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Effectiveness of interventions to strengthen national health service delivery on coverage, access, quality and equity in the use of health services in low and lower middle income countries

What do we want to know?

We conducted a systematic review to synthesise the evidence for the effectiveness of interventions to strengthen national health service delivery on coverage, access, quality and equity in the use of health services in low and lower middle income countries. Health system strengthening includes many components and can occur at many levels. Two frameworks are used to position and structure this review: the WHO’s six building blocks of health system components (World Health Organization, 2007) and a framework of five levels at which constraints to improved access to health care exist: I. community/household; II. health services delivery; III. health sector policy and strategic management; IV. public policies cutting across sectors; and V. environmental and contextual (Hanson et al., 2003).
 
Review objectives:

  1. To identify and describe characteristics of supply-side interventions that are intended to improve health services provided by front-line workers;
  2. To assess and report the effectiveness of these interventions on:
  • coverage of health services;
  • access to health services;
  • quality of health services;
  • equity in the use of health services; and
  • morbidity and mortality 

What did we find?

Studies which strengthened other elements of the health service delivery in addition to technical guidance, as well as community mobilisation and interventions at the health sector policy and strategic management level showed more consistent improvement on quality of care and counselling than those using technical guidance alone.
 
The evidence base for the effect of supply-side interventions was largest for outcomes of quality of care, with little evidence of interventions delivered at scale and evaluated robustly for outcomes of access, equity or mortality.  

What are the implications?

Table 6.1: Implications for policy makers and for research 
 

How did we get these results?

We searched MEDLINE, CENTRAL and Embase electronic databases using a combination of broad search terms relating to health systems (health service delivery, health services, health workforce, quality assurance) AND developing countries AND study design. Complete search strategies are shown in Appendices 2 and 3. The final search strategy was translated from MEDLINE to CENTRAL and Embase databases.

In order to access grey literature, we translated the MEDLINE search strategy to the Global Health database, and browsed studies listed under the health service delivery category within ELDIS.

The EPPI-Centre reference number for this report is 2116.

This report should be cited as:

Willey B, Smith Paintain L, Mangham-Jefferies L, Car J, Armstrong Schellenberg J (2013) Effectiveness of interventions to strengthen national health service delivery on coverage, access, quality and equity in the use of health services in low and lower middle income countries. London: EPPI-Centre, Social Science Research Unit, Institute of Education, University of London.

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