Systems In Low-income Countries Research Articles

User fee removal in low-income countries: sharing knowledge to support managed implementation

User fees have triggered impassioned discussions in international health over the last two decades. Promoted by a number of international organizations since the late 1980s as a strategy to finance struggling public health facilities in many lowincome countries, recent years have seen growing criticism of the impact of fees on access to health services, particularly for the poorest groups. The debate continues and there is evidence for both sides of the argument. User fees are a barrier to users, and the poor in particular, but they also have some valuable characteristics (Meessen et al. 2006). Their contribution to generating resources for the benefit of health facilities that are sometimes deprived of any other source of flexible funding is just the most obvious one. Taking the right stance in this debate is far from easy for countries and their aid partners, as different constraints—including country ownership, fiscal space, other pressing development needs and the obligation to ration available resources—have to be taken into account. In 2005, UNICEF organized an expert consultation to update its position on this controversial strategy. The evidence reviewed at this consultation led to the following consensus: removing user fees has the potential to improve access to health services, especially for the poor. For this to occur, however, fee removal needs to be part of a broader package of reforms that includes increased budgets to offset lost fee revenue, maintain quality and respond to increased demand. It also needs clear communication with a broad stakeholder buy-in, careful monitoring to ensure that official fees are not replaced by informal fees, and appropriate management of the alternative financing mechanisms which are replacing user fees. When the above conditions are not met, fee removal is unlikely to benefit the poor (James et al. 2006). In mid-2008, UNICEF approached a group of researchers with the request to document recent experience with user fee removal. While aid actors in the North were still arguing fiercely about the pros and cons of user fees, a growing number of countries had already decided to remove user fees, at least for some priority services. A consensus was easily reached between UNICEF and the research team led by the Institute of Tropical Medicine, Antwerp: the multi-country review would not (again) focus on evidence against or in favour of user fees, but would instead try to document how countries formulated and implemented user fee removal. This focus was seen as valuable because it could generate practical lessons for other countries interested in such a step. The findings of the multi-country review were presented at a meeting of experts convened by UNICEF New York in February 2009. Presentations covered a number of countries as well as comparisons between countries—including a challenging comparison between Rwanda and Uganda. At some point, the ‘ghosts’ of Bismark and Beveridge entered the room, so there was another episode in the (by now familiar) debate on the relative merits of reducing financial barriers through health insurance or through user fee removal. We do have some country evidence to fuel this broader debate in this supplement; however, its main focus lies elsewhere. Following the New York meeting, the research team judged that the main question of the multi-country review—the challenges related to design and implementation of user fee removal policies—deserved more visibility than just another report. Indeed, while there is a large consensus among experts familiar with health systems in low-income countries that implementation of new policies and interventions raises major challenges (Peters et al. 2009), the formally published knowledge base is still small (Gilson and Raphaely 2008). Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine The Author 2011; all rights reserved. Health Policy and Planning 2011;26:ii1–ii4 doi:10.1093/heapol/czr071

Abolition of user fees: the Uganda paradox

Inadequate health financing is one of the major challenges health systems in low-income countries currently face. Health financing reforms are being implemented with an increasing interest in policies that abolish user fees. Data from three nationally representative surveys conducted in Uganda in 1999/2000, 2002/03 and 2005/06 were used to investigate the impact of user fee abolition on the attainment of universal coverage objectives. An increase in illness reporting was noted over the three surveys, especially among the poorer quintiles. An increase in utilization was registered in the period immediately following the abolition of user fees and was most pronounced in the poorest quintile. Overall, there was an increase in utilization in both public and private health care delivery sectors, but only at clinic and health centre level, not at hospitals. Our study shows important changes in health-care-seeking behaviour. In 2002/03, the poorest population quintile started using government health centres more often than private clinics whereas in 1999/2000 private clinics were the main source of health care. The richest quintile has increasingly used private clinics. Overall, it appears that the private sector remains a significant source of health care. Following abolition of user fees, we note an increase in the use of lower levels of care with subsequent reductions in use of hospitals. Total annual average expenditures on health per household remained fairly stable between the 1999/2000 and 2002/03 surveys. There was, however, an increase of US$21 in expenditure between the 2002/03 and 2005/06 surveys. Abolition of user fees improved access to health services and efficiency in utilization. On the negative side is the fact that financial protection is yet to be achieved. Out-of-pocket expenditure remains high and mainly affects the poorer population quintiles. A dual system seems to have emerged where wealthier population groups are switching to the private sector.

HIV and Health Systems: Research to Bridge the Divide

Concern that HIV programs in low-income countries may strain weak health systems and undermine achievement of other priority health goals has resulted in a research agenda focused on measuring the effects of past HIV investments on non-HIV services and outcomes. However, this research has limited value for informing future health policies and programs, which increasingly view health systems as the common platform for delivery of HIV and other health services. These policies reflect a shift in the framing of HIV care and treatment from emergency response to routine health service. In this paradigm, relevant areas for research are strengthening, scaling, and sustaining health systems in low-income countries to reduce all-cause mortality and morbidity, including deaths from HIV. To build an evidence base to support current and future health systems and policy, researchers need to move from retrospective studies to prospective research and adopt innovative study designs and analytic methods.

Working Paper 11: A framework to assess governance of health systems in low-income countries

As awareness of the role governance in the performance of health systems has increased, so has the need to come up with systematic means to evaluate governance shortcomings to develop adequate interventions.
 This working paper describes a framework to assess governance in the health systems of low-income countries that is intended to have empirical applicability with a problem-driven approach. The analysis is grounded on a re-categorization of governance dimensions for greater heuristic power, with an emphasis made on the importance of strategic systems design and accountability.
 The proposed methodology includes mapping of both formal and informal institutions, actors and networks. This underscores the idea that in order to properly address governance weaknesses it is of utmost importance to have an insight into whether the interplay of formal and informal norms facilitates or undermines system performance.

Evaluating tuberculosis case detection via real-time monitoring of tuberculosis diagnostic services.

Tuberculosis case-detection rates are below internationally established targets in high-burden countries. Real-time monitoring and evaluation of adherence to widely endorsed standards of tuberculosis care might facilitate improved case finding. To monitor and evaluate the quality of tuberculosis case-detection and management services in a low-income country with a high incidence of tuberculosis. We prospectively evaluated tuberculosis diagnostic services at five primary health-care facilities in Uganda for 1 year, after introducing a real-time, electronic performance-monitoring system. We collected data on every clinical encounter, and measured quality using indicators derived from the International Standards of Tuberculosis Care. In 2009, there were 62,909 adult primary-care visits. During the first quarter of 2009, clinicians referred only 21% of patients with cough greater than or equal to 2 weeks for sputum smear microscopy and only 71% of patients with a positive sputum examination for tuberculosis treatment. These proportions increased to 53% and 84%, respectively, in the fourth quarter of 2009. The cumulative probability that a smear-positive patient with cough greater than or equal to 2 weeks would be appropriately evaluated and referred for treatment rose from 11% to 34% (P = 0.005). The quarterly number of tuberculosis cases identified and prescribed treatment also increased four-fold, from 5 to 21. Poor adherence to internationally accepted standards of tuberculosis care improved after introduction of real-time performance monitoring and was associated with increased tuberculosis case detection. Real-time monitoring and evaluation can strengthen health systems in low-income countries and facilitate operational research on the effectiveness and sustainability of interventions to improve tuberculosis case detection.

The impact of Prevention of Mother to Child Transmission (PMTCT) programmes on maternal health care in resource‐poor settings: looking beyond the PMTCT programme—a systematic review

There is increasing debate about the impact of scaled-up HIV/AIDS programmes on fragile healthcare systems in low-income countries. To contribute to the understanding of the relation between HIV/AIDS programmes and healthcare systems, this systematic review focuses on the impact of Prevention of Mother to Child Transmission (PMTCT) programmes on maternal health care. Publications describing the effect of PMTCT programmes on maternal healthcare services were sought through computerised searches in five electronic databases. Abstracts of publications were evaluated for appropriateness for inclusion based on whether they met the inclusion criteria. Copies of all selected publications were obtained. A classification system was developed to group the relevant publications. The findings show that empirical evidence of the effect of PMTCT programmes on maternal health care is scarce and further research is badly needed. Twenty-one studies that were included in the systematic review showed that PMTCT programmes are often semi-integrated in maternal health care with positive as well as negative effects on various aspects of maternal health care. It appears that PMTCT programmes miss the opportunity to have an overall positive effect on maternal health care because of their verticality.

What can global health institutions do to help strengthen health systems in low income countries?

Weaknesses in health systems contribute to a failure to improve health outcomes in developing countries, despite increased official development assistance. Changes in the demands on health systems, as well as their scope to respond, mean that the situation is likely to become more problematic in the future. Diverse global initiatives seek to strengthen health systems, but progress will require better coordination between them, use of strategies based on the best available evidence obtained especially from evaluation of large scale programs, and improved global aid architecture that supports these processes. This paper sets out the case for global leadership to support health systems investments and help ensure the synergies between vertical and horizontal programs that are essential for effective functioning of health systems. At national level, it is essential to increase capacity to manage and deliver services, situate interventions firmly within national strategies, ensure effective implementation, and co-ordinate external support with local resources. Health systems performance should be monitored, with clear lines of accountability, and reforms should build on evidence of what works in what circumstances.

Rethinking localization--a low-income country perspective: the case of Asian vegetables in Ghana

There are few studies that consider the localization/relocalization of food systems in low-income countries and how the social, cultural and economic dynamics of these agri-food systems compare to trends observed in high-income countries. We suggest that food systems in Ghana are localized by necessity when compared to relocalized food systems observed in high-income countries that have emerged in response to global agri-food industrialization. Food systems in Ghana are characterized by policies aimed at enhancing food security and poverty alleviation, as well as market imperfections that limit farmers' access to non-local markets. Copyright 2010, Oxford University Press.

Estimating the capacity for ART provision in Tanzania with the use of data on staff productivity and patient losses.

BackgroundInternational targets for access to antiretroviral therapy (ART) have over-estimated the capacity of health systems in low-income countries in Sub-Saharan Africa. The WHO target for number on treatment by end 2005 for Tanzania was 10 times higher than actually achieved. The target of the national Care and Treatment Plan (CTP) was also not reached. We aimed at estimating the capacity for ART provision and created five scenarios for ART production given existing resource limitations.MethodsA situation analysis including scrutiny of staff factors, such as available data on staff and patient factors including access to ART and patient losses, made us conclude that the lack of clinical staff is the main limiting factor for ART scale-up, assuming that sufficient drugs and supplies are provided by donors. We created a simple formula to estimate the number of patients on ART based on availability and productivity of clinical staff, time needed to initiate vs maintain a patient on ART and patient losses using five different scenarios with varying levels of these parameters.FindingsOur scenario assuming medium productivity (40% higher than that observed in 2002) and medium loss of patients (20% in addition to 15% first-year mortality) coincides with the actual reported number of patients initiated on ART up to 2008, but is considerably below the national CTP target of 90% coverage for 2009, corresponding to 420,000 on ART and 710,000 life-years saved (LY's). Our analysis suggests that a coverage of 40% or 175,000 on treatment and 350,000 LY's saved is more achievable.ConclusionA comparison of our scenario estimations and actual output 2006–2008 indicates that a simple user-friendly dynamic model can estimate the capacity for ART scale-up in resource-poor settings based on identification of a limiting staff factor and information on availability of this staff and patient losses. Thus, it is possible to set more achievable targets.

Performance-based payment: some reflections on the discourse, evidence and unanswered questions

Performance-based payment (PBP) is increasingly advocated as a way to improve the performance of health systems in low-income countries. This study conducted a systematic review of the current literature on this topic and found that while it is a popular term, there was little consensus about the meaning or the use of the concept of PBP. Significant weaknesses in the current evidence base on the success of PBP initiatives were also found. The literature would be strengthened by multi-disciplinary case studies that present both the advantages and disadvantages of PBP, influential factors for success, and more details about the projects from which this evidence is drawn. Where possible, data from control facilities where PBP is not being implemented would be an important addition. This paper suggests a further agenda for research, including assessing optimal conditions for implementation of PBP schemes in less developed health systems, the impact of adopting measures of performance as targets, and the requirements for monitoring PBP adequately.

Pediatric emergency and critical care in low‐income countries

The United Nations' Millennium Development Goal 4 is to reduce the global under-five mortality rate by two-thirds by 2015. Achieving this goal requires substantial strengthening of health systems in low-income countries. Emergency and critical care services are often one of the weakest parts of the health system and improving such care has the potential to significantly reduce mortality. Introducing effective triage and emergency treatments, establishing hospital systems that prioritize the critically ill and ensuring a reliable oxygen delivery system need not be resource intensive. Improving intensive care units, training health staff in the fundamentals of critical care concentrating on ABC - airway, breathing, and circulation - and developing guidelines for the management of common medical emergencies could all improve the quality of inpatient pediatric care. Integration with obstetrics, adult medicine and surgery in a combined emergency and critical care service would concentrate resources and expertise.

How to avoid iatrogenic morbidity and mortality while increasing availability of oxytocin and misoprostol for PPH prevention?

Objective Increased availability of oxytocin and misoprostol is needed to reduce the risk of postpartum hemorrhage. This review compiles rates and risks of adverse maternal and perinatal outcomes associated with use of these medications for labor induction and augmentation in low-income countries. Recommendations are proposed based on the findings. Methods We did a structured literature review using 5 databases followed by analysis of induction and augmentation rates from existing data. Results Combined induction and augmentation rates were documented in up to 50% of hospital-based deliveries identified in the databases. Data are sparse but suggest associations between induction/augmentation and stillbirth, neonatal resuscitation, and uterine rupture, and inappropriate administration of oxytocin and misoprostol both outside and inside healthcare systems in low-income countries. Conclusions Guidelines for labor induction/augmentation are needed specifically for low resourced settings. Rigorous studies should be pursued to quantify the magnitude and effect of inappropriate induction and augmentation on maternal and perinatal morbidity and mortality. Programs are needed to ensure community-wide awareness of the adverse effects of the improper use of these drugs on mothers and babies, especially in out-of-hospital settings.

Global issues in women's health

World population growth in the past century has taxed the ability of healthcare systems in low-income countries to provide reproductive health care. Maternal mortality and morbidity, sexually transmitted diseases, and cervical cancer are major problems. Expansion of reproductive health services, training of appropriate medical personnel, and elevating the status of women in society are all necessary and appropriate solutions to improve the health of women in low-income countries.

Referral Pattern Of Patients Received At The National Referral Hospital: Challenges In Low Income Countries

To examine the medical referral pattern of patients received at the Muhimbili National Hospital (MNH) in order to inform the process of strengthening the referral system. The study design was a prospective study conducted at MNH during a 10-week study period from January to March 2004. The study sample consisted of patients referred to MNH. Of the 11,412 patients seen, 72.5% were self-referrals. More than 70% of the patients seen required admission, though not necessarily at tertiary level. Only 0.8% came from outside the Dar es Salaam region. More than 70% of the patients seen required admission. Surgical services were required by 66.8% of patients, with obstetric conditions being most prominent (24.6% of all patients). For those who were formally referred from other health services, lack of expertise and equipment were the most common reasons given for referral (96.3%). Efforts to improve referral systems in low-income countries require that the primary and secondary level hospitals services be strengthened and increased so as to limit inappropriate use of national referral hospitals.

The health professions and the performance of future health systems in low-income countries: Support or obstacle?

This paper discusses the present and future role of the health professions in health services delivery systems in low-income countries. Unlike richer countries, most low-income countries do not have a tradition of labour market regulation and the capacity of the professions themselves to regulate the provision of health services by their members tends to be weak. The paper looks at the impact of professional monopolies on the performance of health services delivery systems, e.g. equity of access, effectiveness of services, efficiency in the use of scarce resources, responsiveness to users' needs, including protection against the financial impact of utilising health services. It identifies issues which policy-makers face in relation to opening the health labour market while guaranteeing the safety and security of services provided by professionals. The suggestion is made that a “social contract”, granting privileges of practice in exchange of a commitment to actively maintain and enhance the quality of their services, may be a viable course of action. This would require that the actors in the policy process collaborate in strengthening the capacity of regulatory agencies to perform their role.

Staffing remote rural areas in middle- and low-income countries: a literature review of attraction and retention.

BackgroundMany countries in middle- and low-income countries today suffer from severe staff shortages and/or maldistribution of health personnel which has been aggravated more recently by the disintegration of health systems in low-income countries and by the global policy environment. One of the most damaging effects of severely weakened and under-resourced health systems is the difficulty they face in producing, recruiting, and retaining health professionals, particularly in remote areas. Low wages, poor working conditions, lack of supervision, lack of equipment and infrastructure as well as HIV and AIDS, all contribute to the flight of health care personnel from remote areas. In this global context of accelerating inequities health service policy makers and managers are searching for ways to improve the attraction and retention of staff in remote areas. But the development of appropriate strategies first requires an understanding of the factors which influence decisions to accept and/or stay in a remote post, particularly in the context of mid and low income countries (MLICS), and which strategies to improve attraction and retention are therefore likely to be successful. It is the aim of this review article to explore the links between attraction and retention factors and strategies, with a particular focus on the organisational diversity and location of decision-making.MethodsThis is a narrative literature review which took an iterative approach to finding relevant literature. It focused on English-language material published between 1997 and 2007. The authors conducted Pubmed searches using a range of different search terms relating to attraction and retention of staff in remote areas. Furthermore, a number of relevant journals as well as unpublished literature were systematically searched. While the initial search included articles from high- middle- and low-income countries, the review focuses on middle- and low-income countries. About 600 papers were initially assessed and 55 eventually included in the review.ResultsThe authors argue that, although factors are multi-facetted and complex, strategies are usually not comprehensive and often limited to addressing a single or limited number of factors. They suggest that because of the complex interaction of factors impacting on attraction and retention, there is a strong argument to be made for bundles of interventions which include attention to living environments, working conditions and environments and development opportunities. They further explore the organisational location of decision-making related to retention issues and suggest that because promising strategies often lie beyond the scope of human resource directorates or ministries of health, planning and decision-making to improve retention requires multi-sectoral collaboration within and beyond government. The paper provides a simple framework for bringing the key decision-makers together to identify factors and develop multi-facetted comprehensive strategies.ConclusionThere are no set answers to the problem of attraction and retention. It is only through learning about what works in terms of fit between problem analysis and strategy and effective navigation through the politics of implementation that any headway will be made against the almost universal challenge of staffing health service in remote rural areas.

Digitally recycled incubators: better economic alternatives to modern systems in low-income countries

The need to maintain a neutral thermal environment is critical to newborn care. To investigate reasons for the insufficiency of functional incubators and develop a cost-effective technique for using electronic digital components to recycle obsolete incubators in Nigeria. Following interview of 84 clinicians and administrators in Nigerian hospitals, it was identified that inadequate funding was the main reason for lack of functional incubators. Two groups of incubator units were then created and their performance compared. Sixteen units of modern (group A) and 19 units of obsolete (group B) incubators were obtained from six hospitals. An assembly design applying independent generic components for recycling systems was specified and produced. These were sourced through the internet at competitive cost and fitted into the reconstructed panels of the obsolete systems. The functional performance of each recycled system was rigorously monitored for 6 months and graded using ten performance indices. The same indices were used to quantify group A systems. The performance of the recycled incubators (group B) was found to be similar to those of modern incubators. Group B's cost index was found to be 25% of that of group A's. Appropriate incubator recycling is a cost-effective method of re-equipping hospitals in low-income countries.

World Health Organization (WHO) and International Society of Hypertension (ISH) risk prediction charts: assessment of cardiovascular risk for prevention and control of cardiovascular disease in low and middle-income countries

Cardiovascular disease (CVD) is the leading cause of the growing global disease burden due to non-communicable diseases. For successful prevention and control of CVD, strategies that focus on individuals need to complement population-wide strategies. Strategies that focus on individuals are cost effective only when targeted at high-risk groups. Risk prediction tools that easily and accurately predict an individual's absolute risk of CVD are key to targeting limited resources at high-risk individuals who are likely to benefit the most. Health systems in low-income countries do not have the basic infrastructure facilities to support resource-intensive risk prediction tools, particularly in primary healthcare. The WHO/ISH charts presented here, enable the prediction of future risk of heart attacks and strokes in people living in low and middle income countries, for the first time. Furthermore, since the charts use simple variables they can be applied even in low resource settings. Thus the WHO/ISH risk predication charts and the accompanying guideline will improve the effectiveness of cardiovascular risk management even in settings which do not have sophisticated technology.

Diagnostic tests for infectious diseases in the developing world: two sides of the coin

Effective and affordable diagnostics are crucial for health improvement in developing countries but are not accessible to those who need them most. Recent interest highlights innovative technological approaches for overcoming the problem, but these must be balanced by the efforts and research needed to ensure effective implementation in the context of often fragile health systems in low-income countries in the developing world.

The exodus of health professionals from sub‐Saharan Africa: balancing human rights and societal needs in the twenty‐first century

Increased international migration of health professionals is weakening healthcare systems in low-income countries, particularly those in sub-Saharan Africa. The migration of nurses, physicians and other health professionals from countries in sub-Saharan Africa poses a major threat to the achievement of health equity in this region. As nurses form the backbone of healthcare systems in many of the affected countries, it is the accelerating migration of nurses that will be most critical over the next few years. In this paper we present a comprehensive analysis of the literature and argue that, from a human rights perspective, there are competing rights in the international migration of health professionals: the right to leave one's country to seek a better life; the right to health of populations in the source and destination countries; labour rights; the right to education; and the right to non-discrimination and equality. Creative policy approaches are required to balance these rights and to ensure that the individual rights of health professionals do not compromise the societal right to health.