Table 3.

Pressures mentioned in the literature by country, health system functions, and authors (1988 to 2009)

Health system functions	Pressures mentioned in the literature
Ghana
Service delivery	· Increase in utilization [21,31,32,35]
Health workforce	· Increase in workload, loss of income [31]
	· Insufficient medical personnel; increase in workload [32]
Health information	· No information
Medical products, vaccines and technologies	· No information on the number of acts and the amount of reimbursements [31]
Financing	· Funding unpredictable, insufficient and discontinuous; problems with reimbursement in cases of referrals [31]
	· Funding unpredictable, insufficient and discontinuous; informal payments; health centres going into deeper debt [35]
Leadership and governance	· Lack of information and complexity of funding procedures; poor supervision; problems in assigning responsibilities [31]
	· Lack of information and communication (funding); competition with other interventions; poor supervision; ‘no blame’ game [35]
Kenya
Service delivery	· Increase in demand for service [36,37]
Health workforce	· Increase in workload [33]
Health information	· No information
Medical products	· Problems of availability and insufficiency of drugs and kits [33]
Financing	· Informal payments [22]
	· Informal payments; loss of income for health centres [33]
	· Insufficient funding; informal payments [36]
Leadership	· Poor understanding of the policy; problems in assigning responsibilities [33]
Madagascar
Service delivery	· Increase in utilization [19]
Health workforce	· No information
Health information	· No information
Medical products	· Problems of availability of drugs [19]
Financing	· No information
Leadership	· No information
South Africa
Service delivery	· Increase in utilization [29,38-40]
Health workforce	· Increase in workload; lack of time for consultations; feeling of being exploited; frustration, etc. [29]
	· Increase in patient/provider ratio [38]
Health information	· No information
Medical products	· Problems of availability of drugs [29]
Financing	· No information
Leadership	· Feeling of a lack of recognition among workers; poor planning and communication [29]
Senegal
Service delivery	· Increase in utilization [23]
Health workforce	· Increase in workload [23]
Health information	· No information
Medical products	· Delays and under-distribution of consumables [23]
Financing	· Informal payments; delays in reimbursements; loss of revenue for the health centres [23]
Leadership	· Poor understanding of the policy [23]
Tanzania
Service delivery	· No information
Health workforce	· No information
Health information	· No information
Medical products	· No information
Financing	· Informal payments [41]
Leadership	· No information
Uganda
Service delivery	· Increase in utilization [20,24-26,28,34]
	· Increase in utilization; decline in service quality [27]
Health workforce	· Lower morale of providers [27,29]
	· Increase in the average number of consultations per provider; negative attitude of providers [22]
Health information	· No information
Medical products	· Problems of availability of drugs [24,26,27,29,34]
Financing	· Insufficient funding [25,34]
	· Difficulties in meeting recurrent expenses; informal payments [27]
Leadership	· Interference with other types of interventions [27]