Implementation strategies for health systems in low-income countries: an overview of systematic reviews

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Tomas Pantoja1, Newton Opiyo2, Simon Lewin3Elizabeth Paulsen4Agustín Ciapponi5Charles S Wiysonge6, Cristian A Herrera7Gabriel Rada8Blanca Peñaloza9Lilian Dudley10, Marie-Pierre Gagnon11, Sebastian Garcia Marti12Andrew D Oxman13

1. Pontificia Universidad Católica de Chile, Evidence Based Health Care Program, Santiago, Chile
2. Cochrane, Cochrane Editorial Unit, London, UK
3. Norwegian Institute of Public Health, Oslo, Norway
4. Norwegian Institute of Public Health, Oslo, Norway   
5. Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Capital Federal, Argentina
6. South African Medical Research Council, Cochrane South Africa, Cape Town, Western Cape, South Africa
7. Pontificia Universidad Católica de Chile, Evidence Based Health Care Program, Department of Public Health, School of Medicine, Santiago, Chile
8. Pontificia Universidad Católica de Chile, Department of Internal Medicine and Evidence-Based Healthcare Program, Faculty of Medicine, Santiago, Chile
9. Pontificia Universidad Católica de Chile, Evidence Based Health Care Program, Department of Family Medicine,  Faculty of Medicine, Santiago, Chile
10. Stellenbosch University, Division of Community Health, Faculty of Medicine and Health Sciences, Cape Town, South Africa
11. CHU de Québec - Université Laval Research Centre, Population Health and Optimal Health Practices Research Unit, Québec City, QC, Canada
12. Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Capital Federal,
13. Norwegian Institute of Public Health, Global Health Unit, Oslo, Norway

Pantoja T, Opiyo N, Lewin S, Paulsen E, Ciapponi A, Wiysonge CS, Herrera CA, Rada G, Peñaloza B, Dudley L, Gagnon MP, Garcia Marti S, Oxman AD. Implementation strategies for health systems in low-income countries: an overview of systematic reviews. Cochrane Database of Systematic Reviews 2017, Issue 9. Art. No.: CD011086. DOI: 10.1002/14651858.CD011086.pub2.

Access the full-text article here:    http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD011086.pub2/full

Implementation strategies 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 strategies for implementing interventions to improve health in low-income countries.

This overview is based on 39 relevant systematic reviews. Each of these reviews searched for studies that evaluated the different types of implementation strategies within the scope of the question addressed by the review. The reviews included a total of 1332 studies.

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

What was studied in the overview?

A key function of health systems is implementing interventions to improve health. Coverage of essential health interventions remains low in low-income countries. Decision-makers may use a range of strategies to implement health interventions, and these choices should be based on evidence of the strategies' effectiveness.

What are the main results of the overview?

The following implementation strategies had desirable effects on at least one outcome with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects.

Strategies targeted at healthcare workers

- Educational meetings.

- Nutrition training of health workers.

- Educational outreach (vs. no intervention).

- Practice facilitation.

- Local opinion leaders.

- Audit and feedback.

- Tailored interventions (vs. no intervention).

Strategies targeted at healthcare workers for specific types of problems

- Training healthcare workers to be more patient-centred in clinical consultations.

- Use of birth kits.

- Clinician education and patient education to reduce antibiotic prescribing in ambulatory care settings.

- In-service neonatal emergency care training.

Strategies targeted at healthcare recipients

- Mass media interventions to increase immediate uptake of HIV testing (leaflets and gain-framed videos).

- Intensive self-management and adherence, intensive disease management to improve health literacy.

- Behavioural interventions and mobile phone text messages for adherence to antiretroviral therapy.

- A one-time incentive to start or continue tuberculosis prophylaxis.

- Default reminders for patients being treated for active tuberculosis.

- Use of sectioned polythene bags for adherence to malaria medication.

- Community-based health education, and reminders and recall strategies for vaccination uptake.

- Providing free insecticide-treated bednets.

- Interventions to improve uptake of cervical screening (invitations, education, counselling, access to health promotion nurse, and intensive recruitment).

- Health insurance information and application support.

The following implementation strategies had low- or very low-certainty evidence (or no studies available) for all the outcomes that were considered.

Strategies targeted at healthcare organisations

- Strategies to improve organisational culture.

Strategies targeted at healthcare workers

- Printed educational materials.

- Internet-based learning.

- Interprofessional education.

- Teaching critical appraisal.

- Educational outreach (vs. another intervention).

- Pharmacist-provided services.

- Safety checklists for use by medical care teams in acute hospital settings.

- Tailored interventions (vs. non-tailored interventions, and interventions targeted at organisational and individual barriers vs. interventions targeted at individual barriers only).

- Interventions to encourage the use of systematic reviews in clinical decision-making.

Strategies targeted at healthcare workers for specific types of problems

- Interventions to improve handwashing.

- Interventions to reduce unnecessary caesarean section rates.

- Training of traditional birth attendants.

- Skilled birth attendance.

- Training of traditional healers about STD and HIV medicine.

Strategies targeted at healthcare recipients

- Providing information/education for promoting HIV testing (multimedia).

- Providing written medicine information.

- Single interventions to improve health literacy.

- Interventions to improve medication adherence.

- Adherence – TB (immediate versus deferred incentives; cash vs. non-cash incentive; different levels of cash incentives; incentives vs. other interventions).

- Adherence – malarial medication (blister packed tablets and capsules compared to tablets and capsules in paper envelopes; tablets in sectioned polythene bags compared to bottled syrup).

- Training of healthcare workers, home visits, and monetary incentives to improve immunisation coverage.

- Risk factor assessment to improve the uptake of cervical cancer screening.

How up to date is this overview?

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