PublicationsTopic index of systematic reviewsKnowledge pagesDeveloping countries - healthcare
Healthcare in low-income countries
This page contains the findings of systematic reviews undertaken by groups within or related to the EPPI Centre.

Dual practice
Health insurance
Reproductive and sexual health
Strengthening national health service delivery

Dual practice [1]

There are mainly three categories of dual practice mechanisms that have been employed in health care in developing countries: 1) total banning of dual practice; 2) allow dual practice with restrictions; 3) allow dual practice without restrictions.  Specifically, evidence indicated that:

  • Banning dual practice totally, is not generally enforceable,
  • Raising public sector salaries to compete with private sector earnings (in a bid to discourage public sector health workers from working in the private sector) is not realistic in many LMICs with resource constraints 
  • Restricting private practice to services not offered by the public sector, restricting private sector charges, insurance and access to public funds can reduce private practice in the presence of universal insurance coverage and well established financial monitoring systems
  • In many LMICs that are already suffering consequences of health worker shortages, unrestricted dual practice, is not feasible.

in countries where the shortage of health workers is an area of major concern, allowing dual practice without restrictions may hurt the situation further, while a total ban may be challenging to implement in settings where public sector workers earn low salaries. It may therefore be feasible to design mechanisms that take into critical consideration the specific conditions pertaining in individual countries, especially the different ways in which dual practice manifests itself. The most effective mechanisms therefore, may be multi-dimensional.

Vouchers [3]

One approach to delivering health assistance to developing countries is the use of health voucher programmes, where vouchers are distributed to a targeted population for free or subsidised health goods/services. The strongest finding from this review is that these programmes have been successful in increasing utilisation of health goods/services. There is also modest evidence that voucher programmes can effectively target specific populations and can improve the quality of services. While these results are encouraging, the subsequent link that voucher programmes improve the health of the population is not evident in the data analysed in this review. Further research is needed

Health insurance [6]

One systematic review showed inconclusive evidence. Low enrolment was commonly observed in many of the insurance schemes examined. Many health system factors may play a role in explaining low enrolment; studies did not explore supply factors. There was no apparent pattern regarding enrolment and outcome: for example, high enrolment was not correlated with better outcomes. There was some evidence that health insurance may prevent high levels of expenditure. From those studies reporting on whether or not the impact on the subgroup of insured that were poorer was more noticeable, it appears that the impact was smaller for the poorer population. That is, the insured poor may be undertaking higher out-of pocket expenditure than those who are not insured.

Reproductive and sexual health

Social franchising [4] is often considered as a solution for increasing access to and improving the quality of primary care, reproductive and sexual health, TB and HIV/AIDS diagnosis and care in low- and middle-income countries.  Most of the evaluated franchises are from  Asia and Africa, particularly from low-income countries, and most social focus on reproductive health and family planning. There was a paucity of rigorous study designs, so the evidence supporting social franchising is weak. Across settings, the public sector continues to have the highest volume of clients for family planning and other services; however, franchises do better than non-franchised private providers in terms of client volume. The clients of social franchises are satisfied with the quality of care and consistently report an intent to return.

A small literature  on the effects of aid-supported interventions on maternal and sexual health [5] found moderate and poor quality evidence of the effects: lower maternal mortality; more attended births; greater contraceptive use; better antenatal care coverage; and greater use of family planning. No clear difference can be seen between the effects of interventions supported by aid aligned with the Paris Principles and the effects of interventions supported by aid not clearly aligned with the Paris Principles.

Currently, there is no evidence on the impact of post-abortion family planning counselling and services in low-income countries [2] on maternal mortality or morbidity and there is insufficient evidence on their impact on repeat abortions and unplanned pregnancies. Although insufficient, there is promising evidence on the impact of post-abortion family planning counselling and services on acceptance or use of contraception.

One review [8] synthesised the results of systematic reviews investigating a range of modern and traditional contraceptive methods. The review mainly focused on interventions relating to female sterilisation using clips and rings, and these were found to be equally efficacious in preventing pregnancy. There is moderate quality evidence to favour the second-generation oral pill (monophasic norgestrel 0.3mg/EE 30mcg) over first-generation (monophasic norethindrone acetate 1.5mg/EEmcg) in preventing pregnancy. High quality evidence supports the programmatic use of the TCU380A intrauterine device over the Multiload Cu375 device and there is low quality evidence that two-monthly injections of NET-EN/E2V 50mg and three-monthly injections of DMPA/E2c 5mg did not show any difference in pregnancy prevention. There is low quality evidence also that the two implants Implanon and Norplant reduce the risk of pregnancy. Moderate-quality evidence indicates that mid-dose mifepristone (25-50mg) is more effective than low-dose mifepristone (<25mg) for emergency contraception (RR= 0.66, 95% CI 0.47, 0.91), and moderate-quality evidence that there is no difference between spermicides in preventing pregnancy. It was not possible to present evidence on  outcomes for male/female condoms, diaphragms, vasectomy, skin patches or vaginal rings. 

Strengthening national health service delivery [7]

The quality of the evidence found was low. 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.  


1. Dual Practice regulatory mechanisms in the health sector: a systematic review of approaches and implementation (2011)

2. The impact of post-abortion care family planning counselling and services in low-income countries: a systematic review of the evidence (2011)

3. The impact of vouchers on the use and quality of health goods and services in developing countries: a systematic review (2011)

4. Social franchising evaluations: a scoping review (2011)

5. The impact of aid on maternal and reproductive health: a systematic review to evaluate the effect of aid on the outcomes of Millennium Development Goal 5 (2011)

6. Impact of national health insurance for the poor and the informal sector in low- and middle-income countries: a systematic review (2012)

7. 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 (2013)

8. What is the impact of contraceptive methods and mixes of contraceptive methods on contraceptive prevalence, unmet need for family planning, and unwanted and unintended pregnancies? An overview of systematic reviews (2013)

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