Holy grail or convenient excuse? Stakeholder perspectives on the role of health system strengthening evaluation in global health resource allocation.

Background: The role of evaluation evidence in guiding health systems strengthening (HSS) investments at the global-level remains contested. A lack of rigorous impact evaluations is viewed by some as an obstacle to scaling resources. However, others suggest that power dynamics and knowledge hierarchies continue to shape perceptions of rigor and acceptability in HSS evaluations.

How do we design and evaluate health system strengthening? Collaborative development of a set of health system process goals.

Strong health systems are widely recognized as a key requirement for improving health outcomes and also for ensuring that health systems are equitable, resilient and responsive to population needs. However, the related term Health Systems Strengthening (HSS) remains unclear and contested, and this creates challenges for how HSS can be monitored and evaluated. A previous review argued for the need to rethink evaluation methods for HSS to examine systemic effects of HSS investments.

Health system strengthening-Reflections on its meaning, assessment, and our state of knowledge.

Comprehensive reviews of health system strengthening (HSS) interventions are rare, partly because of lack of clarity on definitions of the term but also the potentially huge scale of the evidence. We reflect on the process of undertaking such an evidence review recently, drawing out suggestions on definitions of HSS and approaches to assessment, as well as summarising some key conclusions from the current evidence base. The key elements of a clear definition include, in our view, consideration of scope (with effects cutting across building blocks in practice, even if not in intervention design, and also tackling more than one disease), scale (having national reach and cutting across levels of the system), sustainability (effects being sustained over time and addressing systemic blockages), and effects (impacting on health outcomes, equity, financial risk protection, and responsiveness).

Health worker perspectives on user fee removal in Zambia.

Background: User fees for primary care services were removed in rural districts in Zambia in 2006. Experience from other countries has suggested that health workers play a key role in determining the success of a fee removal policy, but also find the implementation of such a policy challenging. The policy was introduced against a backdrop of a major shortage in qualified health staff.

Why performance-based contracting failed in Uganda--an "open-box" evaluation of a complex health system intervention.

Performance-based contracting (PBC) is a tool that links rewards to attainment of measurable performance targets. Significant problems remain in the methods used to evaluate this tool. The primary focus of evaluations on the effects of PBC (black-box) and less attention to how these effects arise (open-box) generates suboptimal policy learning.

Assessing the effects of removing user fees in Zambia and Niger.

Objectives: This study aims to overcome some of the limitations of previous studies investigating the effects of fee removal, by looking at heterogeneity of effects within countries and over time, as well as the existence of spill-over effects on groups not targeted by the policy change.

Methods: Using routine district health services data before and after recent abolitions of user charges in Zambia and Niger, we examine the effects of the policy change on the use of health services by different groups and over time, using an interrupted timeseries design.

Results: Removing user fees for primary health care services in rural districts in Zambia and for children over five years old in Niger increased use of services by the targeted groups.

Constraints to implementing the Essential Health Package in Malawi.

Increasingly seen as a useful tool of health policy, Essential or Minimal Health Packages direct resources to interventions that aim to address the local burden of disease and be cost-effective. Less attention has been paid to the delivery mechanisms for such interventions. This study aimed to assess the degree to which the Essential Health Package (EHP) in Malawi was available to its population and what health system constraints impeded its full implementation.

The impact of user fees on access to health services in low- and middle-income countries.

Background: Following an international push for financing reforms, many low- and middle-income countries introduced user fees to raise additional revenue for health systems. User fees are charges levied at the point of use and are supposed to help reduce 'frivolous' consumption of health services, increase quality of services available and, as a result, increase utilisation of services.

Objectives: To assess the effectiveness of introducing, removing or changing user fees to improve access to care in low-and middle-income countries

Search Strategy: We searched 25 international databases, including the Cochrane Effective Practice and Organisation of Care (EPOC) Group's Trials Register, CENTRAL, MEDLINE and EMBASE.

The impact of conditional cash transfers on health outcomes and use of health services in low and middle income countries.

Background: Conditional cash transfers (CCT) provide monetary transfers to households on the condition that they comply with some pre-defined requirements. CCT programmes have been justified on the grounds that demand-side subsidies are necessary to address inequities in access to health and social services for poor people. In the past decade they have become increasingly popular, particularly in middle income countries in Latin America.

The impact of contracting out on health outcomes and use of health services in low and middle-income countries.

Background: Recent literature on the lack of efficiency and acceptability of publicly provided health services has led to an interest in the use of partnerships with the private sector to deliver public services.

Objectives: To assess the effectiveness of contracting out healthcare services in improving access to care in low and middle-income countries and, where possible, health outcomes.

Search Strategy: We searched a wide range of international databases, including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE, in addition to development studies and economic databases.

Availability of essential medicines in Ethiopia: an efficiency-equity trade-off?

Objective: To investigate the availability and cost of essential medicines in health centres in rural Ethiopia, and to explore if the fee waiver system protects patients from having to pay for medicines.

Methods: The study took place in five health centres in rural Ethiopia. Availability and price of selected key essential medicines was established in the budget and special pharmacy of the health centre, as well as private outlets.

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.

Changing roles and responses of health care workers in HIV treatment and care.

A key limiting factor in the scale up and sustainability of HIV care and treatment programmes is the global shortage of trained health care workers. This paper discusses why it is important to move beyond conceptualising health care workers simply as 'inputs' in the delivery of HIV treatment and care, and to also consider their roles as partners and agents in the process of health care. It suggests a framework for thinking about their roles and responses in HIV care, considers the current evidence base, and concludes by identifying key areas for future research on health care workers' responses in HIV treatment and care in low and middle income settings.

The impact of user fees on health service utilization in low- and middle-income countries: how strong is the evidence?

Objective: To assess the effects of user charges on the uptake of health services in low- and middle-income countries.

Methods: A systematic search of 25 social science, economics and health literature databases and other sources was performed to identify and appraise studies on the effects of introducing, removing, increasing or reducing user charges on the uptake of various health services in low- and middle-income countries. Only experimental or quasi-experimental study designs were considered: cluster randomized controlled trials (C-RCT), controlled " before and after" (CBA) studies and interrupted time series (ITS) studies.

Conditional cash transfers for improving uptake of health interventions in low- and middle-income countries: a systematic review.

Context: Cash transfers conditional on certain behaviors, intended to provide access to social services, have been introduced in several developing countries. The effectiveness of these strategies in different contexts has not previously been the subject of a systematic review.

Objective: To assess the effectiveness of conditional monetary transfers in improving access to and use of health services, as well as improving health outcomes, in low- and middle-income countries.

Contracting out health services in fragile states.

Non-governmental organisations are contracted to provide most of Afghanistan's health services. What can we learn from their approach and is it sustainable in the longer term?

Trust and health worker performance: exploring a conceptual framework using South African evidence.

Two relationships of particular importance to health care provision are those between patient and provider, and health worker and employer. This paper presents an analytical framework that establishes the key dimensions of trust within these relationships, and suggests how they may combine in influencing health system responsiveness. The paper then explores the relevance of the framework by using it to analyse case studies of primary care providers in South Africa.

Contracts in the real world: case studies from Southern Africa.

The desirability of using the private sector to deliver public services is widely debated internationally. Understanding the nature of contracts that initiate and govern such public-private partnerships, and the extent to which they can define the performance of private providers, is key in addressing the questions that underlie this debate. Such understanding has to be gained through better knowledge of all the influences upon contractual relationships.

Health financing to promote access in low income settings-how much do we know?

In this article we outline research since 1995 on the impact of various financing strategies on access to health services or health outcomes in low income countries. The limited evidence available suggests, in general, that user fees deterred utilisation. Prepayment or insurance schemes offered potential for improving access, but are very limited in scope.

Do malaria control interventions reach the poor? A view through the equity lens.

Malaria, more than any other disease of major public health importance in developing countries, disproportionately affects poor people, with 58% of malaria cases occurring in the poorest 20% of the world's population. If malaria control interventions are to achieve their desired impact, they must reach the poorest segments of the populations of developing countries. Unfortunately, a growing body of evidence from benefit-incidence analyses has demonstrated that many public health interventions that were designed to aid the poor are not reaching their intended target.

The performance of different models of primary care provision in Southern Africa.

Despite the emphasis placed during the last two decades on public delivery of comprehensive and equitable primary care (PC) to developing country populations, coverage remains far from universal and the quality often poor. Users frequently patronise private providers, ranging from informal drug sellers to trained professionals. Interest is increasing internationally in the potential for making better use of private providers, including contractual approaches.

Classical versus relational approaches to understanding controls on a contract with independent GPs in South Africa.

Contracts have played a central role in public sector reforms in developed countries over the last decade, and research increasingly highlights their varied nature. In low and middle income countries the use of contracts is encouraged but little attention has been paid to features of the setting that may influence their operation. A qualitative case study was used to examine different dimensions of a contract with private GPs in South Africa.

A new face for private providers in developing countries: what implications for public health?

The use of private health care providers in low- and middle-income countries (LMICs) is widespread and is the subject of considerable debate. We review here a new model of private primary care provision emerging in South Africa, in which commercial companies provide standardized primary care services at relatively low cost. The structure and operation of one such company is described, and features of service delivery are compared with the most probable alternatives: a private general practitioner or a public sector clinic.

Getting to the truth? Researching user views of primary health care.

In countries at all levels of development, assessing the opinions of health service users is increasingly promoted as an integral part of quality evaluations. However, there has been much debate on how best to measure user opinions. This article discusses findings from a study in South Africa, which employed both closed-ended facility exit interviews (total 337) and open-ended community-based focus group discussions (total 14) to obtain users' views on the same set of primary care providers.