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Background Task shifting has become an increasingly popular way to increase access to health services, especially in low-resource settings. Research has demonstrated that task shifting, including the use of community health workers (CHWs) to deliver care, can improve population health. This systematic review investigates whether task shifting in low-income and middle-income countries (LMICs) results in efficiency improvements by achieving cost savings. Methods Using the PRISMA guidelines for systematic reviews, we searched PubMed, Embase, CINAHL, and the Health Economic Evaluation Database on March 22, 2016. We included any original peer-review articles that demonstrated cost impact of a task shifting program in an LMIC. Results We identified 794 articles, of which 34 were included in our study. We found that substantial evidence exists for achieving cost savings and efficiency improvements from task shifting activities related to tuberculosis and HIV/AIDS, and additional evidence exists for the potential to achieve cost savings from activities related to malaria, NCDs, NTDs, childhood illness, and other disease areas, especially at the primary health care and community levels. Conclusions Task shifting presents a viable option for health system cost savings in LMICs. Going forward, program planners should carefully consider whether task shifting can improve population health and health systems efficiency in their countries, and researchers should investigate whether task shifting can also achieve cost savings for activities related to emerging global health priorities and health systems strengthening activities such as supply chain management or monitoring and evaluation.

Sustainable Development Goal (SDG) 3 aims to “ensure healthy lives and promote well–being for all at all ages” [1]. Unlike the Millennium Development Goals (MDGs), SDG 3 takes a comprehensive view of health and well–being by expanding its focus beyond a core set of diseases. Given the global prominence of the SDGs for driving the development agenda, it is important to consider whether SDG 3 and the indicators it tracks are well–designed to achieve this intended goal. In order to examine whether SDG 3 can actually help achieve this goal, this article considers whether it has an adequate theory of change (ToC) for improving health systems performance. Such an analysis rests on two core assumptions: 1) in order to achieve the SDG 3 goal, one must improve health systems performance, and 2) in order to achieve this goal, the approach must have a strong underlying ToC. Each assumption is considered below. Since the launch of the MDGs, experience has shown that without improvements in health systems performance, progress on the MDGS was both limited and potentially unsustainable [2]. Bottlenecks in the health system limited nations’ ability to achieve progress on combatting specific diseases. In addition, theoretical and empirical work has argued that providing services which are not only clinically effective but also affordable and acceptable has intrinsic and instrumental value. Recognizing the importance of overall health systems performance, numerous organizations including WHO, the World Bank, Global Fund, and GAVI have focused on health systems strengthening (HSS) as an important component of public health programming. Therefore, since SDG 3 aims to improve both health and well–being for all populations in a sustainable way, achieving this goal will likely require broad improvements in health systems performance. With regards to the second assumption, theories of change (ToC) are standard practice in public health and development [3,4]. They help guide priority–setting, decision–making, monitoring and evaluation, budgeting, and resource allocation, among other activities. A strong ToC can ensure that all stakeholders work toward the same goal(s). The SDGs aim to improve both the coherence of development policies and their implementation at the national level, and the United Nations has offered formal guidance on ways that nations can integrate and tailor the SDGs into their national policies [5]. This guidance explicitly advocates for horizontal policy coherence (ie, coherence across different programs and sectors), vertical policy coherence (ie, coherence between different stakeholders), and linking national policies based on the SDGs to budgets [6]. Given that the SDGs aim to improve policy coherence and drive implementation at the national level, it is instructive to consider whether they have internal coherence and a strong underlying logic themselves. The ToC approach provides a useful approach to explore this question. If the inputs and outputs tracked under SDG 3 have clear linkages to improving its impact indicators, then working toward SDG 3 will allow countries to pursue a comprehensive program for improving health systems performance. On the other hand, if the inputs and outputs tracked do not link to each other or do not have logical connections to impact indicators, then aiming to improve all indicators under SDG 3 could lead to a haphazard and uncoordinated set of public health programs.

Introduction Improving health systems performance, especially in low-resource settings facing complex disease burdens, can improve population health. Specifically, the efficiency and effectiveness of supply chains and procurement processes for pharmaceuticals, vaccines and other health products has important implications for health system performance. Pharmaceuticals, vaccines and other health products make up a large share of total health expenditure in low-income and middle-income countries (LMICs), and they are critical for delivering health services. Therefore, programmes which achieve cost savings on these expenditures may help improve a health system9s efficiency, whereas programmes that increase availability of health products may improve a health system9s effectiveness. This systematic review investigates whether changes to supply chains and procurement processes can achieve cost savings and/or improve the availability of drugs in LMICs. Methods Using the PRISMA guidelines for systematic reviews, we searched PubMed, Embase, CINAHL and the Health Economic Evaluation Database to identify. Results We identified 1264 articles, of which 38 were included in our study. We found evidence that centralised procurement and tendering can achieve direct cost savings, while supply chain management programmes can reduce drug stock outs and increase drug availability for populations. Conclusions This research identifies a broad set of programmes which can improve the ways that health systems purchase and delivery health products. On the basis of this evidence, policymakers and programme managers should examine the root causes of inefficiencies in pharmaceutical supply chain and procurement processes in order to determine how best to improve health systems performance in their specific contexts.