A Systematic Review of the Effectiveness of Strategies to Improve Health Care Provider Performance in Low- and Middle-income Countries: Methods and Descriptive Results

Journal Article
  • Samantha Y. Rowe
  • David H. Peters
  • Kathleen A. Holloway
  • John Chalker
  • Dennis Ross-Degnan
  • Alexander K. Rowe
PLoS One
2019; Vol. 14: e0217617. DOI: 10.1371/journal.pone.0217617.



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we searched 15 databases for published studies; in 2008 and 2010, we completed searches of 30 document inventories for unpublished studies.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.