Challenges of Health Care Reforms (HCRS) in Low and Middle-Income Countries (LMICs): A Qualitative Systematic Review

Background: Healthcare reforms (HCRs) are performed by many resource-limited countries to improve the quality of health care. However, reforms do not always lead to the expected benets and implementation problems are not fully considered due to lack of a systematic analysis of HCRs in these countries. Thus, the present study aimed to review the challenges of health care reforms in low and middle-income countries systematically. Method: A systematic review of qualitative studies was used in the present study. Data were searched in ve databases. The references related to the selected articles were searched for any relevant study irrespective of gray literature. The articles were screened based on PRISMA. The duplicates were removed, others were screened based on the title and abstract, and the eligible ones were selected for full-text reading and those matched with inclusion and exclusion criteria were selected for review. Framework analyses were used for data analysis, and the quality of the studies was evaluated by the CASP checklist for qualitative studies. Results: 702 articles were found, among which 149 were duplicated, 553 were selected to primary screening, 390 were excluded, and 163 were selected for full text reading. Finally, 151 articles were excluded, and 12 matched with the inclusion and exclusion criteria were included in the study. and


Results
Study selection: First, 702 articles were extracted after searching in databases and other resources, among which 149 were duplicated, 553 were selected to primary screening in terms of their titles and abstracts, 390 were excluded, and 163 were selected for full-text assessment. Finally, 151 articles were excluded and 12 matching with inclusion and exclusion criteria were considered for the purpose of this study.

Study characteristics
The studies included in the review used the interview as one of the data collection methods. In total, the results of 667 interviews from 12 articles were examined in this review. Interview groups included health system top managers, supervisors, stockholders, health workers, users, policymakers, professionals, etc. The studies entered in the review were related to health system governance, mental health integration in PHC, user fees, maternity health, communitybased services, hospital management, health system strengthening, and decentralization and family nurses. Further, qualitative, cross-sectional descriptive, multi-method situation appraisal, and multiple-case study were considered as the methods used in these studies, and data collection methods were the combination of interview, document reviews, questionnaire, focus group discussion, and observation, among which interview was common in all of these studies. Finally, thematic analysis, framework analysis, and estimating the relationship were used for data analysis (Table 1,2)

Risk of bias in different studies
Among the 12 articles, six were conducted in South Africa, Tanzania, and Nepal which can in uence the results. In addition, two of the articles were in health system governance which can increase the precision in this area.

Synthesis of results
In order to analyze the data, framework analysis was used. Framework analysis is considered as one of the analysis methods in qualitative studies. In this study, Gale et al.'s method was utilized for data analysis. First, two researchers (CH A, A A) read the articles for several times in order to be familiarized with the themes. Then, the data were coded independently in order to extract the related codes. Finally, 136 codes were obtained. In the next step, the framework of health system functions introduced by WHO in 2000 was used. In this framework, the functions of the health system were divided into nancing, resource generation, stewardship (governance), and service delivery. Furthermore, the data were categorized into 25 subthemes. Finally, the matrix was developed and the data were interpreted ( Table 2).

Discussion
LMICs are facing many challenges in designing and implementing the "HCRs". The present study evaluated these challenges in nancing, resource generation, and governance (stewardship) which affected the delivery of quali ed health services.

Health nancing challenges
Based on the results, lack of providing sustainable and adequate funding is considered as one of the most important challenges in HCR nancing among LMICs. In fact, HCRs have some challenges in providing adequate budgets such as allocation of a special amount in the budget plan, delay in receiving the budgets, high debts, budget de cit of hospitals, and the problems related to traditional budgeting systems. In addition, some other studies performed in Iran, Peru, Lithuania, Moldavia, and Brazil reported these challenges. Thus, it seems that providing sustainable and continuing scal resources can be considered as one of the strategies for succeeding the "HCRS" in these countries (7,(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(30)(31)(32).
Further, inequity in resource allocation among different regions is regarded as another challenge in HCR nancing among LMICs, which is increasing due to lack of transparency in guidelines, impact of donor's interests, and existence of competing priorities. However, some studies conducted in Armenia and Moldavia reported an improvement in equity in nancing and directing the budgets received from donors (8,33). Thus, the health system policymakers and The articles which were potentially eligible to be included in the present study were imported to Endnote X8, and the duplicates were excluded based on PRISMA (14) checklist. Then, others were screened base on the titles and abstracts. Further, the selected articles were considered for full-text reading, and those matching with inclusion and exclusion criteria were selected for reviewing. Finally, the framework analyses were used for data analysis.

Data collection process
The data were obtained from general and speci c information. First, titles, rst authors, years of publication and countries were considered. Then, the objectives, data collection method, sample size, and the like were extracted. In order to validate the data, searching strategy was con rmed with one expert in librarianship, and data extraction forms were designed by reviewing several data extraction form and experts' opinions in systematic review workshops.
Regarding the reliability of the collected data, two researchers (Ch A, A A) coded the data independently and disagreements were resolved by consensus (Ch A, A A). Finally, the quality the studies was evaluated by using the CASP (15) checklist for qualitative studies. managers in LMICs should direct the donor's interests for considering appropriate priorities and setting the clear guidelines and regulations for nancial resources management.

Challenges in resource generation
The challenges related to resource generation are divided into human resources, infrastructures, and drug and instrument challenges.

Human resource challenges
Lack of adequate health workforce (HW) which is exaggerated in rural and remote areas is considered as one of the main challenges in human resources. In this regard, the studies conducted in Lithuania and Moldavia reported the shortage of health HW as a challenge in health system reforms (8, 26).
Other challenges are related to lack of motivation, skills, training HW, and structural and legal problems. In addition, some factors such as lack of understanding the skills and abilities by managers, weakness in career management systems, lack of training and high workload, using staffs in positions other than their organizational posts, poor monitoring, and evaluation systems, lack of compensating the weekend and holidays, low salaries, high staff turnover, and ensuring staff safety during night shifts can in uence the motivation of HW, which result in increasing frequent absence, leaving the organization by trained staffs, remaining the inexperienced and low skilled staffs, and making concerns about quality of services. Additionally, structural and legal problems like absence or lack of organizational posts, problems in providing budgets for the existing posts and bureaucracy in the recruitment process can create some problems in HW recruitment. In addition, some studies indicated the challenges in providing needed HW in rural and remote areas, high turnover of HW, limited resources for developing the success experiences, and concerns about training (7,8,26,28,32,(34)(35)(36)(37) Challenges in infrastructures and drugs Based on the results, physical space, equipment, and drugs are considered as other major challenges in resource generation are. Based on the results, the countries coped with some problems and challenges in providing needed physical space for delivering privacy service, lacking drug, delaying in providing drugs, emptying drug stores, increasing service recipients, increasing demands, centralizing drug providing and distribution system, and lacking access to guidelines in some countries. Further, some con icts were reported between providers and recipients due to lack of medicines and drugs. Finally, Manyazavil et al. enumerated a shortage of drugs, medical equipment, and instrument as one of the major challenges in hospital reforms (1).

Governance challenges
Based on the results, many governance challenges in HCRs among LMICs based on Siddigi et al.'s(38) framework were divided into the rule of low, strategic direction, responsibilities, collaboration, e ciency, and effectiveness, ethics, equity and comprehensiveness, transparency and information.
In addition, changing the structures based on political motives instead of real needs, lack of enough legal requirement, inappropriate process for decentralization, lack of clarity in roles and tasks, resistance to implementing guidelines with lack of understanding the reform process by managers, as well as lack of clear guidelines and training resulted in confusing executive units and different interpretations by stockholders, blocking the accountability and responsibility due to the creation of levels of double or multiple accountabilities, and accordingly destroying the trust between the provider and recipient, as well as inter-sectorial and multi-sectoral collaborations.
Further, poor monitoring and evaluation systems such as lack of a good mechanism for data monitoring and evaluating human resource performance was regarded as other challenges in HCRs among LMICs.
Furthermore, the disparity between regions in terms of facilities, HR, infrastructure capacity, and budget increased equity and comprehensiveness problems. Additionally, lack of availability of guidelines on time and an increase in informal payments in some countries are considered as ethical challenges.
Other studies highlighted lack of planning and coordination, lack of management capacity for managerial reforms, gaps in technical skills, lack of trusted performance evaluation system and resistance in change (27,(39)(40).
In addition, lack of collaboration and rules, transparency and accountability in resource distribution, and social and economic inequality were considered as some of the reform challenges in Lithuania and South Africa (26, 41). In China, equity in outcomes and distribution of public resources in the regions were regarded as some challenges in monitoring and evaluation systems, which in uenced the governance of reforming health services (42). Cherry et al. indicated that health care reforms faced many challenges and the main challenge is related to an increase in e ciency and effectiveness of available services (43).
Lawrence outlined three major challenges for "HCRs". Reforms should be conducted in both public and private system agendas. The second challenges are related to the acceptable and appropriate division of work between actors and key organizations. Finally, a reform model, which is very reliable and politically attractive, should be highlighted (44).
Finally, regarding Brazil's health care reform, the sustainability of reform, monitoring, and evaluation, and problems in quality, and effectiveness of healthcare, which caused largely due to de ciencies in guidelines were regarded as some challenges (7).

Health care delivery challenges
The promotion of the people's health status is the main objective of the health system, which is responsible for delivering health services. However, inadequate resources or poor nancing systems can create some weaknesses in this regard (45). Therefore, identifying the related challenges was considered as the main purpose of the present study.
According to WHO, good service delivery should involve comprehensiveness, accessibility, appropriate coverage, continuity, quality, patient-centeredness, coordination, accountability, and e ciency (46). Based on the results, there are challenges in coverage and access, especially in rural and remote areas among LMICs (47,48). Further, it seems that the continuity of reforms can be in uenced by focusing on the unsustainability of nancing resources,.
Furthermore, there are some concerns about the quality of the delivered services regarding the existing lack of skills, training, and motivation in health HW. Additionally, the donor's interests can affect the nancing and kind of reforms and services in some countries since these services are not provided based on the needs. In addition, some studies reported the challenges related to inter-sectorial and multi-sectorial collaborations in these countries, as well as accountability and e ciency may in uence service delivery. Finally, the studies conducted in Brazil, Armenia, Lithuania, Greece, China, Turkey, Moldavia, Iran, and Peru emphasized these challenges, which are consistent with the ndings in the present study (8, 13-14, 29-29, 33-34).

Conclusion
It seems that health care reforms in LMICs face different challenges in nancing, HW, drug and medicine, infrastructure and governance which in uence the delivery of appropriate and quali ed services. Thus, it is recommended for policymakers to make appropriate decisions about agenda setting, regulations, clear guidelines, sustainability of nancial resources, collaborations, detailed roles and tasks of every stakeholder and decision on the way for providing HR, infrastructures, needed drugs, and medicine in order to design and implement any reform. In addition, how access to services in rural and remote areas should be clari ed. Further, policymakers should be very alert to sign the funds for the right needs and priorities in the countries in which the interests of donors can affect the reforms. In other words, comprehensive assessments and evidence are required for implementing health reforms in LMICs. Thus, the road map of reform, tasks, and roles of stakeholders, as well as the process of delivering services, and accountabilities, responsibilities and at least executive and political quarantines should be clearly identi ed.

Limitations
In the present study, the studies written in English language were only considered for reviewing since limitations in translating skills could create some regional limitations, which may affect the results. Further, there were few studies which considered an interview for data collection. Finally, only electronic articles were considered for the purpose of this study. In fact, gray literature and non-published studies were ignored.     Figure 1 study selection process