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

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 different governance arrangements for health systems in low-income countries.

This overview is based on 19 relevant systematic reviews. These systematic reviews searched for studies that evaluated different types of governance arrangements. The reviews included a total of 172 studies.

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

Main results

What are the effects of different ways of organising authority and accountability for health policies?

Three reviews were included and the key findings are that:

- collaboration between local health agencies and other local government agencies may lead to little or no difference in physical health or quality of life (low-certainty evidence);

- placing restrictions on the medicines reimbursed by health insurance systems probably decreases the use of and spending on these medicines (moderate-certainty evidence);

- it is uncertain if fraud prevention, detection and response interventions reduce healthcare fraud and related spending (very low-certainty evidence).

What are the effects of different ways of organising authority and accountability for organisations?

Two reviews were included and the key findings are that:

- Contracting non-state, not-for-profit providers to deliver health services may increase access to and use of these services, improve people's health outcomes and reduce household spending on health (low-certainty evidence). No evidence was available on whether contracting out was more effective than using these funds in the state sector.

What are the effects of different ways of organising authority and accountability for commercial products such as medicines and technologies?

Three reviews were included and the key findings are that:

- systems in which the World Health Organization (WHO) certifies medicine manufacturers (prequalification) and medicines registration (in which medicine regulatory authorities assess medicine manufacturers to ensure they meet international standards) may decrease the proportion of medicines that are substandard or counterfeit (low-certainty evidence);

- establishing a maximum reimbursement for pharmacies dispensing similar medicines covered by insurance may increase the use of generic medicines and may reduce the use of brand-name medicines (low-certainty evidence), but it is uncertain whether this approach affects the overall amount spent on medicines (very low-certainty evidence);

- direct-to-consumer advertising increases people's requests for medicines and the numbers of prescriptions given (high-certainty evidence).

What are the effects of different ways of organising authority and accountability for healthcare providers?

Seven reviews were included and the key findings are that:

- training programmes for district health system managers may increase their knowledge of planning processes and their monitoring and evaluation skills (low-certainty evidence);

- reducing immigration restrictions in high-income countries probably increases the migration of nurses from low- and middle-income to these countries (moderate-certainty evidence);

- it is uncertain whether inspection by an external body of healthcare organisation adherence to quality standards improves adherence, quality of care or health-acquired infection rates in hospitals (very low-certainty evidence).

What are the effects of different ways of organising stakeholder involvement in governing health services?

Four reviews were included and the key findings are that:

- participatory learning and action groups for women probably improve newborn survival (moderate-certainty evidence) and may improve maternal survival (low-certainty evidence);

- disclosing performance data on health insurance scheme quality to the public may lead people to select health plans that have better quality ratings or to avoid those with worse ratings and may lead to slight improvements in clinical outcomes for health insurance schemes (low-certainty evidence);

- disclosing performance data on hospital quality to the public may lead to little or no difference in people's selection of hospitals (low-certainty evidence), probably encourages hospitals to implement quality improvement activities (moderate-certainty evidence) and may lead to slight improvements in hospital clinical outcomes (low-certainty evidence);

- disclosing performance on individual healthcare providers to the public probably leads people to select providers that have better quality ratings (moderate-certainty evidence).

No studies evaluated the effects of stakeholder participation in policy and organisational decisions.

How up-to-date is this overview?

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

Authors' conclusions: 

Investigators have evaluated a wide range of governance arrangements that are relevant for low-income countries using sound systematic review methods. These strategies have been targeted at different levels in health systems, and studies have assessed a range of outcomes. Moderate-certainty evidence shows desirable effects (with no undesirable effects) for some interventions. However, there are important gaps in the availability of systematic reviews and primary studies for the all of the main categories of governance arrangements.

Read the full abstract...
Background: 

Governance arrangements include changes in rules or processes that determine authority and accountability for health policies, organisations, commercial products and health professionals, as well as the involvement of stakeholders in decision-making. Changes in governance arrangements can affect health and related goals in numerous ways, generally through changes in authority, accountability, openness, participation and coherence. A broad overview of the findings of systematic reviews can help policymakers, their technical support staff and other stakeholders to identify strategies for addressing problems and improving the governance of their health systems.

Objectives: 

To provide an overview of the available evidence from up-to-date systematic reviews about the effects of governance arrangements for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on governance arrangements and informing refinements of the framework for governance arrangements outlined in the overview.

Methods: 

We searched Health Systems Evidence in November 2010 and PDQ Evidence up to 17 December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of governance arrangements on patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use (health expenditures, healthcare provider costs, out-of-pocket payments, cost-effectiveness), healthcare provider outcomes (such as sick leave), or social outcomes (such as poverty, employment) and that were published after April 2005. We excluded reviews with limitations that were important enough to compromise the reliability of the findings of the review. Two overview authors independently screened reviews, extracted data and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence) and assessments of the relevance of findings to low-income countries.

Main results: 

We identified 7272 systematic reviews and included 21 of them in this overview (19 primary reviews and 2 supplementary reviews). We focus here on the results of the 19 primary reviews, one of which had important methodological limitations. The other 18 were reliable (with only minor limitations).

We grouped the governance arrangements addressed in the reviews into five categories: authority and accountability for health policies (three reviews); authority and accountability for organisations (two reviews); authority and accountability for commercial products (three reviews); authority and accountability for health professionals (seven reviews); and stakeholder involvement (four reviews).

Overall, we found desirable effects for the following interventions on at least one outcome, with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects.

Decision-making about what is covered by health insurance

- Placing restrictions on the medicines reimbursed by health insurance systems probably decreases the use of and spending on these medicines (moderate-certainty evidence).

Stakeholder participation in policy and organisational decisions

- Participatory learning and action groups for women probably improve newborn survival (moderate-certainty evidence).
- Consumer involvement in preparing patient information probably improves the quality of the information and patient knowledge (moderate-certainty evidence).

Disclosing performance information to patients and the public

- Disclosing performance data on hospital quality to the public probably encourages hospitals to implement quality improvement activities (moderate-certainty evidence).
- Disclosing performance data on individual healthcare providers to the public probably leads people to select providers that have better quality ratings (moderate-certainty evidence).

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