Research gaps in the organisation of primary healthcare in low-income and middle-income countries and ways to address them: a mixed-methods approach

IntroductionSince the Alma-Ata Declaration 40 years ago, primary healthcare (PHC) has made great advances, but there is insufficient research on models of care and outcomes—particularly for low-income and middle-income countries (LMICs). Systematic efforts to identify these gaps and develop evidence-based strategies for improvement in LMICs has been lacking. We report on a global effort to identify and prioritise the knowledge needs of PHC practitioners and researchers in LMICs about PHC organisation.MethodsThree-round modified Delphi using web-based surveys. PHC practitioners and academics and policy-makers from LMICs sampled from global networks. First round (pre-Delphi survey) collated possible research questions to address knowledge gaps about organisation. Responses were independently coded, collapsed and synthesised. Round 2 (Delphi round 1) invited panellists to rate importance of each question. In round 3 (Delphi round 2), panellists ranked questions into final order of importance. Literature review conducted on 36 questions and gap map generated.ResultsDiverse range of practitioners and academics in LMICs from all global regions generated 744 questions for PHC organisation. In round 2, 36 synthesised questions on organisation were rated. In round 3, the top 16 questions were ranked to yield four prioritised questions in each area. Literature reviews confirmed gap in evidence on prioritised questions in LMICs.ConclusionIn line with the 2018 Astana Declaration, this mixed-methods study has produced a unique list of essential gaps in our knowledge of how best to organise PHC, priority-ordered by LMIC expert informants capable of shaping their mitigation. Research teams in LMIC have developed implementation plans to answer the top four ranked research questions.

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Primary care financing: a systematic assessment of research priorities in low- and middle-income countries

BMJ Global Health ◽

10.1136/bmjgh-2019-001483 ◽

2019 ◽

Vol 4 (Suppl 8) ◽

pp. e001483 ◽

Cited By ~ 2

Author(s):

Felicity Goodyear-Smith ◽

Andrew Bazemore ◽

Megan Coffman ◽

Richard Fortier ◽

Amanda Howe ◽

...

Keyword(s):

Primary Care ◽

Research Priorities ◽

Knowledge Gaps ◽

Middle Income ◽

Policy Makers ◽

Diverse Range ◽

Middle Income Countries ◽

Delphi Round ◽

Research Questions ◽

Low And Middle Income

IntroductionFinancing of primary healthcare (PHC) is the key to the provision of equitable universal care. We aimed to identify and prioritise the perceived needs of PHC practitioners and researchers for new research in low- and middle-income countries (LMIC) about financing of PHC.MethodsThree-round expert panel consultation using web-based surveys of LMIC PHC practitioners, academics and policy-makers sampled from global networks. Iterative literature review conducted in parallel. First round (Pre-Delphi survey) elicited possible research questions to address knowledge gaps about financing. Responses were independently coded, collapsed and synthesised to two lists of questions. Round 2 (Delphi Round 1) invited panellists to rate importance of each question. In Round 3 (Delphi Round 2), panellists ranked questions in order of importance.ResultsA diverse range of PHC practitioners, academics and policy-makers in LMIC representing all global regions identified 479 knowledge gaps as potentially critical to improving PHC financing. Round 2 provided 31 synthesised questions on financing for rating. The top 16 were ranked in Round 3e to produce four prioritised research questions.ConclusionsThis novel exercise created an expansive and prioritised list of critical knowledge gaps in PHC financing research questions. This offers valuable guidance to global supporters of primary care evaluation and implementation, including research funders and academics seeking research priorities. The source and context specificity of this research, informed by LMIC practitioners and academics on a global and local basis, should increase the likelihood of local relevance and eventual success in implementing the findings.

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How primary healthcare workers obtain information during consultations to aid safe prescribing in low-income and lower middle-income countries: a systematic review

BMJ Global Health ◽

10.1136/bmjgh-2019-002094 ◽

2020 ◽

Vol 5 (4) ◽

pp. e002094 ◽

Cited By ~ 1

Author(s):

Chris Smith ◽

Michelle Helena van Velthoven ◽

Nguyen Duc Truong ◽

Nguyen Hai Nam ◽

Vũ Phan Anh ◽

...

Keyword(s):

Low Income ◽

Primary Healthcare ◽

Healthcare Workers ◽

Health Workers ◽

Internet Access ◽

Sources Of Information ◽

Quality Of Reporting ◽

Middle Income ◽

Middle Income Countries ◽

Registration Number

BackgroundWe systematically reviewed the evidence on how primary healthcare workers obtain information during consultations to support decision-making for prescribing in low and lower middle-income countries.MethodsWe searched electronic databases, consulted the Healthcare Information For All network, hand searched reference lists, ran citation searches of included studies and emailed authors of identified papers. Two reviewers extracted data and appraised quality with relevant tools.ResultsOf 60 497 records found, 23 studies met our inclusion criteria. Fourteen studies were observational and nine were interventional. Frequently mentioned sources of information were books, leaflets, guidelines, aids and the internet. These sources were sometimes out of date and health workers reported being confused which to use. Internet access varied and even when it was available, use was limited by technical issues. Of the five electronic tools that were assessed, four had positive outcomes. Tools assisted prescribers with medicine selection and dosage calculations, which increased prescribing accuracy. The quality of reporting varied but was overall low.DiscussionStudies indicated a lack of up-to-date and relevant medicine information in low and lower middle-income settings. Internet-based sources appeared to be useful when it is possible to download content for offline use and to update when there is internet access. Electronic tools showed promise, but their accuracy needs to be validated and they should focus on giving actionable advice to guide prescribers.PROSPERO registration numberCRD42018091088.

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Advancing research on emergency care systems in low-income and middle-income countries: ensuring high-quality care delivery systems

BMJ Global Health ◽

10.1136/bmjgh-2018-001265 ◽

2019 ◽

Vol 4 (Suppl 6) ◽

pp. e001265 ◽

Cited By ~ 8

Author(s):

Rachel T Moresky ◽

Junaid Razzak ◽

Teri Reynolds ◽

Lee A Wallis ◽

Benjamin W Wachira ◽

...

Keyword(s):

Health Systems ◽

Emergency Care ◽

Low Income ◽

Communicable Diseases ◽

Middle Income ◽

Care Research ◽

Middle Income Countries ◽

Emergency Care Systems ◽

Care Systems ◽

Research Questions

Emergency care systems (ECS) address a wide range of acute conditions, including emergent conditions from communicable diseases, non-communicable diseases, pregnancy and injury. Together, ECS represent an area of great potential for reducing morbidity and mortality in low-income and middle-income countries (LMICs). It is estimated that up to 54% of annual deaths in LMICs could be addressed by improved prehospital and facility-based emergency care. Research is needed to identify strategies for enhancing ECS to optimise prevention and treatment of conditions presenting in this context, yet significant gaps persist in defining critical research questions for ECS studies in LMICs. The Collaborative on Enhancing Emergency Care Research in LMICs seeks to promote research that improves immediate and long-term outcomes for clients and populations with emergent conditions. The objective of this paper is to describe systems approaches and research strategies for ECS in LMICs, elucidate priority research questions and methodology, and present a selection of studies addressing the operational, implementation, policy and health systems domains of health systems research as an approach to studying ECS. Finally, we briefly discuss limitations and the next steps in developing ECS-oriented interventions and research.

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Primary healthcare system performance in low-income and middle-income countries: a scoping review of the evidence from 2010 to 2017

BMJ Global Health ◽

10.1136/bmjgh-2019-001551 ◽

2019 ◽

Vol 4 (Suppl 8) ◽

pp. e001551 ◽

Cited By ~ 10

Author(s):

Asaf Bitton ◽

Jocelyn Fifield ◽

Hannah Ratcliffe ◽

Ami Karlage ◽

Hong Wang ◽

...

Keyword(s):

Service Delivery ◽

Scoping Review ◽

Low Income ◽

Primary Healthcare ◽

Recent Literature ◽

Future Research ◽

Topic Area ◽

Middle Income ◽

Ample Evidence ◽

Middle Income Countries

IntroductionThe 2018 Astana Declaration reaffirmed global commitment to primary healthcare (PHC) as a core strategy to achieve universal health coverage. To meet this potential, PHC in low-income and middle-income countries (LMIC) needs to be strengthened, but research is lacking and fragmented. We conducted a scoping review of the recent literature to assess the state of research on PHC in LMIC and understand where future research is most needed.MethodsGuided by the Primary Healthcare Performance Initiative (PHCPI) conceptual framework, we conducted searches of the peer-reviewed literature on PHC in LMIC published between 2010 (the publication year of the last major review of PHC in LMIC) and 2017. We also conducted country-specific searches to understand performance trajectories in 14 high-performing countries identified in the previous review. Evidence highlights and gaps for each topic area of the PHCPI framework were extracted and summarised.ResultsWe retrieved 5219 articles, 207 of which met final inclusion criteria. Many PHC system inputs such as payment and workforce are well-studied. A number of emerging service delivery innovations have early evidence of success but lack evidence for how to scale more broadly. Community-based PHC systems with supportive governmental policies and financing structures (public and private) consistently promote better outcomes and equity. Among the 14 highlighted countries, most maintained or improved progress in the scope of services, quality, access and financial coverage of PHC during the review time period.ConclusionOur findings revealed a heterogeneous focus of recent literature, with ample evidence for effective PHC policies, payment and other system inputs. More variability was seen in key areas of service delivery, underscoring a need for greater emphasis on implementation science and intervention testing. Future evaluations are needed on PHC system capacities and orientation toward social accountability, innovation, management and population health in order to achieve the promise of PHC.

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Evidence gap map of performance measurement and management in primary healthcare systems in low-income and middle-income countries

BMJ Global Health ◽

10.1136/bmjgh-2019-001451 ◽

2019 ◽

Vol 4 (Suppl 8) ◽

pp. e001451 ◽

Cited By ~ 2

Author(s):

Wolfgang Munar ◽

Birte Snilstveit ◽

Ligia Esther Aranda ◽

Nilakshi Biswas ◽

Theresa Baffour ◽

...

Keyword(s):

Performance Measurement ◽

Systematic Reviews ◽

Low Income ◽

Primary Healthcare ◽

Implementation Strategies ◽

Sub Saharan Africa ◽

Audit And Feedback ◽

Unintended Effects ◽

Middle Income ◽

Middle Income Countries

IntroductionWe mapped available evidence on performance measurement and management (PMM) strategies in primary healthcare (PHC) systems of low-income and middle-income countries (LMICs). Widely used, their effectiveness remains inconclusive. This evidence gap map characterises existing research and evidence gaps.MethodsSystematic mapping of performance measurement and management research in LMICs from 2000 to mid-2018; literature searches of seven academic databases and institutional repositories of impact evaluations and systematic reviews. Using a combination of manual screening and machine learning, four reviewers appraised 38 088 titles and abstracts, and extracted metadata from 137 impact evaluations and 18 systematic reviews that met the inclusion criteria. The resulting visual representation of the evidence base was uploaded to a web-based platform.ResultsSince 2000, the number of studies has increased; the first systematic reviews were completed in 2010. Two-thirds of the studies were conducted in sub-Saharan Africa and South Asia. Randomised controlled trials were the most frequently used study design. The evidence is concentrated in two types of PMM strategies: implementation strategies (in-service training, continuing education, supervision) and performance-based financing. Major gaps exist in accountability arrangements particularly the use of audit and feedback. The least studied types of outcomes were unintended effects, harm and social equity.ConclusionsThe evidence is clustered around interventions that are unlikely to achieve transformational change in health outcomes. The gaps identified suggest that routinely used PMM strategies are implemented without sufficient knowledge of their effects. Future efforts at redesigning PHC systems need to be informed by evidence on the most effective approaches for using PMM strategies.

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Effects of integrated models of care for diabetes and hypertension in low-income and middle-income countries: a systematic review and meta-analysis

BMJ Open ◽

10.1136/bmjopen-2020-043705 ◽

2021 ◽

Vol 11 (7) ◽

pp. e043705

Author(s):

Anke Rohwer ◽

Jeannine Uwimana Nicol ◽

Ingrid Toews ◽

Taryn Young ◽

Charlotte M Bavuma ◽

...

Keyword(s):

Systematic Review ◽

Usual Care ◽

Integrated Care ◽

Low Income ◽

Meta Analysis ◽

Models Of Care ◽

Controlled Trials ◽

Integrated Models ◽

Middle Income ◽

Middle Income Countries

ObjectivesTo assess the effects of integrated models of care for people with multimorbidity including at least diabetes or hypertension in low-income and middle-income countries (LMICs) on health and process outcomes.DesignSystematic review.Data sourcesWe searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, LILACS, Africa-Wide, CINAHL and Web of Science up to 12 December 2019.Eligibility criteriaWe included randomised controlled trials (RCTs), non-RCTs, controlled before-and-after studies and interrupted time series (ITS) studies of people with diabetes and/or hypertension plus any other disease, in LMICs; assessing the effects of integrated care.Data extraction and synthesisTwo authors independently screened retrieved records; extracted data and assessed risk of bias. We conducted meta-analysis where possible and assessed certainty of evidence using Grading of Recommendations Assessment, Development and Evaluation.ResultsOf 7568 records, we included five studies—two ITS studies and three cluster RCTs. Studies were conducted in South Africa (n=3), Uganda/Kenya (n=1) and India (n=1). Integrated models of care compared with usual care may make little or no difference to mortality (very low certainty), the number of people achieving blood pressure (BP) or diabetes control (very low certainty) and access to care (very low certainty); may increase the number of people who achieve both HIV and BP/diabetes control (very low certainty); and may have a very small effect on achieving HIV control (very low certainty). Interventions to promote integrated delivery of care compared with usual care may make little or no difference to mortality (very low certainty), depression (very low certainty) and quality of life (very low certainty); and may have little or no effect on glycated haemoglobin (low certainty), systolic BP (low certainty) and total cholesterol levels (low certainty).ConclusionsCurrent evidence on the effects of integrated care on health outcomes is very uncertain. Programmes and policies on integrated care must consider context-specific factors related to health systems and populations.PROSPERO registration numberCRD42018099314.

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Primary healthcare policy and governance in low-income and middle-income countries: an evidence gap map

BMJ Global Health ◽

10.1136/bmjgh-2019-001453 ◽

2019 ◽

Vol 4 (Suppl 8) ◽

pp. e001453 ◽

Cited By ~ 3

Author(s):

K M Saif-Ur-Rahman ◽

Razib Mamun ◽

Iffat Nowrin ◽

Shahed Hossain ◽

Khaleda Islam ◽

...

Keyword(s):

Social Responsibility ◽

Low Income ◽

Primary Healthcare ◽

Evidence Synthesis ◽

Nominal Group ◽

Provider Communication ◽

Middle Income ◽

Stakeholder Consultation ◽

Middle Income Countries

IntroductionGovernance is one of the most important aspects for strong primary healthcare (PHC) service delivery. To achieve the targets for the Sustainable Development Goals, good governance may play a prime role in low-income and middle-income countries (LMICs). This evidence gap map (EGM) explored the available evidence in LMICs to identify the knowledge gap concerning PHC policy and governance in these settings.MethodsWe followed the standard 3ie EGM protocol, finalising the scope of the EGM through a stakeholder workshop. We searched a total of 32 bibliographic databases, systematic review databases, impact evaluation databases, and donor and bilateral agency databases using a comprehensive search strategy. Two reviewers screened retrieved studies, extracted data and performed quality assessment. We plotted the interventions and outcomes derived from the included studies in a dynamic platform to build the interactive EGM and conducted a stakeholder consultation with nominal group technique methods to prioritise the identified gaps.ResultsThe EGM included 24 systematic reviews and 7 impact evaluations focusing on PHC policy and governance in LMICs. Most of the sources emphasised workforce management and supervision. There were noticeable evidence gaps regarding accountability and social responsibility. The most highly prioritised themes were the role of accountability, the role of public–private partnerships and the role of user–provider communication in PHC governance.ConclusionsThis EGM identified some important aspects of PHC policy and governance such as accountability, social responsibility, public–private partnership, user–provider communication through the methodological approaches of evidence synthesis and stakeholder consultation. Identified gaps will provide directions for an implementation research plan to improve the governance of PHC in LMICs.

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Effects of community health worker interventions on socioeconomic inequities in maternal and newborn health in low-income and middle-income countries: a mixed-methods systematic review

BMJ Global Health ◽

10.1136/bmjgh-2018-001308 ◽

2019 ◽

Vol 4 (3) ◽

pp. e001308 ◽

Cited By ~ 6

Author(s):

Andrea Katryn Blanchard ◽

Audrey Prost ◽

Tanja A J Houweling

Keyword(s):

Mixed Methods ◽

Low Income ◽

Home Visits ◽

Newborn Health ◽

Maternal And Newborn Health ◽

Women's Groups ◽

Middle Income ◽

Middle Income Countries ◽

Women’S Groups ◽

Maternal And Newborn

IntroductionCommunity health worker (CHW) interventions are promoted to improve maternal and newborn health in low-income and middle-income countries. We reviewed the evidence on their effectiveness in reducing socioeconomic inequities in maternal and newborn health outcomes, how they achieve these effects, and contextual processes that shape these effects.MethodsWe conducted a mixed-methods systematic review of quantitative and qualitative studies published between 1996 and 2017 in Medline, Embase, Web of Science and Scopus databases. We included studies examining the effects of CHW interventions in low-income and middle-income countries on maternal and newborn health outcomes across socioeconomic groups (wealth, occupation, education, class, caste or tribe and religion). We then conducted a narrative synthesis of evidence.ResultsWe identified 1919 articles, of which 22 met the inclusion criteria. CHWs facilitated four types of interventions: home visits, community-based groups, cash transfers or combinations of these. Four studies found that CHWs providing home visits or facilitating women’s groups had equitable coverage. Four others found that home visits and cash transfer interventions had inequitable coverage. Five studies reported equitable effects of CHW interventions on antenatal care, skilled birth attendance and/or essential newborn care. One study found that a CHW home visit intervention did not reduce wealth inequities in skilled birth attendance. A study of women’s groups reported greater reductions in neonatal mortality among lower compared with higher socioeconomic groups. Equity was most improved when CHWs had relevant support for assisting women to improve health practices and access health care within community contexts.ConclusionWhile current evidence remains limited, particularly for mortality, existing studies suggest that CHW interventions involving home visits, cash transfers, participatory women’s groups or multiple components can improve equity in maternal and newborn health. Future mixed-methods research should explore intervention strategies and contextual processes shaping such effects on equity to optimise these efforts.

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A patient–clinician James Lind Alliance partnership to identify research priorities for hyperemesis gravidarum

BMJ Open ◽

10.1136/bmjopen-2020-041254 ◽

2021 ◽

Vol 11 (1) ◽

pp. e041254

Author(s):

Caitlin R Dean ◽

Hyke Bierma ◽

Ria Clarke ◽

Brian Cleary ◽

Patricia Ellis ◽

...

Keyword(s):

Low Income ◽

Online Survey ◽

Hyperemesis Gravidarum ◽

Research Priorities ◽

Developed Countries ◽

Middle Income ◽

Policy Makers ◽

Middle Income Countries ◽

James Lind Alliance ◽

Research Questions

ObjectiveThere are many uncertainties surrounding the aetiology, treatment and sequelae of hyperemesis gravidarum (HG). Prioritising research questions could reduce research waste, helping researchers and funders direct attention to those questions which most urgently need addressing. The HG priority setting partnership (PSP) was established to identify and rank the top 25 priority research questions important to both patients and clinicians.MethodsFollowing the James Lind Alliance (JLA) methodology, an HG PSP steering group was established. Stakeholders representing patients, carers and multidisciplinary professionals completed an online survey to gather uncertainties. Eligible uncertainties related to HG. Uncertainties on nausea and vomiting of pregnancy and those on complementary treatments were not eligible. Questions were verified against the evidence. Two rounds of prioritisation included an online ranking survey and a 1-hour consensus workshop.Results1009 participants (938 patients/carers, 118 professionals with overlap between categories) submitted 2899 questions. Questions originated from participants in 26 different countries, and people from 32 countries took part in the first prioritisation stage. 66 unique questions emerged, which were evidence checked according to the agreed protocol. 65 true uncertainties were narrowed via an online ranking survey to 26 unranked uncertainties. The consensus workshop was attended by 19 international patients and clinicians who reached consensus on the top 10 questions for international researchers to address. More patients than professionals took part in the surveys but were equally distributed during the consensus workshop. Participants from low-income and middle-income countries noted that the priorities may be different in their settings.ConclusionsBy following the JLA method, a prioritised list of uncertainties relevant to both HG patients and their clinicians has been identified which can inform the international HG research agenda, funders and policy-makers. While it is possible to conduct an international PSP, results from developed countries may not be as relevant in low-income and middle-income countries.

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Trends and outcomes in primary health care expenditures in low-income and middle-income countries, 2000–2017

BMJ Global Health ◽

10.1136/bmjgh-2021-005798 ◽

2021 ◽

Vol 6 (8) ◽

pp. e005798

Author(s):

Matthew T Schneider ◽

Angela Y Chang ◽

Sawyer W Crosby ◽

Stephen Gloyd ◽

Anton C Harle ◽

...

Keyword(s):

Low Income ◽

Primary Healthcare ◽

Health Expenditures ◽

Middle Income Country ◽

Income Country ◽

P Value ◽

Care Providers ◽

Middle Income ◽

Middle Income Countries ◽

Per Capita

IntroductionAs the world responds to COVID-19 and aims for the Sustainable Development Goals, the potential for primary healthcare (PHC) is substantial, although the trends and effectiveness of PHC expenditure are unknown. We estimate PHC expenditure for each low-income and middle-income country between 2000 and 2017 and test which health outputs and outcomes were associated with PHC expenditure.MethodsWe used three data sources to estimate PHC expenditures: recently published health expenditure estimates for each low-income and middle-income country, which were constructed using 1662 country-reported National Health Accounts; proprietary data from IQVIA to estimate expenditure of prescribed pharmaceuticals for PHC; and household surveys and costing estimates to estimate inpatient vaginal delivery expenditures. We employed regression analyses to measure the association between PHC expenditures and 15 health outcomes and intermediate health outputs.ResultsPHC expenditures in low-income and middle-income countries increased between 2000 and 2017, from $41 per capita (95% uncertainty interval $33–$49) to $90 ($73–$105). Expenditures for low-income countries plateaued since 2014 at $17 per capita ($15–$19). As national income increased, the proportion of health expenditures on PHC generally decrease; however, the fraction of PHC expenditures spent via ambulatory care providers grew. Increases in the fraction of health expenditures on PHC was associated with lower maternal mortality rate (p value≤0.001), improved coverage of antenatal care visits (p value≤0.001), measles vaccination (p value≤0.001) and an increase in the Health Access and Quality index (p value≤0.05). PHC expenditure was not systematically associated with all-age mortality, communicable and non-communicable disease (NCD) burden.ConclusionPHC expenditures were associated with maternal and child health but were not associated with reduction in health burden for other key causes of disability, such as NCDs. To combat changing disease burdens, policy-makers and health professionals need to adapt primary healthcare to ensure continued impact on emerging health challenges.

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