included reviews in a table that included the date of the last search, any important limitations, what the review authors searched for and what they found (Appendix 3). We summarised our detailed assessments of the reliability of the included reviews in a separate table (Table 6) showing whether individual reviews met each criterion in Appendix 2.
| Review | A. Identification, selection and critical appraisal of studiesa | B. Analysisb | C. Overallc | |||||||||||
| 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 | |
| + | + | + | + | + | + | + | + | + | + | + | + | No | + | |
| + | + | + | + | + | + | + | + | + | + | + | + | No | + | |
| + | + | + | + | + | + | + | + | NA | + | NA | + | No | + | |
| + | ? | + | + | + | + | + | + | + | + | + | + | No | + | |
| + | + | − | + | + | + | + | + | + | + | + | + | No | + | |
| + | + | + | + | + | + | + | + | + | + | + | + | No | + | |
| + | + | + | + | + | + | + | + | + | + | + | + | No | + | |
| + | + | + | + | + | + | + | + | + | + | + | + | No | + | |
| + | ? | + | ? | + | + | + | + | + | + | ? | + | No | + | |
| + | + | + | + | + | + | NA | NA | NA | NA | NA | NA | No | + | |
| + | + | + | + | + | + | NA | NA | NA | NA | NA | NA | No | + | |
| + | + | + | + | + | + | + | + | + | + | + | + | No | + | |
| + | + | + | + | + | + | + | + | + | + | + | + | No | + | |
| + | + | + | + | + | + | + | + | + | + | + | + | No | + | |
| + | + | + | + | + | + | + | + | + | + | + | + | No | + | |
| + | + | + | ? | + | + | + | + | + | + | + | + | No | ||
| ? | − | + | ? | + | − | ? | + | ? | + | NA | + | No | − | |
| + | ? | + | + | + | + | + | + | + | + | NA | + | No | + | |
| + | ? | + | + | + | + | NA | NA | NA | NA | NA | NA | No | + | |
aIdentification, selection and critical appraisal of studies ‐ details of assessment criteria
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)
bAnalysis ‐ details of assessment criteria
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)
cOverall ‐ details of assessment criteria
1. Other considerations: are there any other aspects of the review not mentioned before which lead you to question the results?
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)
We based our structured synthesis of the findings of our overview on two tables (Table 7; Table 8). We summarised the main findings of each review in a table that included the key messages from each SUPPORT Summary (Table 7). In a second table (Table 8), we reported the direction of the results and the certainty of the evidence for each of the following type of outcomes: health and other patient outcomes; access, coverage or utilisation; quality of care; resource use; social outcomes; impacts on equity; healthcare provider outcomes; adverse effects (not captured by undesirable effects on any of the preceding types of outcomes); and any other important outcomes (that did not fit into any of the preceding types of outcomes) (EPOC 2016). We categorised the direction of results as: a desirable effect, little or no effect, an uncertain effect (very low‐certainty evidence), no included studies, an undesirable effect, not reported (i.e. not specified as a type of outcome that was considered by the review authors), or not relevant (i.e. no plausible mechanism by which the type of health system arrangement could affect the type of outcomes).
| Governance arrangement | Key messages |
| Authority and accountability for health policies | |
| Interagency collaboration | ➡ Local interagency collaborative interventions may lead to little or no difference in physical health and quality of life compared with standard care. ➡ It is uncertain whether local interagency collaborative interventions decrease mortality or mental health symptoms. ➡ This review did not include any evidence from low‐income countries. |
| Decision‐making about what or who is covered by health insurance ‐ Restrictions on drug reimbursement | ➡ Restrictions on reimbursement in health insurance systems with substantial coverage for medicines probably decreases targeted drug use and expenditures on targeted drugs or drug classes. ➡ The effects of restrictions on reimbursement vary by drug and drug class, and by how the restrictions are implemented and enforced. ➡ The impacts of restrictions on health outcomes and health service utilisation are uncertain. ➡ All the studies were done in high‐income countries and participants were mainly senior citizens or low‐income adult populations whose medications were being paid for in whole or part through publicly funded drug benefit plans. ➡ There are no studies on the effect of reimbursement restrictions on equity. |
| Policies to reduce corruption | ➡ It is uncertain if prevention, detection or response interventions reduce healthcare fraud and abuse and related expenditures. ➡ None of the included studies took place in a low‐income country. |
| Authority and accountability for organisations | |
| Contracting out | ➡ Contracting out services to non‐state not‐for‐profit providers may increase access to and utilisation of health services. ➡ Patient outcomes may be improved and household health expenditures reduced by contracting out. ➡ None of the included studies presented evidence on whether contracting out was more effective than making a similar investment in the public sector. We are therefore uncertain of the effects of investing in contracting out compared to an equivalent investment in public sector health services. |
| Multi‐institutional arrangements ‐ Social franchising | ➡ We found no evidence regarding the effects of social franchising on access to or the quality of health services in low‐ and middle‐income countries. We are therefore uncertain of the effects of social franchising. ➡ There is a need for well‐designed experimental studies that are informed by the theoretical and empirical literature. |
| Authority and accountability for commercial products | |
| Registration ‐ Drugs | ➡ Certain regulatory measures, specifically drug registration, may decrease the prevalence of counterfeit and substandard drugs. It is uncertain whether licensing of drug outlets reduces the prevalence of counterfeit drugs or the failure rates of drugs undergoing quality testing. ➡ WHO prequalification of drugs may lead to a reduction in the failure rates of drugs undergoing quality testing. ➡ Multifaceted interventions (including a mix of regulations, training of inspectors, public‐private collaborations and legal actions against counterfeiters) may be effective in decreasing the prevalence of counterfeit and substandard drugs. ➡ All studies identified took place in low‐ and middle‐income countries. ➡ The transferability of the findings may be influenced by a country's existing pharmaceutical supply chain and infrastructure, the availability of routine data on drug quality, qualified and skilled personnel, and financial resources. |
| Pricing and purchasing policies ‐ Drugs | ➡ Reference pricing may reduce insurers' cumulative drug expenditures by shifting drug use from cost‐share drugs to reference drugs. ➡ Index pricing may increase the use of generic drugs, reduce the use of brand‐name drugs, slightly reduce the price of generic drugs, and have little or no effect on the price of brand‐name drugs. ➡ It is uncertain whether maximum pricing affects drug expenditures. ➡ The effects of these policies on healthcare utilisation or health outcomes is uncertain. ➡ None of the included studies took place in a low‐income country. ➡ The effects of other pharmaceutical pricing and purchasing policies are uncertain. |
| Marketing regulations ‐ Drugs | ➡ Direct‐to‐consumer advertising increases patient demand for advertised medicines and the number of related prescriptions by doctors. ➡ We found no studies that reported on the impact of direct‐to‐consumer advertising on health outcomes. We are therefore uncertain of their effects. ➡ In light of the lack of evidence of the benefits, potential harms, and costs of direct‐to‐consumer advertising: ‐ the value of policies that allow for the increased use of direct to consumer advertising is uncertain at best; and ‐ rigorous monitoring and evaluation are warranted if such policies are implemented. |
| Authority and accountability for health professionals | |
| Training and licensing ‐ 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: ‐ increase the number of minority students enrolled in health sciences; ‐ slightly increase retention through to graduation; ‐ decrease differences in retention levels through to graduation between minority and non‐minority students in the health sciences. ➡ We found no studies of the effects of other pre‐licensure measures to increase health worker supply. |
| Training and licensing ‐ Training district health system managers | ➡ Private contracting ("contracting in") of district health managers compared to direct employment by the Ministry of Health may improve access and utilisation of healthcare. It is uncertain whether contracting in improves health outcomes. ➡ Intermittent training programmes may increase knowledge of planning processes and monitoring and evaluation skills of district managers. ➡ The effects of other interventions are uncertain, including changes in how district managers are hired, strategies for retaining district managers such as making the positions more attractive, and other training programmes such as in‐service workshops with onsite support. |
| 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 in underserved areas ‐ Educational interventions (e.g. student selection criteria, undergraduate and postgraduate teaching curricula, exposure to rural and urban underserved areas) ‐ Financial interventions (e.g. undergraduate and postgraduate bursaries or scholarships linked to future practice location, rural allowances, increased public sector salaries) ‐ Regulatory strategies (e.g. compulsory community service, relaxing work regulations imposed on foreign medical graduates who are willing to work in rural or urban underserved areas) ‐ Personal and professional support strategies (e.g. providing adequate professional support and attending to the needs of the practitioners family) |
| Recruitment and retention strategiesRockers 2013 | ➡ Private contracting ("contracting in") of district health managers compared to direct employment by the Ministry of Health may improve access and utilisation of healthcare. It is uncertain whether contracting in improves health outcomes. ➡ Intermittent training programmes may increase knowledge of planning processes and monitoring and evaluation skills of district managers. ➡ The effects of other interventions are uncertain, including changes in how district managers are hired, strategies for retaining district managers such as making the positions more attractive, and other training programmes such as in‐service workshops with onsite support. |
| Movement of health workers between public and private organisations | ➡ No rigorous studies have evaluated the effects of interventions to manage the movement of health workers between public and private organisations. ➡ There is a need for well‐designed studies to evaluate the impact of interventions that attempt to regulate health worker movement between public and private organisations in low‐income countries. |
| Emigration and immigration policies | ➡ Lowering immigration restrictions in high‐income countries probably increases the migration of nurses from low‐ and middle‐income countries to high‐income countries. The effectiveness of interventions implemented in low‐ and middle‐income countries to decrease the emigration of health professionals is uncertain. No studies were found that evaluated such interventions. ➡ Low‐ and middle‐income countries should monitor changes in high‐income countrie immigration legislation, model the impact of proposed migration changes on their own retention of domestic health professionals, and lobby for immigration laws in high‐income countries that consider the health system needs of source countries. ➡ Rigorous studies are needed of the effectiveness of interventions designed to decrease the emigration of health professionals, particularly the effectiveness of interventions in low‐ and middle‐income countries. |
| Dual practice | ➡ No studies met the inclusion criteria for the review, as no rigorous studies have evaluated the effects of interventions to manage dual practice. ➡ There is a need for well‐designed studies to evaluate the impact of interventions that attempt to regulate health worker dual practice in low‐income countries. |
| Authority and accountability for quality of practice ‐ Authority and accountability for quality of outpatient care ‐ Authority and accountability for quality assurance of hospital (inpatient) care | ➡ It is uncertain whether external inspection results in improved compliance with accreditation standards, improved quality of care or decreased healthcare‐acquired infection (i.e. methicillin‐resistant Staphylococcus aureus) rates in hospitals. ➡ This review found no direct evidence on the effectiveness of external inspections of compliance with standard in ambulatory settings. We are therefore uncertain of the effects in this setting. ➡ This review found no direct evidence on the effectiveness of external inspections of compliance with standards in low‐income countries. |
| Stakeholder involvement | |
| Stakeholder participation in policy and organisational decisions | ➡ Consumer consultations in developing patient information probably: ‐ facilitate the development of material that is more relevant, readable and understandable to patients; ‐ improve patient knowledge; ‐ make little or no difference in decreasing the anxieties that patients may associate with clinical procedures. ➡ Consumer interviewers may lead to small differences in the results of satisfaction surveys compared to healthcare professional interviewers. ➡ It is uncertain whether telephone discussions compared with face‐to‐face meetings change consumer priorities for community health goals. ➡ Consumer consultation in the development of consent documents may have little or no impact on self‐reported participant understanding of the trial described in the consent document, satisfaction with study participation, adherence to the protocol or refusal to participate ➡ There are good arguments for introducing consumer involvement in low‐income countries. To accomplish this: ‐ strategies to overcome barriers such as low baseline levels of social participation, organisation and education should be explored; ‐ efforts to include consumers or families of disadvantaged groups should be considered in order to achieve inclusive representation; ‐ evaluations are needed of the effects of consumer involvement on healthcare decisions and how to achieve more effective consumer involvement. |
| Community mobilisation | ➡ Women's groups practising participatory learning and action probably improve newborn survival, may improve maternal survival, may slightly reduce stillbirths, and may be a cost‐effective strategy in rural areas in low‐ and middle‐income countries. ➡ The effectiveness of women's groups may depend on participation of a substantial proportion of pregnant women, adequate supervision and support, home visits, access to care, improving the quality of care, and adequate resources. |
| Community mobilisation | ➡ Multi‐component community‐based dengue control programmes may reduce mosquito larval indices. ➡ Multi‐component community‐based dengue control programmes combined with chemical larvicides may reduce mosquito larval indices. ➡ Multi‐component community‐based dengue control programmes combined with fish and chemical larvicides may reduce mosquito larval indices. ➡ Multi‐component community‐based dengue control programmes combined with the use of crustaceans that eat mosquito larvae (Mesocyclops copepods) may reduce mosquito larval indices. ➡ It is uncertain whether multi‐component community‐based dengue control programmes combined with the use of crustaceans that eat mosquito larvae (Mesocyclops copepods) reduce dengue incidence. ➡ Most studies took place in low‐ and middle‐income countries. |
| Patient information ‐ Public disclosure of performance data | ➡ Public disclosure of performance for health plans: ‐ may lead to patients selecting health plans that have better quality ratings; ‐ has uncertain effects on quality improvement activities; ‐ may slightly improve health outcomes. ➡ Public disclosure of performance for hospitals: ‐ may lead to little or no difference in patient selection of hospitals; ‐ probably stimulates quality improvement activities; ‐ may improve health outcomes. ➡ Public disclosure of performance for individual healthcare providers: ‐ probably leads to patients selecting providers that have better quality ratings; ‐ has uncertain effects on quality improvement activities; ‐ may improve health outcomes. ➡ All of the included studies took place in high‐income countries. ‐ Public disclosure of performance may be difficult to implement in low‐income countries because of limitations of the ability of health facilities and providers to produce accurate data, the capacity to disseminate the data, the ability of patients to interpret the data and, in some places, the lack of choice available in terms of facilities or providers. |
| Direction of effects and certainty of the evidencea | |||||||||
| Governance arrangement | Patient outcomes | Access, coverage, utilisation | Quality of care | Resource use | Social outcomes | Impacts on equity | Health care provider outcomes | Adverse effects b | Other |
| Authority and accountability for health policies | |||||||||
| Interagency collaboration | ? ⊕⊖⊖⊖ ∅⊕⊕⊖⊖c | NR | NR | NR | ∅⊕⊕⊖⊖d | NR | NR | NR | NR |
| Decision‐making about what is covered by health insurance – restrictions on drug reimbursement | ? ⊕⊖⊖⊖e | ✔⊕⊕⊕⊖f | NR | ✔⊕⊕⊕⊖f | NR | NR | NR | NR | NR |
| Policies to reduce corruption – fraud detection and response actions | NR | NR | NR | ?⊕⊖⊖⊖g | NR | NR | NR | NR | NR |
| Authority and accountability for organisations | |||||||||
| Contracting out – to non‐state not‐for–profit providers | ✔⊕⊕⊖⊖h | ✔⊕⊕⊖⊖i | NR | NR | NR | NR | NR | NR | NR |
| Multi‐institutional arrangements – social franchising | NS | NS | NS | NS | NS | NS | NS | NS | NS |
| Authority and accountability for commercial products | |||||||||
| Registration – drugs | NR | NR | NR | NR | NR | NR | NR | NR | ✔⊕⊕⊖⊖j |
| Pricing and purchasing policies – medicines – reference pricing | NR | ✔⊕⊕⊖⊖k | NR | ✔⊕⊕⊖⊖k | NR | NR | NR | NR | NR |
| Pricing and purchasing policies – medicines – index pricing | NR | ✔⊕⊕⊖⊖l | NR | ∅⊕⊕⊖⊖m | NR | NR | NR | NR | NR |
| Marketing regulations – medicines direct‐to‐consumer advertising | NS | ✔✕⊕⊕⊕⊕n | NR | NS | NR | NR | NR | NR | NR |
| Authority and accountability for health professionals | |||||||||
| Training and licensing – pre‐licensure education – minority academic advising programme | NR | NR | NR | NR | NR | ✔⊕⊕⊖⊖o | NR | NR | NR |
| Training and licensing – manager training programme versus no training | NR | NR | NR | NR | NR | NR | NR | NR | ✔⊕⊕⊖⊖p |
| Recruitment and retention strategies – health professionals in underserved areas | NS | NS | NS | NS | NS | ?⊕⊖⊖⊖q | NS | NS | NS |
| Recruitment and retention strategies – private versus public contracts of district health managers | ?⊕⊖⊖⊖r | ✔⊕⊕⊖⊖r | NR | NR | NR | NR | NR | NR | NR |
| Movement of health workers between public and private organisations | NS | NS | NS | NS | NS | NS | NS | NS | NS |
| Emigration and immigration policies – reducing immigration restrictions | NS | ✕⊕⊕⊕⊖s | NS | NS | NR | NR | NR | NR | NR |
| Dual practice | NR | NS | NS | NS | NS | NS | NS | NR | NR |
| Authority and accountability for quality of practice – authority and accountability for quality of outpatient care – external inspection | NS | NS | ? ⊕⊖⊖⊖t | NR | NR | NR | NS | NR | NR |
| Stakeholder involvement | |||||||||
| Stakeholder participation in policy and organisational decisions – communication forums | NS | NS | NS | NS | NS | NS | NS | NS | ? ⊕⊖⊖⊖u |
| Stakeholder participation in policy and organisational decisions – consumer involvement in research | NS | NS | ✔⊕⊕⊖⊖v | NS | NS | NS | NS | NS | ∅⊕⊕⊖⊖w |
| Stakeholder participation in policy and organisational decisions – consumer involvement in preparing patient information | ∅⊕⊕⊕⊖x | NS | NS | NS | NS | NS | NS | NS | ✔⊕⊕⊕⊖y |
| Community mobilisation – women's groups practising participatory learning and action | ✔⊕⊕⊖⊖z ✔⊕⊕⊕⊖aa | NS | NS | NS | NS | NS | NS | NS | NS |
| Community mobilisation – community‐based dengue control | ✔⊕⊕⊖⊖bb ✔⊕⊕⊖⊖cc ? ⊕⊖⊖⊖dd | NS | NS | NS | NS | NS | NS | NS | NS |
| Patient information – public disclosure of performance data – health plans | ∅⊕⊕⊖⊖ee | ✔⊕⊕⊖⊖ff | NS | NS | NS | NS | NS | NS | NS |
| Patient information – public disclosure of performance data – hospitals | ✔⊕⊕⊖⊖gg | ✔⊕⊕⊖⊖hh | ✔⊕⊕⊕⊖ii | NS | NS | NS | NS | NS | NS |
| Patient information – public disclosure of performance data –individual healthcare providers | ✔⊕⊕⊖⊖jj | ✔⊕⊕⊕⊖kk | NS | NS | NS | NS | NS | NS | NS |
| The certainty of the evidence is an assessment of how good an indication the research provides of the likely effect; i.e. the likelihood that the effect will be substantially different from what the research found. By 'substantially different' we mean a large enough difference that it might affect a decision. These judgements are made using the GRADE system and the following definitions. | |||||||||
| Ratings | Definitions | Implications | |||||||
| ⊕⊕⊕⊕ High | This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different is low. | This evidence provides a very good basis for making a decision about whether to implement the intervention. Impact evaluation and monitoring of the impact are unlikely to be needed if it is implemented. | |||||||
| ⊕⊕⊕⊖ Moderate | This research provides a good indication of the likely effect. The likelihood that the effect will be substantially different is moderate. | This evidence provides a good basis for making a decision about whether to implement the intervention. Monitoring of the impact is likely to be needed and impact evaluation may be warranted if it is implemented. | |||||||
| ⊕⊕⊖⊖ Low | This research provides some indication of the likely effect. However, the likelihood that it will be substantially different is high. | This evidence provides some basis for making a decision about whether to implement the intervention. Impact evaluation is likely to be warranted if it is implemented. | |||||||
| ⊕⊖⊖⊖ Very low | This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different is very high. | This evidence does not provide a good basis for making a decision about whether to implement the intervention. Impact evaluation is very likely to be warranted if it is implemented. | |||||||
a✓: a desirable effect; ∅: little or no effect; ?: an uncertain effect; ✕: an undesirable effect; NS: no studies found by this review that reported this outcome; NR: outcome not reported by this review.
bOther than adverse effects on any of the outcomes in the previous columns.
cLocal interagency collaborative interventions may lead to little or no difference in physical health and may slightly improve functional level in patients with psychiatric disorders, compared with standard care. It is uncertain whether local interagency collaborative interventions decrease mortality and mental health symptoms.
dLocal interagency collaborative interventions may lead to little or no difference in quality of life.
eIt is uncertain whether pharmaceutical policies that restrict reimbursements change health outcomes.
fRestrictions to pharmaceutical reimbursement probably decrease targeted drug use in the short and long term and reduce expenditures on target drug or drug class.
gIt is uncertain if prevention, detection and response interventions reduce healthcare fraud and abuse and related expenditures.
hPatient outcomes (auto‐reporting of being sick in the past month, diarrhoea incidence) may be improved and household health expenditures reduced by contracting out.
iContracting out services to non‐state not‐for‐profit providers may increase access to and utilisation of health services.
jMedicine registration and multifaceted interventions (including a mix of regulations, training of inspectors, public‐private collaborations and legal actions against counterfeiters) may decrease the prevalence of counterfeit and substandard medicines; WHO prequalification of medicines may lead to a decrease in the failure rates of medicines undergoing quality testing.
kReference pricing (a system in which a reference price is established within a country as the maximum level of reimbursement for a group of medicines) may reduce insurers' cumulative medicine expenditures; may increase the use of reference medicines; and may reduce the use of cost‐share medicines.
lIndex pricing (a maximum refundable price to pharmacies for medicines within an index group of therapeutically interchangeable medicines) may increase the use of generic medicines and reduce the use of brand‐name medicines.
mIndex pricing may slightly reduce the price of generic medicines and may have little or no effect on the price of brand‐name medicines.
nDirect‐to‐consumer advertising increases people's requests for advertised medicines as well as prescription volumes for advertised medicine. The direction of the effect depends on the medicine. For instance, for essential medicines this may be a desirable effect but for non‐essential medicines this may be a harmful effect.
oMinority academic advising programmes may increase the number of black health sciences students enrolled and slighlty increase retention to graduation.
pManager training programmes may increase knowledge of planning processes and monitoring and evaluation skills.
qIt is uncertain whether educational or financial interventions or regulatory or personal and professional support strategies to recruit or retain health professionals increase the number of health professionals practising in in underserved areas.
rHiring district health managers to work within the Ministry of Health system through private contracts may improve access to health care and service use, but it is uncertain if this improves population health outcomes.
sReducing immigration restrictions in high‐income countries probably increases the migration of nurses from low‐ and middle‐income countries to high‐income countries.
tIt is uncertain whether external inspection adherence to accreditation standards improves quality of care.
uIt is uncertain whether telephone discussions compared with face‐to‐face meetings change consumer priorities for community health goals.
vConsumer interviewers may slightly improve responses regarding patient satisfaction, compared to staff interviewers.
wConsumer consultation in the development of consent documents may have little or no impact on self‐reported participant understanding of the trial described in the consent document, satisfaction with study participation, adherence to the protocol or refusal to participate.
xPatients probably experience little or no difference in their levels of worry or anxiety associated with procedures when they receive information material that has been developed following consumer consultation.
yConsumer consultation in developing patient information material probably results in material that is more relevant, readable and understandable to patients, and probably improves the knowledge of patients who read the material.
zWomen's groups practising participatory learning and action cycles may improve survival in mothers and may slightly reduce stillbirths. .
aaWomen's groups practising participatory learning and action cycles probably improve survival in newborn babies.
bbMulti‐component community‐based dengue control programmes may reduce mosquito larval indices, and such programmes combined with fish and chemical larvicides may reduce mosquito larval indices.
ccMulti‐component community‐based dengue control programmes combined with the use of crustaceans that eat mosquito larvae may reduce mosquito larval indices.
ddIt is uncertain whether multi‐component community‐based dengue control programmes combined with the use of crustaceans that eat mosquito larvae reduce dengue incidence.
eePublic disclosure may lead to slight improvements in clinical outcomes for health plans.
ffPublic disclosure may lead patients to select health plans with better quality ratings or to avoid those with worse ratings.
ggMay lead to slight improvements in hospital clinical outcomes.
hhMay lead to little or no difference in patient selection of hospitals.
iiProbably stimulates hospitals to undertake quality improvement activities.
jjPublic disclosure of performance data may improve clinical outcomes (risk‐adjusted mortality rates for surgeons) among individual providers.
kkPublic disclosure probably influences users of health care services to select providers with better quality ratings or to avoid those with worse ratings.
We took into account other relevant considerations besides the findings of the included reviews when drawing conclusions about implications for practice (EPOC 2017). This includes considerations related to the applicability of the findings and likely impacts on equity. Our conclusions about implications for systematic reviews were based on types of governance arrangements for which we were unable to find a reliable, up‐to‐date review and on the limitations identified in the included reviews. This includes considerations related to the applicability of the findings and likely impacts on equity. Our conclusions about implications for future evaluations are based on the findings of the included reviews (EPOC 2017).
Results
We identified 7272 systematic reviews of health systems arrangements and implementation strategies. We excluded 6953 reviews from this overview following a review of titles and abstracts. We retrieved the full texts of 66 reviews for further detailed assessment, excluding 43 for the following reasons (Table 5): they had important methodological limitations (10 reviews), were out‐of‐date (7 reviews), focused on an area already covered by one of the included reviews (20 reviews), did not focus on the effects of interventions (2 reviews), or were of limited relevance to low‐income countries (4 reviews) (Figure 1). We considered two other reviews for inclusion but, after discussion, agreed that they were part of the scope of another of the overviews (Jia 2014; Maharaj 2015).We considered Ketelaar 2011 and WHO 2010 to be supplementary in that they contributed information about interventions for which other reviews were the main source of information (because those reviews, Fung 2008 and Grobler 2015, were more reliable, included more studies, or were more up‐to‐date). Appendix 5 lists the reviews still awaiting classification.
Review flow diagram.
Description of included reviews
We included 19 systematic reviews published between 2005 and 2015 in this overview (Table 4). Of these, 13 were Cochrane Reviews and 6 non‐Cochrane reviews.
The reviews reported results from 172 studies and included the following study designs .
-
28 randomised trials (16.3%).
-
6 non‐randomised trials (3.5%).
-
15 controlled before‐after studies (8.7%).
-
62 interrupted time series studies (36.0%).
-
1 repeated measures study (0.6%).
-
56 observational study designs (32.6%).
-
3 studies used more than one design (1.7%).
-
1 before‐after study, reanalysed as an interrupted time series study (0.6%).
The number of studies included in each review ranged from zero (Koehlmoos 2009; Kiwanuka 2011; Rutebemberwa 2014) to 45 (Fung 2008). The dates of the most recent searches in the reviews ranged from October 2004 in Gilbody 2005 to April 2014 in Grobler 2015.
Nine reviews did not include any studies from low‐ or middle‐income countries (Gilbody 2005; Fung 2008; Pariyo 2009; Green 2010; Nilsen 2010; Hayes 2012; Rashidian 2012; Acosta 2014; Grobler 2015), and four reviews only included studies conducted in low‐ or middle‐income countries (Lagarde 2009; Prost 2013; Rockers 2013; El‐Jardali 2015). Overall, 74% of the studies from the included reviews took place in high‐income countries. Study settings varied and included primary care; home, workplace and community settings; and outpatient and inpatient settings in hospitals and non‐primary level health centres (Appendix 3). Health workers who participated in the studies included in the reviews included: physicians, nurses, pharmacists, psychologists, dentists, social workers and traditional healers. Recipients of care participating in studies included in the reviews included children, adults and pregnant mothers (Appendix 3). Outcomes examined by the reviews included: healthcare provider performance, patient outcomes, access to care, coverage, utilisation of health services, social outcomes, impacts on equity and adverse effects (Table 8).
We grouped the governance arrangements addressed in the reviews into five categories.
-
Authority and accountability for health policies: 3 reviews.
-
Authority and accountability for organisations: 2 reviews.
-
Authority and accountability for commercial products: 3 reviews.
-
Authority and accountability for health professionals: 7 reviews.
-
Stakeholder involvement: 4 reviews.
Methodological quality of included reviews
We present the methodological quality (reliability) of the included reviews in Table 6. One of the 19 included reviews, Rashidian 2012, had important methodological limitations, but we retained it in the overview because no better review was available. We judged the other 18 reviews to have only minor limitations.
We found a number of problems with respect to the identification, selection and critical appraisal of the included studies in reviews. Five reviews had some limitations in relation to the comprehensiveness of the search, and three reviews had some limitations in relation to study selection. We found few problems with respect to the analysis of the available evidence. Two reviews had limitations related to either the description of the extent of heterogeneity or the examination of factors that might explain differences in the results of included studies (Rashidian 2012 and Heintze 2007, respectively).
Effect of interventions
Table 7 summarises the key messages from the included reviews, and Table 8 presents the key findings of the different governance interventions considered by each of the included reviews as well as the certainty of this evidence by outcome. Table 9 summarises the effects and certainty of the evidence from the included reviews according to whether the interventions had desirable effects, little or no effect, undesirable effects, or uncertain effects. In the following text, we report the main findings of the included comparisons.
| Interventions found to have desirable effects on at least one outcome with moderate‐ or high‐certainty evidence and no moderate‐ or high‐certainty evidence of undesirable effects |
| Authority and accountability for health policies |
| Decision‐making about what is covered by health insurance
|
| Authority and accountability for commercial products |
| Marketing regulations
|
| Stakeholder participation in policy and organisational decisions |
| Community mobilisation
|
| Patient information
|
|
|
| Interventions for which the certainty of the evidence was low or very low (or no studies were found) for all outcomes examined |
| Authority and accountability for health policies |
|
|
| Authority and accountability for organisations |
|
|
| Authority and accountability for commercial products |
|
|
| Authority and accountability for health professionals |
|
|
| Stakeholder participation in policy and organisational decisions |
|
|
aFor this intervention, the direction of the effect depends on the medicine. For instance, for essential medicines this may be a desirable effect (and is therefore listed as such above) but for non‐essential medicines this may be a undesirable effect.
Authority and accountability for health policies
Three reviews considered interventions related to authority and accountability for health policies (Green 2010; Hayes 2012; Rashidian 2012).
Interagency collaboration
Hayes 2012 examined the effects of interagency collaboration between local health and other local government agencies and services, comparing it with standard practice or no intervention. The review included 16 studies, all conducted in high‐income countries. The findings suggested that it is uncertain whether local interagency collaborative interventions decrease mortality or mental health symptoms (very low‐certainty evidence). The studies also suggest that these interventions may lead to little or no difference in physical health and quality of life but may slightly improve functional levels among people with psychiatric disorders, compared with standard ways of delivering services (low‐certainty evidence).
Decision‐making about what is covered by health insurance – restrictions on medicines reimbursement
Green 2010 included 29 studies in high‐income countries and assessed the effects of placing restrictions on the medicines reimbursed by health insurance systems. The review found that restrictions on reimbursement probably decrease the use of the targeted medicines as well as expenditures on targeted medicines or medicine classes (moderate‐certainty evidence). The impacts of such restrictions on health outcomes and health service utilisation were uncertain (very low‐certainty evidence). Review authors could not assess the impacts of such restrictions on equity measures, as none of the included studies reported this outcome.
Policies to reduce corruption
Rashidian 2012 studied the effects of interventions to reduce healthcare fraud. It included four studies from high‐income countries. The review found that it is uncertain if prevention, detection and response interventions reduce healthcare fraud and related expenditures (very low‐certainty evidence).
Authority and accountability for organisations
Two reviews considered interventions related to authority and accountability for organisations (Koehlmoos 2009; Lagarde 2009). The review addressing the effects of social franchising, Koehlmoos 2009, did not identify any eligible studies, so we do not discuss it further below.
Contracting out
Lagarde 2009 examined the effects of contracting out (sometimes called sub‐contracting) and included three studies conducted in middle‐income countries. The review found that contracting out services to non‐state, not‐for‐profit providers may increase access to and utilisation of health services (low‐certainty evidence). In addition, patient outcomes may be improved and household health expenditures reduced (low‐certainty evidence). None of the included studies presented evidence on whether contracting out was more effective than making a similar investment in the public sector. We are therefore uncertain of the effects of investing in contracting out compared to an equivalent investment in public sector health services.
Authority and accountability for commercial products
Three reviews considered interventions related to authority and accountability for commercial products (Gilbody 2005; Acosta 2014; El‐Jardali 2015).
Registration of medicines
El‐Jardali 2015 explored the effect of interventions for combating or preventing medicine counterfeiting (e.g. medicines with the wrong ingredients, without active ingredients, with insufficient active ingredients or with fake packaging). The review included 21 studies conducted in low‐ and middle‐income countries and found that it is uncertain whether the licensing of drug or medicines outlets reduces the prevalence of counterfeit medicines or the failure rates of medicines undergoing quality testing (very low‐certainty evidence). The review also found that medicine registration may decrease the prevalence of counterfeit and substandard medicines (low‐certainty evidence) and that the prequalification of medicines by WHO (in which manufacturers receive WHO‐approved certificates of good manufacturing practices) may lead to a decrease in the failure rates of medicines undergoing quality testing (low‐certainty evidence). Finally, multifaceted interventions (that include a mix of regulations, training of inspectors, public‐private collaborations and legal actions against counterfeiters) may be effective in decreasing the prevalence of counterfeit and substandard medicines (low‐certainty evidence).
Pricing and purchasing policies for pharmaceuticals
Acosta 2014 evaluated the effects of reference pricing (a system that establishes a benchmark or reference price within a country as the maximum level of reimbursement for a group of drugs or medicines), maximum pricing (a fixed, maximum price that a medicine can have within a health system) and index pricing (maximum refundable price to pharmacies for medicines within an index group of therapeutically interchangeable medicines). The 18 included studies took place in high‐income countries. Reference pricing may reduce insurers' cumulative medicine expenditures by shifting medicine use from cost‐share medicines (more expensive medicines in the same group as the reference medicines, for which patients have to pay the difference between the reference price and the price of the medicine purchased) to reference medicines; and may increase the use of reference medicines and reduce the use of cost‐share medicines (low‐certainty evidence). Index pricing may increase the use of generic medicines and may reduce the use of brand‐name medicines; may slightly reduce the price of generic medicines; and may have little or no effect on the price of brand‐name medicines (low‐certainty evidence). It is uncertain whether maximum pricing affects medicine expenditures (very low‐certainty evidence). The effects of reference pricing, maximum pricing and index pricing on healthcare utilisation or health outcomes is uncertain, as the included studies did not assess these outcomes.
Marketing regulations
Gilbody 2005 explored the effects of direct‐to‐consumer advertising of prescription‐only medicines. The review included four studies performed in high‐income countries and found that direct‐to‐consumer advertising increases people's requests for advertised medicines as well as the number of related prescriptions by doctors (high‐certainty evidence). The direction of the effect depends on the medicine. For instance, for essential medicines this may be a desirable effect but for non‐essential medicines this may be a undesirable effect. The review did not identify any studies that evaluated the impact of direct‐to‐consumer advertising on health outcomes or the cost‐effectiveness of such advertising.
Authority and accountability for health professionals
Seven reviews considered interventions related to authority and accountability for health professionals (Pariyo 2009; Flodgren 2011; Kiwanuka 2011; Peñaloza 2011; Rockers 2013; Rutebemberwa 2014; Grobler 2015). Kiwanuka 2011 examined the effects of interventions to improve the management of dual practice, in which healthcare providers hold more than one job, but did not identify any eligible studies. Likewise, Rutebemberwa 2014 assessed interventions to manage the movement of health workers between public and private organisations but did not include any studies. Therefore, we do not discuss either of these empty reviews below.
Training and licensing – pre‐licensure education
Pariyo 2009 examined the effects of changes in pre‐licensure education (the training of health professional students prior to their registration as professionals) on the supply of health workers. The review included two studies that addressed the effects of an academic advising programme for minority groups, in which training institutions in a high‐income country provide additional support for minority group students. The review found that such programmes may increase the number of minority group health sciences students enrolled, slightly increase retention to graduation and decrease the difference in retention levels to graduation between a minority group and those in other population groups (low‐certainty evidence). The review did not find any studies of the effects on the supply of health workers of other changes in pre‐licensure education.
Rockers 2013 examined the effects of interventions to hire, retain and train district health systems managers and included two studies conducted in four middle‐income countries. The review found that manager training programmes may increase knowledge of planning processes as well as managers' monitoring and evaluation skills, compared with no training (low‐certainty evidence).
Recruitment and retention strategies
Grobler 2015 examined strategies for the recruitment and retention of health workers practising in underserved and rural areas. The review included one study from a high‐income country (Taiwan), but it is uncertain whether educational or financial interventions, or regulatory, personal and professional support strategies to recruit or retain health professionals increase the number of health professionals practising in underserved areas, as the review did not identify any studies that evaluated such interventions.
Rockers 2013 examined the effects of interventions to hire, retain and train district health systems managers and included two studies conducted in four middle‐income countries. The review found that hiring district health managers to work within the Ministry of Health system through private contracts ('contracting in') may improve access to health care (health facilities open 24 hours and supplies and equipment available) and may increase use of antenatal care and other publicly funded services, compared to hiring managers through public sector contracts (low‐certainty evidence). However, it is uncertain whether this approach improves population health outcomes (very low‐certainty evidence).
Emigration and immigration policies
Peñaloza 2011 examined the effects of interventions for controlling the emigration of health professionals from low‐ and middle‐income countries. It included one study that evaluated the effect of a change to immigration legislation in the USA on the migration of nurses from the Philippines to the USA. It found that reducing immigration restrictions in high‐income countries probably increases the migration of nurses from low‐ and middle‐income to high‐income countries (moderate‐certainty evidence). The review did not identify any studies that evaluated the effectiveness of interventions implemented in low‐income countries to decrease the emigration of health professionals.
Authority and accountability for quality of care
Flodgren 2011 examined the effects on healthcare organisation behaviour, healthcare professional behaviour and patient outcomes of external inspection systems to improve adherence to external quality standards in organisations delivering health care. The review included one study each from a middle‐ and a high‐income country. The review found that it is uncertain whether external inspection of adherence to standards improves adherence and quality of care or decreases health‐acquired infection rates in hospitals (very low‐certainty evidence). This review did not find any studies of the effectiveness of external inspections of adherence to standards in ambulatory (outpatient) settings.
Stakeholder involvement
Four reviews considered interventions related to stakeholder involvement (Heintze 2007; Fung 2008; Nilsen 2010; Prost 2013).
Stakeholder participation in policy and organisational decisions
Nilsen 2010 examined the effects of interventions to involve consumers in developing healthcare policies and research, clinical practice guidelines and patient information material. The review included six randomised trials, all conducted in high‐income countries. One of these studies evaluated consumer involvement in policy development and found that it is uncertain whether telephone discussions change consumer priorities for community health goals compared with face‐to‐face meetings (very low‐certainty evidence). None of the other included studies assessed stakeholder participation in policy and organisational decisions, but rather assessed consumer involvement in developing patient information, delivering satisfaction with care interviews and developing informed consent forms for research.
Community mobilisation
Two reviews examined the effects of community mobilisation – strategies to empower people to organise themselves to address an issue of common concern, and to identify and employ available resources to change a given situation. Prost 2013 included seven cluster‐randomised trials from low‐ and middle‐income countries. The review found that women's groups practising participatory learning and action cycles may improve maternal survival and may slightly reduce stillbirths (low‐certainty evidence), and these interventions probably improve survival in newborn babies (moderate‐certainty evidence). Heintze 2007 included 11 studies of community‐based interventions for dengue control: 9 from middle‐income countries and 2 from high‐income countries. The review found that community‐based dengue control programmes that include some form of mobilisation may reduce mosquito larval indices (low‐certainty evidence).
Patient information – public disclosure of performance data
Fung 2008 examined the effects of public disclosure of performance data on health plans (including health insurance schemes, health maintenance organisations, private health insurance, etc.) as well as on hospitals and healthcare professionals, and included 45 studies from high‐income countries. The review found that public disclosure of performance data on health insurance scheme quality may lead people to select health plans with better quality ratings or to avoid those with worse ratings and may lead to slight improvements in clinical outcomes for health insurance schemes (low‐certainty evidence). Public disclosure of performance data on hospital quality may lead to little or no difference in patient selection of hospitals (low‐certainty evidence), probably stimulates hospitals to undertake quality improvement activities (moderate‐certainty evidence), and may lead to slight improvements in hospital clinical outcomes (low‐certainty evidence). Public disclosure of performance for individual healthcare providers probably leads to patients selecting providers that have better quality ratings (moderate‐certainty evidence) and may improve clinical outcomes among individual providers (low‐certainty evidence).
Discussion
Summary of main results
The evidence from the 19 included systematic reviews of governance arrangements for health systems in low‐income countries covers a range of strategies (e.g. at policy, organisational, commercial, health professional and stakeholder levels), involving diverse settings (geographical, health system level) and populations (managers, health professionals, patients). Of the 24 outcomes for which an intervention had a desirable effect, 7 were supported by evidence of moderate certainty and 17 by evidence of low certainty. The one outcome on which an intervention had an undesirable effect was supported by evidence of moderate certainty. For eight outcomes reported in the included reviews, we assessed the effects as uncertain (very low‐certainty evidence). We found high or moderate‐certainty evidence that interventions in the areas of restrictions on medicine reimbursement, community mobilisation, public disclosure of provider's performance data and patient involvement in decision‐making had desirable effects, with no undesirable effects.
Overall completeness and applicability of evidence
We identified reviews for 19 of 48 types of the governance arrangements. However, three of these reviews did not identify any eligible studies (Koehlmoos 2009; Kiwanuka 2011; Rutebemberwa 2014). We found only three reviews of strategies addressing authority and accountability for commercial products (Gilbody 2005; Acosta 2014; El‐Jardali 2015). Table 8 summarises the outcomes examined in the individual reviews. Only two reviews in the overview reported on the impacts of governance interventions on equity (Pariyo 2009; Grobler 2015). Three reviews reported outcomes related to resource use (Green 2010; Rashidian 2012; Acosta 2014), with none addressing cost‐effectiveness of the interventions. The sparse economic and equity data (in comparison to effectiveness data) limit assessment of the cost‐effectiveness and equity impacts of the interventions examined.
We incorporated our judgments about the applicability of summarised evidence (particularly, indirectness in relation to settings, populations and outcomes) into the GRADE assessments of its certainty, and we reported these applicability judgments in each of the SUPPORT Summaries. In general, it is difficult to draw firm conclusions regarding the applicability of the overview findings to low‐income countries. For many of the comparisons and outcomes, the evidence comes from studies conducted in high‐income countries (mainly the USA, UK, Canada and Australia) with very different on‐the‐ground realities and health systems arrangements. These differences are particularly important in relation to interventions that require substantial resources for design and implementation or that may require advanced technology or specialised skills for delivery, for instance systems for reimbursement and reference pricing for medicines (Green 2010; Acosta 2014), for fraud detection and response actions (Rashidian 2012), and for public disclosure of performance data (Fung 2008). These differences may also affect the applicability of interventions that are complex and may require substantial changes to the organisation of care – for example, improved collaboration between local health and local government agencies (Hayes 2012). It is therefore uncertain whether similar effects are likely if the interventions assessed in these reviews are implemented in low‐income countries.
Certainty of the evidence
Although some of the included reviews had methodological limitations, they were, for the most part, relatively well conducted (Table 6). The certainty of the evidence for the effect estimates for the interventions considered in these reviews ranged from very low to high (Table 8). Of the 39 outcomes considered by at least one study, the certainty of the evidence was high for 1 (3%), moderate for 8 (22%), low for 22 (56%) and very low for 8 (21%) (Table 10).
Potential biases in the overview process
Although our searches were relatively comprehensive, it is possible that we missed some relevant reviews. We also excluded reviews that were published before April 2005. It is possible that some of those reviews provide information that is still useful and that might supplement information provided by the included reviews. Although this cut‐off was arbitrary, it is unlikely that we excluded a substantial amount of useful information. However, 6 of the 19 included reviews were published before 2010, and it is possible that more recent evidence has been published since then that would change the review conclusions. None of these considerations would likely bias the results of this overview, but they might limit its comprehensiveness.
Classifying the interventions in the included reviews was sometimes uncertain and required judgment. For example, Jia 2014 assessed strategies for expanding health insurance coverage in vulnerable populations, and we decided to include it in the implementation strategies overview (Pantoja 2014). Another review evaluated the effects of rapid response systems on clinical outcomes (Maharaj 2015), and we included that one in the delivery overview (Ciapponi 2014). On the other hand, Fung 2008 related to the public disclosure of information directed to patients, and we included it in this overview instead of the implementation strategies overview. Although these judgments and differences in approaches to characterising governance interventions are unlikely to have introduced bias into this overview, they might result in some confusion, since there is no universally agreed upon classification system for governance arrangements. Moreover, any system for categorising health system interventions is, to some extent, arbitrary. A unified taxonomy for classifying health system interventions could facilitate explicit and systematic synthesis and interpretation of the existing body of evidence on health systems interventions across studies.
Judgments about the relevance of some interventions to low‐income countries (applicability, equity, economic considerations, and monitoring and evaluation) were sometimes difficult to make. While these judgments might have led to systematic errors, it seems unlikely. At least two overview authors made all of these judgments on the basis of the SUPPORT Summaries, which undergo peer review by the contact author of the summarised review and by individuals from low‐ and middle‐income countries.
Our general approach towards including reviews of studies from high‐income countries was inclusive rather than exclusive to enable readers to assess for themselves the relevance of the review findings. Similarly, our approach was to assume that findings are applicable to low‐income countries unless we identified differences between the study settings and settings in low‐income countries or factors that would likely modify the effects in low‐income countries.
Agreements and disagreements with other studies or reviews
We identified three related overviews of reviews published in the last 10 years (Lewin 2008; Scott 2009; Brunton 2015). These overviews addressed a range of governance arrangements in diverse settings and populations. As with our overview, most of the studies included in those overviews were from high‐income countries, and data on patient outcomes, equity, costs and cost‐effectiveness were scarce. We describe the findings of the three overviews briefly below.
Brunton 2015 aimed to understand the components of community engagement and the contribution of active content to health and social outcomes. The overview included three reviews, which found that more extensive community engagement (i.e. where community members design, deliver and evaluate health interventions) was associated with improved behavioural outcomes. More extensive engagement across design, delivery and evaluation was noted in studies where community engagement processes included bidirectional communication, collective decision‐making and intervention delivery training support to community members.
Lewin 2008 reviewed the effects of governance, financial and delivery arrangements, and implementation strategies that have the potential to improve the delivery of cost‐effective interventions in primary health care in low‐ and middle‐income countries. It included 21 systematic reviews, one of which addressed governance strategies for working with the private for‐profit sector – including franchising, regulation and accreditation – to improve the use of quality health services by people in low‐income settings (Patouillard 2007). We excluded this particular review in the present overview and did not identify any other eligible reviews that addressed governance strategies for working with the private for‐profit sector. Lewin 2008 did not find any systematic reviews that addressed other questions about governance arrangements for primary health care, including decentralisation of decision‐making, the regulation of training, or the control of corruption.
Scott 2009 included 23 reviews and assessed public scorecards and performance reports, external accreditation and clinical governance arrangements. Review authors found that studies have not adequately evaluated these interventions. These quality improvement strategies are heterogeneous, and methodological flaws in much of the evaluative literature limit the validity and generalisability of results. The authors assert that, based on current best available evidence, clinician/patient‐driven quality improvement strategies appear to be more effective than manager/policymaker driven ones. Some of the included reviews would have been excluded from our overview as they are more than 10 years old; some are covered in the delivery and implementation overviews; and some reviews address interventions that we did not consider to be highly relevant to low‐income countries.
Review flow diagram.
| Governance arrangement | Applicability limitations | ||
| Findings | Interpretation | ||
| Authority and accountability for health policies | |||
| Interagency collaboration | All studies included in this review took place in high income countries. | The reality of local agencies in low‐income countries is probably very different to that in high‐income countries so results reported in this review should be applied with caution in low‐income countries settings. | |
| Decision‐making about what is covered by health insurance – restrictions on drug reimbursement | All of the included studies took place in high‐income countries. Thus there is uncertainty regarding the transferability of the results to low‐ and middle‐income country settings. Participants were mainly senior citizens or low‐income adult populations in publicly subsidised or administered pharmaceutical benefit plans. Only two of the studies included in this review reported health outcome data, precluding any conclusions about the impact of the policies on patient outcomes. | Applicability of these interventions to low‐income country settings depends on there being: – a regulatory framework; – an administrative and managerial system which support the implementation of the policy; –an insurance system with relatively broad medicines benefit; – efficient, timely access to patient‐specific information; – availability of preferred products incentivised by the re‐imbursement policy; – product quality assessments and prescriber and patient trust in the quality of preferred products. | |
| Policies to reduce corruption – fraud detection and response actions | There is no study from low income‐countries and only two from middle‐income countries. | Low‐income countries might be more prone and vulnerable to health care fraud and its consequences. When assessing the transferability of these findings to low‐income countries the following factors should be considered. – The availability of human and technical resources to combat fraud. – The acceptability and costs of the interventions. | |
| Authority and accountability for organisations | |||
| Subcontracting to non‐state not‐for‐profit providers | All of the studies took place in low‐ and middle‐income countries In the three included studies, the contracts were carried out with non‐governmental organisations (NGOs); no studies were found that evaluated contracts with private for‐profit providers. The studies provided very little description of the actual measures implemented by the contractor (management, organisation, salaries, and incentives) to achieve the goals established in the contract. | Differences in health systems; patient and physician attitudes to NGOs; and legal restrictions may limit applicability of the findings. Subcontracting can be a potentially effective strategy in particular settings but it may be difficult for governments to re‐deploy public funds to private providers when available funds are already committed to public services. Factors that need to be considered to asses whether the intervention effects are likely to be transferable include: – the availability of not‐for‐profit organisations to carry out the contracts; – the capacity within the public sector for set up and monitor the contracts. | |
| Multi‐institutional arrangements –social franchising | The review did not find any studies conducted in low‐ and middle‐income countries that met its inclusion criteria. | Although social franchising is currently used and advocated in low‐ and middle‐income countries, no rigorous evaluations of its impacts (both positive and negative) are available. | |
| Authority and accountability for commercial products | |||
| Registration – drugs | The studies were all undertaken in low‐ and middle‐income countries. The results suggest that drug registration, WHO prequalification of drugs, and multi‐faceted interventions may be effective in reducing the prevalence of counterfeit drugs. | The findings are applicable to low‐ and middle‐ income settings. However, a country's existing pharmaceutical supply chain and infrastructure, availability of routine data on quality of drugs, qualified and skilled personnel, and financial resources may facilitate the transferability of the findings. While registration may be effective, it should probably encompass both domestic manufacturers and importers and be complemented with routine postmarketing surveillance to sustain the quality of drugs circulating in the market. Countries that rely heavily on imported drugs may consider opting for drugs that are WHO‐prequalified. However, even among WHO‐prequalified products, the quality may vary depending on the country of export. The success of multifaceted interventions requires collaborations with drug regulatory bodies, skilled human resources, and technical capacity for routine drug inspections. | |
| Reference pricing | All of the 18 studies included were in high‐income countries. | The effectiveness of reference pricing policy in low‐income countries may depend on factors such as: – health systems structure and settings as copayments, reimbursment and cost share; – access to prices data sources; – availability of adequate incentives for healthcare providers, patients, physicians, pharmacists and pharmaceutical companies to comply with the reference pricing policy; – significant price differences between the drugs in the intervention group before reference pricing is introduced; – clear information for managers, clinicians and patients; – availability and access to drugs in the reference group; – a regulatory framework that allows generic substitution or prescribing by international non‐proprietary name (INN); – appropriate exemptions (exemptions that are too limited could lead to higher co‐payments for appropriate use of more expensive drugs and incentives to use a less effective drug. Exemptions that are too broad could reduce savings by not shifting drug use towards appropriate use of less expensive drugs.). | |
| Marketing regulations – Drugs direct‐to‐consumer advertising | The studies, all conducted in high‐income countries, show that direct‐to‐consumer advertising alters prescribing behaviour and volume, but no studies examined the impact of such advertising on health outcomes | Given the absence of any evidence of improvement in health outcomes from direct‐to‐consumer advertising, its benefits are uncertain in any setting. | |
| Authority and accountability for health professionals | |||
| Pre‐licensure education | All included studies took place in high‐income countries. | The challenges faced in health care 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 | Some observational studies, mostly from high‐income countries, suggest that some interventions, such as selecting students from rural areas, exposing students to clinical rotations in rural areas, or financial incentive programmes might increase the number of health professionals in underserved areas. However, the certainty of this evidence is very low. | 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 from high‐ to low‐income countries. | |
| Training/recruitment and retention strategies | The two included studies took place in low and middle income countries. Tested in a low income country, there is uncertainty about the impact of having private contracts (contract‐in districts) compared to public contracts of district health managers. | The capacity and strength of the government to oversee and supervise districts with private contracts could be an important issue to consider when it comes to assure the attainment of public regulations and goals. The level of power decentralisation in the districts might change the impact of policies related with health managers. The higher the degree of decentralisation, the higher the impact they might have. | |
| Movement of health workers between public and private organisations | No studies met the inclusion criteria for the review. | Health worker availability remains one of the key barriers to strengthening health systems in low‐income countries. Effective interventions to manage the movement of health professionals could help to address this and need to be evaluated rigorously. | |
| Emigration and immigration policies – reducing immigration restrictions | The available evidence is based on an intervention made in a high‐income country. | Policies in high‐income countries may have an effect on the number of health workers migrating from low‐ and middle‐income countries. Low‐ and middle‐income countries have little direct influence on high‐income country policies, including immigration policies. However, low‐ and middle‐income countries may attempt to influence such policies by means of diplomacy, lobbying, or public relations before they are enacted. | |
| Dual practice | No studies met the inclusion criteria for the review. | Dual practice may be more of a problem in low‐income countries, due to low wages in the public sector, and interventions to manage it may have different effects, e.g. the risk of health professionals migrating is likely to be greater in low‐income countries compared to high‐income countries. | |
| Authority and accountability for quality of practice – authority and accountability for quality of outpatient care – external inspection | Neither of the two studies included in this review took place in a low‐income country: one was done in South Africa and the other in England. Both studies assessed the effect of external inspection of compliance of different standards on quality of hospital services. According to the findings in this review, it is uncertain whether external inspection contributes or not to improve quality of health services in hospital setting. | External inspection of compliance standards may have varying acceptability and impact across different healthcare and cultural settings; may involve different components from training to organisational restructuring; and may impact in different ways on consumer and provider satisfaction across different settings Although quality of care is an objective of care in all health systems, it is not possible to be confident about the applicability of the reported interventions to low income countries and to settings other than hospital care | |
| Stakeholder involvement | |||
| Stakeholder participation in policy and organisational decisions – consumer involvement in preparing patient information | All the studies took place in high‐income countries. Some interventions used technologies such as telephones and email. Baseline levels of consumers involvement were not reported. | Strategies to overcome barriers such as low baseline levels of social participation and education should be explored when considering consumer involvement in low‐income countries. Training and support may be essential. The attitudes and the perspectives of health professionals and policymakers regarding consumer involvement should also be considered. As the availability of communication technologies may be a problem, face‐to‐face involvement may be most appropriate. | |
| Community mobilisation – women's groups practising participatory learning and action | All 7 studies took place in low‐and middle‐income countries, including Bangladesh, Malawi, India and Nepal. | The use of women's groups practicing participatory learning and action probably decreases newborn mortality and may reduce maternal mortality in rural areas in low‐income countries. However, its effectiveness may depend on participation of a substantial proportion of pregnant women. It might also depend on adequate supervision and support, home visits, access to care, improving the quality of care, and adequate resources. The intervention might be less effective in urban areas if there is less community cohesion and interaction among women included in women's groups, and higher baseline use of health services. | |
| Community mobilisation – community‐based dengue control | 10 out of 11 studies included in the systematic review took place in low‐ and middle‐income countries. | These findings are applicable to low‐income countries; however, the availability acceptability and costs of the interventions should be considered. | |
| Patient information – public disclosure of performance data | The studies, all conducted in high‐income countries, provided mixed evidence for using the public disclosure of performance data to improve the quality of care. | There is no evidence to date that the public disclosure of performance data affects the quality of care. Even if public disclosure were effective in improving quality of care in high‐income countries, the results would not be directly transferable to low‐income country settings because of differences in health infrastructure, the ability of health facilities and providers to produce accurate data, the capacity to disseminate the data, and the ability of consumers to interpret the data. There is a need for high‐quality studies of public disclosure of performance data in high‐, middle‐ and low‐income countries. | |
| aPriorities for primary research are based on the applicability limitations to low‐income countries of the governance arrangement interventions identified by the included reviews. We did not search for additional primary studies. | |||
| Governance arrangement | Included review | No studies | Very low certainty of evidence | Low certainty of evidence |
| Authority and accountability for health policies | ||||
| Interagency collaboration | PO, ACU, QoC, RU | PO | PO | |
| Decision‐making about what is covered by health insurance – Restrictions on drug reimbursement | QoC | PO | — | |
| Policies to reduce corruption – fraud detection and response actions | PO, ACU, QoC | RU | — | |
| Authority and accountability for organisations | ||||
| Subcontracting to non‐state not‐for‐profit providers | QoC, RU | — | PO, ACU | |
| Multi‐institutional arrangements Social franchising | PO, ACU, QoC, RU | — | — | |
| Authority and accountability for commercial products | ||||
| Registration – drugs | — | — | PO, ACU, QoC, RU | |
| Reference pricing – reference and index price | PO, QoC | — | ACU, RU | |
| Marketing regulations – drugs direct to consumer advertising | PO, QoC, RU | — | — | |
| Authority and accountability for health professionals | — | — | — | — |
| Training and licensing Pre‐licensure education – minority academic advising programme | PO, ACU, QoC, RU | — | — | |
| Recruitment and retention strategies | PO, ACU, QoC, RU | — | ||
| Training and licensing/recruitment and retention strategies | QoC, RU | PO, ACU | — | |
| Movement of health workers between public and private organisations | PO, ACU, QoC, RU | — | — | |
| Emigration and immigration policies – reducing immigration restrictions | PO, QoC, RU | — | — | |
| Dual practice | PO, ACU, QoC, RU | — | — | |
| Authority and accountability for quality of practice Authority and accountability for quality of outpatient care – external inspection | PO, ACU, RU | QoC | — | |
| Stakeholder involvement | ||||
| Stakeholder participation in policy and organisational decisions ‐ consumer involvement in preparing patient information | PO, ACU, RU | — | QoC | |
| Community mobilisation – women's groups practising participatory learning and action | ACU, QoC, RU | — | — | |
| Community mobilisation – community‐based dengue control | ACU, QoC, RU | — | — | |
| Patient information Public disclosure of performance data | QoC, RU | — | PO, ACU | |
| ACU: access, coverage and utilisation outcomes; PO: patient outcomes; QoC: quality of care outcomes; RU: resource use outcomes. | ||||
| Governance arrangement | What we found |
| Authority and accountability for health policies | |
| Decentralised versus centralised authority for health services | No reviews identified |
| Policies that regulate what drugs are reimbursed | No reviews identified |
| Policies that regulate what services are reimbursed | No reviews identified |
| Restrictions on reimbursement for health insurance | No reviews identified |
| Strategies for expanding health insurance coverage | No reviews identified |
| Policies to manage absenteeism | No reviews identified |
| Requirements for monitoring or evaluation | No reviews identified |
| Authority and accountability for organisations | |
| Ownership | Review in progress (Herrera 2013) |
| Stewardship of private health services | No reviews identified |
| Accreditation | No reviews identified |
| Provision of drug insurance | Review in progress (Pantoja 2015) |
| Provision of health insurance | No reviews identified |
| Policies that regulate interactions between donors and governments | No reviews identified |
| Governance arrangements for coordinating care across multiple providers | No reviews identified |
| Mergers | No reviews identified |
| Authority and accountability for commercial products | |
| Registration of health technology | No reviews identified |
| Patents and profits of drugs | No reviews identified |
| Patents and profits of health technology | No reviews identified |
| Pricing and purchasing policies of health technology and services | No reviews identified |
| Marketing regulations for health technology and services | No reviews identified |
| Sales and dispensing policies for drugs | Review in progress (Peñaloza 2015) |
| Liability for commercial products | No reviews identified |
| Authority and accountability for health professionals | |
| Licensure of health professionals | No reviews identified |
| Specialty certification | No reviews identified |
| Scope of practice | No reviews identified |
| Authority and accountability for quality assurance of hospital care | No reviews identified |
| Professional competence | No reviews identified |
| Professional liability | No reviews identified |
| Stakeholder involvement | |
| Community monitoring | No reviews identified |
| Patient information about drugs | No reviews identified |
| Patients' rights | No reviews identified |
| Governance: definitions |
|
|
| Stewardhip: definitions and features distinguishing it from governance |
| Stewardship is similar to the concept of public governance but, as envisaged by the WHO, is more specifically focused on the state's role in taking responsibility for the health and well‐being of the population, and guiding the health system as a whole (Travis 2003). Stewardship has been described as one of the four basic functions of health system organisations (Murray 2000). The other three functions in this model are financing, provision, and resource generation. Definitions of stewardship include the following.
|
| Governance arrangement | Definition |
| Authority and accountability for health policies | |
| Interagency collaboration | Collaboration and partnerships for health and social development between the health sector and other different sectors |
| Centralisation and decentralisation | Policies to regulate the degree of which managerial responsibilities are transferred to regional or local authorities in contrast to having them at the central level |
| District management | Policies that regulate the management of district health systems |
| Decision‐making about what or who is covered by health insurance | Processes for deciding what is reimbursed and who is covered by health insurance |
| Policies to reduce corruption | Policies for reducing corruption in the health sector |
| Policies to manage absenteeism | Regulations for managing absenteeism of health professionals |
| Requirements for monitoring or evaluation | Policies that regulate programme monitoring and evaluation |
| Authority and accountability for organisations | |
| Ownership | Policies that regulate who can own health service organisations |
| Stewardship of private health services | Policies that regulate health services provided by the private sector |
| Insurance | Policies that regulate the provision of insurance (e.g. who can provide insurance, mandatory open enrolment, coverage of essential drugs) |
| Accreditation | Processes for accrediting healthcare providers |
| Multi‐institutional arrangements | Policies for how multiple organisations work together |
| Authority and accountability for commercial products | |
| Registration | Procedures for registering or licensing commercial products (e.g. drugs) |
| Patents and profits | Policies that regulate patents and profits |
| Pricing and purchasing policies | Policies that determine the price that is paid or how commercial products are purchased |
| Marketing regulations | Policies that regulate marketing of commercial products |
| Sales and dispensing | Policies that regulate the sale and dispensing of drugs or other healthcare products |
| Liability for commercial products | Policies that regulate liability for commercial products |
| Authority and accountability for health professionals | |
| Training and licensing | Policies that regulate training and licensure requirements for health professionals |
| Scope of practice | Policies that regulate what health professionals can do |
| Recruitment and retention strategies | Policies that regulate where health professionals work (e.g. restrictions on where they can work or requirements to work in rural areas) |
| Emigration and immigration policies | Policies that regulate emigration and immigration of health professionals |
| Dual practice | Policies that regulate dual practice, in which health workers hold two or more jobs, for example in both the public or private sectors |
| Quality of practice | Policies or systems for assuring quality of care |
| Professional competence | Policies or procedures for assuring professional competence |
| Policies to manage absenteeism | Policies for managing absenteeism of health professionals |
| Professional liability | Policies that regulate liability for health professionals |
| Stakeholder involvement | |
| Stakeholder participation in policy and organisational decisions | Policies and procedures for involving stakeholders in decision‐making |
| Community mobilisation | Processes that enable people to organise themselves |
| Community monitoring | Monitoring of health services by individuals or community organisations |
| Patient information | Policies that regulate what information is provided to patients |
| Patients' rights | Policies that regulate patients' rights, including access to care and information |
| Governance arrangement | Definition |
| Authority and accountability for health policies | |
| Interagency collaboration | Policies to facilitate interagency collaboration, for instance, between local government and local health authorities in order to address social determinants of health, can contribute to improve health of the population. |
| Decentralisation and centralisation | Shifting authority closer to those who are affected might improve accountability, openness and participation, which might in turn lead to more appropriate priorities, more efficiency and less corruption, and in turn better health outcomes. |
| District management | Regulations that lead to improvements in the management of district health systems can improve access to and the quality of care, and in turn better health outcomes. |
| Decision‐making about what or who is covered by health insurance | Changes in processes used to decide what is reimbursed or who is covered by health insurance might improve access to cost‐effective interventions, and in turn lead to better health outcomes. |
| Policies to reduce corruption | Regulations that reduce corruption can increase the availability of resources for care, and in turn improve health outcomes. |
| Requirements for monitoring or evaluation | Policies that improve decisions about when and how healthcare programmes are monitored or evaluated can lead to better‐informed decisions, and in turn better health outcomes. |
| Authority and accountability for organisations | |
| Ownership | For‐profit health services might limit access for people who cannot afford to pay or divert funds from care to profits and taxes, which might result in poorer quality care and worse health outcomes. |
| Stewardship of private health services | Regulations that increase the accountability of the private sector might improve the quality of care, and in turn lead to better health outcomes. |
| Insurance | Changes in regulations that determine who can provide insurance, who receives it, who pays for it, and who makes decisions about reimbursement might affect coverage and access to care, and in turn health outcomes. |
| Accreditation | Changes in provider accreditation might improve the quality of care, and in turn health outcomes. |
| Multi‐institutional arrangements | Changes in how donors and governments work together might result in more effective and efficient use of resources, and in turn lead to better health outcomes. |
| Authority and accountability for commercial products | |
| Registration | Changes in how drugs or other health technologies are licensed might improve safety, and in turn health outcomes, |
| Patents and profits | Changes in patent regulations might affect the development and availability of drugs or other health technologies, and in turn health outcomes. |
| Pricing and purchasing policies | Regulations that reduce the price that is paid or how drugs or services are purchased might improve access to care, and in turn health outcomes. |
| Marketing regulations | Regulations that limit inappropriate marketing of drugs, other technologies or services might reduce inappropriate use and increase the availability of resources for cost‐effective care, and in turn improve health outcomes. |
| Sales and dispensing | Changes in who can sell drugs or other healthcare products might improve access or improve quality, and in turn health outcomes. |
| Liability for commercial products | Changes in liability for drugs, other technologies or services might improve safety, and in turn health outcomes. |
| Authority and accountability for health professionals | |
| Training and licensing | Regulations that improve training or licensure of health professionals might improve the safety and quality of care, and in turn health outcomes. |
| Scope of practice | Regulations that determine what health professionals can do might improve access to care or safety, and in turn health outcomes. |
| Recruitment and retention strategies | Regulations that determine where health professionals can work might improve access to care, and in turn health outcomes. |
| Emigration and immigration policies | Regulations that determine emigration or immigration of health professionals might improve access to care, and in turn health outcomes. |
| Dual practice | Regulations that affect the extent of dual practice might improve access to care, and in turn health outcomes. |
| Quality of practice | Policies or systems for assuring quality of care might improve the quality of care, and in turn health outcomes. |
| Professional competence | Policies or procedures for assuring professional competence might improve the safety and quality of care, and in turn health outcomes. |
| Policies to manage absenteeism | Regulations that reduce absenteeism can improve access to care, and in turn health outcomes. |
| Professional liability | Changes in liability for health professionals might improve safety or remove impediments to evidence‐based care, and in turn improve health outcomes. |
| Stakeholder involvement | |
| Stakeholder participation in policy and organisational decisions | Involving stakeholders in decision‐making might improve the overall decision‐making about how to use resources and organise care, and in turn lead to better health outcomes. |
| Community mobilisation | Processes that enable people to organise themselves might raise awareness, change behaviours and lead to improvements in access and utilisation of health services, and in turn improve health outcomes. |
| Community monitoring | Monitoring of health services by individuals or community organisations might help to ensure quality, improve access to care, and reduce corruption, and in turn improve health outcomes. |
| Patient information | Regulations that improve the extent to which patients are well‐informed might lead to better informed decisions, and in turn improve health outcomes. |
| Patients' rights | Policies that regulate patients' rights, such as access to care and information, might improve access and utilisation of health services and improve the quality of health services, and in turn improve health outcomes. |
| Governance arrangement | Included reviews |
| Authority and accountability for health policies | |
| Interagency collaboration | Collaboration between local health and local government agencies for health improvement (Hayes 2012) |
| Decentralisation and centralisation | No eligible systematic review found |
| District management | No eligible systematic review found |
| Decision‐making about what or who is covered by health insurance | |
| Policies that regulate what drugs are reimbursed | No eligible systematic review found |
| Policies that regulate what services are reimbursed | No eligible systematic review found |
| Restrictions on drug reimbursement | Pharmaceutical policies: effects of restrictions on reimbursement (Green 2010) |
| Restrictions on reimbursement for health insurance | No eligible systematic review found |
| Strategies for expanding health insurance coverage | No eligible systematic review found |
| Policies to reduce corruption | No evidence of the effect of the interventions to combat health care fraud and abuse: a systematic review of literature (Rashidian 2012) |
| Policies to manage absenteeism | No eligible systematic review found |
| Requirements for monitoring or evaluation | No eligible systematic review found |
| Authority and accountability for organisations | |
| Ownership | No eligible systematic review found |
| Stewardship of private health services | No eligible systematic review found |
| Contracting out | The impact of contracting out on health outcomes and use of health services in low and middle income countries (Lagarde 2009) |
| Accreditation | No eligible systematic review found |
| Regulation of insurance provision | |
| Provision of drug insurance | No eligible systematic review found |
| Provision of health insurance | No eligible systematic review found |
| Multi‐institutional arrangements | |
| Policies that regulate interactions between donors and governments | No eligible systematic review found |
| Social franchising | The effect of social franchising on access to and quality of health services in low‐ and middle‐income countries (Koehlmoos 2009) |
| Governance arrangements for coordinating care across multiple providers | No eligible systematic review found |
| Mergers | No eligible systematic review found |
| Authority and accountability for commercial products | |
| Registration | |
| Drugs | Interventions to combat or prevent drug counterfeiting: a systematic review (El‐Jardali 2015) |
| Health technology | No eligible systematic review found |
| Patents and profits | |
| Drugs | No eligible systematic review found |
| Health technology | No eligible systematic review found |
| Pricing and purchasing policies | |
| Drugs | Pharmaceutical policies: effects of reference pricing, other pricing, and purchasing policies (Acosta 2014) |
| Health technology and services | No eligible systematic review found |
| Marketing regulations | |
| Drugs | Benefits and harms of direct to consumer advertising: a systematic review (Gilbody 2005) |
| Health technology and services | No eligible systematic review found |
| Sales and dispensing | |
| Drugs | No eligible systematic review found |
| Health technology | No eligible systematic review found |
| Liability for commercial products | No eligible systematic review found |
| Authority and accountability for health professionals | |
| Training and licensing | |
| Pre‐licensure education | Effects of changes in the pre‐licensure education of health workers on health‐worker supply (Pariyo 2009) |
| Training district health system managers | Interventions for hiring, retaining and training district health system managers in low‐ and middle‐income countries (Rockers 2013) |
| Licensure | No eligible systematic review found |
| Specialty certification | No eligible systematic review found |
| Scope of practice | No eligible systematic review found |
| Recruitment and retention strategies | Interventions for increasing the proportion of health professionals practising in underserved communities (Grobler 2015) |
| Recruitment and retention strategies | Interventions for hiring, retaining and training district health system managers in low‐ and middle‐income countries (Rockers 2013) |
| Movement of health workers between public and private organisations | Financial interventions and movement restrictions for managing the movement of health workers between public and private organizations in low‐ and middle‐income countries (Rutebemberwa 2014) |
| Emigration and immigration policies | Interventions for controlling emigration of health professionals from low‐ and middle‐income countries (Peñaloza 2011) |
| Dual practice | Interventions to manage dual practice among health workers (Kiwanuka 2011) |
| Authority and accountability for quality of practice | |
| Authority and accountability for quality of outpatient care | External inspection versus external standards for improving healthcare organisation behaviour, healthcare professional behaviour or patient outcomes (Flodgren 2011) |
| Authority and accountability for quality assurance of hospital (inpatient) care | External inspection versus external standards for improving healthcare organisation behaviour, healthcare professional behaviour or patient outcomes (Flodgren 2011) |
| Professional competence | No eligible systematic review found |
| Professional liability | No eligible systematic review found |
| Stakeholder involvement | |
| Stakeholder participation in policy and organisational decisions | Methods of consumer involvement in developing healthcare policy and research, clinical practice guidelines and patient information material (Nilsen 2010) |
| Community mobilisation | Women's groups practicing participatory learning and action to improve maternal and newborn health in low‐resource settings: a systematic review and meta‐analysis (Prost 2013) |
| What do community‐based dengue control programmes achieve? A systematic review of published evaluations (Heintze 2007) | |
| Community monitoring | No eligible systematic review found |
| Patient information | |
| Drug information | No eligible systematic review found |
| Public disclosure of performance data | Systematic review: the evidence that publishing patient care performance data improves quality of care (Fung 2008) |
| Patients’ rights | No eligible systematic review found |
| Review ID | Excluded reviews | Reasons for exclusion |
| Financial incentives for return of service in underserved areas: a systematic review | Addressed by Grobler 2015 | |
| Quality of private and public ambulatory health care in low and middle income countries: systematic review of comparative studies | Addressed by upcoming Herrera 2013 | |
| Consumer involvement in health research: a review and research agenda | More than 10 years out of date | |
| Quality of care in for‐profit and not‐for‐profit nursing homes: systematic review and meta‐analysis | Not transferable to low‐income countries | |
| Systematic review of involving patients in the planning and development of health care | Addressed by Nilsen 2010 | |
| A systematic review and meta‐analysis of studies comparing mortality rates of private for‐profit and private not‐for‐profit hospitals. | More than 10 years out of date | |
| Comparison of mortality between private for‐profit and private not‐for‐profit hemodialysis centers | More than 10 years out of date | |
| Payments for care at private for‐profit and private not‐for‐profit hospitals: a systematic review and meta‐analysis | Not transferable to low‐income countries | |
| Community‐based health insurance in low‐income countries: a systematic review of the evidence | Addressed by Meng 2010 | |
| Public reporting in health care: how do consumers use quality‐of‐care information? A systematic review | Addressed by Fung 2008 | |
| Active pharmaceutical management strategies of health insurance systems to improve cost‐effective use of medicines in low‐ and middle‐income countries: a systematic review of current evidence. | Major limitations | |
| Health sector accreditation research: a systematic review | Major limitations | |
| The standard of healthcare accreditation standards: a review of empirical research underpinning their development and impact | Major limitations | |
| Effectiveness of intermediate care in nursing‐led in‐patient units | Not transferable to low‐income countries | |
| Provision of a surgeon’s performance data for people considering elective surgery | Addressed by Fung 2008 | |
| Strategies for expanding health insurance coverage in vulnerable populations | Scope of the Implementation overview | |
| Evidence from systematic reviews to inform decision making regarding financing mechanisms that improve access to health services for poor people. A policy brief prepared for the International Dialogue on Evidence‐Informed Action to Achieve Health Goals in Developing Countries IDEAHealth | Addressed by Lagarde 2009 | |
| Linking families and facilities for care at birth: what works to avert intrapartum‐related deaths? | Major limitations | |
| Staffing remote rural areas in middle‐ and low‐income countries: a literature review of attraction and retention | Addressed by Grobler 2015 | |
| The effectiveness of contracting‐out primary health care services in developing countries: a review of the evidence | Addressed by Lagarde 2009 | |
| Contracting for the delivery of community health services: a review of global experience | Addressed by Lagarde 2009 | |
| The public release of performance data: what do we expect to gain? A review of the evidence | More than 10 years out of date | |
| Expanding health insurance coverage in vulnerable groups: a systematic review of options | Addressed by Jia 2014 | |
| Community accountability at peripheral health facilities: a review of the empirical literature and development of a conceptual framework | Major limitations | |
| Private versus public strategies for health service provision for improving health outcomes in resource‐limited settings | Major limitations | |
| Comparison of tiered formularies and reference pricing policies: a systematic review | Addressed by Acosta 2014 | |
| Rural retention of human resources for health | Addressed by Grobler 2015 | |
| Can working with the private for‐profit sector improve utilization of quality health services by the poor? A systematic review of the literature | Major limitations | |
| Systematic review of the links between human resource management practices and performance | Major limitations | |
| Strategies for engaging the private sector in sexual and reproductive health: how effective are they? | More than 10 years out of date | |
| Can clinical governance deliver quality improvement in Australian general practice and primary care? A systematic review of the evidence | Addressed by Flodgren 2011 | |
| Community participation in rural primary health care: intervention or approach? | Addressed by Nilsen 2010 | |
| Impact of pharmaceutical prior authorisation policies: a systematic review of the literature | Addressed by Green 2010 | |
| Ranji 2007 | Effects of rapid response systems on clinical outcomes: systematic review and meta‐analysis | Scope of the Delivery overview |
| Nurse‐led clinics as an effective service for cardiac patients: results from a systematic review | Major limitations | |
| Can interventions improve health services from informal private providers in low and middle‐income countries? A comprehensive review of the literature | Major limitations | |
| Specialty board certification and clinical outcomes: the missing link | More than 10 years out of date | |
| Hospital ownership and financial performance: a quantitative research review | Not transferable to low‐income countries | |
| Physician dual practice: a review of literature | Addressed by Kiwanuka 2011 | |
| Improving antibiotic selection: a systematic review and quantitative analysis of quality improvement strategies | Addressed by New Reference | |
| Clinical governance in primary care: a literature review | Addressed by Phillips 2010 | |
| Examining characteristics, knowledge and regulatory practices of specialised drug shops in Sub‐Saharan Africa: a systematic review of the literature | Not a review of effects of interventions | |
| Working with the private sector for child health | More than 10 years out of date | |
| Motivation and retention of health workers in developing countries: a systematic review | Not a review of effects of interventions | |
| A critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas | Addressed by Grobler 2015 |
| Review | A. Identification, selection and critical appraisal of studiesa | B. Analysisb | C. Overallc | |||||||||||
| 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 | |
| + | + | + | + | + | + | + | + | + | + | + | + | No | + | |
| + | + | + | + | + | + | + | + | + | + | + | + | No | + | |
| + | + | + | + | + | + | + | + | NA | + | NA | + | No | + | |
| + | ? | + | + | + | + | + | + | + | + | + | + | No | + | |
| + | + | − | + | + | + | + | + | + | + | + | + | No | + | |
| + | + | + | + | + | + | + | + | + | + | + | + | No | + | |
| + | + | + | + | + | + | + | + | + | + | + | + | No | + | |
| + | + | + | + | + | + | + | + | + | + | + | + | No | + | |
| + | ? | + | ? | + | + | + | + | + | + | ? | + | No | + | |
| + | + | + | + | + | + | NA | NA | NA | NA | NA | NA | No | + | |
| + | + | + | + | + | + | NA | NA | NA | NA | NA | NA | No | + | |
| + | + | + | + | + | + | + | + | + | + | + | + | No | + | |
| + | + | + | + | + | + | + | + | + | + | + | + | No | + | |
| + | + | + | + | + | + | + | + | + | + | + | + | No | + | |
| + | + | + | + | + | + | + | + | + | + | + | + | No | + | |
| + | + | + | ? | + | + | + | + | + | + | + | + | No | ||
| ? | − | + | ? | + | − | ? | + | ? | + | NA | + | No | − | |
| + | ? | + | + | + | + | + | + | + | + | NA | + | No | + | |
| + | ? | + | + | + | + | NA | NA | NA | NA | NA | NA | No | + | |
| aIdentification, selection and critical appraisal of studies ‐ details of assessment criteria 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) bAnalysis ‐ details of assessment criteria 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) cOverall ‐ details of assessment criteria 1. Other considerations: are there any other aspects of the review not mentioned before which lead you to question the results? 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) | ||||||||||||||
| Governance arrangement | Key messages |
| Authority and accountability for health policies | |
| Interagency collaboration | ➡ Local interagency collaborative interventions may lead to little or no difference in physical health and quality of life compared with standard care. ➡ It is uncertain whether local interagency collaborative interventions decrease mortality or mental health symptoms. ➡ This review did not include any evidence from low‐income countries. |
| Decision‐making about what or who is covered by health insurance ‐ Restrictions on drug reimbursement | ➡ Restrictions on reimbursement in health insurance systems with substantial coverage for medicines probably decreases targeted drug use and expenditures on targeted drugs or drug classes. ➡ The effects of restrictions on reimbursement vary by drug and drug class, and by how the restrictions are implemented and enforced. ➡ The impacts of restrictions on health outcomes and health service utilisation are uncertain. ➡ All the studies were done in high‐income countries and participants were mainly senior citizens or low‐income adult populations whose medications were being paid for in whole or part through publicly funded drug benefit plans. ➡ There are no studies on the effect of reimbursement restrictions on equity. |
| Policies to reduce corruption | ➡ It is uncertain if prevention, detection or response interventions reduce healthcare fraud and abuse and related expenditures. ➡ None of the included studies took place in a low‐income country. |
| Authority and accountability for organisations | |
| Contracting out | ➡ Contracting out services to non‐state not‐for‐profit providers may increase access to and utilisation of health services. ➡ Patient outcomes may be improved and household health expenditures reduced by contracting out. ➡ None of the included studies presented evidence on whether contracting out was more effective than making a similar investment in the public sector. We are therefore uncertain of the effects of investing in contracting out compared to an equivalent investment in public sector health services. |
| Multi‐institutional arrangements ‐ Social franchising | ➡ We found no evidence regarding the effects of social franchising on access to or the quality of health services in low‐ and middle‐income countries. We are therefore uncertain of the effects of social franchising. ➡ There is a need for well‐designed experimental studies that are informed by the theoretical and empirical literature. |
| Authority and accountability for commercial products | |
| Registration ‐ Drugs | ➡ Certain regulatory measures, specifically drug registration, may decrease the prevalence of counterfeit and substandard drugs. It is uncertain whether licensing of drug outlets reduces the prevalence of counterfeit drugs or the failure rates of drugs undergoing quality testing. ➡ WHO prequalification of drugs may lead to a reduction in the failure rates of drugs undergoing quality testing. ➡ Multifaceted interventions (including a mix of regulations, training of inspectors, public‐private collaborations and legal actions against counterfeiters) may be effective in decreasing the prevalence of counterfeit and substandard drugs. ➡ All studies identified took place in low‐ and middle‐income countries. ➡ The transferability of the findings may be influenced by a country's existing pharmaceutical supply chain and infrastructure, the availability of routine data on drug quality, qualified and skilled personnel, and financial resources. |
| Pricing and purchasing policies ‐ Drugs | ➡ Reference pricing may reduce insurers' cumulative drug expenditures by shifting drug use from cost‐share drugs to reference drugs. ➡ Index pricing may increase the use of generic drugs, reduce the use of brand‐name drugs, slightly reduce the price of generic drugs, and have little or no effect on the price of brand‐name drugs. ➡ It is uncertain whether maximum pricing affects drug expenditures. ➡ The effects of these policies on healthcare utilisation or health outcomes is uncertain. ➡ None of the included studies took place in a low‐income country. ➡ The effects of other pharmaceutical pricing and purchasing policies are uncertain. |
| Marketing regulations ‐ Drugs | ➡ Direct‐to‐consumer advertising increases patient demand for advertised medicines and the number of related prescriptions by doctors. ➡ We found no studies that reported on the impact of direct‐to‐consumer advertising on health outcomes. We are therefore uncertain of their effects. ➡ In light of the lack of evidence of the benefits, potential harms, and costs of direct‐to‐consumer advertising: ‐ the value of policies that allow for the increased use of direct to consumer advertising is uncertain at best; and ‐ rigorous monitoring and evaluation are warranted if such policies are implemented. |
| Authority and accountability for health professionals | |
| Training and licensing ‐ 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: ‐ increase the number of minority students enrolled in health sciences; ‐ slightly increase retention through to graduation; ‐ decrease differences in retention levels through to graduation between minority and non‐minority students in the health sciences. ➡ We found no studies of the effects of other pre‐licensure measures to increase health worker supply. |
| Training and licensing ‐ Training district health system managers | ➡ Private contracting ("contracting in") of district health managers compared to direct employment by the Ministry of Health may improve access and utilisation of healthcare. It is uncertain whether contracting in improves health outcomes. ➡ Intermittent training programmes may increase knowledge of planning processes and monitoring and evaluation skills of district managers. ➡ The effects of other interventions are uncertain, including changes in how district managers are hired, strategies for retaining district managers such as making the positions more attractive, and other training programmes such as in‐service workshops with onsite support. |
| 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 in underserved areas ‐ Educational interventions (e.g. student selection criteria, undergraduate and postgraduate teaching curricula, exposure to rural and urban underserved areas) ‐ Financial interventions (e.g. undergraduate and postgraduate bursaries or scholarships linked to future practice location, rural allowances, increased public sector salaries) ‐ Regulatory strategies (e.g. compulsory community service, relaxing work regulations imposed on foreign medical graduates who are willing to work in rural or urban underserved areas) ‐ Personal and professional support strategies (e.g. providing adequate professional support and attending to the needs of the practitioners family) |
| Recruitment and retention strategiesRockers 2013 | ➡ Private contracting ("contracting in") of district health managers compared to direct employment by the Ministry of Health may improve access and utilisation of healthcare. It is uncertain whether contracting in improves health outcomes. ➡ Intermittent training programmes may increase knowledge of planning processes and monitoring and evaluation skills of district managers. ➡ The effects of other interventions are uncertain, including changes in how district managers are hired, strategies for retaining district managers such as making the positions more attractive, and other training programmes such as in‐service workshops with onsite support. |
| Movement of health workers between public and private organisations | ➡ No rigorous studies have evaluated the effects of interventions to manage the movement of health workers between public and private organisations. ➡ There is a need for well‐designed studies to evaluate the impact of interventions that attempt to regulate health worker movement between public and private organisations in low‐income countries. |
| Emigration and immigration policies | ➡ Lowering immigration restrictions in high‐income countries probably increases the migration of nurses from low‐ and middle‐income countries to high‐income countries. The effectiveness of interventions implemented in low‐ and middle‐income countries to decrease the emigration of health professionals is uncertain. No studies were found that evaluated such interventions. ➡ Low‐ and middle‐income countries should monitor changes in high‐income countrie immigration legislation, model the impact of proposed migration changes on their own retention of domestic health professionals, and lobby for immigration laws in high‐income countries that consider the health system needs of source countries. ➡ Rigorous studies are needed of the effectiveness of interventions designed to decrease the emigration of health professionals, particularly the effectiveness of interventions in low‐ and middle‐income countries. |
| Dual practice | ➡ No studies met the inclusion criteria for the review, as no rigorous studies have evaluated the effects of interventions to manage dual practice. ➡ There is a need for well‐designed studies to evaluate the impact of interventions that attempt to regulate health worker dual practice in low‐income countries. |
| Authority and accountability for quality of practice ‐ Authority and accountability for quality of outpatient care ‐ Authority and accountability for quality assurance of hospital (inpatient) care | ➡ It is uncertain whether external inspection results in improved compliance with accreditation standards, improved quality of care or decreased healthcare‐acquired infection (i.e. methicillin‐resistant Staphylococcus aureus) rates in hospitals. ➡ This review found no direct evidence on the effectiveness of external inspections of compliance with standard in ambulatory settings. We are therefore uncertain of the effects in this setting. ➡ This review found no direct evidence on the effectiveness of external inspections of compliance with standards in low‐income countries. |
| Stakeholder involvement | |
| Stakeholder participation in policy and organisational decisions | ➡ Consumer consultations in developing patient information probably: ‐ facilitate the development of material that is more relevant, readable and understandable to patients; ‐ improve patient knowledge; ‐ make little or no difference in decreasing the anxieties that patients may associate with clinical procedures. ➡ Consumer interviewers may lead to small differences in the results of satisfaction surveys compared to healthcare professional interviewers. ➡ It is uncertain whether telephone discussions compared with face‐to‐face meetings change consumer priorities for community health goals. ➡ Consumer consultation in the development of consent documents may have little or no impact on self‐reported participant understanding of the trial described in the consent document, satisfaction with study participation, adherence to the protocol or refusal to participate ➡ There are good arguments for introducing consumer involvement in low‐income countries. To accomplish this: ‐ strategies to overcome barriers such as low baseline levels of social participation, organisation and education should be explored; ‐ efforts to include consumers or families of disadvantaged groups should be considered in order to achieve inclusive representation; ‐ evaluations are needed of the effects of consumer involvement on healthcare decisions and how to achieve more effective consumer involvement. |
| Community mobilisation | ➡ Women's groups practising participatory learning and action probably improve newborn survival, may improve maternal survival, may slightly reduce stillbirths, and may be a cost‐effective strategy in rural areas in low‐ and middle‐income countries. ➡ The effectiveness of women's groups may depend on participation of a substantial proportion of pregnant women, adequate supervision and support, home visits, access to care, improving the quality of care, and adequate resources. |
| Community mobilisation | ➡ Multi‐component community‐based dengue control programmes may reduce mosquito larval indices. ➡ Multi‐component community‐based dengue control programmes combined with chemical larvicides may reduce mosquito larval indices. ➡ Multi‐component community‐based dengue control programmes combined with fish and chemical larvicides may reduce mosquito larval indices. ➡ Multi‐component community‐based dengue control programmes combined with the use of crustaceans that eat mosquito larvae (Mesocyclops copepods) may reduce mosquito larval indices. ➡ It is uncertain whether multi‐component community‐based dengue control programmes combined with the use of crustaceans that eat mosquito larvae (Mesocyclops copepods) reduce dengue incidence. ➡ Most studies took place in low‐ and middle‐income countries. |
| Patient information ‐ Public disclosure of performance data | ➡ Public disclosure of performance for health plans: ‐ may lead to patients selecting health plans that have better quality ratings; ‐ has uncertain effects on quality improvement activities; ‐ may slightly improve health outcomes. ➡ Public disclosure of performance for hospitals: ‐ may lead to little or no difference in patient selection of hospitals; ‐ probably stimulates quality improvement activities; ‐ may improve health outcomes. ➡ Public disclosure of performance for individual healthcare providers: ‐ probably leads to patients selecting providers that have better quality ratings; ‐ has uncertain effects on quality improvement activities; ‐ may improve health outcomes. ➡ All of the included studies took place in high‐income countries. ‐ Public disclosure of performance may be difficult to implement in low‐income countries because of limitations of the ability of health facilities and providers to produce accurate data, the capacity to disseminate the data, the ability of patients to interpret the data and, in some places, the lack of choice available in terms of facilities or providers. |
| Direction of effects and certainty of the evidencea | |||||||||
| Governance arrangement | Patient outcomes | Access, coverage, utilisation | Quality of care | Resource use | Social outcomes | Impacts on equity | Health care provider outcomes | Adverse effects b | Other |
| Authority and accountability for health policies | |||||||||
| Interagency collaboration | ? ⊕⊖⊖⊖ ∅⊕⊕⊖⊖c | NR | NR | NR | ∅⊕⊕⊖⊖d | NR | NR | NR | NR |
| Decision‐making about what is covered by health insurance – restrictions on drug reimbursement | ? ⊕⊖⊖⊖e | ✔⊕⊕⊕⊖f | NR | ✔⊕⊕⊕⊖f | NR | NR | NR | NR | NR |
| Policies to reduce corruption – fraud detection and response actions | NR | NR | NR | ?⊕⊖⊖⊖g | NR | NR | NR | NR | NR |
| Authority and accountability for organisations | |||||||||
| Contracting out – to non‐state not‐for–profit providers | ✔⊕⊕⊖⊖h | ✔⊕⊕⊖⊖i | NR | NR | NR | NR | NR | NR | NR |
| Multi‐institutional arrangements – social franchising | NS | NS | NS | NS | NS | NS | NS | NS | NS |
| Authority and accountability for commercial products | |||||||||
| Registration – drugs | NR | NR | NR | NR | NR | NR | NR | NR | ✔⊕⊕⊖⊖j |
| Pricing and purchasing policies – medicines – reference pricing | NR | ✔⊕⊕⊖⊖k | NR | ✔⊕⊕⊖⊖k | NR | NR | NR | NR | NR |
| Pricing and purchasing policies – medicines – index pricing | NR | ✔⊕⊕⊖⊖l | NR | ∅⊕⊕⊖⊖m | NR | NR | NR | NR | NR |
| Marketing regulations – medicines direct‐to‐consumer advertising | NS | ✔✕⊕⊕⊕⊕n | NR | NS | NR | NR | NR | NR | NR |
| Authority and accountability for health professionals | |||||||||
| Training and licensing – pre‐licensure education – minority academic advising programme | NR | NR | NR | NR | NR | ✔⊕⊕⊖⊖o | NR | NR | NR |
| Training and licensing – manager training programme versus no training | NR | NR | NR | NR | NR | NR | NR | NR | ✔⊕⊕⊖⊖p |
| Recruitment and retention strategies – health professionals in underserved areas | NS | NS | NS | NS | NS | ?⊕⊖⊖⊖q | NS | NS | NS |
| Recruitment and retention strategies – private versus public contracts of district health managers | ?⊕⊖⊖⊖r | ✔⊕⊕⊖⊖r | NR | NR | NR | NR | NR | NR | NR |
| Movement of health workers between public and private organisations | NS | NS | NS | NS | NS | NS | NS | NS | NS |
| Emigration and immigration policies – reducing immigration restrictions | NS | ✕⊕⊕⊕⊖s | NS | NS | NR | NR | NR | NR | NR |
| Dual practice | NR | NS | NS | NS | NS | NS | NS | NR | NR |
| Authority and accountability for quality of practice – authority and accountability for quality of outpatient care – external inspection | NS | NS | ? ⊕⊖⊖⊖t | NR | NR | NR | NS | NR | NR |
| Stakeholder involvement | |||||||||
| Stakeholder participation in policy and organisational decisions – communication forums | NS | NS | NS | NS | NS | NS | NS | NS | ? ⊕⊖⊖⊖u |
| Stakeholder participation in policy and organisational decisions – consumer involvement in research | NS | NS | ✔⊕⊕⊖⊖v | NS | NS | NS | NS | NS | ∅⊕⊕⊖⊖w |
| Stakeholder participation in policy and organisational decisions – consumer involvement in preparing patient information | ∅⊕⊕⊕⊖x | NS | NS | NS | NS | NS | NS | NS | ✔⊕⊕⊕⊖y |
| Community mobilisation – women's groups practising participatory learning and action | ✔⊕⊕⊖⊖z ✔⊕⊕⊕⊖aa | NS | NS | NS | NS | NS | NS | NS | NS |
| Community mobilisation – community‐based dengue control | ✔⊕⊕⊖⊖bb ✔⊕⊕⊖⊖cc ? ⊕⊖⊖⊖dd | NS | NS | NS | NS | NS | NS | NS | NS |
| Patient information – public disclosure of performance data – health plans | ∅⊕⊕⊖⊖ee | ✔⊕⊕⊖⊖ff | NS | NS | NS | NS | NS | NS | NS |
| Patient information – public disclosure of performance data – hospitals | ✔⊕⊕⊖⊖gg | ✔⊕⊕⊖⊖hh | ✔⊕⊕⊕⊖ii | NS | NS | NS | NS | NS | NS |
| Patient information – public disclosure of performance data –individual healthcare providers | ✔⊕⊕⊖⊖jj | ✔⊕⊕⊕⊖kk | NS | NS | NS | NS | NS | NS | NS |
| The certainty of the evidence is an assessment of how good an indication the research provides of the likely effect; i.e. the likelihood that the effect will be substantially different from what the research found. By 'substantially different' we mean a large enough difference that it might affect a decision. These judgements are made using the GRADE system and the following definitions. | |||||||||
| Ratings | Definitions | Implications | |||||||
| ⊕⊕⊕⊕ High | This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different is low. | This evidence provides a very good basis for making a decision about whether to implement the intervention. Impact evaluation and monitoring of the impact are unlikely to be needed if it is implemented. | |||||||
| ⊕⊕⊕⊖ Moderate | This research provides a good indication of the likely effect. The likelihood that the effect will be substantially different is moderate. | This evidence provides a good basis for making a decision about whether to implement the intervention. Monitoring of the impact is likely to be needed and impact evaluation may be warranted if it is implemented. | |||||||
| ⊕⊕⊖⊖ Low | This research provides some indication of the likely effect. However, the likelihood that it will be substantially different is high. | This evidence provides some basis for making a decision about whether to implement the intervention. Impact evaluation is likely to be warranted if it is implemented. | |||||||
| ⊕⊖⊖⊖ Very low | This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different is very high. | This evidence does not provide a good basis for making a decision about whether to implement the intervention. Impact evaluation is very likely to be warranted if it is implemented. | |||||||
| a✓: a desirable effect; ∅: little or no effect; ?: an uncertain effect; ✕: an undesirable effect; NS: no studies found by this review that reported this outcome; NR: outcome not reported by this review. | |||||||||
| Interventions found to have desirable effects on at least one outcome with moderate‐ or high‐certainty evidence and no moderate‐ or high‐certainty evidence of undesirable effects |
| Authority and accountability for health policies |
| Decision‐making about what is covered by health insurance
|
| Authority and accountability for commercial products |
| Marketing regulations
|
| Stakeholder participation in policy and organisational decisions |
| Community mobilisation
|
| Patient information
|
|
|
| Interventions for which the certainty of the evidence was low or very low (or no studies were found) for all outcomes examined |
| Authority and accountability for health policies |
|
|
| Authority and accountability for organisations |
|
|
| Authority and accountability for commercial products |
|
|
| Authority and accountability for health professionals |
|
|
| Stakeholder participation in policy and organisational decisions |
|
|
| aFor this intervention, the direction of the effect depends on the medicine. For instance, for essential medicines this may be a desirable effect (and is therefore listed as such above) but for non‐essential medicines this may be a undesirable effect. |
