Effects of delivery arrangements for health systems in low-income countries

Ciapponi A, Lewin S, Herrera CA, Opiyo N, Pantoja T, Paulsen E, Rada G, Wiysonge CS, Bastías G, Dudley L, Flottorp S, Gagnon M, Garcia Marti S, Glenton C, Okwundu CI, Peñaloza B, Suleman F, Oxman AD

What is the aim of this overview?

The aim of this Cochrane Overview is to provide a broad summary of what is known about the effects of delivery arrangements for health systems in low-income countries.

This overview is based on 51 systematic reviews. These systematic reviews searched for studies that evaluated different types of delivery arrangements. The reviews included a total of 850 studies.

This overview is one of a series of four Cochrane Overviews that evaluate health system arrangements.

What was studied in the overview?

Delivery arrangements include changes in who receives care and when, who provides care, the working conditions of those who provide care, coordination of care amongst different health care providers, where care is provided, the use of information and communication technology to deliver care, and quality and safety systems. How services are delivered can have impacts on the effectiveness, efficiency and equity of health systems. This overview can help policymakers and other stakeholders to identify evidence-informed strategies to improve the delivery of services.

What are the main results of the overview?

When focusing only on evidence assessed as high to moderate certainty, the overview points to a number of delivery arrangements that had at least one desirable outcome and no evidence of any undesirable outcomes. These include the following:

Who receives care and when

- Queuing strategies

- Group antenatal care

Who provides care – role expansion or task shifting

- Lay or community health workers supporting the care of people with hypertension

- Community-based neonatal packages that include additional training of outreach workers

- Lay health workers to deliver care for mothers and children or for infectious diseases

- Mid-level, non-physician providers for abortion care

- Health workers providing social support during at-risk pregnancies

- Midwife-led care for childbearing women and their infants

- Non-specialist health workers or other professionals with health roles to help people with mental, neurological and substance-abuse disorders

- Nurses substituting for physicians in providing care

Coordination of care

- Structured multidisciplinary care plans (care pathways) used by health care providers in hospitals to detail essential steps in the care of people with a specific clinical problem

- Interactive communication between collaborating primary care physicians and specialist physicians in outpatient care

- Planning to facilitate patients’ discharge from hospital to home

- Adding a new health service to an existing service and integrating services in health care delivery

- Integrating vaccination with other healthcare services

- Using physicians rather than nurses to lead triage in emergency departments

- Groups or teams of midwives providing care for a group of women during pregnancy and childbirth and after childbirth

Where care is provided – site of service delivery

- Clinics or hospitals that manage a high volume of people living with HIV and AIDS rather than smaller volumes

- Intensive home-based care for people living with HIV and AIDS

- Home-based management of malaria in children

- Providing care closer to home for children with long-term health conditions

- Community-based interventions using lay health workers for childhood diarrhoea and pneumonia

- Youth HIV and reproductive health services provided outside of health facilities

- Decentralising care for initiation and maintenance of HIV and AIDS medicine treatment to peripheral health centres or lower levels of healthcare

Information and communication technology

- Mobile phone messaging for people with long-term illnesses

- Mobile phone messaging reminders for attendance at healthcare appointments

- Mobile phone messaging to promote adherence to antiretroviral therapy

- Women carrying their own case notes in pregnancy

- Information and communication interventions to improve childhood vaccination coverage

Quality and safety systems

- Establishing clinical information systems to organize patient data for people living with HIV and AIDS

Packages that include multiple interventions

- Interventions to improve referral for emergency care during pregnancy and childbirth

How up to date is this overview?

The overview authors searched for systematic reviews that had been published up to 17 December 2016.

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