Research Article: A systematic review of the effectiveness of strategies to improve health care provider performance in low- and middle-income countries: Methods and descriptive results

Date Published: May 31, 2019

Publisher: Public Library of Science

Author(s): Samantha Y. Rowe, David H. Peters, Kathleen A. Holloway, John Chalker, Dennis Ross-Degnan, Alexander K. Rowe, Manuela De Allegri.


Health care provider (HCP) performance in low- and middle-income countries (LMICs) is often inadequate. The Health Care Provider Performance Review (HCPPR) is a comprehensive systematic review of the effectiveness and cost of strategies to improve HCP performance in LMICs. We present the HCPPR’s methods, describe methodological and contextual attributes of included studies, and examine time trends of study attributes.

The HCPPR includes studies from LMICs that quantitatively evaluated any strategy to improve HCP performance for any health condition, with no language restrictions. Eligible study designs were controlled trials and interrupted time series. In 2006, we searched 15 databases for published studies; in 2008 and 2010, we completed searches of 30 document inventories for unpublished studies. Data from eligible reports were double-abstracted and entered into a database, which is publicly available. The primary outcome measure was the strategy’s effect size. We assessed time trends with logistic, Poisson, and negative binomial regression modeling. We were unable to register with PROSPERO (International Prospective Register of Systematic Reviews) because the protocol was developed prior to the PROSPERO launch.

We screened 105,299 citations and included 824 reports from 499 studies of 161 intervention strategies. Most strategies had multiple components and were tested by only one study each. Studies were from 79 countries and had diverse methodologies, geographic settings, HCP types, work environments, and health conditions. Training, supervision, and patient and community supports were the most commonly evaluated strategy components. Only 33.6% of studies had a low or moderate risk of bias. From 1958–2003, the number of studies per year and study quality increased significantly over time, as did the proportion of studies from low-income countries. Only 36.3% of studies reported information on strategy cost or cost-effectiveness.

Studies have reported on the efficacy of many strategies to improve HCP performance in LMICs. However, most studies have important methodological limitations. The HCPPR is a publicly accessible resource for decision-makers, researchers, and others interested in improving HCP performance.

Partial Text

Each year in low- and middle-income countries (LMICs), millions of children and adults die prematurely [1,2]; although many interventions exist that can prevent such deaths [3–6]. Low coverage of these interventions has been identified as a critical public health problem [3,6] and a major obstacle to achieving Millennium Development Goals [4] and the Sustainable Development Goals [7].

The methods and results of our systematic review are presented in a series of articles that, taken together, include all elements recommended by the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines [61]. This article presents the review’s methodology and contextual attributes of included studies, and examines time trends of some of these attributes. Articles in preparation will present results on strategy effectiveness, training and supervision strategies, and a network meta-analysis of results. The PRISMA checklist (S1 File) and study protocol (S2 File) are available as on-line Supporting Information files. We attempted to register our protocol with PROSPERO (International prospective register of systematic reviews). However, the protocol for this review was developed and the review was underway prior to the launch of PROSPERO and as such, it was ineligible to be registered. We were unable to identify another site to register the protocol.

The HCPPR identified an unexpectedly large number of studies that evaluated strategies to improve HCP performance in LMICs. About two-thirds of study reports described studies with study designs that did not meet the criteria for inclusion in the review. There remained a remarkable 499 studies with stronger designs (i.e., controlled studies and ITS), which were included. These studies represent evaluations of a great diversity of strategies to improve HCP performance for numerous health conditions, tested in a wide variety of settings.

The HCPPR addresses an important gap in our knowledge about the effectiveness and cost of strategies to improve HCP performance in LMICs. Analyses of the studies included in the review’s database that are described in this report will allow program managers, policy analysts, donors, technical agencies, and researchers to identify effective approaches to improve HCP performance tested in a variety of settings, and to choose components that will strengthen future improvement strategies.




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