Search

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.

This study examines the distributional impact of a community-based insurance scheme which covers death, hospitalization, and asset loss benefits in a bundled package. It looks at the distribution of insurance benefits between urban and rural members and between the poorest and least-poor members. Urban members benefited much more from the scheme than rural members. While the scheme provided considerably higher benefit to the poor within urban areas, the rural poor benefited far less than the better-off rural members. The results have implications for scheme administration and policy; changes need to be made at both levels to provide a more balanced distribution of scheme benefits. Key words South Asia, India, insurance, benefit distribution, access, community-based insurance

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.socscimed.2005.06.037 Byline: M. Kent Ranson (a), Tara Sinha (b), Mirai Chatterjee (b), Akash Acharya (c), Ami Bhavsar (b), Saul S. Morris (d), Anne J. Mills (a) Keywords: Community-based health insurance; Equity; India; Inpatient care; Gender Abstract: 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. Author Affiliation: (a) Health Economics and Financing Programme, Health Policy Unit, London School of Hygiene and Tropical Medicine (LSHTM), Keppel Street, WC1E 7HT London, UK (b) SEWA Reception Centre, Opposite Victoria Garden, Bhadra, Ahmedabad 380 001, India (c) Department of Economics, South Gujarat University, Udhna-Magdalla Road, Surat, Gujarat 395 007, India (d) Department for International Development of the United Kingdom Government, London SW1E 7HE, UK

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.