SeriesStrategies to improve health coverage and narrow the equity gap in child survival, health, and nutrition
Introduction
Over the past two decades child mortality has decreased by 35% and maternal mortality by 34%.1, 2 These improvements can be attributed mostly to the increased coverage of highly cost-effective preventive and curative interventions. For example, increased coverage of measles vaccination resulted in a 92% reduction in measles mortality between 2000 and 2008 in sub-Saharan Africa, the worst affected region worldwide.3 Estimates suggest that most of the 7·6 million deaths from all causes in children younger than 5 years in 2010 could be averted by increasing coverage of proven, low-cost interventions.1
Improving access to and use of these interventions, especially in the world's poorest people, requires identification and overcoming of entrenched bottlenecks. Weak health systems—typically characterised by insufficient numbers of health workers, poorly functioning supply chains, and low-quality care—and financial, social, structural, and cultural barriers to services and interventions are common in the poorest settings and the most marginalised and isolated subnational populations.
Several different approaches have been developed to identify such coverage impediments. UNICEF and the World Bank have been working with other partners to systematically assess bottlenecks on the basis of influential work by Tanahashi4 and Piot,5 who developed coverage models for the assessment of health services, and, in the case of Piot, tuberculosis control. Both researchers recognised that the gap between the efficacy and effectiveness of public health interventions related to the existence of critical bottlenecks (panel).
In this Series paper, we summarise the necessary steps for identification and analysis of the bottlenecks that prevent interventions from reaching poor people in low-income and middle-income countries and subsequently identify evidence-based strategies and innovations to overcome these issues. This assessment was crucial to inform the design of the equity-focused approach to health and nutrition programming that is modelled and tested in the accompanying Series paper by Carrera and colleagues.6
Section snippets
Identification of the main delivery channels
One of the first steps in identification of bottlenecks is to delineate the main ways in which health interventions are delivered. Kerber and colleagues7 reviewed roughly 190 essential maternal and child health interventions and proposed that they could be packaged into eight sets and delivered through three main channels: clinical and curative services, outreach services, and community-based preventive and health promotion services. We propose that the use of legislative mechanisms and mass
Overcoming bottlenecks
Identification of strategies to overcome bottlenecks for the poor and marginalised within each delivery channel is the next step (table 2). The most common set of strategies aims to improve the delivery channel to address the various supply, demand, and quality challenges. Examples include strategies to improve distribution of health workers in underserved areas and strengthen supervision to enhance quality of care.
In some cases, changing the way interventions are delivered within the same
Search strategy and selection criteria
We searched Medline, Google Scholar, and the Cochrane Database of Systematic Reviews for papers published in English between Jan 1, 2000, and Nov 30, 2011, that examined each of the strategies listed in table 2. The appendix lists all search terms used. We explored peer-reviewed and so-called grey literature and identified additional reviews via their reference lists. We used a two-step inclusion process: screening on the basis of references and abstracts and screening on the basis of the full
Analysis
If the quality of a review had been assessed previously, we retained the authors’ assessment, irrespective of differences in methods. Evidence from the remaining reviews was classified as high, moderate, or low quality according to study design, study limitations, consistency, and directness—ie, the four key components of the GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria, a systematic approach used to establish the quality of evidence and strength of
Lay health workers
Robust evidence shows that delivery of several key interventions can be safely and effectively transferred from clinical services (ie, provided by qualified health professionals) to community health workers. For example, training of traditional birth attendants and other community-based workers to dispense simple immediate preventive and curative actions for neonate care, including neonatal resuscitation and injectable antibiotics, has significantly reduced stillbirths and perinatal mortality
Outreach campaigns and child health days
Transference of interventions that necessitate little discretionary action—such as immunisation and vitamin A supplementation—from clinical services to large-scale campaigns is also an effective way to boost coverage, although most studies examine only short-term effects.18 These campaigns are regularly used by low-income and middle-income countries to deliver key child survival interventions more efficiently, overcome coverage bottlenecks such as distance to health clinics, and improve equity
Social marketing
Some evidence20, 21 suggests that mass media campaigns addressing both one-off and episodic behaviours can directly and indirectly produce positive changes or prevent negative changes in health-related behaviours across large populations, and thereby can substitute for individual counselling. Concurrent supply availability and access to key services are crucial to persuade individuals motivated by media messages to act on them. Grilli and colleagues22 concluded that mass media can have a
Structural interventions to change behaviours
A growing body of evidence underscores the effectiveness of structural interventions, especially when combined with media campaigns, in changing of behaviours—eg, mandatory fortification of foods, restrictions in smoking, and use of taxation or subsidies.25 Gupta and coworkers26 reviewed policies, programmes, and transformational processes that aim to change the social, economic, political, or environmental factors that affect HIV risk and vulnerability. They reported that interventions,
Task shifting
Task shifting is an innovation that can reduce coverage bottlenecks and support equity by transferring tasks typically done by qualified health and nutritional providers to less qualified people. This strategy has the potential to both improve the efficiency and expand the capacity of the delivery channel.29, 30, 31 A review32 of four African studies showed that nurses and medical assistants could provide some obstetric services, including caesarean deliveries, cost effectively. Another
Increased use of outreach services
More intensive and extensive use of outreach services is another strategy to change how interventions are delivered within channels. Studies33 show that increasing the number of locations (eg, health posts and schools) offering immunisation services can lead to moderate-to-high gains in coverage.
Additionally, provision of specialist outreach services can substantially improve access without compromising the quality of care, and might improve the skills and morale of the health workers in remote
Private service providers
Subcontracting of services, such as obstetric care, maintenance of health services, and administration, to private sector providers is another strategy that could reduce bottlenecks associated with geographical access, particularly for isolated districts.35, 36, 37 However, these findings should be interpreted with caution. Most of the studies we reviewed about this topic were of low quality, and the estimated effects of use of private sector providers to increase access varied greatly.35
Human resource availability and geographical access
Little rigorous evidence is available for strategies that change selection and training conditions to favour rural or underserved settings, with published work restricted largely to observational studies.38 Factors associated with an increased likelihood of practising in a rural area include being from a rural area,39, 40, 41, 42 having a spouse from a rural area,41, 42 male sex,41 and stated intent to practise in a rural area at the time of enrolment.41 Recruitment and training for rural
Reduction or elimination of user fees
Reduction or elimination of user fees increases use of curative services and facility-based deliveries, although the effect sizes vary from low to high, depending on study site and outcome examined.37, 47, 48 Equity also seems to improve, with the greatest increases in access noted in households from the poorest quintiles.48 However, quality of care can be negatively affected by several factors. These include difficulties in meeting increased demand and in provision of drugs to more patients,
Community-based and social health insurance
Community-based insurance can reduce out-of-pocket expenses and increase access, although the effect sizes are small. In Africa, when obstetric services are covered by insurance, the frequency of facility-based deliveries increases.37 Community-based insurance does not seem to improve equity47, 49 and has not been implemented at scale.
Evidence for social insurance schemes is weak and mainly from high-income countries.50 Such initiatives seem to improve coverage in some but not all instances,50
Cash transfers and vouchers
Cash transfers are an effective way to increase use of health and nutrition services and have moderate effect sizes depending on the indicator.37, 51, 52 In a 2011 review,52 Forde and colleagues concluded that cash transfers have clear effects on health outcomes, particularly morbidity, and on some longer-term outcomes, such as stunting and anaemia.52 Despite the quality of some studies, reviewers noted that disentanglement of the effects of different programme components (especially non-cash
Improving continuity of care
Evidence for continuity of care is weak and limited to high-income settings, but shows that performance-based incentives have short-term positive effects on immunisation rates.54 These incentives also have a positive effect on coordination of care,55 but no discernible effect on equity.56 Willis-Shattuck and colleagues57 concluded from their review that financial incentives alone are insufficient to motivate health workers in low-income and middle-income countries.
The effect of provider payment
Improving quality of care
Audit and feedback strategies prompt providers to modify their assessment and management practices when these practices are not consistent with accepted guidelines. Although few studies have been done in low-income and middle-income countries, reported effect sizes range from small to moderate for improved provider practices61, 62, 63 and are large for drug management64 and perinatal and intrapartum mortality.64, 65
Increased supervision is another strategy used to improve health-worker
Fostering demand
Individual or group education or knowledge-transfer interventions (eg, counselling, training, and education) applied to specific services or practices, such as breastfeeding and complementary feeding, can greatly improve coverage. For example, in rural south Asian settings with high rates of home deliveries, engagement of communities through the use of community health workers increased early breastfeeding,72 health-care seeking for neonatal morbidity,73 and institutional deliveries.37
Discussion
We present an innovative framework for use by policy makers and planners for classification of strategies as they work to improve the availability of interventions for disadvantaged populations. We also provide an overview of the evidence for the different types of strategies that have been used to overcome barriers. The collation and review of such information is important for policy makers and planners choosing the strategies in which to invest their scarce resources.
Our review has several
Equity-focused approaches
The structure of national health systems in many countries continues to direct most resources away from the poorest,77 despite early evidence that pro-poor strategies can have important effects on coverage in underserved populations and equity in use across income groups.46, 78 Unless the bottlenecks faced by poor and marginalised people in access to and use of health interventions and services are explicitly addressed, inequities will probably worsen as more expensive and elaborate
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In-country data will illuminate under-5 mortality disparities
2021, The LancetA Systematic Review of Equity in Healthcare Financing in Low- and Middle-Income Countries
2020, Value in Health Regional IssuesCitation Excerpt :Thus they are directly affected by higher costs of services.11 Therefore equity is a vital issue for health policy makers,12 and various countries have established institutions and implemented reforms for creating equity in healthcare financing.13-15 When the financing system is not equitable and people do not have support programs like medical insurance, people with rare diseases face higher costs than others.16