A scoping review about conference objectives and evaluative practices: how do we get more out of them?

Large multi-day conferences have often been criticized as ineffective ways to improve social outcomes and to influence policy or practice. Unfortunately, many conference evaluations have also been inadequate in determining the impact of a conference on its associated social sector, with little evidence gathered or analyzed to substantiate or refute these criticisms. The aim of this scoping review is to investigate and report stakeholders' objectives for planning or participating in large multi-day conferences and how these objectives are being evaluated. We conducted a scoping review supplemented by a small number of key informant interviews. Eight bibliographic databases were systematically searched to identify papers describing conference objectives and/or evaluations. We developed a conference evaluation framework based on theoretical models and empirical findings, which structured the descriptive synthesis of the data. We identified 3,073 potential papers for review, of which 44 were included in this study. Our evaluation framework connects five key elements in planning a conference and its evaluation (number in brackets refers to number of themes identified): conference objectives (8), purpose of evaluation (7), evaluation methods (5), indicators of success (9) and theories/models (8). Further analysis of indicators of success identified three categories of indicators with differing scopes (i.e. immediate, prospective or follow-up) as well as empirical links between the purpose of evaluations and these indicators. Conference objectives and evaluations were largely correlated with the type of conference (i.e. academic, political/governmental or business) but diverse overall. While much can be done to improve the quality and usefulness of conference evaluations, there are innovative assessments that are currently being utilized by some conferences and warrant further investigation. This review provides conference evaluators and organizers a simple resource to improve their own assessments by highlighting and categorizing potential objectives and evaluation strategies.

Measuring improved targeting of health interventions to the poor in the context of a community-randomised trial in rural India.

In spite of growing interest in socioeconomic differentials in health outcomes and access to health services, little has been written about methodologies for assessing the impact of equity-enhancing policies or programs. This paper describes three methodological challenges involved in designing a randomised trial with an equity outcome, and how these were met in a trial of alternative strategies to improving the uptake of benefits of a health insurance scheme among its poorest members. The Vimo SEWA trial is nested within a community-based insurance scheme in rural India. While conducting this trial, three methodological problems were encountered: (i) measuring poverty (or "wealth", or "socioeconomic status") (ii) assessing beneficiaries against an appropriate reference standard population and (iii) settling on an appropriate equity measure as an outcome indicator. These problems are likely to arise in any policy or program assessment that has an equity outcome. In the Vimo SEWA trial, the socioeconomic status of beneficiaries (claimants) is assessed relative to that of all scheme members living in same sub-district by applying a rapid assessment questionnaire--which reduces to an integrated index of socioeconomic status--to both a random sample of members in each sub-district, and to all claimants. The results are used to estimate the full distribution of socioeconomic status of members in each sub-district, with each member given a rank score between 0 and 100. Interpolation is used to estimate the rank scores of claimants relative to the membership base. The primary outcome measure for the trial is the mean socioeconomic rank score of claimants. In developing country settings, using an index of socioeconomic status is simpler than assessing household income or the value of household consumption. It is also relatively straightforward to compare the socioeconomic status of health program beneficiaries with a relevant reference population, although two independent surveys are required. Expressing relative wealth on a scale from zero to 100 is conceptually appealing, and the mean value of this rank score provides an equity-specific outcome measure readily integrated into the usual analytic framework for cluster-randomised trials.

Quasi-experimental study designs series-paper 12: strengthening global capacity for evidence synthesis of quasi-experimental health systems research.

Evidence from quasi-experimental studies is often excluded from systematic reviews of health systems research despite the fact that such studies can provide strong causal evidence when well conducted. This article discusses global coordination of efforts to institutionalize the inclusion of causal evidence from quasi-experiments in systematic reviews of health systems research. In particular, we are concerned with identifying opportunities for strengthening capacity at the global and local level for implementing protocols necessary to ensure that reviews that include quasi-experiments are consistently of the highest quality. We first describe the current state of the global infrastructure that facilitates the production of systematic reviews of health systems research. We identify five important types of actors operating within this infrastructure: review authors; synthesis collaborations that facilitate the review process; synthesis interest groups that supplement the work of the larger collaborations; review funders; and end users, including policymakers. Then, we examine opportunities for intervening to build the capacity of each type of actors to support the inclusion of quasi-experiments in reviews. Finally, we suggest practical next steps for proceeding with capacity building efforts. Because of the complexity and relative nascence of the field, we recommend a carefully planned and executed approach to strengthening global capacity for the inclusion of quasi-experimental studies in systematic reviews.

Making health insurance work for the poor: learning from the Self-Employed Women's Association's (SEWA) community-based health insurance scheme in India.

How best to provide effective protection for the poorest against the financial risks of ill health remains an unanswered policy question. Community-based health insurance (CBHI) schemes, by pooling risks and resources, can in principal offer protection against the risk of medical expenses, and make accessible health care services that would otherwise be unaffordable. The purpose of this paper is to measure the distributional impact of a large CBHI scheme in Gujarat, India, which reimburses hospitalization costs, and to identify barriers to optimal distributional impact. The study found that the Vimo Self-employed Women's Association (SEWA) scheme is inclusive of the poorest, with 32% of rural members, and 40% of urban members, drawn from households below the 30th percentile of socio-economic status. Submission of claims for inpatient care is equitable in Ahmedabad City, but inequitable in rural areas. The financially better off in rural areas are significantly more likely to submit claims than are the poorest, and men are significantly more likely to submit claims than women. Members living in areas that have better access to health care submit more claims than those living in remote areas. A variety of factors prevent the poorest in rural and remote areas from accessing inpatient care or from submitting a claim. The study concludes that even a well-intentioned scheme may have an undesirable distributional impact, particularly if: (1) the scheme does not address the major barriers to accessing (inpatient) health care; and (2) the process of seeking reimbursement under the scheme is burdensome for the poor. Design and implementation of an equitable scheme must involve: a careful assessment of barriers to health care seeking; interventions to address the main barriers; and reimbursement requiring minimum paperwork and at the time/place of service utilization.

CRTs--cluster randomized trials or "courting real troubles": challenges of running a CRT in rural Gujarat, India.

This paper addresses the logistical challenges of implementing public health interventions in the setting of cluster randomized trials (CRTs), drawing on the experience of carrying out a CRT within a community-based health insurance (CBHI) scheme in rural India. Our CRT is seeking to improve the equity impact--i.e., reduce the differential in claims submission for hospitalization between poor and less poor--of this CBHI in rural areas. Five main challenges are identified and discussed: 1) assigning control clusters, 2) blinding, 3) implementing interventions simultaneously, 4) minimizing leakage, and 5) piggy-backing on a changing scheme. These challenges are not likely to be unique to low-income settings, although the fifth challenge is particularly likely when working with relatively small and resource-constrained programs. While compromises to methodological best-practice may reduce internal validity, they make the intervention more 'real', and potentially more applicable, to other programs and settings. Further, careful documentation of compromises allows them to be considered in the final analysis.

Helping members of a community-based health insurance scheme access quality inpatient care through development of a preferred provider system in rural Gujarat.

We describe and analyse the experience of piloting a preferred provider system (PPS) for rural members of Vimo SEWA, a fixed-indemnity, community-based health insurance (CBHI) scheme run by the Self-Employed Women's Association (SEWA). The objectives of the PPS were (i) to facilitate access to hospitalization by providing financial benefits at the time of service utilization; (ii) to shift the burden of compiling a claim away from members and towards Vimo SEWA staff; and (iii) to direct members to inpatient facilities of acceptable quality. The PPS was launched between August and October 2004, in 8 subdistricts covering 15,000 insured. The impact of the scheme was analysed using data from a household survey of claimants and qualitative data from in-depth interviews and focus group discussions. The PPS appears to have been successful in terms of two of the three primary objectives--it has transferred much of the burden of compiling a health Insurance claim onto Vimo SEWA staff, and it has directed members to inpatient facilities with acceptable levels of technical quality (defined in terms of structural Indicators). However, even under the PPS, user fees pose a financial barrier, as the insured have to mobilize funds to cover the costs of medicines, supplies, registration fee, etc. before receipt of cash payment from Vimo SEWA. Other barriers to the success of the PPS were the geographic Inaccessibility of some of the selected hospitals, lack of awareness about the PPS among members and a variety of administrative problems. This pilot project provides useful lessons relating to strategic purchasing by CBHI schemes and, more broadly, managed care in India. In particular, the pragmatic approach taken to assessing hospitals and identifying preferred providers is likely to be useful elsewhere.

Community-based health insurance schemes in India: a review.

There is an increasing inclination among multinational agencies--including the World Bank, World Health Organization and International Labour Organization--to advocate community-based health insurance (CBHI) schemes as part of a comprehensive solution to improving access for healthcare services in India. This paper reviews the experience of Indian CBHI schemes, their impact on health system goals, such as access to hospitalization and protection from indebtedness, and the factors--particularly scheme design and management--that may contribute to success. The CBHI schemes in India are extremely diverse in terms of their designs, sizes and target populations. While some of the schemes are run by non-governmental organization (NGO) providers, there is an increasing trend towards collaboration with the Government Insurance Company (GIC). In its partnership with NGOs, the GIC seems to have provided favourable group plans compared to the individual Mediclaim and Jan Arogya policies. We have little information on the impact of existing CBHI schemes--most importantly, in terms of access and protection from indebtedness--and even less on factors that make for a successful scheme. This review suggests that there is a demand for health insurance services among the poor. To date, there is little evidence to suggest that these schemes can include the poorest of the poor or improve access to inpatient care. Furthermore, the schemes have done little to address the issue of low/variable quality of healthcare services. Empirically derived data on the existing schemes in India are extremely limited, making this fertile ground for future research.

Promoting health equity in conflict-affected fragile states.

Issues around health equity in conflict-affected fragile states have received very little analysis to date. This paper examines the main factors that threaten health equity, the populations that are most vulnerable and potential strategies to improve health equity. The methods employed are a review of the published and grey literature, key informant interviews and an analysis of data on social determinants of health indicators. A new conceptual framework was developed outlining types of inequity, factors that influence equity and possible strategies to strengthen equity. Factors that affect equity include displacement, gender and financial barriers. Strategies to strengthen health equity include strengthening pro-equity policy and planning functions; building provider capacity to provide health services; and reducing access and participation barriers for excluded groups. In conclusion, conflict is a key social determinant of health. More data is needed to determine how conflict affects within-country and between-country equity, and better evaluated strategies are needed to reduce inequity.

Management initiatives in a community-based health insurance scheme.

Community-based health insurance (CBHI) schemes have developed in response to inadequacies of alternate systems for protecting the poor against health care expenditures. Some of these schemes have arisen within community-based organizations (CBOs), which have strong links with poor communities, and are therefore well situated to offer CBHI. However, the managerial capacities of many such CBOs are limited. This paper describes management initiatives undertaken in a CBHI scheme in India, in the course of an action-research project. The existing structures and systems at the CBHI had several strengths, but fell short on some counts, which became apparent in the course of planning for two interventions under the research project. Management initiatives were introduced that addressed four features of the CBHI, viz. human resources, organizational structure, implementation systems, and data management. Trained personnel were hired and given clear roles and responsibilities. Lines of reporting and accountability were spelt out, and supportive supervision was provided to team members. The data resources of the organization were strengthened for greater utilization of this information. While the changes that were introduced took some time to be accepted by team members, the commitment of the CBHI's leadership to these initiatives was critical to their success.

Equitable utilisation of Indian community based health insurance scheme among its rural membership: cluster randomised controlled trial.

OBJECTIVE: To evaluate alternative strategies for improving the uptake of benefits of a community based health insurance scheme by its poorest members. DESIGN: Prospective cluster randomised controlled trial. SETTING: Self Employed Women's Association (SEWA) community based health insurance scheme in rural India. Participants 713 claimants at baseline (2003) and 1440 claimants two years later among scheme members in 16 rural sub-districts. INTERVENTIONS: After sales service with supportive supervision, prospective reimbursement, both packages, and neither package, randomised by sub-district. MAIN OUTCOME MEASURES: The primary outcome was socioeconomic status of claimants relative to members living in the same sub-district. Secondary outcomes were enrolment rates in SEWA Insurance, mean socioeconomic status of the insured population relative to the general rural population, and rate of claim submission. RESULTS: Between 2003 and 2005, the mean socioeconomic status of SEWA Insurance members (relative to the rural population of Gujarat) increased significantly. Rates of claims also increased significantly, on average by 21.6 per 1000 members (P<0.001). However, differences between the intervention groups and the standard scheme were not significant. No systematic effect of time or interventions on the socioeconomic status of claimants relative to members in the same sub-district was found. CONCLUSIONS: Neither intervention was sufficient to ensure that the poorer members in each sub-district were able to enjoy the greater share of the scheme benefits. Claim submission increased as a result of interventions that seem to have strengthened awareness of and trust in a community based health insurance scheme. Trial registration Clinical trials NCT00421629.

Barriers to accessing benefits in a community-based insurance scheme: lessons learnt from SEWA Insurance, Gujarat.

This paper seeks to examine barriers faced by members of a community-based insurance (CBI) scheme, which is targeted at poor women and their families, in accessing scheme benefits. CBI schemes have been developed and promoted as mechanisms to offer protection to poor families from the risks of ill-health, death and loss of assets. However, having voluntarily enrolled in a CBI scheme, poor households may find it difficult or impossible to access scheme benefits. The paper describes the results of qualitative research carried out to assess the barriers faced in accessing scheme benefits by members of the CBI scheme run by the Self-Employed Women's Association (SEWA) in Gujarat, India. The study finds that the members face a variety of different barriers, particularly in seeking hospitalization and in submitting insurance claims. Some of the barriers are rooted in factors outside the scheme's control, such as illiteracy and financial poverty amongst members, and inadequacies of the transportation and health care infrastructure. But other barriers relate to the scheme's design and management, for example, lack of clarity among scheme staff regarding the scheme's rules and processes, and requirements that claimants submit documents to prove the validity of their claims. The paper makes recommendations as to how SEWA Insurance can address some of the identified barriers and discusses the relevance of these findings to other CBI schemes in India and elsewhere.

Intervention complexity--a conceptual framework to inform priority-setting in health.

Health interventions vary substantially in the degree of effort required to implement them. To some extent this is apparent in their financial cost, but the nature and availability of non-financial resources is often of similar importance. In particular, human resource requirements are frequently a major constraint. We propose a conceptual framework for the analysis of interventions according to their degree of technical complexity; this complements the notion of institutional capacity in considering the feasibility of implementing an intervention. Interventions are categorized into four dimensions: characteristics of the basic intervention; characteristics of delivery; requirements on government capacity; and usage characteristics. The analysis of intervention complexity should lead to a better understanding of supply- and demand-side constraints to scaling up, indicate priorities for further research and development, and can point to potential areas for improvement of specific aspects of each intervention to close the gap between the complexity of an intervention and the capacity to implement it. The framework is illustrated using the examples of scaling up condom social marketing programmes, and the DOTS strategy for tuberculosis control in highly resource-constrained countries. The framework could be used as a tool for policy-makers, planners and programme managers when considering the expansion of existing projects or the introduction of new interventions. Intervention complexity thus complements the considerations of burden of disease, cost-effectiveness, affordability and political feasibility in health policy decision-making. Reducing the technical complexity of interventions will be crucial to meeting the health-related Millennium Development Goals.

Quality of hysterectomy care in rural Gujarat: the role of community-based health insurance.

Community-based health insurance (CBHI) may be a mechanism for improving the quality of health care available to people outside the formal sector in developing countries. The purpose of this paper is to identify problems associated with the quality of hysterectomy care accessed by members of SEWA (Self-Employed Women's Association), an Indian CBHI scheme, and discuss mechanisms that would optimize quality of care. Data on hysterectomy care were collected through a review of 63 insurance claims and semi-structured interviews with 12 providers. Quality of hysterectomy care accessed by SEWA's members varied from potentially dangerous to excellent. Dangerous conditions included operating theatres without separate hand-washing facilities or proper lighting, the absence of qualified nursing staff, performing hysterectomy on demand, removing both ovaries without consulting or notifying the patient, and failing to send the excised organs for histopathology, even when signs were suggestive of disease. Women paid substantial amounts of money, even for poor and potentially dangerous care. In order to improve the quality of care for its members, a CBHI scheme can: (1) gather data on the costs and complications for each provider, and investigate where these are excessive; (2) use incentives to encourage providers to make efficient and equitable resource allocations; (3) contract with providers giving a high standard of care or who agree to certain conditions; and (4) inform and advise doctors and the insured about the costs and benefits of different interventions. In the case of SEWA, it is most feasible to identify a limited number of hospitals providing better quality care and contract directly with them.

Global and regional estimates of the effectiveness and cost-effectiveness of price increases and other tobacco control policies.

The objective of this study was to provide conservative estimates of the global and regional effectiveness and cost-effectiveness of tobacco control policies. Using a static model of the cohort of smokers alive in 1995, we estimated the number of smoking-attributable deaths that could be averted by: (1) price increases, (2) nicotine replacement therapy (NRT), and (3) a package of non-price interventions other than NRT. We calculated the cost-effectiveness of these policy interventions by weighing the approximate public-sector costs against the years of healthy life saved, measured in disability-adjusted life years, or DALYs. Even with deliberately conservative assumptions, tax increases that would raise the real price of cigarettes by 10% worldwide would prevent between 5 and 16 million tobacco-related deaths, and could cost 3-70 US dollars per DALY saved in low-income and middle-income regions. NRT and a package of non-price interventions other than NRT are also cost-effective in low-income and middle-income regions, at 280-870 US dollars per DALY and 36-710 US dollars per DALY, respectively. In high-income countries, price increases were found to have a cost-effectiveness of 83-2771 US dollars per DALY, NRT 750-7206 US dollars per DALY and other non-price interventions 696-13,924 US dollars per DALY. Tobacco control policies, particularly tax increases on cigarettes, are cost-effective relative to other health interventions. Our estimates are subject to considerable variation in actual settings; thus, local cost-effectiveness studies are required to guide local policy.

Estimates of global and regional smoking prevalence in 1995, by age and sex.

OBJECTIVES: We calculated regional and sex- and age-specific smoking prevalence estimates worldwide in 1995. METHODS: Sex-specific smoking prevalence data from studies in 139 countries and age distribution data from 7 studies were analyzed. RESULTS: Globally, 29% of persons aged 15 years or older were regular smokers in 1995. Four fifths of the world's 1.1 billion smokers lived in low- or middle-income countries. East Asian countries accounted for a disproportionately high percentage (38%) of the world's smokers. Males accounted for four fifths of all smokers, and prevalence among males and females was highest among those aged 30 to 49 years (34%). CONCLUSIONS: Future decades will see dramatic increases in tobacco-attributable deaths in low- and middle-income regions. Although much of this excess mortality can be prevented if smokers stop smoking, quitting remains rare in low- and middle-income countries.