Background
Methods
Health system functions | Definition |
---|---|
(1) Service provision | Good health services are those which deliver effective, safe, quality personal and non-personal health interventions to those who need them, when and where needed, with minimum waste of resources. |
(2) Health personnel | A well-performing health workforce is one which works in ways that are responsive, fair and efficient to achieve the best health outcomes possible, given available resources and circumstances. |
(3) Health information | A well-functioning health information system is one that ensures the production, analysis, dissemination and use of reliable and timely information on health determinants, health systems performance and health status. |
(4) Drugs and vaccines | A well-functioning health system ensures equitable access to essential medical products, vaccines and technologies of assured quality, safety, efficacy and cost-effectiveness, and their scientifically sound and cost-effective use. |
(5) Funding | A good health financing system raises adequate funds for health, in ways that ensure people can use needed services, and are protected from financial catastrophe or impoverishment associated with having to pay for them. |
(6) Governance and leadership | Leadership and governance involves ensuring strategic policy frameworks exist and are combined with effective oversight, coalition-building, the provision of appropriate regulations and incentives, attention to system-design, and accountability. |
Results
Description of the studies identified
Authors and date | Date | Topic | Qualitative | Quantitative randomized controlled | Quantitative non-randomized | Quantitative descriptive | Mixed methods |
---|---|---|---|---|---|---|---|
Ghana (n = 4)
| |||||||
Penfold et al. | 2007 | Service utilization | X | ||||
Witter & Adjei | 2007 | Implementation | X | ||||
Witter, Arhinful, et al. | 2007 | Implementation | X | ||||
Witter, Kusi, et al. | 2007 | Effect of exemption on health workers | X | ||||
Kenya (n = 4)
| |||||||
Chuma et al. | 2009 | Facilites' adherence to exemption | X | ||||
Mwabu et al. | 1997 | Service demand | X | ||||
Mwabu et al. | 1995 | Service demand, and effect on income and quality | X | ||||
Perkins et al. | 2009 | Costs of service utilization | X | ||||
Madagascar (n = 1)
| |||||||
Fafchamps et al. | 2007 | Impact of 3 political periods on the health sector | X | ||||
South Africa (n = 4)
| |||||||
Bhayat et al. | 2003 | Service utilization | X | ||||
Walker et al. | 2004 | Implementation | X | ||||
Wilkinson et al. | 2001 | Service utilization | X | ||||
Wilkinson et al. | 1997 | Service utilization | X | ||||
Senegal (n = 1)
| |||||||
Witter et al. | 2008 | Exemption processes and effects | X | ||||
Tanzania (n = 1)
| |||||||
Kruk et al. | 2008 | Costs of utilization | X | ||||
Uganda (n = 8)
| |||||||
Burnham et al. | 2004 | Service utilization | X | ||||
Deiniger et al. | 2004 | Effect of exemption on accessibility and illness | X | ||||
Kajula et al. | 2004 | Political analysis of exemption | X | ||||
Nabyonga et al. | 2005 | Service utilization | X | ||||
Nabyonga-Orem et al. | 2008 | Quality of services | X | ||||
Pariyo et al. | 2009 | Service utilization | X | ||||
Xu et al. | 2006 | Service utilization and catastrophic expenses | X | ||||
Yates et al. | 2006 | Effects of exemption | X | ||||
TOTAL
|
3
|
0
|
12
|
2
|
6
|
Service delivery
Health workforce
Health information system
Medical products, vaccines and technologies
Health systems financing
Leadership and governance
Health system functions | Pressures mentioned in the literature |
---|---|
Ghana
| |
Service delivery
| |
Health workforce
| · Increase in workload, loss of income [31] |
· Insufficient medical personnel; increase in workload [32] | |
Health information
| · No information |
Medical products, vaccines and technologies
| · No information on the number of acts and the amount of reimbursements [31] |
Financing
| · Funding unpredictable, insufficient and discontinuous; problems with reimbursement in cases of referrals [31] |
· Funding unpredictable, insufficient and discontinuous; informal payments; health centres going into deeper debt [35] | |
Leadership and governance
| · Lack of information and complexity of funding procedures; poor supervision; problems in assigning responsibilities [31] |
· Lack of information and communication (funding); competition with other interventions; poor supervision; ‘no blame’ game [35] | |
Kenya
| |
Service delivery
| |
Health workforce
| · Increase in workload [33] |
Health information
| · No information |
Medical products
| · Problems of availability and insufficiency of drugs and kits [33] |
Financing
| · Informal payments [22] |
· Informal payments; loss of income for health centres [33] | |
· Insufficient funding; informal payments [36] | |
Leadership
| · Poor understanding of the policy; problems in assigning responsibilities [33] |
Madagascar
| |
Service delivery
| · Increase in utilization [19] |
Health workforce
| · No information |
Health information
| · No information |
Medical products
| · Problems of availability of drugs [19] |
Financing
| · No information |
Leadership
| · No information |
South Africa
| |
Service delivery
| |
Health workforce
| · Increase in workload; lack of time for consultations; feeling of being exploited; frustration, etc. [29] |
· Increase in patient/provider ratio [38] | |
Health information
| · No information |
Medical products
| · Problems of availability of drugs [29] |
Financing
| · No information |
Leadership
| · Feeling of a lack of recognition among workers; poor planning and communication [29] |
Senegal
| |
Service delivery
| · Increase in utilization [23] |
Health workforce
| · Increase in workload [23] |
Health information
| · No information |
Medical products
| · Delays and under-distribution of consumables [23] |
Financing
| · Informal payments; delays in reimbursements; loss of revenue for the health centres [23] |
Leadership
| · Poor understanding of the policy [23] |
Tanzania
| |
Service delivery
| · No information |
Health workforce
| · No information |
Health information
| · No information |
Medical products
| · No information |
Financing
| · Informal payments [41] |
Leadership
| · No information |
Uganda
| |
Service delivery
| |
· Increase in utilization; decline in service quality [27] | |
Health workforce
| |
· Increase in the average number of consultations per provider; negative attitude of providers [22] | |
Health information
| · No information |
Medical products
| |
Financing
| |
· Difficulties in meeting recurrent expenses; informal payments [27] | |
Leadership
| · Interference with other types of interventions [27] |
Discussion
Health system functions | Pressures on the health system |
---|---|
Service provision
| Increase in service utilization and in the demand for services |
Health personnel
| Increase in workload, increase in the patient/provider ratio, insufficient medical staff |
Loss of income | |
Lack of time for consultations | |
Feeling of being exploited, frustrated, overworked | |
Negative attitude of providers | |
Deterioration in staff morale | |
Health information
| Lack of information on the number and type of services carried out in the health centres and on the amount of reimbursements. |
Drugs and vaccines
| Problems of availability of drugs |
Insufficient drugs and kits to meet local needs | |
Delays and under-distribution of consumables | |
Funding
| Funding unpredictable, insufficient and discontinuous |
Loss of income for health centres and increased debt | |
Problems with reimbursements for cases of referrals | |
Reverting back to charging for services and drugs | |
Insufficient funding | |
Service providers having difficulty paying recurrent expenses | |
Delays in reimbursements | |
Governance and leadership
| Poor planning and communication; poor understanding of the policies |
Inadequate supervision | |
“No blame” game and problems in obtaining accounting reports and in assigning responsibilities for acts | |
Complexity of funding procedures | |
Interference with other health policies and programs |