Schneider Institutes for Health Policy, Heller School, Brandeis University, 415 South Street, MS 035, Waltham, MA 02454, USA.
School of Public Health, Shanghai Jiao Tong University, 280 Chongqing South Road, Shanghai, 200025 China.
Health Policy Plan. 2018 Mar 1;33(2):283-297. doi: 10.1093/heapol/czx172.
Health systems strengthening (HSS) interventions are increasingly being implemented to improve maternal and child health (MCH) services in low- and middle-income countries (LMICs). This study reviews global literature on cost-effectiveness of HSS interventions in improving MCH. A systematic review was conducted. Keywords, based on World Health Organization framework on health systems and prior studies, were applied to search in bibliographic databases and on the web. Articles that estimated cost-effectiveness of HSS interventions in LMICs were included in the analysis. Each of the 24 selected studies from 15 countries was assessed in terms of quality and biases using Cochrane's criteria. Review Manager and an Excel template were used to extract data and synthesize findings. HSS interventions concentrated on the components of service delivery, health financing, human resources and quality improvement. Within each component, there existed diverse strategies to strengthen health systems. Among the 24 studies, 15 were rated as high quality, 5 as medium and 4 as low quality. A majority of studies reported cost per disability-adjusted life year (DALY) averted or cost per quality-adjusted life year (QALY) gained; other studies reported cost per life saved or life year gained. However, studies used mixed perspectives of analyses. Compared with gross domestic product per capita, interventions in studies reporting cost per DALY averted or QALY gained were all cost-effective, including performance-based financing, health insurance and quality improvement. This review shows the diversity of HSS interventions in improving MCH, and their potential cost-effectiveness. However, the different perspectives employed in the studies, costing components included in the analyses, and heterogeneous measures of effectiveness and outputs, made it challenging to compare cost-effectiveness across all studies, calling for more and standardized cost-effectiveness studies. For policy making, it is critical to examine long-term cost-effectiveness of programs and cost-effectiveness of synergistic demand- and supply-side interventions.
卫生系统强化（HSS）干预措施正越来越多地被应用于改善中低收入国家（LMICs）的母婴健康（MCH）服务。本研究综述了全球关于 HSS 干预措施提高 MCH 成本效益的文献。采用系统评价方法。根据世界卫生组织的卫生系统框架和先前的研究，应用关键词在文献数据库和网络上进行检索。纳入分析的文章均为在 LMICs 中评估 HSS 干预措施成本效益的研究。使用 Cochrane 标准评估来自 15 个国家的 24 项研究的质量和偏倚。Review Manager 和 Excel 模板用于提取数据和综合研究结果。HSS 干预措施集中在服务提供、卫生筹资、人力资源和质量改进等卫生系统组成部分。在每个组成部分中，都存在不同的强化卫生系统的策略。在 24 项研究中，15 项被评为高质量，5 项为中等质量，4 项为低质量。大多数研究报告了每例残疾调整生命年（DALY）减少的成本或每例质量调整生命年（QALY）获得的成本；其他研究报告了每例生命挽救或生命年获得的成本。然而，研究采用了混合的分析视角。与人均国内生产总值相比，报告每例 DALY 减少或 QALY 获得的成本效益的干预措施均具有成本效益，包括基于绩效的融资、医疗保险和质量改进。本综述展示了 HSS 干预措施在改善母婴健康方面的多样性及其潜在的成本效益。然而，研究中采用的不同视角、分析中包含的成本构成部分以及衡量效果和产出的不同方法，使得难以在所有研究之间进行成本效益比较，需要更多的标准化成本效益研究。对于政策制定，检验方案的长期成本效益和需求侧与供给侧协同干预措施的成本效益至关重要。
