Four new Cochrane overviews of systematic reviews on Health Systems in LMICs

Four Cochrane overviews of systematic reviews published in the Cochrane Library show reliable evidence on the effects of different ways of organising, financing, and governing health systems in low-income countries.

Strengthening health systems in low-income countries is key to achieving universal health coverage. Systematic reviews on the effects of different health system arrangements are essential for making informed decisions, and many such reviews are available. However, policy makers and other stakeholders may struggle to identify which reviews are reliable and what are the key results.

Broad overviews of the findings of systematic reviews can help policy makers, their support staff, and other stakeholders to identify strategies for addressing problems with how their health systems are organised, financed, and governed and with identifying effective strategies for implementing changes. It can also help to identify needs and priorities for new evaluations of health system arrangements and for systematic reviews.

A team of Cochrane researchers from Argentina, Chile, Norway, and South Africa prepared four overviews of the available evidence from up-to-date systematic reviews about the effects of health system arrangements in low-income countries. They included 124 systematic reviews in the four overviews. For each review, a user-friendly summary of key findings was produced (see http://supportsummaries.org/), enabling users to explore the overview findings in more depth. The summaries include over 480 key messages about the effects of health system arrangements in low-income countries.

An overview of delivery arrangements included 51 systematic reviews that included a total of 919 studies. These reviews found that that many delivery arrangements probably have desirable effects, including task shifting or role expansion and strategies for co-ordinating care. The new overview 'Delivery arrangements for health systems in low-income countries: an overview of systematic reviews' (Effective Practice and Organisation of Care Group, 10.1002/14651858.CD011083.pub2) was published in the Cochrane Database of Systematic Reviews, Issue 9, 2017.

An overview of financial arrangements included 15 systematic reviews that included a total of 276 studies. The effects of most of the financial arrangements that were reviewed were uncertain. This includes the effects of providing financial incentives and disincentives for health care workers, and the effects of most types of financial incentives and disincentives for people using health services. The new overview 'Financial arrangements for health systems in low-income countries: an overview of systematic reviews' (Effective Practice and Organisation of Care Group, 10.1002/14651858.CD011084.pub2) was published in the Cochrane Database of Systematic Reviews, Issue 9, 2017.

An overview of governance arrangements included 21 systematic reviews that included a total of 172 studies. These reviews found that restrictions on medicines reimbursement (pre-authorisation), community mobilisation, and disclosing to the public performance data on health facilities and providers probably have desirable effects. The effects of other governance arrangements that were reviewed were uncertain. The new overview 'Governance arrangements for health systems in low-income countries: an overview of systematic reviews' (Effective Practice and Organisation of Care Group, 10.1002/14651858.CD011085.pub2) was published in the Cochrane Database of Systematic Reviews, Issue 9, 2017.

An overview of implementation strategies included 39 systematic reviews that included a total of 1332 studies. These reviews found that many different implementation strategies probably improve professional practice, including educational meetings, educational outreach, practice facilitation, local opinion leaders, audit and feedback, and tailored interventions. Many strategies targeted at healthcare recipients also probably have desirable effects on the use of health care. For example, mass media interventions lead to an increase in immediate uptake of HIV testing and reminders and recall strategies for caregivers probably increase routine childhood vaccination uptake. The new overview 'Implementation strategies for health systems in low-income countries: an overview of systematic reviews' (Effective Practice and Organisation of Care Group, 10.1002/14651858.CD011086.pub2) was published in the Cochrane Database of Systematic Reviews, Issue 9, 2017.

Dr Simon Lewin, Joint Co-ordinating Editor of Cochrane’s Effective Practice and Organisation of Care (EPOC) Group and Cochrane author noted that: “These overviews are a key source of evidence for decision makers in low-income countries who are considering options for strengthening the health system in their setting. The overviews use a unique approach, based on user-friendly summaries of each contributing review, and we hope that this will make the evidence identified much more accessible to decision makers and those who support them.”

Dr Charles Shey Wiysonge, one of the overview authors and the Director of Cochrane South Africa noted that: “These overviews have come at an opportune moment, when African countries are considering the best approaches for achieving Universal Health Coverage. The overviews and the underlying user-friendly evidence summaries – the SUPPORT Summaries - are important resources for constructive engagement and exchange between Cochrane Africa and relevant national stakeholders for evidence-informed health decision making in Africa.”