BACKGROUND: Task shifting has become an increasingly popular way to increase access to health services, especially in low-resource settings. Research has demonstrated that task shifting, including the use of community health workers (CHWs) to deliver care, can improve population health. This systematic review investigates whether task shifting in low-income and middle-income countries (LMICs) results in efficiency improvements by achieving cost savings.
METHODS: Using the PRISMA guidelines for systematic reviews, we searched PubMed, Embase, CINAHL, and the Health Economic Evaluation Database on March 22, 2016. We included any original peer-review articles that demonstrated cost impact of a task shifting program in an LMIC.
RESULTS: We identified 794 articles, of which 34 were included in our study. We found that substantial evidence exists for achieving cost savings and efficiency improvements from task shifting activities related to tuberculosis and HIV/AIDS, and additional evidence exists for the potential to achieve cost savings from activities related to malaria, NCDs, NTDs, childhood illness, and other disease areas, especially at the primary health care and community levels.
CONCLUSIONS: Task shifting presents a viable option for health system cost savings in LMICs. Going forward, program planners should carefully consider whether task shifting can improve population health and health systems efficiency in their countries, and researchers should investigate whether task shifting can also achieve cost savings for activities related to emerging global health priorities and health systems strengthening activities such as supply chain management or monitoring and evaluation.
There is a broad consensus and evidence that shows qualified, accessible, and responsive human resources for health (HRH) can make a major impact on the health of the populations. At the same time, there is widespread recognition that HRH crises particularly in low- and middle-income countries (LMICs) impede the achievement of better health outcomes/targets. In order to achieve the Sustainable Development Goals (SDGs), equitable access to a skilled and motivated health worker within a performing health system is need to be ensured. This review contributes to the vast pool of literature towards the assessment of HRH for maternal health and is focused on interventions delivered by skilled birth attendants (SBAs). Studies were included if (a) any HRH interventions in management system, policy, finance, education, partnership, and leadership were implemented; (b) these were related to SBA; (c) reported outcomes related to maternal health; (d) the studies were conducted in LMICs; and (e) studies were in English. Studies were excluded if traditional birth attendants and/or community health workers were trained. The review identified 25 studies which revealed reasons for poor maternal health outcomes in LMICs despite the efforts and policies implemented throughout these years. This review suggested an urgent and immediate need for formative evidence-based research on effective HRH interventions for improved maternal health outcomes. Other initiatives such as education and empowerment of women, alleviating poverty, establishing gender equality, and provision of infrastructure, equipment, drugs, and supplies are all integral components that are required to achieve SDGs by reducing maternal mortality and improving maternal health.
BACKGROUND: Each year almost 3 million newborns die within the first 28 days of life, 2.6 million babies are stillborn, and 287,000 women die from complications of pregnancy and childbirth worldwide. Effective and cost-effective interventions and behaviours for mothers and newborns exist, but their coverage remains inadequate in low- and middle-income countries, where the vast majority of deaths occur. Cost-effective strategies are needed to increase the coverage of life-saving maternal and newborn interventions and behaviours in resource-constrained settings.
METHODS: A systematic review was undertaken on the cost-effectiveness of strategies to improve the demand and supply of maternal and newborn health care in low-income and lower-middle-income countries. Peer-reviewed and grey literature published since 1990 was searched using bibliographic databases, websites of selected organizations, and reference lists of relevant studies and reviews. Publications were eligible for inclusion if they report on a behavioural or health systems strategy that sought to improve the utilization or provision of care during pregnancy, childbirth or the neonatal period; report on its cost-effectiveness; and were set in one or more low-income or lower-middle-income countries. The quality of the publications was assessed using the Consolidated Health Economic Evaluation Reporting Standards statement. Incremental cost per life-year saved and per disability-adjusted life-year averted were compared to gross domestic product per capita.
RESULTS: Forty-eight publications were identified, which reported on 43 separate studies. Sixteen were judged to be of high quality. Common themes were identified and the strategies were presented in relation to the continuum of care and the level of the health system. There was reasonably strong evidence for the cost-effectiveness of the use of women's groups, home-based newborn care using community health workers and traditional birth attendants, adding services to routine antenatal care, a facility-based quality improvement initiative to enhance compliance with care standards, and the promotion of breastfeeding in maternity hospitals. Other strategies reported cost-effectiveness measures that had limited comparability.
CONCLUSION: Demand and supply-side strategies to improve maternal and newborn health care can be cost-effective, though the evidence is limited by the paucity of high quality studies and the use of disparate cost-effectiveness measures.
TRIAL REGISTRATION: PROSPERO_ CRD42012003255.
It has been 30 years since the Declaration of Alma Ata. During that time, primary care has been the central strategy for expanding health services in many low- and middle-income countries. The recent global calls to redouble support for primary care highlighted it as a pathway to reaching the health Millennium Development Goals. In this systematic review we described and assessed the contributions of major primary care initiatives implemented in low- and middle-income countries in the past 30 years to a broad range of health system goals. The scope of the programs reviewed was substantial, with several interventions implemented on a national scale. We found that the majority of primary care programs had multiple components from health service delivery to financing reform to building community demand for health care. Although given this integration and the variable quality of the available research it was difficult to attribute effects to the primary care component alone, we found that primary care-focused health initiatives in low- and middle-income countries have improved access to health care, including among the poor, at reasonably low cost. There is also evidence that primary care programs have reduced child mortality and, in some cases, wealth-based disparities in mortality. Lastly, primary care has proven to be an effective platform for health system strengthening in several countries. Future research should focus on understanding how to optimize the delivery of primary care to improve health and achieve other health system objectives (e.g., responsiveness, efficiency) and to what extent models of care can be exported to different settings.
MAIN FINDINGS: The review included 83 studies (two quasi-experimental, 16 before–after, five cross-sectional and 60 descriptive studies) mostly from sub-Saharan Africa and South Asia. All included effectiveness studies focused on either training, policies, or multiple combined interventions. Overall, the authors found that HRH intervention can improve both health-worker performance and maternal health outcomes. The authors found two quasi-experimental, two cross-sectional and eight before–after studies, mostly from Africa and South East Asia, assessing the effects of HR training interventions. They found that training skilled birth attendants and other health-care workers improved the basic knowledge and skills (such as abdominal examinations and safety measures when taking blood samples) of more than 70 per cent of staff, and reduced maternal mortality in most locations. However, in other performance areas such as obtaining clients’ medical and behavioural histories, and client education, the training interventions improved skills of only around 40 per cent of trained staff. Facilities where training had been provided also observed an increase in the utilisation of services and in the number of deliveries at emergency obstetric facilities. Only one cross-sectional study assessed the effect of task-shifting on maternal outcomes. The study, conducted in Mozambique, assessed the impact of a three-year surgical training of Assistant Medical Officers (AMOs) and found that trained AMOs were generally as effective at performing caesarean-section operations as obstetricians. The study also noted that the training has increased the availability of skilled birth attendants at the referral level in district hospitals. Four before–after studies explored the effects of policy implementation. The authors found that all four policies were associated with positive maternal health outcomes. Two policies (Bangladesh and Nepal) focused on improving emergency obstetric services and facilities. They were associated with increases in professional care seeking, facility deliveries and caesarean sections and reduced maternal mortality in Bangladesh, and increases in met need and births attended by skilled birth attendants in Nepal. In Cambodia, introduction of user fees was associated with increased revenues, bed occupancy, number of outpatients and number of deliveries, and improved services and patient satisfaction. In Ghana, a fee-exemption policy was associated with improved early reporting and handling of complications. Six before–after studies assessed the effects of combined interventions of HRH management, composed of a variety of components including service-provider training, policy and advocacy, partnerships and supervision. The authors found that all studied interventions led to significant reductions in maternal mortality. The authors analysed 60 descriptive studies exploring health-care delivery and the maternal health context in developing countries to assess factors influencing maternal-mortality outcomes. They identified several key factors associated with poor maternal-health outcomes, including lack of skilled birth attendants, failures in referral, absence of transportation systems, and inadequate infrastructure, especially in rural areas. Other factors mentioned in the studies included lack of integration of emergency obstetric care services with other parts of the health-care system; insufficient collaboration between health-care providers; brain drain and other barriers to the recruitment, deployment and retention of skilled health-care professionals; lack of ongoing training; absence of a continuum of care; and limited management capacity. On the demand side, the studies highlighted gender and cultural barriers preventing access to and utilisation of health services. The authors note that future research should focus on evaluating HRH interventions promoting recruitment, deployment and retention of health workers, especially in rural areas, as well as interventions improving the health-care work environment and conditions and HRH information systems. BACKGROUND: Reducing maternal mortality has been a key item on the global health agenda. The fifth Millennium Development Goal has set a target of a 75 per cent reduction in maternal mortality by 2015. Nevertheless, progress has been slow, and child birth remains the leading cause of mortality and disability for women of reproductive age in low- and middle-income countries. Human-resource shortages, inequitable access, poor planning, and inefficient management and distribution are some of the most important factors impeding efficient use of human resources for better maternal and child health outcomes. While there is a large body of literature and experience sharing on this topic, there are no studies systematically reviewing this evidence to highlight the important lessons, gaps and recommendations in the literature. RESEARCH OBJECTIVES: To review and synthesise existing evidence on the implementation and effects of human resources for health (HRH) interventions on maternal health outcomes, focusing on skilled birth attendants (defined as health personnel with midwifery skills). The review aims to draw out lessons learned, identify gaps and offer recommendations for the improvement of HRH interventions for better maternal outcomes. METHODOLOGY: The authors included randomised, quasi-randomised and before–after studies which evaluated interventions in system management of human resources for health (for example, policy, finance, education, partnership and leadership) related to skilled birth attendants in home, community and referral facility settings in low- and middle-income countries. They also included qualitative and observational studies to gather information about the implementation context and the interventions. The authors excluded interventions provided by Traditional Birth Attendants and Community Health Workers. The authors searched peer-reviewed English-language literature published between 2000 and 2010. They searched the electronic database PubMed and the HRH Global Resource Centre, examined cross-references and searched reference lists of identified studies. The authors analysed the results using narrative synthesis and thematic analysis. QUALITY ASSESSMENT: The review uses appropriate methods to reduce risk of bias in terms of adopting explicit criteria for study inclusion, screening and data-extraction processes and information about the included studies. However, the review has some major limitations. The search was not sufficiently comprehensive within the grey literature and does not cover literature in languages other than English, so it is not clear that publication bias was avoided. Finally, the review does not assess the quality of the included studies. As a result, the review does not make clear which evidence is subject to low risk of bias in assessing causality and it does not report and analyse findings separately by risk-of-bias status. This is a particular concern, because the review includes a number of study designs with potentially high risk of bias in attributing effects to the intervention. The review does not acknowledge these limitations, but nevertheless draws relatively strong policy conclusions.
Task shifting has become an increasingly popular way to increase access to health services, especially in low-resource settings. Research has demonstrated that task shifting, including the use of community health workers (CHWs) to deliver care, can improve population health. This systematic review investigates whether task shifting in low-income and middle-income countries (LMICs) results in efficiency improvements by achieving cost savings.
METHODS:
Using the PRISMA guidelines for systematic reviews, we searched PubMed, Embase, CINAHL, and the Health Economic Evaluation Database on March 22, 2016. We included any original peer-review articles that demonstrated cost impact of a task shifting program in an LMIC.
RESULTS:
We identified 794 articles, of which 34 were included in our study. We found that substantial evidence exists for achieving cost savings and efficiency improvements from task shifting activities related to tuberculosis and HIV/AIDS, and additional evidence exists for the potential to achieve cost savings from activities related to malaria, NCDs, NTDs, childhood illness, and other disease areas, especially at the primary health care and community levels.
CONCLUSIONS:
Task shifting presents a viable option for health system cost savings in LMICs. Going forward, program planners should carefully consider whether task shifting can improve population health and health systems efficiency in their countries, and researchers should investigate whether task shifting can also achieve cost savings for activities related to emerging global health priorities and health systems strengthening activities such as supply chain management or monitoring and evaluation.
