How area health management leads to improved equity in health: How area health management leads to improved equity in health: a scoping review a scoping review

Background : The scoping review of published studies aims to explore what practices and processes can improve equity (horizontal and vertical) in countries that adopted Area Health Management (AHM) utilizing the “ Six Building Blocks Plus ” (SBBP) concept. Method : An electronic search was conducted from the inception to January 27, 2021, from 6 databases (Embase, Social Sciences, Web of Science, PubMed, CINAHL, and WHO) and the gray literature. The inclusion criteria were AH, SBBP, and equity. Data extraction was using a standardized data collection form. Results : This scoping review includes 63 full-text studies. SBBP are identical in the horizontal and vertical equity. However, the majority of SBBP were health service delivery, leadership & governance, and health workforce. The result showed the practice and process to improve health equity were related to a health service delivery (HSD). Conclusion : The included study showed horizontal and vertical equity. The equity measurement focused on utilization. AHM utilizing SBBP was mostly showed in HSD, HWF, leadership & governance. This review indicates that HSD could improve equity or cooperate with other SBBP by increasing healthcare accessibility and utilization. The demographic factor that affected equity is ethnicity. Therefore, HSD in area health was crucial in enhancing health promotion equity in different areas, speci ﬁ c diseases, and target patients.


Introduction
A health system (HS) refers to the healthcare provider organizations that furnish services to meet the health needs of populations. A HS drives necessary actions to achieve health equity [1]. Establishing effective HS management can improve healthcare accessibility, quality of health service delivery, and efficiency in allocating scarce resources. In this review, health management refers to the planning and developing process of health services in a HS. Area Health Management (AHM) can be separated into 'centralized' and 'decentralized' models. The main difference between these models is the authority to decide planning, delivering, and monitoring processes in HS.
The advantages of decentralization are: 1) the local authority to implement local data for flexibility in making decisions that lead to achieving equity [2,3], 2) the ability to strengthen participation by encouraging local organizations and people [4], and 3) recommending local alternatives for service delivery to foster a sense of ownership through participation [5].
The goal of a healthcare system is to improve equity, especially at the population level. Enhancing health outcomes and organizing activities that reduce health disparities among subgroups can improve equity [6]. Health equity is a fundamental human right. So effective area health management is essential for enhancing equity [1,7,8]. The dimensions of equity can be categorized into horizontal and vertical equity. Horizontal equity refers to people with the same healthcare needs receiving equal healthcare treatment, regardless of socioeconomic factors. Vertical equity refers to people with unequal needs receiving different treatments [9,10]. Reducing socioeconomic inequalities and increasing the participation of stakeholders and people is a way to improve equity in a HS. Therefore, AHM is a key factor in considering the performance of a HS under decentralization on either central or local levels.
The World Health Organization (WHO) created a framework for monitoring and evaluating health management with Six Building Blocks (SBBs): 1) health service delivery, 2) health workforce, 3) health information systems, 4) essential medication accessibility, 5) health system financing, and 6) leadership & governance. The SBBs provide the key indicators and monitoring factors for health systems management. The SBB concepts can inform the decisions made to achieve more equitable and sustainable improvements across health services and health outcomes [11]. The Thai Ministry of Health describes the various areas to achieve effective health management as the "Six Building Blocks Plus" (SBBP) [12]. SBBP stands for the SBBs outlined by the WHO plus people participation. People participation under the decentralized model involves cooperation between people and health providers for essential decisionmaking processes, such as planning, managing, and budgeting [13].
This scoping review of published studies aims to explore what practices and processes of AHM utilizing SBBP can improve equity in countries that have adopted these concepts, thereby furthering the mission of promotion, prevention, treatment, and rehabilitation in healthcare.

Method
We investigated the published evidence in order to: 1) determine the characteristics of AHM utilizing SBBP to achieve horizontal or vertical health equity, 2) assess how AHM utilizing SBBP leads to improvement of health equity. This scoping review adhered to the PRISMA statement for maintaining the criteria of the review pattern [14]. The method covers the stages of identification, screening, eligibility, and inclusion of identified studies.

Identification
The search was performed from the inception of each database (Table A1 in Appendix A) to January 27, 2021, by using six databases (PubMed, EMBASE, Social Sciences, Web of Science, CINAHL, World Health Organization (WHO)), gray literature (from gray literature reports), and the equity conference of the WHO to identify research focusing on area health, SBBP, and health equity. The search terms included equity, area health, and the allowed synonyms of area health (including primary care trust, district health authority, district health board, region health board, area health board, and regional health authority). The number of results for each database is shown in Fig. 1

Screening, eligibility, and inclusion of studies
We included original studies that focused on AHM utilizing SBBP and reported the data related to equity as either horizontal, vertical, or both. We excluded studies that focused on non-clinical issues that were not related to health care professions. In the initial screening, we reviewed the titles and abstracts related to the inclusion criteria. Two reviewers (MI and JW) reviewed the full text of potential studies. A third reviewer (NU) resolved any disagreements in study selection.

Data extraction
We extracted data using data charting and an adapted version of a standardized data collection form [15]. We used PROGRESS PLUS to identify, extract, and analyze predefined concepts relevant to health equity. There are ten equity aspects identified in the PROGRESS Plus framework: 1) Place of residence, 2) Race/ethnicity/culture/language, 3) Occupation, 4) Gender/Sex, 5) Religion, 6) Education, 7) Socioeconomic status, 8,9,10) Social capital with a) personal characteristics associated with discrimination, b) features of relationships, and c) time-dependent relationships [16]. Two independent reviewers extracted the relevant data from included studies including key characteristics (authors, country, year of publication, and study design), SBBP, and health equity (horizontal or vertical equity). A third reviewer resolved any disagreement between the other two reviewers.
We interpreted the results by reporting a top three most frequent SBBP components in our findings.
We explored which activities led to improved equity by using the SBBP framework.

Data coding and analysis
We synthesized the findings from the included studies by using a content analysis approach [17,18]. The content analysis consisted of three main stages as follows: Stage 1: We prepared the selection data from the included studies.
Stage 2: We generated preliminary coding to categorize the manifest content. We grouped the findings into two components: measurements (financing and service delivery) [19] and outcomes (health, financing, and responsiveness) [20]. Details of the findings are shown in Appendix A2.
Stage 3: We applied a descriptive approach to analyze the findings. Then we explored the results concerning the impact of AHM utilizing SBBP on equity. Two reviewers (MI and NU) made all decisions regarding data interpretation in this study. The agreement of these reviewers' preliminary, independently generated decisions was measured by the Kappa value [21]. The average Kappa value was 1.0. When preliminary differed, a third reviewer (TD) made the final decision.
We included studies that showed or defined any terms related to the process of SBBP, the practice that showed the activity intervention, the measurement of horizontal or vertical equity in healthcare services, and other factors related to equity (PROGRESS-PLUS). We recorded the details of studies that matched the inclusion criteria, as shown in Appendix B. We applied a descriptive approach to analyze the findings. In addition, we explored the results concerning the impact of AHM utilizing SBBP on equity. We interpreted the results by reporting the top three most frequent SBBP components in our identified articles to answer the first objective. Finally, we explored what practices and processes led to improving health equity (horizontal or vertical) using the SBBP framework to answer the second objective.

Quality assessment
This review classified the included studies into three types: qualitative, quantitative, and mixed-method research, based on various data characteristics in the collecting and analyzing process [22]. We conducted a quality assessment when quantitative studies showed the impact of investigation of AHM and equity. We used the New castleeOttawa Quality Assessment Scale (NOS) [23] and Cochrane Effective Practice and Organization of Care (EPOC) [24] in the quality assessment of the quantitative studies in this review. The NOS is for non-experimental studies, while EPOC is for experimental studies. NOS's criteria emphasize the quality of selection, comparability, and outcomes. We assessed the risk of bias by using the modified Cochrane Collaboration tool. We evaluated the bias to three levels (high, low, or unclear). The individual components consisted of 5 parts (selection, performance, attrition, reporting, and others).
We did not assess the quality of the qualitative study included in this review. However, we did achieve a concise methodology in the agreement of all decision processes.
We performed a quality assessment of an included observation and intervention study by using NOS and EPOC. We utilized the NOS for four cohort studies with a non-experimental (observation) study design. We employed the EPOC for one randomized controlled trial (RCT) with an experimental (intervention) study design. The included studies are shown in Appendix B.

Study selection
The initial search yielded 2855 studies, after the removal of 1992 duplications. We further excluded 2707 studies, after screening the titles and abstracts. After a full-text review of the remaining 170 studies, 107 studies were excluded for the reasons outlined in Fig. 1. This scoping review aims to explore what practices and processes can improve equity in countries that adopted AHM utilizing the SBBP concepts. We conducted content analysis on all the included 63 studies that involved AHM utilizing SBBP. Only 5 studies (1 RCT and 4 cohorts) were selected to determine the effect of AHM utilizing SBBP on health equity. A PRISMA diagram of the study selection and process of the search is shown in Fig. 1.

Characteristics of included studies
These studies (N ¼ 63) were published between 1980 and 2021. We found that most countries were considered high-income: England, Australia, and New Zealand. We observed differences in the types of studies between the income levels. We found horizontal equity among all levels, but vertical equity only in high-income countries. In addition, more than half of the studies focused on primary care rather than secondary and tertiary healthcare settings. Regarding the factors that affected equity, most studies focused on three aspects of PROGRESS PLUS: a place of residence, personal characteristics, and socioeconomic status. We found all methods in the included studies for quality assessment. The details of these characteristics are shown in Appendix B.

Quality assessment
This review comprised of qualitative, quantitative, and mixed-method research studies. Most of the studies were conducted with a quantitative study design (N ¼ 38), followed by qualitative (N ¼ 18) and mixed-method research (N ¼ 7).
We aimed to assess how AHM utilizing SBBP leads to improvement of equity. Thus, we conducted content analysis to determine the impact of intervention or observation (practices and processes) that affect AHM utilizing SBBP on the outcome (equity, accessibility, or utilization) on patients and comparable groups. We found 5 (out of 63 studies) utilized objective measures to quantify the impact of SBBP on equity. The overall quality of the four cohort studies was good (8/9 [25e27] and 9/9 [28]). In addition, the quality assessment of the one RCT included in our review showed a low risk of bias [29].

1) characteristics of AHM utilizing SBBP and equity
Considering all included studies in which AHM utilized SBBP, the top three most popular SBBP concepts included in the studies were health service delivery, leadership & governance, and health workforce. Similarly, these three SBBP concepts were also observed among studies on horizontal and vertical equity. The top three components of PROGRESS PLUS among studies with horizontal equity included residence, socioeconomic status, and social capital. In comparison, the top three components of PROGRESS PLUS in studies with vertical equity included place of residence, personal characteristics associated with discrimination, and socioeconomic status. The studies measured health equity by assessing service delivery (accessibility and utilization measurement) and financing. The characteristics of included studies in this review and their relevance to SBBP, equity, and PROGRESS PLUS are shown in Appendix B.

2) how AHM utilizing SBBP leads to improve equity
We found evidence that AHM aimed to improve equity. Five studies met these criteria. A summary of the intervention and observational studies is shown below.

The association of AHM utilizing SBBP and equity
The designs of the included studies were cohort [25e28] and RCT [29]. Health equity was shown to be horizontal [25,26,28,29] and vertical [27]. Participation focused on vulnerable populations including pregnant women, minority or marginalized ethnic groups, children, adolescent, and the elderly. We measured the outcomes from the frequency of hospital visits and utilization of healthcare services. We found that AHM utilizing SBBP emphasized health service delivery and health workforce.

The impact of AHM utilizing SBBP to equity
Both New Zealand and Canada have a long history of area health management that aimed to improve health equity. We categorized their health care management using SBBP criteria. Most studies focused on Health Service Delivery (HSD). In Canada, local organizations were Regional Health Authorities. The healthcare responsibilities of this organization were to regulate and manage the processes related to policy requirements. They applied the benefits of local information for improving efficiency [30,31]. In New Zealand, the local organizations provided primary healthcare. The National Health Service (NHS) provided free secondary healthcare services [32,33]. The responsibility of the local organizations was the same in both Canada and New Zealand. They provided services for specific purposes in their areas.
We found that all 5 studies included measures to improve horizontal equity by focusing on providing health services and basic health promotion for all ages. AHM utilizing SBBP consists of 7 components: 1) health service delivery (HSD), 2) health workforce (HWF), 3) health information systems (HIS), 4) access to essential medicines, 5) health systems financing, 6) leadership & governance, and 7) population participation. The Health Service Delivery (HSD) of SBBP showed the greatest impact on health care management by to increasing health care accessibility and utilization. Nevertheless, the others are also essential, such as the health workforce (HWF). Such evidence is shown in Fig. 2, Table  1, and Table 2. The studies we examined provided interventions to engage patients with health care providers in healthcare services to increase health care utilization. We describe the details of practices and processes of HSD which increase utilization and accessibility as follows. A coordinator provided more information by telephone than the usual care of reminding letters for all participants, who were of Maori, Pacific, and Asian ethnicity. The active telephone follow-up led to higher bowel screening than usual care [29]. Many maternal or childbirth programs were available for mothers choose to participate themselves. An example is the Lead Maternity Carer (LMC) program, which was an LMC program that promoted a healthy pregnancy for pregnant women and their babies. The participants' perception, ethnicity, education, well-being, and age affected program selection. The variety of programs benefited different pregnant women [25]. A school vaccination program for girls showed that vaccine services in schools could improve equity among different ethnicities [25e28]. The vaccination program involved nurses recommending that female teenagers in the community get the human papillomavirus (HPV) vaccine. Researchers found that there were differing rates of human papillomavirus (HPV) vaccination completion among various service delivery models [28].
Our findings showed that HSD is a key practice and process to improve equity. For example, HSD practices included a vaccination program for a target population and a disease-specific early detection screenings for a specific group. The HSD process by itself or in collaboration with other SBBPs led to improved health outputs (such as accessibility or utilization). These processes did not necessarily lead to better equity. However, programs that focused on specific ethnic groups may have improved health equity because ethnicity may be a factor in economic disparities, and may interact with cultural, political, and external influence factors.
Improving HSD and HWF together resulted in an increase in the amount or rate of health care utilization. In addition, when the process incorporated HWF, we found that programs using a payment incentive in the HSD improved participation. An example of a payment incentive is the Pay-For-Performance (P4P) program in healthcare service to motivate healthcare providers.
One study measured the impact of a P4P on reducing inequity in childhood vaccination rates among different income groups. Researchers used REVIEW income quintiles as a proxy of socioeconomic status (SES). They found a SES-related inequity in vaccination completion, in which vaccine completion was higher among high-income groups. The P4P had no impact on increasing equity in vaccination completion among different income groups. The difference in concentration index was 0.006 after the P4P was completed, which indicated that the higher vaccine completion rate among wealthier income groups persisted [26].
The benefit of cooperation between HSD and health information systems (HIS) processes was an increase in the number of target patients that received healthcare services, according studies examining the implementation of the related health care database in information systems [25,26,28]. HIS referred to the use of health data standards, validation process, sharing, visualization, analysis, peer-to-peer networks, knowledge sharing, and technical assistance.
Two studies explored the effect of HSD on equity [25,26,28,29]. However, the studies found that HSD and other SBBP factors were not sufficient to achieve health equity. Other factors, such as ethnicity, were significant barriers to achieving health equity. However, the results of 5 studies we examined showed that HSD improved health equity by increasing health care utilization and accessibility. Specifically, we found the following examples: 1) Utilization rate of bowel screening process increased 2.0% among intervention compared to control groups [29], 2) different utilization rates of maternity care among women who had experience for maternity care (88%) compared to no experience for any maternity care (12%) [25]; 2) Accessibility rate increased to 71.5% coverage in a school-based vaccination service [27], 3) Vaccination rate was higher for an in-school based program (75%) compared with the community (36%) [28], and 4) there was a different in vaccination completion among different SES groups (difference in concentration index ¼ 0.037, 95% CI: 0.013e0.060). The result showed the vaccination completion was greater in high-income groups [26].

Discussion
This review of published studies aimed to explore what practices and processes can improve equity in countries that adopted the "AHM utilizing the SBBP" concept. The included studies showed horizontal and vertical health equity. We found that horizontal equity among countries of all income levels, while vertical equity appeared only in highincome countries. In addition, the included studies evaluated the patients' health care utilization and  REVIEW health status. Therefore, the equity measurement focused on health care utilization, and the equity outcomes focused on health status and clinical outcomes. The factors that affected health equity, access to care, amount of healthcare utilization, and frequency of healthcare use included a place of residence, socioeconomic status, personal characteristics (such as age, disability), and social capital according to the restricted patients' capacity to obtain healthcare. These factors represented patients' perspectives on health outcomes, needs, and finance. Evidence from the included studies showed the attempt to increase accessibility and utilization by managing the proper budget under the authorities and responsibilities of healthcare providers. "AHM utilizing SBBP" was mostly shown in HSD, HWF, leadership & governance of the SBBPs because this review retrieved original studies collected from the first period of equity in healthcare. Therefore, objective measurement and internal management was derived from the practices and processes in health management. Furthermore, during this period, we could not identify any studies illustrating health information technology. Equity focused on horizontal equity in health service delivery (accessibility and utilization), while vertical equity focused on financing. Our results correlated with a study by Manyazewal and colleagues. HSD was the primary SBB for allocating healthcare services for vulnerable patients to gain health promotion in primary health care (vaccine and maternal care) or disease prevention (severe disease screening) [34].
This review consists of 5 (out of 63 studies) intervention or observation studies that were measured objectively and showed the impact of "AHM utilizing SBBP" on equity. The evidence showed that the included studies focus on HSD. HSD might improve equity by providing healthcare treatment in response to patient needs [25e29]. Another reason was the direct measurement from the healthcare provider, which is assumed to reflect the results of accessibility and utilization by patients. The other "AHM utilizing SBBP" did not show effects because their outcomes were not objective measurements. Besides, some "AHM utilizing SBBP" were complex measurements that caused took time to evaluate. For example, one HWF measurement demonstrated the impact of an integrated P4P for childhood immunization. However, the collaboration did not show any effect on other conditions such as cancer screening. Vaccination studies in Canada and New Zealand showed that the vaccine target risk group was adolescent girls. Researchers have also assessed how P4P incorporating HWF could diminish the equity gap. One such study examined whether clinics receiving P4P had reductions in inequity in childhood immunization completion rates among different income groups over the study time period. Though the P4P was not associated with a decline in inequity, researchers found that the inequity remained stable. This finding contrasted with increasing inequity among clinics that did not have the P4P program [26]. In our review, evidence only from the healthcare providers' perspectives might be biased from the perception of their services. Hence, expanding the sources of the study data to be obtained from patients is necessary for future studies. On the other hand, despite our review's limited available studies, we identified several approaches that proved the benefit of "AHM utilizing SBBP" in improving health equity. The included studies were limited to studies published between 1980 and 2019. Therefore, this review gathered studies that showed the variation of the health system spanning more than 30 years. As a result, we found some changes to the healthcare system in some countries that could affect health outcomes. However, our review may lack information about other comprehensive "AHM utilizing SBBP" approaches through efficient management processes, including human resources, medicines and supplies, data information and technology, financial management, people participation, and most importantly, the implementation of the health service plans under governance.
The concept of SBBP has been relatively new and has existed for less than a decade. Based on our review, we found that the current evidence focused mainly on HSD. We expect that other SBBP, such as health workforce, leadership and governance, and health information system, will be implemented in AHM shortly.
We assessed the quality of the observational and intervention studies (cohort and RCT). We also found that the cohort studies were of good quality, and the one RCT study we reviewed showed a low risk of bias. The cohort studies we reviewed had good control for the most important confounding factors, while RCT showed a well-controlled selection process. To the best of our knowledge, this is the first study that aims to explore the practice and process of "AHM utilizing SBBP" for improving equity in health. We searched also unpublished literature from different sources including gray literature reports and conferences of the WHO.
The results were consistent between horizontal and vertical equity. The evidence focused on the allocation and distribution of healthcare services with management processes. Under a decentralized model, AHM enabled workplace organizations to be more efficient by accessing information and providing services that meet patient needs, resulting in increasing the utilization and accessibility of various health services. The collaboration of targeted people's participation and cooperation with the target community was also beneficial to achieving healthcare equity in Canada and New Zealand. Five studies showed the same target and specific people participating in healthcare services, such as vaccination, screening, and maternal care services in horizontal and vertical equity.
Nevertheless, the risk was the administration of the distribution of limited resources such as the budget. Recent studies show that the HSD includes inputs and processes to the health system. The healthcare service measurement of HSD comes from the rate or amount of accessibility and utilization to patients. In this review, HSD showed an impact on intervention from providers to patients, resulting in increased healthcare consumption. For example, HWF might increase vaccination rates in the target population. Thus, the implementation of HSD, the comprehensiveness management on leadership & governance, and the collaboration of HWF were the management processes in the current literature. From providers' perspectives, these implemented "processes" created benefits for healthcare services in health promotion and disease prevention to patients who differ in age, sex, ethnicity, and socioeconomic status. The results of only HSD or integrated into other "AHM utilizing SBBP" showed that HSD could not accomplish the outcomes to achieve equity because of certain factors, such as ethnicity. However, the results of the included studies showed that health care utilization and accessibility increased.

Conclusion
This scoping review identified 63 published studies that explored the issues related to "AHM utilizing SBBP." Under decentralization, the area health system's benefit was that the local organization took a vital role in health services for specific purposes in their area health. The area of health varied in each country because of differences in the transfer of authority and responsibility from the central to local governments. However, the practices and processes of "AHM utilizing SBBP" appeared similar between countries. We found HSD or cooperation with others leads to improved equity. In addition, health promotion and disease prevention lead to enhancing equity. We found that HSD or cooperation with others could improve equity by increasing healthcare accessibility and utilization for health REVIEW promotion in different areas (urban or rural), specific diseases (communicable or non-communicable disease), and targeted patients (such as the elderly or pregnant).

Conflict of interest
There is no conclict of interest.

Approval number for ethics in human research
None (Scoping review of data from research did not require human subjects ethical review.) Appendix A A1: Search terms and results of searching in each database.
A2: The details of synonym term of "Area health". A3: The details of measurements and outcomes in stage 2 of data coding and analysis. "area health" OR "primary care trust" OR "district health authority" OR "district health board" OR "region health board" OR "area health board" OR "regional health authority" "area health" OR "primary care trust" OR "district health authority" OR "district health board" OR "region health board" OR "area health board" OR "regional health authority" "area health" OR "primary care trust" OR "district health authority" OR "district health board" OR "region health board" OR "area health board" OR "regional health authority" "area health" OR "primary care trust" OR "district health authority" OR "district health board" OR "region health board" OR "area health board" OR "regional health authority" "area health" OR "primary care trust" OR "district health authority" OR "district health board" OR "region health board" OR "area health board" OR "regional health authority" area health OR primary care trust OR district health authority OR district health board OR region health board OR area health board OR regional health authority 17 3 1 AND 2 (search filter: advance search in title and abstract) 0 Grey Literature Report (greylit.org) A2: The details of synonym term of "Area health".
The term "area health" [35] refers to the geographically decentralized health care systems. Any given country has a specific equivalent name to area health, such as primary care trust, district health authority, district health board, region health board, area health board, and regional health authority. The countries that adopt the idea of "area health" are Australia, Canada, Denmark, England, New Zealand, Sweden, Wales, South Africa, and Tanzania. The examples of activities and responsibility organizations in each country are as follows.
The federal government of Australia funded the establishment of a Primary Health Care (PHC). The PHC organization takes a role in oversee urbanrural areas and support the foundation of a regional PHC [36]. In Canada, there are some arguments about the pattern and management of each area that is very independent. In addition, there are service privileges defined between different territories [30,31]. However, the similarities between Canada and Australia are that local organizations take responsibility and apply local information to improve service efficiency. The area health system of Sweden is called the Regional Health Area. The administration of this organization locates in the county to meet their patient's needs. Applying providers-purchasers split for efficiency in health management [37].
There was an administrative reform in Denmark in 2001. In 2012 and 2013, the Danish National Board of Health authorized the municipalities to take responsibility for disease prevention and health promotion for their people, such as school health services [38]. The similarity of Denmark and Wales is national health organization takes responsibility to health care service. National Health Service (NHS) is the pattern of area health in Wales [39]. The benefit of cooperation in services by centralization of health care is to achieve equity for accessibility. However, the quality of some expertise may decrease, and financial management may be less effective.
There was a long-standing background about changes and developments of the area health system in England. In April 2013, the clinical commissioning groups (CCGs) replaced a role from the primary care trusts (PCTs). CCGs conducted the statutory of NHS to the clinical taskings, planning, and commissioning of healthcare services in their local area [40e44]. The consistency of England and New Zealand is that NHS is the origin of the autonomous body pattern. In New Zealand, the Regional Health Board developed to the District Health Board (DHB). Government supports the funds for total fundamental healthcare, whereas the NHS provides secondary healthcare for all residents [32,33].
The National Health Insurance (NHI) reform in South Africa intended to achieve and cover universal health coverage (UHC) by implementing the Patients' Rights Charter (PRC) policies for health equity. NHI operates by promoting actions on equity, removing access barriers, and strengthening the motivation of health workers [45]. Tanzania set the District Health System (DHS) in 1990. DHS is a decentralized structure from a centralized to local governments. This major transformation is for changing the policy in the administrative system [46].
A3: The details of measurements and outcomes in stage 2 of data coding and analysis The details of equity measurements as follows: A. The measurement of service delivery classified into.
1) Accessibility which referred to the process or measurement for accessibility to service place such as spatial, geography, geo-spatial, geography information system (GIS), rural or remote, distance, time to service 2) Utilization was a proxy of accessibility which presented by frequency and/or amount in healthcare consumption such as vaccination. The details of equity outcomes classified into: 1) Health status of clinical outcomes 2) Financing outcomes 3) Responsiveness referred to providers' roles that concerned to patients under equity concept. The proxy of responsiveness were patient satisfaction and quality of care as follows.
Patient satisfaction showed content related to perceived needs, expectations, experience of care. Quality of care showed content related to interaction between provider and patient, continuity of care, cost, accommodation, and accessibility process [47].
Appendix B Table B1 -Characteristics of included studies.  1 ¼ Primary care is often the first point of contact for people in need of healthcare, and may be provided by professionals such as GPs, dentists, and pharmacists.
2 ¼ Secondary care, which is sometimes referred to as 'hospital and community care', can either be planned (elective) care such as a cataract operation, or urgent and emergency care such as treatment for a fracture.
3 ¼ Tertiary care refers to highly specialized treatment such as neurosurgery, transplants, and secure forensic mental health services. More than half of the studies pointed to primary care (N ¼ 38), comparing to secondary (N ¼ 25) and tertiary (N ¼ 15).

No
Author ( [91].  Was the allocation sequence adequately generated?

Low
The principal investigator (who was not involved in the allocation process) used a predefine simple random series generated from Excel. They performed group allocation of the sample in batches 2e3 times per week. Was the allocation adequately concealed?

Low
The specific person (who responsible for the randomization process) conducted this process from allocation concealment and sequence generation. They confirmed that no possible of selection bias, no stratification or blocking in this process. Were baseline outcome measurements similar? There was a limitation about the selection bias, the description of the analysis, and reporting of the results e.g., differences in baseline characteristics of each provider. Overall assessment of bias within a study Low From all reasons above *EPOC ¼ Cochrane Effective Practice and Organization of Care.