A systematic review of strategies to increase access to health services among children in low and middle income countries

In many LMIC settings, health centres are concentrated in urban areas making it logistically difficult and prohibitively expensive to reach for many people particularly in rural areas [3]. This review suggested that interventions aimed at addressing these geographical and financial accessibility barriers by bringing services closer to the home may be beneficial in terms of improving health care utilisation, immunisation and medication/referral compliance for children. For example, the use of CHW for delivery of services has been identified as one strategy to address the growing shortage of health workers in LMIC [93, 94]. CHW programmes are likely to improve cost-effectiveness of healthcare systems by reaching large numbers of previously underserved people with basic services at low cost. The term “community health worker” encompasses a range of community health assistants who are trained to work within the communities from which they come [93, 94]. Given that they are members of the community in which they work, this is thought to increase acceptability of services. Their role may involve provision of preventive or curative treatment or health education programmes. Further primary studies are needed to explore the long term sustainability and cost-effectiveness of these interventions. In addition, while all but one of the studies evaluating interventions that delivered services at or closer to home were RCTs, the quality was generally poor or unclear and therefore some caution in the interpretation is warranted.

Non-monetary service level improvement interventions identified in this review included health worker training, integration of services, and scale up of services. Four studies that evaluated integration of services were identified, thought to target availability and acceptability of services. Findings were mixed, aligning with previous work by Briggs et al. (2006) [20]. Health worker training interventions included in this review were designed to target multiple dimensions of access, primarily availability, but also acceptability through community mobilisation. Overall, these interventions were associated with an increase in health care utilisation and immunisation uptake. This aligns with findings from a review by Willey et al. (2013) that found that health worker training had a positive impact on quality of care and coverage of services [95].

There were very few studies identified in this review that were classified as supply side financial interventions. Those that were identified used pay for performance, tackling availability and acceptability barriers, and contracting, which potentially targets all four barriers of access depending on available resources [14]. Health systems strengthening is seen as a global health priority and is particularly relevant for achieving UHC. Thus, further evidence is warranted on the effectiveness of these interventions that tackle inefficiencies within the health system and their impact on access for children.

Our review found that educational interventions delivered by health care workers generally had a positive impact on health care utilisation or immunization uptake. We did not find evidence of significant improvements in health access outcomes for children associated with participatory women’s learning groups. This aligns to some extent with a meta-analysis of trials of women’s groups by Prost et al. (2013) which found a non-significant reduction in maternal and neonatal mortality across all the included trials [96]. However, in a sub-group analysis of 4 studies in which at least 30% of pregnant women participated in the groups found that the reduction in neonatal mortality was significant. Although such sub-group analyses were beyond the scope of this current review, this warrants further attention in the context of the impact of participatory women’s groups on access to health care for children. Evidence from this review suggested that educational programmes delivered by CHWs was varied. Previous reviews have suggested that this method is associated with improved immunisation uptake, and reduce childhood diarrhoea. [97, 98] The mixed impact on health care access as a result of educational programmes may reflect the broad range of delivery modes and intervention content as well as the variable quality of the studies. In addition, as health education is thought to principally target acceptability barriers, the impact of health promotion on access to health care may be limited if financial and geographical barriers prevent access to health services [14].

With evolving mobile phone technology and rapidly increasing numbers of mobile phone users in LMIC, there is increased interest in the use of this relatively low cost technology within health services [99]. The generally positive impact of text messages to remind carers about appointments or send health promotional messages in studies included in this review concurs with previous systematic reviews which found mobile phone reminders generally improved attendance at health appointments among adults [100], health care outcomes (all ages) [99], and ART adherence among adults [101]. While it is encouraging that the majority studies of text messages in the current review were RCTs, the study quality was of some concern, echoing previous reviews [99, 100]. Further, all the studies were conducted in Sub-Saharan Africa, thus their generalisability to other settings is unclear. The use of text messages is potentially promising area for improving health care access for children in LMIC which deserves further attention. However, there is a need for more evidence in different geographical settings using well designed RCTs.

Financial or other incentives appear to tackle financial accessibility as participants do not incur fees for service or receive food at the health appointment. Conditional cash transfers may in addition tackle geographic accessibility by making money available for transport as well as acceptability through tackling issues of cultural preferences and stigma [14]. Our findings contrast somewhat to a systematic review by Lagarde et al. (2007) of conditional cash transfers for improving uptake of health services in LMIC, which concluded that these programmes are effective in increasing the use of preventive services [17]. However, the authors confirmed the dearth of evidence on the topic and many of the studies included were from grey literature sources or used study designs that did not meet our inclusion criteria. In addition, the previous review did not have a specific focus on children. Although there were few studies, the removal of user fees was associated with a positive or mixed positive outcome. As discussed by Jacobs’ et al. (2012), user fee removal could result in reduced access if increased drug supply is not considered [14].