Second Global Symposium on Health Systems Research: a conference impact evaluation.

Evaluation researchers have confirmed the importance of conference evaluation, but there remains little research on the topic, perhaps in part because evaluation methodology related to conference impact is underdeveloped. We conducted a study evaluating a 4-day long health conference, the Second Global Symposium on Health Systems Research (HSR), which took place in Beijing in November 2012. Using a conference evaluation framework and a mixed-methods approach that involved in-conference surveys, in-conference interviews and 7-month post-conference interviews, we evaluated the impact of the Symposium on attendees' work and the field of health systems research. The three major impacts on participants' work were new knowledge, new skills and new networks, and many participants were able to provide examples of how obtaining new knowledge, skills or collaborations had changed the way they conduct their work. Participants noted that the Symposium influenced the field of HSR only in so far as it influenced the capacity of stakeholders, but did not lead to any high level agenda or policy changes, perhaps due to the insufficient length of time (7 months) between the Symposium and post-conference follow-up. This study provides an illustration of a framework useful for conference organizers in the evaluation of future conferences, and of a unique methodology for evaluation researchers.

Strategies for coping with the costs of inpatient care: a mixed methods study of urban and rural poor in Vadodara District, Gujarat, India.

BACKGROUND: In India, coping mechanisms for inpatient care costs have been explored in rural areas, but seldom among urbanites. This study aims to explore and compare mechanisms employed by the urban and rural poor for coping with inpatient expenditures, in order to help identify formal mechanisms and policies to provide improved social protection for health care. METHODS: A three-step methodology was used: (1) six focus-group discussions; (2) 800 exit survey interviews with users of public and private facilities in both urban and rural areas; and (3) 18 in-depth interviews with poor (below 30th percentile of socio-economic status) hospital users, to explore coping mechanisms in greater depth. RESULTS: Users of public hospitals, in both urban and rural areas, were poor relative to users of private hospitals. Median expenditures per day were much higher at private than at public facilities. Most respondents using public facilities (in both urban and rural areas) were able to pay out of their savings or income; or by borrowing from friends, family or employer. Those using private facilities were more likely to report selling land or other assets as the primary source of coping (particularly in rural areas) and they were more likely to have to borrow money at interest (particularly in urban areas). Poor individuals who used private facilities cited as reasons their closer proximity and higher perceived quality of care. CONCLUSIONS: In India, national and state governments should invest in improving the quality and access of public first-referral hospitals. This should be done selectively-with a focus, for example, on rural areas and urban slum areas-in order to promote a more equitable distribution of resources. Policy makers should continue to explore and support efforts to provide financial protection through insurance mechanisms. Past experience suggests that these efforts must be carefully monitored to ensure that the poorer among the insured are able to access scheme benefits, and the quality and quantity of health care provided must be monitored and regulated.

Priorities for research into human resources for health in low- and middle-income countries.

OBJECTIVE: To identify the human resources for health (HRH) policy concerns and research priorities of key stakeholders in low- and middle-income countries; to assess the extent to which existing HRH research addresses these concerns and priorities; and to develop a prioritized list of core research questions requiring immediate attention to facilitate policy development and implementation. METHODS: The study involved interviews with key informants, including health policy-makers, researchers and community and civil society representatives, in 24 low- and middle-income countries in four regions, a literature search for relevant reviews of research completed to date, and the assessment of interview and literature search findings at a consultative multinational workshop, during which research questions were prioritized. FINDINGS: Twenty-one research questions emerged from the key informant interviews, many of which had received little or no attention in the reviewed literature. The questions ranked as most important at the consultative workshop were: (i) To what extent do incentives work in attracting and retaining qualified health workers in underserviced areas? (ii) What is the impact of dual practice and multiple employment? and (iii) How can incentives be used to optimize efficiency and the quality of health care? CONCLUSION: There was a clear consensus about the type of HRH policy problems faced by different countries and the nature of evidence needed to tackle them. Coordinated action to support and implement research into the highest priority questions identified here could have a major impact on health worker policies and, ultimately, on the health of the poor.

Eliciting policymakers' and stakeholders' opinions to help shape health system research priorities in the Middle East and North Africa region.

Evidence-informed decisions can strengthen health systems. Literature suggests that engaging policymakers and other stakeholders in research priority-setting exercises increases the likelihood of the utilization of research evidence by policymakers. To our knowledge, there has been no previous priority-setting exercise in health policy and systems research in countries of the Middle East and North Africa (MENA) region. This paper presents the results of a recent research priority-setting exercise that identified regional policy concerns and research priorities related to health financing, human resources and the non-state sector, based on stakeholders in nine low and middle income countries (LMICs) of the MENA region. The countries included in this study were Algeria, Egypt, Jordan, Lebanon, Morocco, Palestine, Syria, Tunisia and Yemen. This multi-phased study used a combination of qualitative and quantitative research techniques. The overall approach was guided by the listening priority-setting approach, adapted slightly to accommodate the context of the nine countries. The study was conducted in four key phases: preparatory work, country-specific work, data analysis and synthesis, and validation and ranking. The study identified the top five policy-relevant health systems research priorities for each of the three thematic areas for the next 3-5 years. Study findings can help inform and direct future plans to generate, disseminate and use research evidence for LMICs in the MENA region. Our study process and results could help reduce the great chasm between the policy and research worlds in the MENA region. It is hoped that funding agencies and countries will support and align financial and human resources towards addressing the research priorities that have been identified.

Reduction of catastrophic health care expenditures by a community-based health insurance scheme in Gujarat, India: current experiences and challenges.

OBJECTIVE: To assess the Self Employed Women's Association's Medical Insurance Fund in Gujarat in terms of insurance coverage according to income groups, protection of claimants from costs of hospitalization, time between discharge and reimbursement, and frequency of use. METHODS: One thousand nine hundred and thirty claims submitted over six years were analysed. FINDINGS: Two hundred and fifteen (11%) of 1927 claims were rejected. The mean household income of claimants was significantly lower than that of the general population. The percentage of households below the poverty line was similar for claimants and the general population. One thousand seven hundred and twelve (1712) claims were reimbursed: 805 (47%) fully and 907 (53%) at a mean reimbursement rate of 55.6%. Reimbursement more than halved the percentage of catastrophic hospitalizations (>10% of annual household income) and hospitalizations resulting in impoverishment. The average time between discharge and reimbursement was four months. The frequency of submission of claims was low (18.0/1000 members per year: 22-37% of the estimated frequency of hospitalization). CONCLUSIONS: The findings have implications for community-based health insurance schemes in India and elsewhere. Such schemes can protect poor households against the uncertain risk of medical expenses. They can be implemented in areas where institutional capacity is too weak to organize nationwide risk-pooling. Such schemes can cover poor people, including people and households below the poverty line. A trade off exists between maintaining the scheme's financial viability and protecting members against catastrophic expenditures. To facilitate reimbursement, administration, particularly processing of claims, should happen near claimants. Fine-tuning the design of a scheme is an ongoing process - a system of monitoring and evaluation is vital.