scholarly journals The impacts of decentralization on health system equity, efficiency and resilience: a realist synthesis of the evidence

2019 ◽  
Vol 34 (8) ◽  
pp. 605-617 ◽  
Author(s):  
Seye Abimbola ◽  
Leonard Baatiema ◽  
Maryam Bigdeli
Keyword(s):  
Health System ◽  
Health Systems ◽  
Negative Impact ◽  
Contextual Factors ◽  
Evidence Synthesis ◽  
Implementation Strategies ◽  
Cochrane Library ◽  
Local Initiative ◽  
Middle Income ◽  
The Impact

Abstract One constant refrain in evaluations and reviews of decentralization is that the results are mixed. But given that decentralization is a complex intervention or phenomenon, what is more important is to generate evidence to inform implementation strategies. We therefore synthesized evidence from the literature to understand why, how and under what circumstances decentralization influences health system equity, efficiency and resilience. In doing this, we adopted the realist approach to evidence synthesis and included quantitative and qualitative studies in high-, low- and middle-income countries that assessed the the impact of decentralization on health systems. We searched the Medline and Embase databases via Ovid, and the Cochrane library of systematic reviews and included 51 studies with data from 25 countries. We identified three mechanisms through which decentralization impacts on health system equity, efficiency and resilience: ‘Voting with feet’ (reflecting how decentralization either exacerbates or assuages the existing patterns of inequities in the distribution of people, resources and outcomes in a jurisdiction); ‘Close to ground’ (reflecting how bringing governance closer to the people allows for use of local initiative, information, feedback, input and control); and ‘Watching the watchers’ (reflecting mutual accountability and support relations between multiple centres of governance which are multiplied by decentralization, involving governments at different levels and also community health committees and health boards). We also identified institutional, socio-economic and geographic contextual factors that influence each of these mechanisms. By moving beyond findings that the effects of decentralization on health systems and outcomes are mixed, this review presents mechanisms and contextual factors to which policymakers and implementers need to pay attention in their efforts to maximize the positive and minimize the negative impact of decentralized governance.

scholarly journals The impact of economic sanctions on health and health systems in low- and middle-income countries

2020 ◽  
Vol 30 (Supplement_5) ◽  
Author(s):  
M Suhrcke ◽  
M Pinna Pintor ◽  
C Hamelmann
Keyword(s):  
Health Outcomes ◽  
Health System ◽  
Health Systems ◽  
Grey Literature ◽  
Economic Sanctions ◽  
Political Crisis ◽  
Middle Income ◽  
Financial Flows ◽  
Adverse Health ◽  
The Impact

Abstract Background Economic sanctions, understood as measures taken by one state or a group of states to coerce another into a desired conduct (eg by restricting trade and financial flows) do not primarily seek to adversely affect the health or health system of the target country's population. Yet, there may be indirect or unintended health and health system consequences that ought to be borne in mind when assessing the full set of effects of sanctions. We take stock of the evidence to date in terms of whether - and if so, how - economic sanctions impact health and health systems in LMICs. Methods We undertook a structured literature review (using MEDLINE and Google Scholar), covering the peer-reviewed and grey literature published from 1970-2019, with a specific focus on quantitative assessments. Results Most studies (23/27) that met our inclusion criteria focus on the relationship between sanctions and health outcomes, ranging from infant or child mortality as the most frequent case over viral hepatitis to diabetes and HIV, among others. Fewer studies (9/27) examined health system related indicators, either as a sole focus or jointly with health outcomes. A minority of studies explicitly addressed some of the methodological challenges, incl. control for relevant confounders and the endogeneity of sanctions. Taking the results at face value, the evidence is almost unanimous in highlighting the adverse health and health system effects of economic sanctions. Conclusions Quantitatively assessing the impact of economic sanctions on health or health systems is a challenging task, not least as it is persistently difficult to disentangle the effect of sanctions from many other, potentially major factors at work that matter for health (as, for instance, war). In addition, in times of severe economic and political crisis (which often coincide with sanctions), the collection of accurate and comprehensive data that could allow appropriate measurement is typically not a priority. Key messages The existing evidence is almost unanimous in highlighting the adverse health and health system effects of economic sanctions. There is preciously little good quality evidence on the health (system) impact of economic sanctions.

scholarly journals Enhancing the Understanding of Resilience in Health Systems of Low- and Middle-Income Countries: A Qualitative Evidence Synthesis

2021 ◽  
Author(s):  
Pauline Yongeun Grimm ◽  
Sandy Oliver ◽  
Sonja Merten ◽  
Wai Wai Han ◽  
Kaspar Wyss
Keyword(s):  
Health System ◽  
Conceptual Framework ◽  
Health Systems ◽  
Evidence Synthesis ◽  
A Priori ◽  
Qualitative Evidence Synthesis ◽  
Middle Income ◽  
Middle Income Countries ◽  
Dynamic Attributes ◽  
Low And Middle Income

Background: A country’s health system faces pressure when hit by an unexpected shock, such as what we observe in the midst of the coronavirus disease 2019 (COVID-19) pandemic. The concept of resilience is highly relevant in this context and is a prerequisite for a health system capable of withstanding future shocks. By exploring how the key dimensions of the resilient health system framework are applied, the present systematic review synthesizes the vital features of resilient health systems in low- and middle-income countries. The aim of this review is to ascertain the relevance of health system resilience in the context of a major shock, through better understanding its dimensions, uses and implications. Methods: The review uses the best-fit framework synthesis approach. An a priori conceptual framework was selected and a coding framework created. A systematic search identified 4284 unique citations from electronic databases and reports by non-governmental organisations, 12 of which met the inclusion criteria. Data were extracted and coded against the pre-existing themes. Themes outside of the a priori framework were collated to form a refined list of themes. Then, all twelve studies were revisited using the new list of themes in the context of each study. Results: Ten themes were generated from the analysis. Five confirmed the a priori conceptual framework that capture the dynamic attributes of a resilient system. Five new themes were identified as foundational for achieving resilience: realigned relationships, foresight and motivation as drivers, and emergency preparedness and change management as organisational mechanisms. Conclusion: The refined conceptual model shows how the themes inter-connect. The foundations of resilience appear to be critical especially in resource-constrained settings to unlock the dynamic attributes of resilience. This review prompts countries to consider building the foundations of resilience described here as a priority to better prepare for future shocks.

scholarly journals Covid-19 Infection, Illness and Deaths Among Healthcare Workers in Low- and Middle-Income Countries: A Systematic Review Protocol

2021 ◽  
Author(s):  
Moses Ocan ◽  
Brenda Allen Kawala ◽  
Ephraim Kisangala ◽  
Regina Ndagire ◽  
Rachel Nante Wangi ◽  
...  
Keyword(s):  
Systematic Review ◽  
Healthcare Workers ◽  
Low Cost ◽  
Evidence Synthesis ◽  
Cochrane Library ◽  
Middle Income ◽  
Middle Income Countries ◽  
Mesh Terms ◽  
The Impact ◽  
Low And Middle Income

Abstract Background: Globally, health care workers continue to be infected, fall ill and die at the frontline of the Coronavirus disease 2019 (COVID-19) fight, an indicator of inadequate safety in health facilities. This rapid evidence synthesis aims to highlight the impacts of COVID-19 on healthcare workers in low-and middle-income countries (LMICs) in terms of infections, illnesses and deaths. Methods: A systematic review will be done. Article search will be performed by an experienced librarian in PubMed, MEDLINE Ovid, Google Scholar, COVID-END, Cochrane library and targeted search from other relevant sources. MeSH terms and Boolean operators “AND” and “OR” will be used in the article search. Independent reviewers will screen the retrieved articles using a priori criteria. Data abstraction will be done using an excel based abstraction tool and synthesized using structured narratives and summary of findings tables. Discussion and anticipated use of results: This evidence synthesis seeks to analyze the impact of COVID-19 on the healthcare systems of low- and middle-income countries. Information on healthcare worker infections, illness, and deaths due to COVID-19, will be collated from published research articles. This will help guide decision makers in establishing low- cost high impact interventions to mitigate the effects of COVID-19 in the health work force.Protocol registration: PROSPERO CRD 42020204174

scholarly journals Covid-19 Infection, Illness and Deaths Among Healthcare Workers in Low- and Middle-income Countries: A Systematic Review Protocol

2021 ◽  
Author(s):  
Moses Ocan ◽  
Brenda Allen Kawala ◽  
Ephraim Kisangala ◽  
Regina Ndagire ◽  
Rachel Nante Nante Wangi ◽  
...  
Keyword(s):  
Systematic Review ◽  
Healthcare Workers ◽  
Evidence Synthesis ◽  
Cochrane Library ◽  
Middle Income ◽  
Middle Income Countries ◽  
Mesh Terms ◽  
Protocol Registration ◽  
The Impact ◽  
Low And Middle Income

Abstract Background: Globally, health care workers continue to be infected, fall ill and die at the frontline of the Coronavirus Disease 2019 (COVID-19) fight, an indicator of inadequate safety in health facilities. This rapid evidence synthesis aims to highlight the impacts of COVID-19 on healthcare workers in low-and middle-income countries (LMICs) in terms of infections, illnesses and deaths. Methods: A systematic review will be done. Article search will be performed by an experienced librarian in PubMed, MEDLINE Ovid, Google Scholar, COVID-END, Cochrane library and targeted search from other relevant sources. MeSH terms and Boolean operators “AND” and “OR” will be used in the article search. Independent reviewers will screen the retrieved articles using a priori criteria. Data abstraction will be done using an excel based abstraction tool and synthesized using structured narratives and summary of findings tables. Discussion: This evidence synthesis seeks to analyze the impact of COVID-19 on the healthcare systems of low- and middle-income countries. Information on healthcare worker infections, illness, and deaths due to COVID-19, will be collated from published research articles. This will help guide decision makers in establishing low- cost high impact interventions to mitigate the effects of COVID-19 in the health work force.Protocol registration: PROSPERO CRD 42020204174 [1] [1] This protocol registration can be found at; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020204174

scholarly journals The impacts of health systems financing fragmentation in low- and middle-income countries: a systematic review protocol

2021 ◽  
Vol 10 (1) ◽  
Author(s):  
Marina Siqueira ◽  
Maíra Coube ◽  
Christopher Millett ◽  
Rudi Rocha ◽  
Thomas Hone
Keyword(s):  
Systematic Review ◽  
Health Outcomes ◽  
Health System ◽  
Health Systems ◽  
Cochrane Library ◽  
Financial Risk Protection ◽  
Middle Income ◽  
Middle Income Countries ◽  
Patient Reported ◽  
Low And Middle Income

Abstract Background Health systems are often fragmented in low- and middle-income countries (LMICs). This can increase inefficiencies and restrict progress towards universal health coverage. The objective of the systematic review described in this protocol will be to evaluate and synthesize the evidence concerning the impacts of health systems financing fragmentation in LMICs. Methods Literature searches will be conducted in multiple electronic databases, from their inception onwards, including MEDLINE, EMBASE, LILACS, CINAHL, Scopus, ScienceDirect, Scielo, Cochrane Library, EconLit, and JSTOR. Gray literature will be also targeted through searching OpenSIGLE, Google Scholar, and institutional websites (e.g., HMIC, The World Bank, WHO, PAHO, OECD). The search strings will include keywords related to LMICs, health system financing fragmentation, and health system goals. Experimental, quasi-experimental, and observational studies conducted in LMICs and examining health financing fragmentation across any relevant metric (e.g., the presence of different health funders/insurers, risk pooling mechanisms, eligibility categories, benefits packages, premiums) will be included. Studies will be eligible if they compare financing fragmentation in alternative settings or at least two-time points. The primary outcomes will be health system-related goals such as health outcomes (e.g., mortality, morbidity, patient-reported outcome measures) and indicators of access, services utilization, equity, and financial risk protection. Additional outcomes will include intermediate health system objectives (e.g., indicators of efficiency and quality). Two reviewers will independently screen all citations, abstract data, and full-text articles. Potential conflicts will be resolved through discussion and, when necessary, resolved by a third reviewer. The methodological quality (or risk of bias) of selected studies will be appraised using established checklists. Data extraction categories will include the studies’ objective and design, the fragmentation measurement and domains, and health outcomes linked to the fragmentation. A narrative synthesis will be used to describe the results and characteristics of all included studies and to explore relationships and findings both within and between the studies. Discussion Evidence on the impacts of health system fragmentation in LMICs is key for identifying evidence gaps and priority areas for intervention. This knowledge will be valuable to health system policymakers aiming to strengthen health systems in LMICs. Systematic review registration PROSPERO CRD42020201467

scholarly journals Assessing trauma care systems in low-income and middle-income countries: a systematic review and evidence synthesis mapping the Three Delays framework to injury health system assessments

2021 ◽  
Vol 6 (5) ◽  
pp. e004324
Author(s):  
John Whitaker ◽  
Nollaig O'Donohoe ◽  
Max Denning ◽  
Dan Poenaru ◽  
Elena Guadagno ◽  
...  
Keyword(s):  
Systematic Review ◽  
Health System ◽  
Evidence Synthesis ◽  
Rapid Assessment ◽  
Sub Saharan Africa ◽  
Trauma Systems ◽  
Middle Income ◽  
Middle Income Countries ◽  
Low Middle Income Countries ◽  
Three Delays

BackgroundThe large burden of injuries falls disproportionately on low/middle-income countries (LMICs). Health system interventions improve outcomes in high-income countries. Assessing LMIC trauma systems supports their improvement. Evaluating systems using a Three Delays framework, considering barriers to seeking (Delay 1), reaching (Delay 2) and receiving care (Delay 3), has aided maternal health gains. Rapid assessments allow timely appraisal within resource and logistically constrained settings. We systematically reviewed existing literature on the assessment of LMIC trauma systems, applying the Three Delays framework and rapid assessment principles.MethodsWe conducted a systematic review and narrative synthesis of articles assessing LMIC trauma systems. We searched seven databases and grey literature for studies and reports published until October 2018. Inclusion criteria were an injury care focus and assessment of at least one defined system aspect. We mapped each study to the Three Delays framework and judged its suitability for rapid assessment.ResultsOf 14 677 articles identified, 111 studies and 8 documents were included. Sub-Saharan Africa was the most commonly included region (44.1%). Delay 3, either alone or in combination, was most commonly assessed (79.3%) followed by Delay 2 (46.8%) and Delay 1 (10.8%). Facility assessment was the most common method of assessment (36.0%). Only 2.7% of studies assessed all Three Delays. We judged 62.6% of study methodologies potentially suitable for rapid assessment.ConclusionsWhole health system injury research is needed as facility capacity assessments dominate. Future studies should consider novel or combined methods to study Delays 1 and 2, alongside care processes and outcomes.

scholarly journals Development and application of a hybrid implementation research framework to understand success in reducing under-5 mortality in Rwanda

2021 ◽  
Vol 5 ◽  
pp. 72
Author(s):  
Lisa R. Hirschhorn ◽  
Miriam Frisch ◽  
Jovial Thomas Ntawukuriryayo ◽  
Amelia VanderZanden ◽  
Kateri Donahoe ◽  
...  
Keyword(s):  
Health System ◽  
Implementation Research ◽  
Contextual Factors ◽  
Common Pathway ◽  
Middle Income ◽  
Middle Income Countries ◽  
Mixed Methods Case Study ◽  
Hybrid Framework ◽  
Successes And Challenges

Background: We describe the development and testing of a hybrid implementation research (IR) framework to understand the pathways, successes, and challenges in addressing amenable under-5 mortality (U5M) – deaths preventable through health system-delivered evidence-based interventions (EBIs) – in low- and middle-income countries (LMICs). Methods: We reviewed existing IR frameworks to develop a hybrid framework designed to better understand U5M reduction in LMICs from identification of leading causes of amenable U5M, to EBI choice, identification and testing of strategies, work to achieve sustainability at scale and key contextual factors. We then conducted a mixed-methods case study of Rwanda using the framework to explore its utility in understanding the steps the country took in EBI-related decision-making and implementation between 2000-2015, key contextual factors which hindered or facilitated success, and extract actionable knowledge for other countries working to reduce U5M. Results: While relevant frameworks were identified, none individually covered the scope needed to understand Rwanda’s actions and success. Building on these frameworks, we combined and adapted relevant frameworks to capture exploration, planning, implementation, contextual factors in LMICs such as Rwanda, and outcomes beyond effectiveness and coverage. Utilizing our hybrid framework in Rwanda, we studied multiple EBIs and identified a common pathway and cross-cutting strategies and contextual factors that supported the country’s success in reducing U5M through the health system EBIs. Using these findings, we identified transferable lessons for other countries working to accelerate reduction in U5M. Conclusions: We found that a hybrid framework building on and adapting existing frameworks was successful in guiding data collection and interpretation of results, emerging new insights into how and why Rwanda achieved equitable introduction and implementation of health system EBIs that contributed to the decline in U5M, and generated lessons for countries working to drop U5M.

scholarly journals How the ‘plates’ of a health system can shift, change and adjust during economic recessions. A qualitative interview study of public and private health providers in Brazil’s São Paulo and Maranhão states

2020 ◽  
Author(s):  
Giuliano Russo ◽  
Maria Luiza Levi Paim ◽  
Maria Teresa Seabra Soares de Britto e Alves ◽  
Bruno Luciano Carneiro Alves de Oliveira ◽  
Ruth Helena de Souza Britto Ferreira de Carvalho ◽  
...  
Keyword(s):  
Health System ◽  
Access To Care ◽  
Health Systems ◽  
Low Income ◽  
Sao Paulo ◽  
São Paulo ◽  
Public And Private ◽  
Qualitative Interview Study ◽  
Economic Recessions ◽  
The Impact

Background. Economic recessions carry an impact on population health and access to care; less is known on how health systems adapt to the conditions brought by a downturn. This particularly matters now that the COVID-19 epidemic is putting health systems under stress. Brazil is one of the world’s most affected countries, and its health system was already living the aftermath of the 2015 recession. Methods. Between 2018 and 2019 we conducted 46 semi-structured interviews with health practitioners, managers and policy-makers to explore the impact of the 2015 recession on public and private providers in prosperous (São Paulo) and impoverished (Maranhão) states in Brazil. Thematic analysis was employed to identify drivers and consequences of system adaptation and coping strategies. Nvivo software was used to aid data collection and analysis. We followed the Standards for Reporting Qualitative Research to provide an account of the findings.Results. We found the concept of ‘health sector crisis’ to be politically charged among healthcare providers in São Paulo and Maranhão. Contrary to expectations, the public sector was reported to have found ways to compensate for diminishing federal funding, having outsourced services and adopted flexible – if insecure – working arrangements. Following a drop in employment and health plans, private health insurance companies streamlined their offer, at times at the expenses of coverage. Low-cost walk-in clinics were hit hard by the recession, but also credited for having moved to cater for higher-income customers in Maranhão.Conclusions. The ‘plates’ of a health system may shift and adjust in unexpected ways in response to recessions, and some of these changes might outlast the crisis. As low-income countries enter post-COVID recessions, it will be important to monitor the adjustments taking place in health systems, to ensure that past gains in access to care and job security are not eroded.

scholarly journals Measuring the efficiency of health systems in Asia: a data envelopment analysis

BMJ Open ◽  
2019 ◽  
Vol 9 (3) ◽  
pp. e022155 ◽  
Author(s):  
Sayem Ahmed ◽  
Md Zahid Hasan ◽  
Mary MacLennan ◽  
Farzana Dorin ◽  
Mohammad Wahid Ahmed ◽  
...  
Keyword(s):  
Data Envelopment Analysis ◽  
Health System ◽  
Technical Efficiency ◽  
Health Systems ◽  
Income Group ◽  
Data Envelopment ◽  
System Efficiency ◽  
Asian Countries ◽  
Middle Income ◽  
Health System Efficiency

ObjectiveThis study aims to estimate the technical efficiency of health systems in Asia.SettingsThe study was conducted in Asian countries.MethodsWe applied an output-oriented data envelopment analysis (DEA) approach to estimate the technical efficiency of the health systems in Asian countries. The DEA model used per-capita health expenditure (all healthcare resources as a proxy) as input variable and cross-country comparable health outcome indicators (eg, healthy life expectancy at birth and infant mortality per 1000 live births) as output variables. Censored Tobit regression and smoothed bootstrap models were used to observe the associated factors with the efficiency scores. A sensitivity analysis was performed to assess the consistency of these efficiency scores.ResultsThe main findings of this paper demonstrate that about 91.3% (42 of 46 countries) of the studied Asian countries were inefficient with respect to using healthcare system resources. Most of the efficient countries belonged to the high-income group (Cyprus, Japan, and Singapore) and only one country belonged to the lower middle-income group (Bangladesh). Through improving health system efficiency, the studied high-income, upper middle-income, low-income and lower middle-income countries can improve health system outcomes by 6.6%, 8.6% and 8.7%, respectively, using the existing level of resources. Population density, bed density, and primary education completion rate significantly influenced the efficiency score.ConclusionThe results of this analysis showed inefficiency of the health systems in most of the Asian countries and imply that many countries may improve their health system efficiency using the current level of resources. The identified inefficient countries could pay attention to benchmarking their health systems within their income group or other within similar types of health systems.

scholarly journals High-Fat Ketogenic Diets and Physical Performance: A Systematic Review

2020 ◽  
Author(s):  
Nancy E Murphy ◽  
Christopher T Carrigan ◽  
Lee M Margolis
Keyword(s):  
Systematic Review ◽  
Physical Performance ◽  
Performance Test ◽  
Negative Impact ◽  
Performance Outcomes ◽  
Cochrane Library ◽  
Time To Exhaustion ◽  
High Fat ◽  
Ketogenic Diets ◽  
The Impact

ABSTRACT Use of high-fat, ketogenic diets (KDs) to support physical performance has grown in popularity over recent years. While these diets enhance fat and reduce carbohydrate oxidation during exercise, the impact of a KD on physical performance remains controversial. The objective of this work was to assess the effect of KDs on physical performance compared with mixed macronutrient diets [control (CON)]. A systematic review of the literature was conducted using PubMed and Cochrane Library databases. Randomized and nonrandomized studies were included if participants were healthy (free of chronic disease), nonobese [BMI (kg/m2) <30], trained or untrained men or women consuming KD (<50 g carbohydrate/d or serum or whole-blood β-hydroxybutyrate >0.5 mmol/L) compared with CON (fat, 12–38% of total energy intake) diets for ≥14 d, followed by a physical performance test. Seventeen studies (10 parallel, 7 crossover) with 29 performance (13 endurance, 16 power or strength) outcomes were identified. Of the 13 endurance-type performance outcomes, 3 (1 time trial, 2 time-to-exhaustion) reported lower and 10 (4 time trials, 6 time-to-exhaustion) reported no difference in performance between the KD compared with CON. Of the 16 power or strength performance outcomes, 3 (1 power, 2 strength) reported lower, 11 (4 power, 7 strength) no difference, and 2 (power) enhanced performance in the KD compared with the CON. Risk of bias identified some concern of bias primarily due to studies allowing participants to self-select diet intervention groups and the inability to blind participants to the study intervention. Overall, the majority of null results across studies suggest that a KD does not have a positive or negative impact on physical performance compared with a CON diet. However, discordant results between studies may be due to multiple factors, such as the duration consuming study diets, training status, performance test, and sex differences, which will be discussed in this systematic review.

Sign in / Sign up

Export Citation Format

Share Document