Elsevier

The Lancet

Volume 372, Issue 9642, 13–19 September 2008, Pages 928-939
The Lancet

Series
Supporting the delivery of cost-effective interventions in primary health-care systems in low-income and middle-income countries: an overview of systematic reviews

https://doi.org/10.1016/S0140-6736(08)61403-8Get rights and content

Summary

Strengthening health systems is a key challenge to improving the delivery of cost-effective interventions in primary health care and achieving the vision of the Alma-Ata Declaration. Effective governance, financial and delivery arrangements within health systems, and effective implementation strategies are needed urgently in low-income and middle-income countries. This overview summarises the evidence from systematic reviews of health systems arrangements and implementation strategies, with a particular focus on evidence relevant to primary health care in such settings. Although evidence is sparse, there are several promising health systems arrangements and implementation strategies for strengthening primary health care. However, their introduction must be accompanied by rigorous evaluations. The evidence base needs urgently to be strengthened, synthesised, and taken into account in policy and practice, particularly for the benefit of those who have been excluded from the health care advances of recent decades.

Introduction

In 1978, representatives from 134 countries gathered in Alma-Ata in the former USSR and declared that primary health care, “based on practical, scientifically sound and socially acceptable methods and technology made universally accessible through people's full participation”,1 was key to delivering health for all by the year 2000. Recent years have seen a renewed interest in primary health care, particularly in low-income and middle-income countries. Reasons for this renewed interest include profound inequities in health; inadequate progress towards the Millennium Development Goals, especially in sub-Saharan Africa;2, 3, 4 major shortfalls in the human resources needed to improve delivery of cost-effective interventions;5, 6 and the fragmented and weakened state of health systems in many countries.7

Key messages

  • Financial incentives can be used to influence provider and patient behaviours, but can also have undesirable effects

  • User fees reduce the use of both essential and non-essential health services. However, removal of user fees needs to be implemented with care since it can have undesirable consequences. Alternative health financing strategies have not been adequately assessed

  • Task shifting, for example from doctors to nurses and from health professionals to lay providers, offers opportunities for expanding coverage and addressing human resource shortfalls

  • Although multiple vertical programmes can lead to service duplication, fragmentation, and inefficiency, the effects of strategies to integrate primary health-care services have not been assessed adequately

  • Quality improvement strategies, including those tailored to address identified barriers, can have important, although modest, effects on primary health-care quality

More generally, there have been calls to redress the balance between the now dominant vertical, disease-focused programmes and the horizontal, systems-focused perspective that underpins most approaches for primary health care.8 The GAVI Alliance, for example, has committed US$800 million over a 5-year period to help countries overcome health system weaknesses that impede sustainable increases in immunisation coverage,9 and the Global Fund to Fight AIDS, Tuberculosis and Malaria is also calling for integrated responses.10

Strengthening health systems to improve the delivery of cost-effective interventions is complicated by differing ideas of what constitutes primary health care. This is affected, in part, by financial and human resources and the underlying political and ideological perspective of different countries. The broader approach for primary health care is seen as encompassing equitable distribution, community participation, an emphasis on prevention, the use of appropriate technology, and the involvement of of a diverse range of health and other departments.11 By contrast, narrower views of primary health care, often from high-income settings, emphasise the first contact of the patient with the health care system and focus specifically on the roles of health professionals.12, 13

There are also differing iseas of what constitutes health systems. WHO's building blocks of health systems include leadership and governance, financing, service delivery, health workforce, medical products and technologies, and information and evidence.14 A taxonomy of health system arrangements provides additional categorisation, distinguishing between governance arrangements (political, economic, and administrative authority in the management of health systems),15 financial arrangements (funding and incentive systems, as well as financing), delivery arrangements (human resources for health, as well as service delivery), and interventions (programmes, services, and technologies).16 Most descriptions of health system elements omit the implementation strategies to support the use of cost-effective interventions.17, 18

In this overview we summarise the evidence from systematic reviews on 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-income and middle-income countries. We do not address specific clinical or public health interventions but rather the health system arrangements and implementation strategies that support their delivery in primary health care. We discuss how the available evidence relates to both the aspirations of the Alma-Ata Declaration and a taxonomy of health system arrangements (panel 1). We have also reviewed indicators of the relevance of reviews to primary health care in low-income and middle-income countries, graded the strength of evidence, and identified applicability and equity considerations.

Section snippets

Methods

We searched two electronic databases of systematic reviews: the Cochrane Effective Practice and Organisation of Care (EPOC) register of systematic reviews and the Program in Policy Decision-Making/Canadian Cochrane Network and Centre (PPD/CCNC) database of systematic reviews of the effects of governance, financial, and delivery arrangements. The EPOC register of systematic reviews included 1020 records as of Feb 12, 2008. These were identified through electronic searches of Medline (up to

Results

Over 20 000 references were screened to develop the EPOC and PPD/CCNC databases. By screening the abstracts, 195 of over 1000 reviews were deemed potentially relevant, and 20 systematic reviews were selected on the basis of their relevance and the feasibility of reviewing them within resource and time constraints (figure). These reviews included a total of 812 randomised controlled trials, interrupted time-series studies, and controlled before-and-after assessments, although some studies were

Discussion

Most of the included reviews were of high quality, with only minor deficiencies, although the primary research that was reviewed was often of low-to-moderate quality. This overview has several limitations which result partly from the relative dearth of evidence from low-income and middle-income countries and partly from the need to focus on the most relevant reviews. We assessed only systematic reviews and might therefore have excluded non-systematic reviews with useful information, as well as

References (76)

  • International Conference on Primary Health Care A-A, USSR, 6–12 September. Declaration of Alma-Ata;...
  • A Haines et al.

    Can the millennium development goals be attained?

    BMJ

    (2004)
  • DM Sanders et al.

    Confronting Africa's health crisis: more of the same will not be enough

    BMJ

    (2005)
  • The Millennium Development Goals for health: rising to the challenges

    (2004)
  • World Health Report 2006: Working Together for Health

    (2006)
  • Informed choices for attaining the Millennium Development Goals: towards an international cooperative agenda for health-systems research

    Lancet

    (2004)
  • Health system strengthening

  • Fact Sheet: The Global Fund's approach to health systems strengthening

  • G Walt et al.

    An introduction to the primary health care approach in developing countries. A review with selected annotated references

    (1981)
  • J De Maeseneer et al.

    Primary health care as a strategy for achieving equitable care: a literature review commissioned by the Health Systems Knowledge Network

    (2007)
  • S Bennett

    What is health policy and systems research and why does it matter?

    (2007)
  • Ninth Futures Forum on health systems governance and public participation

    (2006)
  • JN Lavis et al.

    Examining the role of health services research in public policymaking

    Milbank Q

    (2002)
  • A Haines et al.

    Bridging the implementation gap between knowledge and action for health

    Bull World Health Organ

    (2004)
  • F Althabe et al.

    Strategies for improving the quality of health care in maternal and child health in low- and middle-income countries: an overview of systematic reviews

    Paediatr Perinat Epidemiol

    (2008)
  • Supporting policy relevant reviews and trials

  • GH Guyatt et al.

    GRADE: an emerging consensus on rating quality of evidence and strength of recommendations

    BMJ

    (2008)
  • M Lagarde et al.

    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). Geneva: Alliance for Health Policy and Systems Research

  • LA Grobler et al.

    Interventions for increasing the proportion of health professionals practising in under-served communities (protocol)

    Cochrane Database Syst Rev

    (2005)
  • S Lewin et al.

    Lay health workers in primary and community health care: A systematic review of trials

    (2006)
  • LM Sibley et al.

    Traditional birth attendant training for improving health behaviours and pregnancy outcomes

    Cochrane Database Syst Rev

    (2007)
  • A Akbari et al.

    Interventions to improve outpatient referrals from primary care to secondary care

    Cochrane Database Syst Rev

    (2005)
  • E Patouillard et al.

    Can working with the private for-profit sector improve utilization of quality health services by the poor? A systematic review of the literature

    Int J Equity Health

    (2007)
  • M Lagarde et al.

    Conditional cash transfers for improving uptake of health interventions in low- and middle-income countries: a systematic review

    JAMA

    (2007)
  • A Austvoll-Dahlgren et al.

    Pharmaceutical policies: effects of cap and co-payment on rational drug use

    Cochrane Database Syst Rev

    (2008)
  • LA Petersen et al.

    Does pay-for-performance improve the quality of health care?

    Ann Intern Med

    (2006)
  • ME Hulscher et al.

    Interventions to implement prevention in primary care

    Cochrane Database Syst Rev

    (2001)
  • CJ Briggs et al.

    Strategies for integrating primary health services in middle- and low-income countries at the point of delivery

    Cochrane Database Syst Rev

    (2006)
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      PHC also improved health coverage, lowered the service cost, reduced morbidity, and mortality, and improved the overall health systems [6]. The cost-effective interventions harbored by PHC are promising in the context of LMICs [7]. In low-resource settings, engaging the community and utilizing PHC brings positive results in addressing the emerging disease burden caused by non-communicable diseases (NCDs) [8].

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