BACKGROUND: Mixed health care systems to work simultaneously on both public and private facilities, is common today. This phenomenon referred to as dual practice (DP), has potential implications for access, quality, cost and equity of health services. This paper aimed to review systematically studies that assess the implications of DP among health workers.
METHODS: MEDLINE, EMBASE, and The Cochrane library were searched for obtaining published literature between Feb 1990 and May 2014. Google and Google Scholars, organizational websites, and reference lists of relevant papers searched to get grey literature. Only studies concentrated on consequences and impacts of DP among health professionals and conducted using "randomized controlled trials", "non-randomized controlled trials", "controlled before and after studies", or "interrupted time series" were eligible for inclusion.
RESULTS: From 3242 records, we focused on 19 studies, which aimed to assess effects and impacts of dual practice. After that, the current understanding of DP positive and negative implications was categorized and discussed based on two perspectives.
CONCLUSION: There has been a propensity to over-reliance on theoretical methods in predicting the implications of this phenomenon. Almost all of the mentioned implications are based on theoretical predictions undermined in the broader literature. Furthermore, assessing the current literature showed positive and negative impacts of DP on different parts of the health system and various dimensions of service delivery. These implications are contexted specific and may vary from system to system.
In low- and middle-income countries (LMICs), the private sector-including international donors, non-governmental organizations, for-profit providers and traditional healers-plays a significant role in health financing and delivery. The use of the private sector in furthering public health goals is increasingly common. By working with the private sector through public -: private engagement (PPE), states can harness private sector resources to further public health goals. PPE initiatives can take a variety of forms and understanding of these models is limited. This paper presents the results of a Campbell systematic literature review conducted to establish the types and the prevalence of PPE projects for health service delivery and financing in Southern Africa. PPE initiatives identified through the review were categorized according to a PPE typology. The review reveals that the full range of PPE models, eight distinct models, are utilized in the Southern African context. The distribution of the available evidence-including significant gaps in the literature-is discussed, and key considerations for researchers, implementers, and current and potential PPE partners are presented. It was found that the literature is disproportionately representative of PPE initiatives located in South Africa, and of those that involve for-profit partners and international donors. A significant gap in the literature identified through the study is the scarcity of information regarding the relationship between international donors and national governments. This information is key to strengthening these partnerships, improving partnership outcomes and capacitating recipient countries. The need for research that disaggregates PPE models and investigates PPE functioning in context is demonstrated.
BACKGROUND: Public-private mix (PPM), recommended by the World Health Organization (WHO), was introduced to cope with the tuberculosis (TB) epidemic worldwide. In many developing countries, PPM has played a powerful role in TB control, while in others it has failed to meet expectations. Thus we performed a systematic review to determine the mechanisms used by global PPM programs implemented in different countries and to evaluate their performance.
METHODS: A comprehensive search of the current literature for original studies published up to May 2014 was done using electronic databases and online resources; these publications were then screened using rigorous criteria. Descriptive information and evaluative outcomes data were extracted from eligible studies for synthesis and analysis.
RESULTS: A total of 78 eligible studies were included in the final review. These assessed 48 PPM TB programs worldwide, subsequently categorized into three mechanisms based on collaborative characteristics: support, contract, and multi-partner group. Furthermore, we assessed the effectiveness of PPM programs against six health system themes, including utilization of the directly observed treatment strategy (DOTS), case detection, treatment outcomes, case management, costs, and access and equity, under the different collaborative mechanisms. Analysis of the comparative studies suggested that PPM could improve overall outcomes of a TB service, and multiple collaborative mechanisms may significantly promote case detection, treatment, referral, and service accessibility, especially in resource-limited areas. However, the less positive outcomes of several programs indicated limited funding and poor governance to be the predominant reasons.
CONCLUSIONS: PPM is a promising strategy to strengthen global TB care and control, but is affected by contextual characteristics in different areas. The scaling-up of PPM should contain essential commonalities, particularly substantial financial support and continuous material input. Additionally, it is important to improve program governance and training for the health providers involved, through integrated collaborative mechanisms.
INTRODUCTION: Harmful gender norms and inequalities, including gender-based violence, are important structural barriers to effective HIV programming. We assess current evidence on what forms of gender-responsive intervention may enhance the effectiveness of basic HIV programmes and be cost-effective.
METHODS: Effective intervention models were identified from an existing evidence review ("what works for women"). Based on this, we conducted a systematic review of published and grey literature on the costs and cost-effectiveness of each intervention identified. Where possible, we compared incremental costs and effects.
RESULTS: Our effectiveness search identified 36 publications, reporting on the effectiveness of 22 HIV interventions with a gender focus. Of these, 11 types of interventions had a corresponding/comparable costing or cost-effectiveness study. The findings suggest that couple counselling for the prevention of vertical transmission; gender empowerment, community mobilization, and female condom promotion for female sex workers; expanded female condom distribution for the general population; and post-exposure HIV prophylaxis for rape survivors are cost-effective HIV interventions. Cash transfers for schoolgirls and school support for orphan girls may also be cost-effective in generalized epidemic settings.
CONCLUSIONS: There has been limited research to assess the cost-effectiveness of interventions that seek to address women's needs and transform harmful gender norms. Our review identified several promising, cost-effective interventions that merit consideration as critical enablers in HIV investment approaches, as well as highlight that broader gender and development interventions can have positive HIV impacts. By no means an exhaustive package, these represent a first set of interventions to be included in the investment framework.
Objective To examine the relationship between condom social marketing programmes and condom use. Methods Standard systematic review and meta-analysis methods were followed. The review included studies of interventions in which condoms were sold, in which a local brand name(s) was developed for condoms, and in which condoms were marketed through a promotional campaign to increase sales. A definition of intervention was developed and standard inclusion criteria were followed in selecting studies. Data were extracted from each eligible study, and a meta-analysis of the results was carried out. Findings Six studies with a combined sample size of 23 048 met the inclusion criteria. One was conducted in India and five in sub-Saharan Africa. All studies were cross-sectional or serial cross-sectional. Three studies had a comparison group, although all lacked equivalence in sociodemographic characteristics across study arms. All studies randomly selected participants for assessments, although none randomly assigned participants to intervention arms. The random-effects pooled odds ratio for condom use was 2.01 (95% confidence interval, CI: 1.42-2.84) for the most recent sexual encounter and 2.10 (95% CI: 1.51-2.91) for a composite of all condom use outcomes. Tests for heterogeneity yielded significant results for both meta-analyses. Conclusion The evidence base for the effect of condom social marketing on condom use is small because few rigorous studies have been conducted. Meta-analyses showed a positive and statistically significant effect on increasing condom use, and all individual studies showed positive trends. The cumulative effect of condom social marketing over multiple years could be substantial. We strongly encourage more evaluations of these programmes with study designs of high rigour.
WHAT DO WE WANT TO KNOW?: Dual job holding, also referred to as dual practice in the health care setting, has been documented as a common practice in both developed and developing countries. The practice refers to the holding of more than one job by a health professional. In other settings however, it may encompass health professionals working within different aspects of health such as allopathic medicine combined with traditional medicine or combining health related activities such as clinical practice with research. In most Low and Middle Income Countries (LMICs), dual practice refers to health professionals engaged in both public and private (health or non health) related work. However, dual practice regulation remains debatable for many governments.
While the impact of dual practice varies from country to country, based on its extent and the presence or absence of regulatory policies, regulation remains debateable for many governments in LMICs. The International Centre for Systematic Reviews on Human Resources for Health, Makerere University School of Public Health, working with the EPPI-Centre in London, therefore, conducted a systematic review to assess the different regulatory mechanisms employed to deal with dual practice and the effect of these mechanisms on health worker performance.
The review aimed at synthesizing the dual practice regulatory mechanisms proposed and implemented worldwide and to document factors key to their implementation, either barriers or facilitators and some of their reported outcomes. WHO WANTS TO KNOW?: Policy-makers by providing evidence on what mechanisms are working and the conditions under which the mechanisms are working and what consequences they might expect as a result of adopting some of these approaches.
Health planners and managers- the review provides evidence on the importance of recognizing that dual practice exists and the available by which dual practice can be reduced at health service delivery level. WHAT DID WE FIND?: We found out that there are mainly three categories of dual practice mechanisms that have been employed: 1) total banning of dual practice; 2) allow dual practice with restrictions; 3) allow dual practice without restrictions.
Specifically, evidence indicated that:
• Banning dual practice totally, is not generally enforceable,
• Raising public sector salaries to compete with private sector earnings (in a bid to discourage public sector health workers from working in the private sector) is not realistic in many LMICs with resource constraints
• Restricting private practice to services not offered by the public sector, restricting private sector charges, insurance and access to public funds can reduce private practice in the presence of universal insurance coverage and well established financial monitoring systems
• In many LMICs that are already suffering consequences of health worker shortages, unrestricted dual practice, is not feasible. WHAT ARE THE IMPLICATIONS?: The findings of this review imply that in countries where the shortage of health workers is an area of major concern, allowing dual practice without restrictions may hurt the situation further, while total ban may be challenging to implement in settings where public sector workers earn low salaries. It may therefore be feasible to design mechanisms that take into critical consideration the specific conditions pertaining in individual countries, especially the different ways in which dual practice manifests itself. The most effective mechanisms therefore, may be multi-dimensional. HOW DID WE GET THESE RESULTS?: The three review questions that enabled us collect the evidence were;
1. What mechanisms have been used to regulate or manage dual practice among health workers?
2. What challenges arise or may be anticipated to emerge from existing or proposed mechanisms to regulate dual practice?
3. What factors may enhance existing or proposed mechanisms to regulate practice?
The review considered literature describing a range of strategies on dual practice regulatory mechanisms as well as identifying and describing factors influencing (barriers or facilitators) the implementation of these mechanisms.
The purpose of the current study was to conduct a 10-year systematic review of HIV/AIDS mass communication campaigns focused on sexual behavior, HIV testing, or both (1998-2007) and to compare the results with the last comprehensive review of such campaigns, conducted by Myhre and Flora (2000). A comprehensive search strategy yielded 38 HIV/AIDS campaign evaluation articles published in peer-reviewed journals, representing 34 distinct campaign efforts conducted in 23 countries. The articles were coded on a variety of campaign design and evaluation dimensions by two independent coders. Results indicated that compared with the previous systematic review (1986-1998 period), campaigns increasingly have employed the following strategies: (1) targeted defined audiences developed through audience segmentation procedures; (2) designed campaign themes around behavior change (rather than knowledge change); (3) used behavioral theories; (4) achieved high message exposure; (5) used stronger research designs for outcome evaluation; and (6) included measures of behavior (or behavioral intentions) in outcome assessments. In addition, an examination of 10 campaign efforts that used more rigorous quasi-experimental designs revealed that the majority (8 of 10) demonstrated effects on behavior change or behavioral intentions. Despite these positive developments, most HIV/AIDS campaigns continue to use weak (i.e., preexperimental) outcome evaluation designs. Implications of these results for improved design, implementation, and evaluation of HIV/AIDS campaign efforts are discussed.
MAIN FINDINGS: The authors included evidence from 16 studies assessing the effectiveness of 13 contracted-out health-service interventions in Sub-Saharan Africa, Latin America and the Caribbean, Europe, South Asia and East Asia and the Pacific. The results of the review are heterogeneous. On the one hand, the authors deduce that contracting-out health services significantly improves access and availability, especially within under-served regions. On the other hand, they fail to find conclusive evidence concerning the impact of contracting-out on other dimensions of health-system performance such as equity, quality and efficiency. Indeed, the authors report that these factors are addressed in only a very few studies, and they highlight the need for more rigorous studies exploring the impact of contracting-out health services on the equity, quality and efficiency of health systems. The authors suggest that the effectiveness and success of contracting-out depend on a range of contextual and contract-design factors. More specifically, they observe that contractual financial incentives and the application of a payment-by-performance scheme have been demonstrated to be key determinants in the success of an intervention.Contextual factors related to the capacity of the public sector to develop the contracted-out services and the degree to which these services complement or replace existing services are also important determinants of the impact of contracted-out interventions on the equity, access, quality and efficiency of health systems. Finally, the authors highlight the need for more research on possible side effects of contracting-out interventions, which so far have been only barely assessed. BACKGROUND: During the past decade, improving the performance of health systems has become a key objective for the governments of many developing countries. Contracting-out is defined as a “contractual arrangement by which the government provides compensation to private providers in exchange for a defined set of health services for specified target population”. By providing incentives to health-care professionals and by fostering competition among health-service providers, contracting-out health-service interventions can improve the quality and efficiency of health-care services, leading to improvements in the performance of the health system. The findings of previous reviews on the effectiveness of contracting-out health services are mixed, and this systematic review aims to shed light on the effectiveness of contracting-out on the four main dimensions of health-system performance: access, equity, quality and efficiency. RESEARCH OBJECTIVES: To assess and synthesise the evidence on the impact of contracting-out interventions on health-system performance in developing countries. METHODOLOGY: The authors included all studies assessing the effectiveness of contracting-out health-care services to private providers in developing countries. As quality criteria, the authors only included studies that used one of the following study designs: experimental, non-randomised controlled designs, before-and-after designs without controls and cross-sectional studies with controls. They conducted a systematic search in published and unpublished literature for relevant studies. They searched the electronic database PubMed, and used the search engine Google. They also searched the websites of relevant organisations, including the World Bank and the World Health Organization, and checked previous reviews in the field and other literature for additional studies.Finally, the authors grouped the results by health-system performance dimension – access, equity, quality and efficiency – and synthesised the results in a narrative format. QUALITY ASSESSMENT: This systematic review has clearly defined inclusion criteria and use appropriate methods for analysis of results. It has some limitations however. The search is not sufficiently comprehensive, and it is not clear whether language bias is avoided. Moreover, although the inclusion criteria in terms of methodology are wide, the authors do not report any systematic assessment of the quality of included studies. The authors acknowledge the weaknesses of the evidence base and do not provide and strong policy conclusions, and this mitigates some of the limitations of the review.
The purpose of this study is to review the research literature on the effectiveness of contracting-out of primary health care services and its impact on both programme and health systems performance in low- and middle-income countries. Due to the heightened interest in improving accountability relationships in the health sector and in rapidly scaling up priority interventions, there is an increasing amount of interest in and experimentation with contracting-out. Overall, while the review of the selected studies suggests that contracting-out has in many cases improved access to services, the effects on other performance dimensions such as equity, quality and efficiency are often unknown. Moreover, little is known about the system-wide effects of contracting-out, which could be either positive or negative. Although the study results leave open the question of how contracting-out can be used as a policy tool to improve overall health system performance, the results indicate that the context in which contracting-out is implemented and the design features of the interventions are likely to greatly influence the chances for success.
BACKGROUND: There has been a growing interest in the role of the private for-profit sector in health service provision in low- and middle-income countries. The private sector represents an important source of care for all socioeconomic groups, including the poorest and substantial concerns have been raised about the quality of care it provides. Interventions have been developed to address these technical failures and simultaneously take advantage of the potential for involving private providers to achieve public health goals. Limited information is available on the extent to which these interventions have successfully expanded access to quality health services for poor and disadvantaged populations. This paper addresses this knowledge gap by presenting the results of a systematic literature review on the effectiveness of working with private for-profit providers to reach the poor. METHODS: The search topic of the systematic literature review was the effectiveness of interventions working with the private for-profit sector to improve utilization of quality health services by the poor. Interventions included social marketing, use of vouchers, pre-packaging of drugs, franchising, training, regulation, accreditation and contracting-out. The search for published literature used a series of electronic databases including PubMed, Popline, HMIC and CabHealth Global Health. The search for grey and unpublished literature used documents available on the World Wide Web. We focused on studies which evaluated the impact of interventions on utilization and/or quality of services and which provided information on the socioeconomic status of the beneficiary populations. RESULTS: A total of 2483 references were retrieved, of which 52 qualified as impact evaluations. Data were available on the average socioeconomic status of recipient communities for 5 interventions, and on the distribution of benefits across socioeconomic groups for 5 interventions. CONCLUSION: Few studies provided evidence on the impact of private sector interventions on quality and/or utilization of care by the poor. It was, however, evident that many interventions have worked successfully in poor communities and positive equity impacts can be inferred from interventions that work with types of providers predominantly used by poor people. Better evidence of the equity impact of interventions working with the private sector is needed for more robust conclusions to be drawn.
Mixed health care systems to work simultaneously on both public and private facilities, is common today. This phenomenon referred to as dual practice (DP), has potential implications for access, quality, cost and equity of health services. This paper aimed to review systematically studies that assess the implications of DP among health workers.
METHODS:
MEDLINE, EMBASE, and The Cochrane library were searched for obtaining published literature between Feb 1990 and May 2014. Google and Google Scholars, organizational websites, and reference lists of relevant papers searched to get grey literature. Only studies concentrated on consequences and impacts of DP among health professionals and conducted using "randomized controlled trials", "non-randomized controlled trials", "controlled before and after studies", or "interrupted time series" were eligible for inclusion.
RESULTS:
From 3242 records, we focused on 19 studies, which aimed to assess effects and impacts of dual practice. After that, the current understanding of DP positive and negative implications was categorized and discussed based on two perspectives.
CONCLUSION:
There has been a propensity to over-reliance on theoretical methods in predicting the implications of this phenomenon. Almost all of the mentioned implications are based on theoretical predictions undermined in the broader literature. Furthermore, assessing the current literature showed positive and negative impacts of DP on different parts of the health system and various dimensions of service delivery. These implications are contexted specific and may vary from system to system.
