Four new Cochrane EPOC overviews of reviews show reliable evidence on the effects of different ways of organising, financing, and governing health systems in low-income countries and identify important evidence gaps.
Strengthening health systems in low-income countries is key to achieving universal health coverage and achieving the health-related Sustainable Development Goals. Achieving these goals requires informed decisions about health systems. Systematic reviews on the effects of different health system arrangements are essential for making informed decisions, and many such reviews are available. However, policymakers and other stakeholders may struggle to identify which reviews are reliable and what are the key results.
Broad overviews of the findings of systematic reviews can help policymakers, their support staff, and other stakeholders to identify strategies for addressing problems with how their health systems are organised, financed, and governed and with identifying effective strategies for implementing changes. It can also help to identify needs and priorities for new evaluations of health system arrangements and for systematic reviews.
A team of Cochrane researchers from Argentina, Chile, Norway, and South Africa prepared four overviews of the available evidence from up-to-date systematic reviews about the effects of health system arrangements in low-income countries. They included 124 systematic reviews in the four overviews. For each review, a user-friendly summary of key findings was produced (see http://supportsummaries.org/), enabling users to explore the overview findings in more depth. The summaries include over 480 key messages about the effects of health system arrangements in low-income countries.
An overview of delivery arrangements included 50 systematic reviews that included a total of 919 studies. These reviews found that that many delivery arrangements probably have desirable effects, including task shifting or role expansion and strategies for coordinating care.
An overview of financial arrangements included 15 systematic reviews that included a total of 276 studies. The effects of most of the financial arrangements that were reviewed were uncertain. This includes the effects of providing financial incentives and disincentives for health care workers, and the effects of most types of financial incentives and disincentives for people using health services.
An overview of governance arrangements included 21 systematic reviews that included a total of 172 studies. These reviews found that restrictions on medicines reimbursement (pre-authorisation), community mobilisation, and disclosing to the public performance data on health facilities and providers probably have desirable effects. The effects of other governance arrangements that were reviewed were uncertain.
An overview of implementation strategies included 39 systematic reviews that included a total of 1332 studies. These reviews found that many different implementation strategies probably improve professional practice, including educational meetings, educational outreach, practice facilitation, local opinion leaders, audit and feedback, and tailored interventions. Many strategies targeted at healthcare recipients also probably have desirable effects on the use of health care. For example, mass media interventions lead to an increase in immediate uptake of HIV testing and reminders and recall strategies for caregivers probably increase routine childhood vaccination uptake.
For the health system arrangements that were considered in the included systematic reviews, there was high or moderate certainty evidence for 37% (65 out of 176) of the comparisons of different delivery arrangements, 34% (20 out of 59) of the comparisons of different implementation strategies, 29% (6 out of 21) of the comparisons of governance arrangements, and 17% (3 out of 18) of the comparisons of implementation strategies.
Dr Simon Lewin, one of the overview authors and the Joint Coordinating Editor of the Cochrane EPOC Group noted that “These overviews are a key source of evidence for decision makers in low-income countries who are considering options for strengthening the health system in their setting. The overviews use a unique approach, based on user-friendly summaries of each contributing review, and we hope that this will make the evidence identified much more accessible to decision makers and those who support them.”
Dr Andy Oxman, another one of the overview authors and a Senior Researcher at the Norwegian Institute of Public Health added: “On the one hand, these overviews show that there is a large body of evidence that can inform decisions about health systems in low-income countries. On the other hand, they show that there are many important gaps in what is known. In addition to using the evidence identified in these overviews to inform their decisions, health policymakers and those who support them should routinely consider rigorously evaluating the effects of decisions to change health system arrangements when there are important uncertainties about the benefits and harms.”
For more information please contact; Simon Lewin: Simon.Lewin@fhi.no