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.



Oregon Experiment

In a previous blog I promised to disclose the results of the Oregon experiment on the effects of providing health insurance to previously uninsured people. To recap, in the USA all young and middle-aged adults below the poverty line are provided with national insurance called Medicaid. The state of Oregon wished to extend such insurance to a category of slightly better-off people, yet did not have enough money to provide insurance for all in this category. Eligibility was therefore determined by lottery, on the grounds that this would be a fair way to distribute a scarce resource – a reverse of the draft if you like. Of course, such distributional exercises constitute an unintended RCT if one can find out who was randomised to which condition and then follow them up. Baicker et al. did just that.[1] The results are politically sensitive (as you will see if you search the internet), but wisely the authors published the protocol before analysing the data.

The results show that the group offered insurance sought more services, engaged in more preventive activities, had lower expenses, and were more likely to avoid catastrophic payments than those not offered cover. There was no difference between groups in proportions with high blood pressure or elevated glycosylated haemoglobin and death rates did not differ (under 1% in both groups). Patients offered insurance were more likely than those not selected in the lottery to report improved health and the mental component of the quality of life score was improved.

Only two year follow-up data are available. A health economic analysis was not attempted. Despite the study size (over 12,000 people), the power to detect changes in rates of diseases, such as diabetes and hypertension, was low. What is not in doubt is that insurance relieves financial stress and the anxiety that goes with it. This study is relevant for two reasons. First, the results are of policy relevance world-wide. Second, it is a fine example of a high quality academic output from an entirely service-led intervention. Indeed, it conforms with the CLAHRC model, where the service dog wags the research tail.

— Richard Lilford, CLAHRC WM Director


  1. Baicker K, Taubman SL, Allen HL, et al. The Oregon Experiment – Effects of Medicaid on Clinical Outcomes. N Engl J Med. 2013; 368: 1713-22.

Antibiotic resistance – a technical solution after all?

Killing bacteria outside of the body is a relatively simple and straightforward process – denature their proteins by heat or chemicals and thereby kill them. The bacteria can’t get resistant since the denaturalisation process is non-selective, targeting all proteins. Such an approach is not possible once the bacteria have colonized the body, however, since it would harm or kill the host. It is therefore necessary to find a (relatively) specific aspect of microbial metabolism and attack that. However, life-forms can continue using alternative pathways for which the anti-microbial selects if used over a long enough period – a living example of evolution. The obvious place to hit a bacterium is the cell wall, since there is no equivalent in mammalian cells, which are surrounded only by a membrane. Bacteria, however, find a way around this solution, producing neutralizing enzymes to destroy the active part of the antibiotic. So what we need is a molecule that attacks the cell wall and which lies outside the range of neutralizing proteins afforded by nature. A recent report suggests that just such a compound may have been discovered.[1] This compound, termed teixobactin, has been discovered in a soil bacterium, Eleftheria terrae, which cannot be cultured by traditional means. This compound is bactericidal against Gram-positive bacteria (such as MRSA, VRSA and C. difficile) and it has proven impossible to generate resistance in the laboratory – at least so far!

Further, the method used to obtain texiobactin may also be able to help us find other bactericidal compounds. Conventional laboratory methods of growing microbes from soil kill off 99%, but the authors followed a different strategy using “isolation cells” that protect the bacterium sample with a semi-permeable membrane and allow it to grow in its natural environment prior to plating. This method could potentially allow us to recover 50% of soil bacteria, and hence potentially identify many more new antibiotics.

— Richard Lilford, CLAHRC WM Director
— Peter Chilton, Research Fellow


  1. Ling LL, Schneider T, Peoples AJ, et al. A new antibiotic kills pathogens without detectable resistance. Nature. 2015; 517(7535): 455-9.




Readers of the Economist will know about a column fictitiously attributed to Schumpeter; the Nobel Prize winning economist who explicated the role of innovation in economic development. The issue of networking was recently discussed in the Schumpeter column.[1] This caught the eye of the CLAHRC WM Director because networking is part of the job description for a CLAHRC director whose role is to link research and health service management. The guidelines laid out for good networking, however, did not appeal to the Director. He could just about go along with the idea of doing homework on who you might meet before attending a gathering, but identifying ‘targets’ and then engineering chance meetings – say in the gym at 6 a.m. – seemed a step too far. Deliberately sucking up to the target by lavishing praise on him or her had the Director reaching for the basin! But worse was in store; the Director was then told he should not challenge the prevailing ideology if he really wanted to climb the networking ladder. Was the article a spoof like Polonius’ homily to his departing son?

— Richard Lilford, CLAHRC WM Director


  1. The Economist. Schumpeter: The network effect. The Economist. 17 Jan 2015.

Medicine for the soul…

This was the inscription above the door of the library in the ancient Egyptian city of Thebes. The Egyptians clearly recognised the therapeutic benefits of reading. The idea of Bibliotherapy as a concept therefore is not new, but has recently been re-packaged and rolled out in a national scheme called ‘Information/Books on Prescription’ (I/BOP).

A collaboration between Health Services, The Reading Agency and local libraries, the I/BOP project offers an alternative approach to dealing with mental health issues by enabling patients to ‘self-help’. The project was introduced nationally in June 2013. Put simply, a GP diagnosing early stage mental health issues can prescribe an ‘Information Prescription’, which recommends either specific or general self-help study books from a list compiled with input from health specialists. The patient takes the prescription along to a local participating library, which provides the books.

A report by The Centre for Economic Performance’s Mental Health Policy Group states that “mental illness accounts for nearly 40% of morbidity, compared for example 2% due to diabetes”.[1] The annual expenditure on healthcare for mental illness amounts to some £14 billion. Interventions such as I/BOP are essential projects working to reduce both the expenditure and the human costs of mental illness.

The self-help approach through Bibliotherapy has a ‘wealth of evidence…’ that supports its use for illnesses such as depression, anxiety and self-harm.[2] Using book-based cognitive behavioural therapy, the I/BOP scheme has reached 275,000 people during its first year, and seen a 113% increase in the loan of titles on the list.[3] The patient is not required to have library membership, although evidence shows that those participating in the scheme are more likely to join and access additional books to those prescribed.

Furthermore, although the focus of I/BOP is on self-help books, The Reading Agency runs another scheme alongside I/BOP entitled ‘Reading Well – Mood Boosting books’, which urges users of I/BOP (indeed everyone) to read the uplifting novels, non-fiction and poetry titles recommended on their reading list as a means of maintaining well-being. The subject of a study carried out by cognitive neurophysiologist Dr David Lewis suggests that reading for as little as six minutes can reduce stress levels by 68%, compared with listening to music (61%) having a cup of tea/coffee (54%) or taking a walk (42%).[4] Other studies have shown that the very act of reading literary fiction improves Theory of Mind (ToM), the ability to understand others’ emotions,[5] although it may be argued that the I/BOP mood boosting list is compiled more of popular fiction than literary, we gain further insight into how reading literature has positive cognitive connotations.

On 26 January 2015 an I/BOP scheme specifically aimed at suffers of dementia and their carers was launched nationally, and a scheme accessible to children and young people with mental health issues is expected to be launched in 2016. To discover more about the scheme and the reading lists follow the link to The Reading Agency website.[3] I’d be interested to hear suggestions of ‘mood boosting books’ from you.

— Michelle Brown, Administrative Assistant


  1. The Centre for Economic Performance’s Mental Health Policy Group. How mental health loses out in the NHS. London: The London School of Economics and Political Science. 2012.
  2. Chamberlain D, Heaps D, Robert I. Bibliotherapy and information prescriptions: a summary of the published evidence-base and recommendations from past and ongoing Books on Prescription projects. J Psychiatr Mental Health Nurs. 2008; 15: 24-36.
  3. The Reading Agency. Reading Well Books on Prescription Evaluation Report 2013/14. London: The Reading Agency. 2013.
  4. Telegraph Health News. Reading ‘can help reduce stress’. The Telegraph. 30 March 2009.
  5. Kidd DC, Castano E. Reading Literary Fiction Improves Theory of Mind. Science. 2013; 342: 377-80.

Bad Apples vs. Bad Systems

The bad apples versus bad systems argument has erupted again. This argument has been put forcibly in the Los Angeles Times by Philip Levitt.[1] He points out that:

  1. Error rates are not declining, despite humongous effort. This is not quite right; they declined quite markedly in England over the last decade,[2] and on many dimensions of safety adherence it was near 100%. Nevertheless, adverse events remain a substantial problem.
  2. Many interventions, such as surgical check-lists [3] and antisepsis bundles,[4] yield positive interventions when first introduced, but these cannot be replicated.[5] [6] [7]
  3. Analysis of the cognitive form of errors put them down mostly to individual failure rather than the system – most are technical errors during procedures, or misdiagnosis.[8] [9]
  4. Many studies show that a small pool of doctors generate a large proportion of complaints (3% of doctors triggering half of all complaints in an Australian study).[10] Arguably this proportion would be reflected among adverse events as well.

So maybe we should re-think our basic safety science premises. Certainly, falls, pressure ulcers, hospital infections, and medication errors can be blamed in large part on the system. However, these are not the major safety issues; over three-quarters of serious adverse events result from misdiagnosis and errors during procedures. While the system may play a part in these failures the CLAHRC WM Director, who practised at various times as physician and surgeon, is not convinced that the main problem lies in the system. No, diagnosis and safe surgery turn on individual skill. So we need to think about selection and improving the performance of individual clinicians – most especially those who make diagnoses and carry out procedures (i.e. doctors). Of course, if the definition of the system is made very broad, then of course selection and training are included, but the solution lies in medical schools and training programmes, rather than individual organisations. Can we identify an error prone phenotype before they end up in court or a complaints tribunal? Identifying such a phenotype is elusive – as work carried out in our pilot CLAHRC discovered.[11]

— Richard Lilford, CLAHRC WM Director


  1. Levitt P. When medical errors kill. Los Angeles Times. 15 March 2014.
  2. Benning A, Dixon-Woods M, Nwulu U, Ghaleb M, Dawson J, Barber N, et al. Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase. BMJ. 2011; 342: d199.
  3. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al. A Surgical Checklist to Reduce Morbidity and Mortality in a Global Population. N Engl J Med. 2009; 360: 491-9.
  4. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006; 355(26): 2725-32.
  5. Urbach DR, Govindarajan A, Saskin R, Wilton AS, Baxter NN. Introduction of Surgical Safety Checklists in Ontario, Canada. N Engl J Med. 2014; 370: 1029-38.
  6. Reames BN, Scally CP, Thumma JR, Dimick JB. Evaluation of the Effectiveness of a Surgical Checklist in Medicare Patients. Med Care. 2015; 53(1): 87-94.
  7. Bion J, Richardson A, Hibbert P, Beer J, Abrusci T, McCutcheon M, et al. ‘Matching Michigan’: a 2-year stepped interventional programme to minimise central venous catheter-blood stream infections in intensive care units in England. BMJ Qual Saf. 2013; 22(2): 110-23.
  8. Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991; 324(6): 370-6.
  9. Fabri PJ, Zayas-Castro JL. Human error, not communication and systems, underlies surgical complications. Surgery. 2008; 144(4): 557-65.
  10. Bismark MM, Spittal MJ, Gurrin LC, Ward M, Studdert DM. Identification of doctors at risk of recurrent complaints: a national study of healthcare complaints in Australia. BMJ Qual Saf. 2013; 22(7): 532-40.
  11. Coleman JJ, Hemming K, Nightingale PG, Clark IR, Dixon-Woods M, Ferner RE, Lilford RJ. Can an electronic prescribing system detect doctors more likely to make a serious prescribing error? J R Soc Med. 2011; 104(5): 208-18.

Improve Long-Term Development of Children

Readers of this CLAHRC WM News Blog will know that we have an enduring interest in early childhood interventions to improve long-term psychosocial development. First, we have carried out an individually randomised trial of perinatal lay support for over 1,400 women at high social risk.[1] Second, we summarised two recent RCTs of infant support (published almost simultaneously in the BMJ [2] and the Lancet [3]) in a previous post. In that post we suggested that a systematic review of experimental evidence is urgently needed. Now we report a third fascinating study from Science to add to studies for review.[4] This was an RCT of 129 participants conducted back in 1986, of whom 105 were available for interview 20 years later. The participants were growth-stunted children aged 9 to 24 months. As in the trials reported in a previous post, they were randomized to four groups:

  1. Psychosocial intervention given weekly by community health workers to encourage mothers in active play.
  2. A nutritional intervention.
  3. Both.
  4. Neither.

There was no selective attrition and the samples were balanced with respect to prognostic factors at baseline. Although multiple outcomes were tested, the authors used a previously published step-down algorithm. The results show that those given the psychosocial intervention did better than controls in terms of completing school and subsequent earnings. In terms of earning capacity, they had caught up with the general population of non-stunted children.

— Richard Lilford, CLAHRC WM Director


  1. Kenyon S, Jolly K, Hemming K, et al. Evaluation of Lay Support in Pregnant women with Social risk (ELSIPS): a randomised controlled trial. BMC Preg Child. 2012; 12: 11.
  2. Attanasio OP, Fernandez C, Fitzsimons EO, Grantham-McGregor SM, Meghir C, Rubio-Codina M. Using the infrastructure of a conditional cash transfer program to deliver a scalable integrated early child development program in Colombia: cluster randomized controlled trialBMJ. 2014; 349: g5785.
  3. Yousafzai AK, Rasheed MA, Rizvi A, Armstrong R, Bhutta ZA.Effect of integrated responsive stimulation and nutrition interventions in the Lady Health Worker programme in Pakistan on child development, growth, and health outcomes: a cluster-randomised factorial effectiveness trialLancet. 2014; 384: 1282-93.
  4. Gertler P, Heckman J, Pinto R, et al. Labor market returns to an early childhood stimulation intervention in Jamaica. Science. 2014; 344: 998-1001.

The EarlyBird Study

Our CLAHRC, like many sibling CLAHRCs, has a primary prevention theme partnering with local authorities. Local authorities are having to deal with increasingly constrained budgets. Dr Ewan Hamlett, adviser to the Birmingham Council, recently drew the CLAHRC WM Director’s attention to the EarlyBird study.

This unique study, based in Southampton, follows a cohort of five year-olds to see what factors are associated with obesity and insulin resistance, and detailed information relating to metabolism is collected from participants. Results are starting to emerge and many are highly policy-relevant.[1]

Some headline, policy-relevant findings include:

  • Provide more school playing fields if you wish, but not because it will increase exercise or tackle obesity – it won’t do either of these things.
  • As with education, don’t wait until school age to tackle the problem – children are programmed to over-eat before they go to school.
  • Obese parents produce obese children, yet they tend to be oblivious to the problem. Follow policies to get parents ‘on-side’.
  • Among children, the mean weight has shot up, but the median has not. A subgroup of children with fat parents is at greatest risk.

— Richard Lilford, CLAHRC WM Director


  1. EarlyBird Diabetes Trust. “Key Findings from EarlyBird.” 2015. [Online].

For Educationalists

Clinical skills are increasingly tested in simulations rather than real world (clinical) settings. A noble exception, where skill was tested in real world settings rather than simulation scenarios, was published recently.[1]

Nevertheless, performance in a simulation seems to be a good surrogate for the latter according to a recent systematic review.[2] Only one study in the review examined the effect of a change in score in a simulation on the score in actual clinical practice and found that they were correlated.[3]

— Richard Lilford, CLAHRC WM Director


  1. Laiou E, Clutton-Brock TH, Lilford RJ, Taylor CA. The effects of laryngeal mask airway passage simulation training on the acquisition of undergraduate clinical skills: a randomised controlled trial. BMC Med Educ. 2011; 11: 57.
  2. Brydges R, Hatala R, Zendejas B, Erwin PJ, Cook DA. Linking Simulation-Based Educational Assessments and Patient-Related Outcomes: A Systematic Review and Meta-Analysis. Acad Med. 2014. [ePub].
  3. Yudkowsky R, Luciano C, Banerjee P, et al. Practice on an augmented reality/haptic simulator and library of virtual brains improves residents’ ability to perform a ventriculostomy. Simul Healthc. 2013; 8: 25-31.

Prevention of CVD in Nairobi Slums

CLAHRC Africa collaborators at the African Population Health Research Center have recently produced a health economic model for cardiovascular risk reduction in slum areas (abstracted at a recent conference). Populating the model with evidence from the literature suggests that an intervention to prevent hypertension, costing only $1 per person per year, would be both effective and cost-effective. The full publication is awaited with great interest.

— Richard Lilford, CLAHRC WM Director