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Medicines coverage and community-based health insurance in low-income countries
ObjectivesThe 2004 International Conference on Improving Use of Medicines recommended that emerging and expanding health insurances in low-income countries focus on improving access to and use of medicines. In recent years, Community-based Health Insurance (CHI) schemes have multiplied, with mounting evidence of their positive effects on financial protection and resource mobilization for healthcare in poor settings. Using literature review and qualitative interviews, this paper investigates whether and how CHI expands access to medicines in low-income countries.
Methods:
We used three complementary data collection approaches: (1) analysis of WHO National Health Accounts (NHA) and available results from the World Health Survey (WHS); (2) review of peer-reviewed articles published since 2002 and documents posted online by national insurance programs and international organizations; (3) structured interviews of CHI managers about key issues related to medicines benefit packages in Lao PDR and Rwanda.
Results:
In low-income countries, only two percent of WHS respondents with voluntary insurance belong to the lowest income quintile, suggesting very low CHI penetration among the poor. Yet according to the WHS, medicines are the largest reported component of out-of-pocket payments for healthcare in these countries (median 41.7%) and this proportion is inversely associated with income quintile. Publications have mentioned over a thousand CHI schemes in 19 low-income countries, usually without in-depth description of the type, extent, or adequacy of medicines coverage. Evidence from the literature is scarce about how coverage affects medicines utilization or how schemes use cost-containment tools like co-payments and formularies. On the other hand, interviews found that medicines may represent up to 80% of CHI expenditures.
Conclusion:
This paper highlights the paucity of evidence about medicines coverage in CHI. Given the policy commitment to expand CHI in several countries (e.g. Rwanda, Lao PDR) and the potential of CHI to improve medicines access and use, systematic research is needed on medicine benefits and their performance, including the impacts of CHI on access to, affordability, and use of medicines at the household level.
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Step-wedge cluster-randomised community-based trials: An application to the study of the impact of community health insurance
Background:
We describe a step-wedge cluster-randomised community-based trial which has been conducted since 2003 to accompany the implementation of a community health insurance (CHI) scheme in West Africa. The trial aims at overcoming the paucity of evidence-based information on the impact of CHI. Impact is defined in terms of changes in health service utilisation and household protection against the cost of illness. Our exclusive focus on the description and discussion of the methods is justified by the fact that the study relies on a methodology previously applied in the field of disease control, but never in the field of health financing.
Methods:
First, we clarify how clusters were defined both in respect of statistical considerations and of local geographical and socio-cultural concerns. Second, we illustrate how households within clusters were sampled. Third, we expound the data collection process and the survey instruments. Finally, we outline the statistical tools to be applied to estimate the impact of CHI.
Conclusion:
We discuss all design choices both in relation to methodological considerations and to specific ethical and organisational concerns faced in the field. On the basis of the appraisal of our experience, we postulate that conducting relatively sophisticated trials (such as our step-wedge cluster-randomised community-based trial) aimed at generating sound public health evidence, is both feasible and valuable also in low income settings. Our work shows that if accurately designed in conjunction with local health authorities, such trials have the potential to generate sound scientific evidence and do not hinder, but at times even facilitate, the implementation of complex health interventions such as CHI.
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Association between co-authorship network and scientific productivity and impact indicators in academic medical research centers: A case study in Iran
Background:
We aimed to examine the co-authorship networks in three successful Iranian academic research centers, in order to find the association between the scientific productivity and impact indicators with network features in a case study.
Methods:
We searched for English articles of the three research centers. We drew co-authorship maps of each center and calculated social network measures.
Results:
The collaboration networks in centers shared many structural features, including a "star-like" pattern of relations. Centers with more successful scientific profile showed denser and more cooperative networks. Key figures in each center were interviewed for their understandings of the reasons for the emergence of these patterns.
Conclusion:
Star shape network structure and dependency on a single big member is a common feature observed in our case study. Scientific output measures correlate with the network structure of research centers. Network analysis seems a useful method to explore the subtle scientific contexts in research organizations.
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Developing health systems research capacities through north-south partnership: An evaluation of collaboration with South Africa and Thailand
Background:
Over the past ten years, calls to strengthen health systems research capacities in low and middle income countries have increased. One mechanism for capacity development is the partnering of northern and southern institutions. However, detailed case-studies of north-south partnerships, at least in the domain of health systems research, remain limited.This study aims to evaluate the partnerships developed between the Health Economics and Financing Programme of the London School of Hygiene and Tropical Medicine and three research partners in South Africa and Thailand to strengthen health economics-related research capacity.
Methods:
Data from programme documents were collected over five years to measure quantitative indicators of capacity development. Qualitative data were obtained from 25 in-depth interviews with programme staff from South Africa, Thailand and London.Results and DiscussionFive years of formal partnership resulted in substantial strengthening of individual research skills and moderate instituonalised strengthening in southern partner institutions. Activities included joint proposals, research and articles, staff exchange and post-graduate training. In Thailand, individual capacities were built through post-graduate training and the partner institution developed this as part of a package aimed at retaining young researchers at the institution. In South Africa, local post-graduate teaching programs were strengthened, regular staff visits/exchanges initiated and maintained and funding secured for several large-scale, multi-partner projects. These activities could not have been achieved without good personal relationships between members of the partner institutions, built on trust developed over twenty years. In South Africa, a critical factor was the joint appointment of a London staff member on long-term secondment to one of the partner institutions.
Conclusion:
As partnerships mature the needs of partners change and new challenges emerge. Partners' differing research priorities (national v international; policy-led v academic-led) need to be balanced and equitable funding mechanisms developed recognising the needs and constraints faced by both southern and northern partners. Institutionalising partnerships (through long-term development of trust, engagement of a broad range of staff in joint activities and joint appointment of staff), and developing responsive mechanisms for governing these partnerships (through regular joint negotiation of research priorities and funding issues), can address these challenges in mutually acceptable ways. Indeed, by late 2005 the partnership under scrutiny in this paper had evolved into a wider consortium involving additional partners, more explicit mechanisms for managing institutional relationships and some core funding for partners. Most importantly, this study has shown that it is possible for long-term north-south partnership commitments to yield fruit and to strengthen the capacities of public health research and training institutions in less developed countries.
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Asking the right questions: Scoping studies in the commissioning of research on the organisation and delivery of health services
Scoping studies have been used across a range of disciplines for a wide variety of purposes. However, their value is increasingly limited by a lack of definition and clarity of purpose. The UK's Service Delivery and Organisation Research Programme (SDO) has extensive experience of commissioning and using such studies; twenty four have now been completed.This review article has four objectives; to describe the nature of the scoping studies that have been commissioned by the SDO Programme; to consider the impact of and uses made of such studies; to provide definitions for the different elements that may constitute a scoping study; and to describe the lessons learnt by the SDO Programme in commissioning scoping studies.Scoping studies are imprecisely defined but usually consist of one or more discrete components; most commonly they are non-systematic reviews of the literature, but other important elements are literature mapping, conceptual mapping and policy mapping. Some scoping studies also involve consultations with stakeholders including the end users of research.Scoping studies have been used for a wide variety of purposes, although a common feature is to identify questions and topics for future research. The reports of scoping studies often have an impact that extends beyond informing research commissioners about future research areas; some have been published in peer reviewed journals, and others have been published in research summaries aimed at a broader audience of health service managers and policymakers.Key lessons from the SDO experience are the need to relate scoping studies to a particular health service context; the need for scoping teams to be multi-disciplinary and to be given enough time to integrate diverse findings; and the need for the research commissioners to be explicit not only about the aims of scoping studies but also about their intended uses. This necessitates regular contact between researchers and commissioners.Scoping studies are an essential element in the portfolio of approaches to research, particularly as a mechanism for helping research commissioners and policy makers to ask the right questions. Their utility will be further enhanced by greater recognition of the individual components, definitions for which are provided.
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Institutional operating figures in basic and applied sciences: Scientometric analysis of quantitative output benchmarking
Background:
Institutional operating figures and benchmarking systems are important features for the implementation of efficacy in basic and applied sciences. They are needed for research evaluation and funding policy. However, the current policy settings for research evaluation urgently need review since there may be imbalances present in many areas.
Methods:
The present study assessed benchmarking of research output. By the use of large data bases research output was categorized and analyzed. Specific areas of major research activity were identified by comparing publication density on different organ systems and inter- and intrafield comparison was performed for selected countries.
Results:
Novel density-equalizing mappings were constructed that illustrate trends of publication activity and identify subsets of major interest in a total of 5,527,558 published items. A dichotomy was present between Western countries such as the US, UK or Germany and Asian countries such as Japan, China or South Korea concerning research focuses.
Conclusion:
The present study is the first large scale analysis of global research activity and output over the last 50 years. The presently described assessment of operating figures at the national and international level can be used to identify single areas of research that are heavily focused. Further research on qualitative output benchmarking is needed to improve current policy settings for research evaluation.
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The Quality Improvement Demonstration Study: An example of evidence-based policy-making in practice
Background:
Randomized trials have long been the gold-standard for evaluating clinical practice. There is growing recognition that rigorous studies are similarly needed to assess the effects of policy. However, these studies are rarely conducted. We report on the Quality Improvement Demonstration Study (QIDS), an example of a large randomized policy experiment, introduced and conducted in a scientific manner to evaluate the impact of large-scale governmental policy interventions.
Methods:
In 1999 the Philippine government proposed sweeping reforms in the National Health Sector Reform Agenda. We recognized the unique opportunity to conduct a social experiment. Our ongoing goal has been to generate results that inform health policy. Early on we concentrated on developing a multi-institutional collaborative effort. The QIDS team then developed hypotheses that specifically evaluated the impact of two policy reforms on both the delivery of care and long-term health status in children. We formed an experimental design by randomizing matched blocks of three communities into one of the two policy interventions plus a control group. Based on the reform agenda, one arm of the experiment provided expanded insurance coverage for children; the other introduced performance-based payments to hospitals and physicians. Data were collected in household, hospital-based patient exit, and facility surveys, as well as clinical vignettes, which were used to assess physician practice. Delivery of services and health status were evaluated at baseline and after the interventions were put in place using difference-in-difference estimation.
Results:
We found and addressed numerous challenges conducting this study, namely: formalizing the experimental design using the existing health infrastructure; securing funding to do research coincident with the policy reforms; recognizing biases and designing the study to account for these; putting in place a broad data collection effort to account for unanticipated findings; introducing sustainable policy interventions based on the reform agenda; and providing results in real-time to policy makers through a combination of venues.
Conclusion:
QIDS demonstrates that a large, prospective, randomized controlled policy experiment can be successfully implemented at a national level as part of sectoral reform. While we believe policy experiments should be used to generate evidence-based health policy, to do this requires opportunity and trust, strong collaborative relationships, and timing. This study nurtures the growing attitude that translation of scientific findings from the bedside to the community can be done successfully and that we should raise the bar on project evaluation and the policy-making process.
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Exploring evidence-policy linkages in health research plans: A case study from six countries
The complex evidence-policy interface in low and middle income country settings is receiving increasing attention. Future Health Systems (FHS): Innovations for Equity, is a research consortium conducting health systems explorations in six Asian and African countries: Bangladesh, India, China, Afghanistan, Uganda, and Nigeria. The cross-country research consortium provides a unique opportunity to explore the research-policy interface. Three key activities were undertaken during the initial phase of this five-year project. First, key considerations in strengthening evidence-policy linkages in health system research were developed by FHS researchers through workshops and electronic communications. Four key considerations in strengthening evidence-policy linkages are postulated: development context; research characteristics; decision-making processes; and stakeholder engagement. Second, these four considerations were applied to research proposals in each of the six countries to highlight features in the research plans that potentially strengthen the research-policy interface and opportunities for improvement. Finally, the utility of the approach for setting research priorities in health policy and systems research was reflected upon. These three activities yielded interesting findings. First, developmental consideration with four dimensions – poverty, vulnerabilities, capabilities, and health shocks – provides an entry point in examining research-policy interfaces in the six settings. Second, research plans focused upon on the ground realities in specific countries strengthens the interface. Third, focusing on research prioritized by decision-makers, within a politicized health arena, enhances chances of research influencing action. Lastly, early and continued engagement of multiple stakeholders, from local to national levels, is conducive to enhanced communication at the interface. The approach described has four main utilities: first, systematic analyses of research proposals using key considerations ensure such issues are incorporated into research proposals; second, the exact meaning, significance, and inter-relatedness of these considerations can be explored within the research itself; third, cross-country learning can be enhanced; and finally, translation of evidence into action may be facilitated. Health systems research proposals in low and middle income countries should include reflection on transferring research findings into policy. Such deliberations may be informed by employing the four key considerations suggested in this paper in analyzing research proposals.
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From inclusion to independence – Training consumers to review research
Health and medical research invariably impacts on the lives of everyday people. Organisations in the developed world are increasingly involving the public in health research projects, and research governance structures and processes. The form the involvement takes varies, as does the level of involvement, from individuals, to groups, to the wider community. Lay community members can be trained to independently review health and medical research, and wider societal involvement in funding decisions, can be effectively fostered. The theoretical foundation, design and development of a task based consumer-training program, including a number of enabling factors to support the success of such training are presented. This work is likely to be of value to those planning to train consumers in technical or complex areas.
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Freedom and need: The evolution of public strategy for biomedical and health research in England
The optimal support of health-related research and development with public money is a complex challenge. Over the last century, policy makers in England have conceived and implemented a variety of models, ranging from independent, curiosity driven research to needs-based state commissions, and promoting different bodies to oversee scientific work. This paper traces these approaches, identifies the principles that drove them, and discusses their role in shaping policy for publicly funded health research, up to the recent launch of a new research strategy by the Department of Health.
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