Effectiveness of strategies to improve health-care provider practices in low-income and middle-income countries: a systematic review
Open accessAbstract
BACKGROUND: Inadequate health-care provider performance is a major challenge to the delivery of high-quality health care in low-income and middle-income countries (LMICs). The Health Care Provider Performance Review (HCPPR) is a comprehensive systematic review of strategies to improve health-care provider performance in LMICs. METHODS: For this systematic review we searched 52 electronic databases for published studies and 58 document inventories for unpublished studies from the 1960s to 2016. Eligible study designs were controlled trials and interrupted time series. We only included strategy-versus-control group comparisons. We present results of improving health-care provider practice outcomes expressed as percentages (eg, percentage of patients treated correctly) or as continuous measures (eg, number of medicines prescribed per patient). Effect sizes were calculated as absolute percentage-point changes. The summary measure for each comparison was the median effect size (MES) for all primary outcomes. Strategy effectiveness was described with weighted medians of MES. This study is registered with PROSPERO, number CRD42016046154. FINDINGS: We screened 216 477 citations and selected 670 reports from 337 studies of 118 strategies. Most strategies had multiple intervention components. For professional health-care providers (generally, facility-based health workers), the effects were near zero for only implementing a technology-based strategy (median MES 1·0 percentage points, IQR -2·8 to 9·9) or only providing printed information for health-care providers (1·4 percentage points, -4·8 to 6·2). For percentage outcomes, training or supervision alone typically had moderate effects (10·3-15·9 percentage points), whereas combining training and supervision had somewhat larger effects than use of either strategy alone (18·0-18·8 percentage points). Group problem solving alone showed large improvements in percentage outcomes (28·0-37·5 percentage points), but, when the strategy definition was broadened to include group problem solving alone or other strategy components, moderate effects were more typical (12·1 percentage points). Several multifaceted strategies had large effects, but multifaceted strategies were not always more effective than simpler ones. For lay health-care providers (generally, community health workers), the effect of training alone was small (2·4 percentage points). Strategies with larger effect sizes included community support plus health-care provider training (8·2-125·0 percentage points). Contextual and methodological heterogeneity made comparisons difficult, and most strategies had low quality evidence. INTERPRETATION: The impact of strategies to improve health-care provider practices varied substantially, although some approaches were more consistently effective than others. The breadth of the HCPPR makes its results valuable to decision makers for informing the selection of strategies to improve health-care provider practices in LMICs. These results also emphasise the need for researchers to use better methods to study the effectiveness of interventions. FUNDING: Bill & Melinda Gates Foundation, CDC Foundation.
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Human resource constraints provide a substantial obstacle, notably a deficiency of qualified professionals, including medical physicists and radiologists.
“Human resource constraints provide a substantial obstacle, notably a deficiency of qualified professionals, including medical physicists and radiologists.”
From Computed Tomography Diagnostic Reference Levels Worldwide and in Jordan: Implications for Patient Dose Reduction (2026) · cites this paper as [121]
The Introduction discusses inadequate health-care provider performance in low-income and middle-income countries and includes availability within its definition of performance. It does not report a shortage of qualified professionals or identify medical physicists or radiologists; searches for those professions and for workforce shortages found no supporting passage. (LLM, conf=0.75)
Experimental — accuracy not yet measuredIn numerous low- and middle-income countries, healthcare practitioners sometimes have excessive clinical responsibilities, resulting in minimal capacity for data collecting, analysis, or research dissemination.
“In numerous low- and middle-income countries, healthcare practitioners sometimes have excessive clinical responsibilities, resulting in minimal capacity for data collecting, analysis, or research dissemination.120,121”
From Computed Tomography Diagnostic Reference Levels Worldwide and in Jordan: Implications for Patient Dose Reduction (2026) · cites this paper as [121]
The Discussion recommends using routinely collected data to reduce the time and cost of studies, but does not say that excessive clinical responsibilities leave practitioners little capacity for data collection, analysis, or dissemination. Searches for clinical workload, research time, and dissemination found no passage addressing that causal claim. The indexed passages provide section labels but no page numbers. (LLM, conf=0.76)
Experimental — accuracy not yet measuredThe World Health Organization advises that digital diagnostic platforms may be valuable for patients in low- and middle-income countries where expert clinical advice is difficult to access.
“The World Health Organization already advises that digital diagnostic platforms may be valuable for patients in low- and middle-income countries where expert clinical advice is difficult to access.”
From What is the clinical value of mHealth for patients? (2020) · cites this paper as [8]
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“Motivated by global examples such as the UK’s audits, Japan’s tiered DRLs, and Saudi Arabia’s academic initiatives, Jordan can establish its own DRL framework by standardizing CTDIvol and DLP reporting across institutions.”
- Authors
- Rowe, A. K., Rowe, S. Y., Peters, D. H., Holloway, K. A., Chalker, J., & Ross-Degnan, D.
- Affiliations
- Centers for Disease Control and Prevention (US)
- Johns Hopkins University (US)
- University of Sussex (GB)
- Management Sciences for Health (US)
- Corresponding author
- Rowe, Alexander K
- Venue
- The Lancet Global Health
- Publisher
- Elsevier BV
- Published
- 2018-11
- Volume
- 6
- Issue
- 11
- Pages
- e1163-e1175
- ISSN
- 2214-109X (ISSN-L)
- PMC
- PMC6185992
- OpenAlex
- W2894656887
- Cited by
- 482
- References
- 33
- Citations by year
- 2026: 59 · 2025: 50 · 2024: 55 · 2023: 54 · 2022: 58 · 2021: 79 · 2020: 81 · 2019: 44 · 2018: 1
- FWCI
- 9.33
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- The Lancet Global Health (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, other-oa)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Figshare (submittedVersion, cc-by)
- OpenDocs (Institute of Development Studies) (submittedVersion, cc-by)
- Funders
- World Bank Group (P098685)
- Centers for Disease Control and Prevention
- ADC Foundation
- Bill and Melinda Gates Foundation (OPP52730)
- Topics
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Health Sciences › Health Professions › Health Information Management › Healthcare Quality and Management
- Health Sciences › Health Professions › General Health Professions › Primary Care and Health Outcomes
- Keywords
- quality of care, low- and middle-income countries, training and supervision, group problem solving, community health workers, multicomponent intervention, community support, effect size
- MeSH terms
- Developing Countries, Health Personnel, Humans, Quality Assurance, Health Care, Program Evaluation, Randomized Controlled Trials as Topic
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