Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Human Development DIRECTIONS INDEVELOPMENT David H. Peters, Sameh El-Saharty, Banafsheh Siadat, Siadat, Banafsheh Sameh El-Saharty, Peters, H. David Developing Countries Developing Service Delivery in Improving Health Improving From Evidence toAction Evidence From Katja Janovsky, Marko Vujicic, Marko Katja Janovsky, 48790 Editors Improving Health Service Delivery in Developing Countries Improving Health Service Delivery in Developing Countries From Evidence to Action Editors David H. Peters Sameh El-Saharty Banafsheh Siadat Katja Janovsky Marko Vujicic © 2009 The International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org E-mail: [email protected] All rights reserved 1 2 3 4 12 11 10 09 This volume is a product of the staff of the International Bank for Reconstruction and Development / The World Bank. The findings, interpretations, and conclusions expressed in this volume do not necessarily reflect the views of the Executive Directors of The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The bound- aries, colors, denominations, and other information shown on any map in this work do not imply any judgement on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. 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ISBN: 978-0-8213-7888-5 eISBN: 978-0-8213-7943-1 DOI: 10.1596/978-0-8213-7888-5 Cover photo: © World Bank/Tran Thi Hoa Library of Congress Cataloging-in-Publication Data Improving health service delivery in developing countries : from evidence to action / edited by David H. Peters ... [et al.]. p. ; cm. — (Directions in development) Includes bibliographical references and index. ISBN 978-0-8213-7888-5 (alk. paper) 1. Medical care—Developing countries. 2. Public health—Developing countries. 3. Health services accessibility—Developing countries. I. Peters, David H., 1962- II. World Bank III. Series: Directions in development (Washington, D.C.) [DNLM: 1. Delivery of Health Care. 2. Developing Countries. 3. Evaluation Studies as Topic. 4. Health Services. 5. Outcome and Process Assessment (Health Care) WA 395 I343 2009] RA441.5.I47 2009 362.109172'4—dc22 2009008335 Contents Preface xiii Acknowledgments xv About the Editors xvii Abbreviations xxi Overview 1 Health Services and the Challenge of Implementation 2 Common Strategies to Strengthen Health Services 4 Framework 5 How to Gain Knowledge on Strengthening Health Services 8 Overview of the Studies 24 Notes 31 References 31 Chapter 1 Review of Strategies to Strengthen Health Services 35 John Ovretveit, Banafsheh Siadat, David H. Peters, Anil Thota, and Sameh El-Saharty Reasons for Conducting the Review 36 v vi Contents Objectives of the Review 36 Methods Used 37 Main Findings 37 Main Limitations 47 Implications for Decision Makers 51 References 51 Annex 1.1 Electronic Databases Searched 52 Annex 1.2 Key Search Terms 52 Annex 1.3 Studies Reviewed 54 Chapter 2 Review of Strategies to Strengthen the Performance of Health Organizations 69 Anbrasi Edward, David H. Peters, Amy Daniels, Yong Rang, and Toru Matsubayashi Reasons for Conducting the Review 70 Objectives of the Review 72 Methods Used 72 Main Findings 75 Main Limitations 77 Implications for Decision Makers 81 References 82 Annex 2.1 Outcome Measures of Selected Health Organization Performance Models 84 Annex 2.2 Key Search Terms 86 Annex 2.3 Studies Reviewed 92 Chapter 3 Review of Strategies to Improve Health Care Provider Performance 101 Alexander K. Rowe, Samantha Y. Rowe, Marko Vujicic, Dennis Ross-Degnan, John Chalker, Kathleen A. Holloway, and David H. Peters Reasons for Conducting the Review 102 Objectives of the Review 103 Methods Used 103 Main Findings 104 Main Limitations 108 Implications for Decision Makers 108 Notes 109 Contents vii References 109 Annex 3.1 Databases Searched 111 Annex 3.2 Key Search Terms in a Medline Search 112 Annex 3.3 Studies Included in the Review 117 Chapter 4 Review of Community Empowerment Strategies for Health 127 Bahie Rassekh and Nathanial Segaren Reasons for Conducting the Review 128 Objectives of the Review 128 Methods Used 129 Main Findings 130 Main Limitations 139 Implications for Decision Makers 140 Reference 141 Annex 4.1 Electronic Databases Searched 141 Annex 4.2 Studies Reviewed 142 Chapter 5 Analysis of Cross-country Changes in Health Services 173 Toru Matsubayashi, David H. Peters, and Hafiz Rahman Reasons for Conducting the Study 174 Objectives of the Study 176 Methods Used 177 Main Findings 178 Main Limitations 189 Implications for Decision Makers 191 Note 192 References 192 Chapter 6 Institutional Context of Health Services 203 Gerry Bloom, Hilary Standing, and Anu Joshi Reasons for Conducting the Review 204 Objectives of the Review 204 Methods Used 205 What Are the Main Limitations, Findings, and Implications? 205 viii Contents Note 213 References 213 Chapter 7 Evaluation of Changes in Health Results in World Bank-assisted Health Projects 217 Savitha Subramanian and David H. Peters Reasons for Conducting the Review 218 Objective of the Review 220 Methods Used 221 Main Findings 223 Main Limitations 224 Implications for Decision Makers 226 Notes 227 References 227 Chapter 8 Seven Country Case Studies 233 Sameh El-Saharty, Katja Janovsky, Banafsheh Siadat, and Finn Schleimann Introduction 234 Research Questions 235 Methods 236 Limitations 237 Country Findings 238 Key Implementation Factors and Lessons Learned 263 Concluding Thoughts 272 Note 273 References 274 Chapter 9 From Evidence to Learning and Action 277 David H. Peters, Sameh El-Saharty, and Katja Janovsky Findings 277 How to Improve Implementation 281 Notes 294 References 295 Glossary 297 Index 331 Contents ix Boxes 1 Innovations and the Poor 7 9.1 A Learning-doing Strategy 282 9.2 A Structured Learning Strategy 292 Figures 1 Descriptive Health Services Framework 6 2.1 Conceptual Framework for Health Organization Performance Review 73 3.1 Distribution of 74 Median Effect Sizes (1 per Strategy Tested) from 56 Studies of Adequate Design (Preliminary Results) 106 3.2 Distribution of 74 Median Effect Sizes from 56 Studies of Adequate Design Stratified by Number of Components in the Strategy (Preliminary Results) 106 3.3 Summary of Distribution of Median Effect Size for Selected Strategies from 56 Studies of Adequate Design Testing Strategies Alone or in Combination with Other Strategies (Preliminary Results) 107 4.1 Odds Ratios for Contextual Factors and Organizations Involved 138 4.2 Odds Ratios of Approaches Used in Community Empowerment 138 5.1 Trends in Selected Health Service Indicators in LMICs between 1990 and 2004 179 5.2 Country-specific Estimates of DPT3 Immunization Coverage and Skilled Birth Attendance from 1990 to 2004 Using Multilevel Models 180 7.1 Percentage of Projects Showing Improvements in Health Services, Health Financing, or Health Status, According to Organizational Approach 224 7.2 Odds Ratios for Improving Health Services and Health Status According to Organizational Approach and Project Activity 225 8.1 Health Services Indicators, Afghanistan 240 8.2 Health Services Indicators, Ethiopia 243 8.3 Health Services Indicators, Ghana 248 8.4 Health Services Indicators, Rwanda 252 8.5 Health Services Indicators, Uganda 255 8.6 Health Services Indicators, Vietnam 259 xContents 8.7 Health Services Indicators, Zambia 263 9.1 Simplistic Causal Chain from Health Intervention to Health Outcomes 288 Tables 1 Judgments about Health Strategies and Their Implications for Evaluation and Research Design 10 2 Summary of Health Services Reviews, Other Analyses, and Country Case Studies 12 3 Number of Studies Screened and Included in Systematic Reviews 26 4 Categories of Study Designs Used for Inclusion and Exclusion in Systematic Reviews 27 5 Category of Strength of Evidence 29 1.1 Primary Health Strengthening Strategy by Study Design 39 1.2 Scale of Implementation 41 1.3 Direction of Outcomes from Reviewed Literature 44 1.4 Aspects of Health Strategy Implementation and Their Association with Positive Outcomes 45 1.5 Summary of Recommendations Based on Review 48 2.1 Classification of Clinical and Managerial Outcomes 74 2.2 Number of Studies Employing Specific Strategies to Improve Performance (All Studies) 76 2.3 Median Effect Sizes for Strategies Used to Improve Organizational Performance 78 2.4 Approach to Organizational Change (RCTs and NRCTs Only) 79 2.5 Quality of Studies Reviewed (All Studies) 79 3.1 Types of Strategy