Health Service Research in High- and Low-Income Countries

CLAHRC WM is just over one year old and its associated international centre is almost exactly the same age. An obvious question then is “how does service delivery/health services research differ among high- and low-income countries?” In some ways, they are similar – the rules governing a cluster study and the need to pilot complex interventions apply in both contexts, for example. Some of the issues seem similar, at least at first glance. For example, the effect of skill substitution is of universal interest (clinical officers in low-income countries and physicians assistants here in England). But there is also a fundamental difference across contexts. In high-income countries, the fundamental infrastructure is largely in place, while in low-income countries it is inadequate, often woefully inadequate.

Thus, the most pressing problems in high-income countries seem to concern how to make best use of the established infrastructure, while in low-income countries the most pressing need is establishing such infrastructure in the first place. For example, how processes can be improved to recognise the deteriorating patient, avoid falls and prevent pressure ulcers, are recurring patient safety issues in high-income countries. But at the Kenyatta National Hospital, Nairobi, the need is for more nurses. Introducing a scoring system to identify patients at high-risk of pressure ulcers would be wide of the mark in many parts of Sub-Saharan Africa, where there are issues over availability of gloves or re-use of syringes.

It is not my argument that this distinction is absolute – it is more a question of emphasis. After all, a CLAHRC WM affiliated study is examining the effect of improving consultant cover at weekends in England, while we are proposing efficient routines to improve the recognition of hypertension and diabetes in the course of routine care in three African countries. Nevertheless, the difference in emphasis is supported by three types of argument:

  1. Empirical support. The notion that structural solutions should precede process improvement is supported by an iconic study of service interventions in diabetes care. In an analysis of results from over 120 RCTs of diabetes care pathways, Tricco et al. [1] found that structural solutions yield greatest effect sizes where care is poor at baseline, while process solutions are relatively more effective when care is already of a reasonable standard.
  2. Anecdotal evidence: Lack of infrastructure, especially in terms of clinical staff, is a recurring theme in conversations with managers, clinicians and researchers in low-income countries. In fact, this blog was inspired by a conversation with Nkee Ezeh in Nairobi earlier this month.
  3. Labour economics theory: Labour force productivity demonstrates diminishing returns to labour supply. One must imagine that South Sudan, Botswana and Norway occupy very different positions on the “production curve,” as represented below.

Supply of labour vs. Output for South Sudan, Botswana and Norway

None of this is to say that research methods differ across settings, that knowledge from one context is irrelevant in another and, of course, we can expect economies and their facilities to converge over time. As always, comments are invited from those who can improve or demolish this argument.

— Richard Lilford, CLAHRC WM Director


  1. Tricco AC, Ivers NM, Grimshaw JM, et al. Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis. Lancet. 2012; 379: 2252-61.



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