Many people who have suffered a stroke require rehabilitation to help them resume their previous activities and roles in their own environment, but only some of them receive inpatient or even outpatient rehabilitation services. Partial and unmet rehabilitation needs may ultimately lead to a loss of functional autonomy, which increases utilization of health services, number of hospitalizations and early institutionalization, leading to a significant psychological and financial burden on the patients, their families and the health care system. The aim of this study was to explore partially met and unmet rehabilitation needs of older adults who had suffered a stroke and who live in the community. The emphasis was put on needs that act as obstacles to social participation in terms of personal factors, environmental factors and life habits, from the point of view of four target populations.Using the focus group technique, we met four types of experts living in three geographic areas of the province of Québec (Canada): older people with stroke, caregivers, health professionals and health care managers, for a total of 12 groups and 72 participants. The audio recordings of the meetings were transcribed and NVivo software was used to manage the data. The process of reducing, categorizing and analyzing the data was conducted using themes from the Disability Creation Process model.Rehabilitation needs persist for nine capabilities (e.g. related to behaviour or motor activities), nine factors related to the environment  and 11 life habits . The caregivers and health professionals identified more unmet needs and insisted on an individualized rehabilitation. Older people with stroke and the health care managers had a more global view of rehabilitation needs and emphasized the availability of resources.Better knowledge of partially met or unmet rehabilitation needs expressed by the different types of people involved should lead to increased attention being paid to education for caregivers, orientation of caregivers towards resources in the community, and follow-up of patients' needs in terms of adjustment and rehabilitation, whether for improving their skills or for carrying out their activities of daily living. Stroke is the third leading cause of long-term disability  and its The aim of this study was to explore partially met and unmet needs of adults aged 65 years or over who had suffered a stroke and who live in the community, with or without services. The emphasis was put on the needs that are considered obstacles to social participation from the point of view of older adults with stroke, caregivers, health professionals and health care managers.What do we know about social participation and rehabilitation needs for people with stroke?According to the Disability Creation Process (DCP) model, social participation or its opposite, handicap situation, is identified as a situational result that varies over time depending on the interaction between personal factors  and environmental factors  ,18 . The consequences of these impairments are operationalized through the presence of disabilities in capabilities . Depending on the number and extent of these disabilities, people vary in their ability to accomplish daily activities and social roles  [Stroke highly affects e other) .environmental factors include elements such as the support from the family and utilization of health and social services, whereas physical environmental factors refer to natural or technological elements . As obstacles or facilitators, these factors can either hinder or help in the accomplishment of daily activities and social roles.The characteristics of the person's environment also affect social participation after stroke. Social life habits' in the model) are divided into 12 domains. Six of these domains refer to the person's daily activities  whereas the other six refer to social roles . It is in these activities and roles that handicap situations or restriction of participation can arise. In the DCP model, needs might be considered as the outcome of a lack of congruence between personal factors and different factors in the environment [Finally, the different activities and roles that the person values  . Indeed,Some needs related to environmental factors are documented in literature but most of them refer mainly to rehabilitation services and education, without considering other important environmental elements. Following inpatient rehabilitation, people who had suffered a stroke expressed unmet needs related to preparation for discharge, instructions, information and support with referrals to community resources, rehabilitation services, exercise programs at home, support in doing exercise programs, support for the individual and couple during the adaptation process, nutrition, safety and housework ,60,65-68For needs related to life habits, the third component of the DCP model, most of the previous studies point out general problems with mobility and instrumental activities of daily life ,60-62,74The present group of authors had previously carried out a preliminary study with four different small groups of experts  from a single semi-urban area . ResultsIn summary, context of all of the above studies was restricted, which limits their external validity. Most literature considers capabilities, the socio-health system, the education system and some life habits (daily activities); there is very little information about unmet rehabilitation needs related to social roles and environmental factors such as social assistance, public infrastructures, community organizations, social network and physical factors. Also, most of the literature refers to normative needs . In 2002, when our study began, very few studies put emphasis on expressed needs from the standpoint of older adults with stroke and caregivers. After 2004, studies were published on that subject ,38,77,82This study examined partially met and unmet rehabilitation needs (expressed and normative) for people with stroke aged 65 and over, with respect to their personal factors (capabilities) and life habits, and environmental factors, with a view to maintaining optimal social participation. Better knowledge and understanding of rehabilitation needs and services for this population should contribute to changes in clinical and organizational practices.The study, conducted in 2005, followed a cross-sectional design using the focus group technique , individ2, 15% over 65 years old), Eastern Townships:  and Chaudière-Appalaches . In Canada (30000000 people), there are over 50,000 strokes each year – including 16,000 deaths. Four target populations were identified: 1) older people with stroke, hereinafter called 'patients', 2) family caregivers, 3) health professionals, and 4) health care managers involved in the rehabilitation of older adults. Caregivers and stroke survivors were independent of each others. The patients and family caregivers were recruited through support groups for people who had suffered a stroke, such as stroke clubs or community home services centres. Specific criteria  were defined, such as various levels of disabilities, gender, and different ages, in order to capture different experiences. The health professionals and the health care managers came from various clinical, institutional and community environments providing rehabilitation services to older adults. The health professionals were recruited through professional service coordinators, who were contacted by phone after receiving a letter explaining the research project. The health care managers were recruited through the regional health and social service boards in the three study regions.To enhance the transferability ,81 of reFor the eligibility criteria, the patients had to: a) have had at least one stroke, with the most recent occurring after the age of 65 and the previous at least two years earlier b) be living at home, and c) be able to verbally express their needs. Three quarters of people who had a stroke are aged over 65 years and, in Canada, specific health care programs are offered to this clientele, justifying the age criterion. We excluded people affected by other limitative neurological, sensory, musculoskeletal or chronic diseases, to avoid confusion between the needs related to these diseases and the needs associated with stroke. The caregivers had to: a) be the informal (family) caregiver for at least one year of a person with stroke who meets the above criteria, b) provide at least two hours of help per week, and c) be 18 years or older. The health professionals had to have at least two years' experience in an environment providing services to older adults with stroke. Finally, the health care managers had to come from the rehabilitation settings specified above. All participants should have been able to express themselves in French.Focus groups were organized in each region, with patients, family caregivers, health professionals and health care managers, for a total of 12 groups (4 populations × 3 regions). The meetings lasted approximately two hours each and were recorded on audiotape. A moderator, an assistant moderator and an observer (researcher) were present at each group meeting. The same research team attended the meetings in all three regions. Focus group interview guides, refined after the pilot study, are presented in Talbot et al.'s paper . To ensuIn addition, to capture a wider variety of experience related to the needs expressed, 4 individual interviews with patients and caregivers were conducted, since some participants were not able to participate in the focus group meetings for various reasons .The focus group participants' profile was described in terms of age, gender and other relevant characteristics, depending on the group. The audiotape of the content of each group (n = 12) and during interviews (n = 4) was transcribed, then coded, recoded and classified. NVivo software (v.2) was used to manage the data. The analysis process was systematic and rigorous and respected scientific criteria for qualitative research ,80. An iIn all three regions, 17 persons with stroke and living at home took part in individual interviews (n = 3) and focussed discussion groups (n = 14) (Table Twelve close caregivers aged between 41 and 69 participated in focussed discussion groups (n = 11) and one individual interview (n = 1) Table . In geneTwenty-five health professionals participated in the discussion groups Table . They haFinally, 18 health care managers took part in the discussion groups Table . They caNine categories of capabilities were documented out of a possibility of 10 listed in the DCP model . In factTable social assistance emerges as an unmet need that is criticized by many. Access to support groups for caregivers, sitting and respite services and temporary lodging remain unmet needs expressed by many participants.At the medical care level, all the groups agreed on needs relating to financial and human resources (scarcity of resources), and most participants talked of difficulty accessing the services (delays and disparities) and obtaining follow-up. Partially met or unmet needs were reported at several levels of rehabilitation. For ease of understanding in Table Regarding the education system, with respect to other types of instruction (not related to academics), there is a pressing need to educate caregivers and to give the instruction at the right time. The need for education was discussed in all the groups and to a greater degree among the health professionals. Insofar as public infrastructure is concerned, only the need for accessible/adapted transportation or paratransit was described as being partially met or unmet. The issue of community resources was hardly raised at all; this appeared to be a little known subject by all the groups of participants. Finally, with respect to support from community organizations, the caregivers and health professionals were the two main groups who expressed concerns about needs in this area.Just one sociocultural factor was discussed: the social network. This aspect remains an unmet need that was identified unanimously by the caregivers, health professionals and patients alike. The main points raised concerned relations with family, friends and organizations promoting awareness in the community.At the development level of the DCP model's physical factors, partial and unmet needs were addressed, if succinctly, in terms of architecture, national and regional development and technology related to medical devices or assistive technology used by people with stroke.Table The results show that partially met and unmet needs exist with respect to nine types of personal capabilities, nine environmental factors and the majority of life habits (11 out of 12). In light of these results, what conclusions can we draw from the analysis of the expressed and normative needs of each of the four groups of experts consulted? Furthermore, how can the results obtained improve what we currently know about the rehabilitation needs of people with stroke? Finally, what were the advantages and limitations of using the DCP model for this study?Half of the expressed needs corresponded to patients' demands and were inherent to activities carrying social importance, such as feeling well, walking, having sexual relations, cooking, keeping fit, visiting friends, driving or using public transport. Few had restarted social activities outside the home. Patients interviewed individually expressed the same opinions as those participating in the focus groups. They would like more access to resources to reduce the burden on caregivers and to be more independent, but they did not mention what kind of resources, except for adapted/accessible transportation or paratransit. It is also possible that the stroke survivors did not specifically mention what kind of resources because they did not know what resources were available. Like the health care managers, they talked less about the nature and type of needs that are unmet or partially met.The other half of the expressed needs corresponded to requests from caregivers. They said they would like more means with which to facilitate patients' integration at home and in the community. They find it hard to cope with the behavioural problems of stroke sufferers and, like the health professionals, they deplore certain shortcomings in the adjustment and rehabilitation services  arising in the various capabilities remain similar to those that have been documented (normative needs) with regard to cognitive problems  ,47-51, pThe partially met and unmet needs that emerged with respect to environmental factors go beyond those that are already known and published in scientific journals. The importance of meeting needs such as preparing for going back home, care to be given, education, information and referral to community support resources -67,72,83Finally, partially met and unmet needs expressed in relation to life habits are concordant with previous studies, but they are more specific than the problems identified of a functional nature (stroke and mobility) ,60,61 anIn short, the DCP model will have made it possible to highlight the partially met and unmet needs relating to environmental factors that were not mentioned in literature. This finding is hardly surprising, for most of the studies already conducted did not concentrate on elderly people's adjustment to their home environments, whether in the home or in the community.This study presents a number of strong points with respect to trustworthiness of qualitative research. Certain strategies suggested by Krefting  ensure rThe limitations of this study are associated with the research design . The results only take account of the socio-political, socio-cultural and physical environments of three regions of Quebec. Due to the size of the groups, the transferability of the data cannot be completely assured, at least for persons with stroke. Indeed, given the various possible profiles of stroke patients, it is plausible that some needs were not addressed in our study, because we did not have a sufficiently wide representation of patients. There is a certain selection bias inherent to participation in the focus groups or interviews: patients whose cognitive capabilities are more greatly affected or those who have difficulty expressing themselves could not be interviewed. Nevertheless, such patients were, in part, represented by the caregivers.Other studies are necessary to continue validation of the needs according to the Disability Creation Process framework. The expected results of a far-reaching longitudinal study led by our group will enable us to document more precisely the various degrees and types of disabilities of people with stroke, how they carry out their life habits and the obstacles they come up against in their environment.Better knowledge of the needs of people with stroke in accomplishing the activities and social roles they value is essential for improving rehabilitation services, because social participation is recognized as being the ultimate goal of rehabilitation. The presence of handicap situations in areas such as interpersonal relationships, mobility and leisure can isolate the person and foster the development of secondary disabilities if appropriate interventions are not offered. A better knowledge of rehabilitation needs and changes in them after discharge from formal services will improve coordination of these services and develop other services to address needs that are not currently being met, in the aim of maintaining the population active in social roles. In this respect, the results show that needs persist after patients are discharged, relating to nine capabilities in patients, nine environmentally related factors and eleven life habits. Close caregivers and health professionals identify more unmet needs and put the emphasis on the importance of making the rehabilitation process more personalized. The patients and health care managers have a more global vision of rehabilitation needs and put greater emphasis on available resources. To encourage better social participation of elderly people with stroke when going back at home, the study suggests that more should be done to meet the needs relating to capabilities, the patient's environment and life habits. Reducing the obstacles in the socio-politico-economic environment becomes essential for assuring a more personalized approach to rehabilitation and better instruction for caregivers.The authors declare that they have no competing interests.CV conceived the design of the study, participated in the data analysis, and outlined and drafted the manuscript. ID managed the database, performed the data analysis and commented the manuscript. LR conceived design the study, participated in the data analysis and commented the manuscript. JR conceived design the study, participated in the data analysis and commented the manuscript. ChV formed the focus groups and conducted the interviews, performed the data analysis and commented the manuscript. JD was the principal investigator, submitted the research protocol for its financing, conceived the design of the study and the coordination of all the research meetings, participated in the data analysis and commented the manuscript. These authors contributed equally to this work. LRT participated in the design of the present study, formed the focus groups and commented the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


In 1997 there was a major reform of the government run urban health insurance system in China. The principal aims of the reform were to widen coverage of health insurance for the urban employed and contain medical costs. Following this reform there has been a transition from the dual system of the Government Insurance Scheme (GIS) and Labour Insurance Scheme (LIS) to the new Urban Employee Basic Health Insurance Scheme (BHIS).This paper uses data from the National Health Services Surveys of 1998 and 2003 to examine the impact of the reform on population coverage. Particular attention is paid to coverage in terms of gender, age, employment status, and income levels. Following a description of the data between the two years, the paper will discuss the relationship between the insurance reform and the growing inequities in population coverage.An examination of the data reveals a number of key points:a) The overall coverage of the newly established scheme has decreased from 1998 to 2003.b) The proportion of the urban population without any type of health insurance arrangement remained almost the same between 1998 and 2003 in spite of the aim of the 1997 reform to increase the population coverage.c) Higher levels of participation in mainstream insurance schemes (i.e. GIS-LIS and BHIS) were identified among older age groups, males and high income groups. In some cases, the inequities in the system are increasing.d) There has been an increase in coverage of the urban population by non-mainstream health insurance schemes, including non-commercial and commercial ones.The paper discusses three important issues in relation to urban insurance coverage: institutional diversity in the forms of insurance, labour force policy and the non-mainstream forms of commercial and non-commercial forms of insurance.The paper concludes that the huge economic development and expansion has not resulted in a reduced disparity in health insurance coverage, and that limited cross-group subsidy and regional inequality is possible. Unless effective measures are taken, vulnerable groups such as women, low income groups, employees based on short-term contracts and rural-urban migrant workers may well be left out of sharing the social and economic development. In 1997 a major reform of the government run urban health insurance system was undertaken in China. Previous to this, there were two government systems – the Government Insurance Scheme (GIS) and the Labour Insurance Scheme (LIS). Particular problems of these two systems were fragmentation, small risk pooling capacity and low population coverage. The absence of mechanisms to control 'moral hazard' behaviour by both suppliers and users also meant escalating costs. To address these problems, the Chinese government launched a nation-wide urban health insurance reform in 1997. The reform, which was based on local reforms during the 1990's . By the It is well recognised that different forms and combinations of public and private health financing can have differing implications for equity through enhancing or impeding the access to and use of health services by different social groups. It has also been argued that the exact impact of different financing approaches on equity of access is yet to be fully understood . As a foAlthough the development of BHIS has been quick, it has not been without controversy and there are clearly important issues raised in the process of transition ,2,7. ThiFollowing this introduction, the paper will then describe the methods used by the NHSS. Data from the 1998 and 2003 surveys will then be compared in relation to overall coverage, and with reference to age, income level, employment status and gender. The discussion section then refers to three key explanatory features of coverage: organisational diversity, the labour market and its interface with the new insurance system, and regional diversity of non-mainstream health insurance schemes. The paper concludes by pointing to two areas of policy options open to the health system and possible features of follow-up research. However, before proceeding to the above subheadings, the background and the aims of the reform, and the new BHIS in China will be described.Prior to 1997 there were two principal insurance schemes for the urban population in China – GIS and LIS. These had been established after the Chinese Communist Party came to power in 1949. Relying heavily on government funds, the urban health care system was established to cater for the health care needs of the urban elites and the labour force vital to the urgently needed industrial expansion. Both GIS and LIS were developed through central government policy guidelines although they were managed, funded and operated by local governments and enterprises for their own employees and retirees. In this sense, work units operated as "semi-enclosed communities" providing the constituencies with a package of free or heavily subsidised services including health care .National industrialisation was a clear government priority and this had a propelling effect on the expansion of the urban labour workforce, leading to the rapid expansion of a complex and duplicated network of urban health care services . As the Another prominent issue was the inequality of health insurance coverage. This was expressed in two ways. Firstly, the entitlement for insurance benefits was determined by factors such as the workplace . WhereasThe principal aims of the 1997 health insurance reform were: a) to achieve a wider population coverage with basic medical care benefits across all the groups participating in the scheme; and b) to control the oversupply and the over-utilisation of health care through setting mechanisms to alter the behaviour of health service users and providers [Since the 1997 reform, there has been a process of transition from the old GIS-LIS system to the new BHIS, although both systems still operate in parallel. Certain key similarities and differences between the old and new systems may be highlighted.In the GIS-LIS system only the government and individual enterprises make contributions to a fund. GIS is usually funded from local government budgets, while LIS is funded from welfare funds generated by enterprises. In the BHIS contributions are from employees  and employers .The GIS-LIS system is operated by individual local governments and enterprises with centrally determined rules and regulations. The new system is managed by insurance management agencies located within local governments. Within the BHIS national policy framework, local governments have the autonomy for setting up rules of collecting and allocating funds, and operating the scheme . TherefoThe GIS-LIS system is employment-based and mostly in public sector and state-and collectively-owned enterprises. The beneficiaries are the employees and the retirees, while dependents , have partial coverage. The BHIS system is employment based, covering both employees and retirees in the public sector and also extends to private and joint-venture enterprises. However, BHIS does not cover any dependents of the insured.Individual Account Fund (IAF) and the Social Pooling Fund (SPF). The former is a pot of money made up of an income related contribution from the employee plus an age adjusted contribution from the employer. This means that the older the employee is, the greater proportion of the contribution from the employer is allocated into his/her individual saving fund. There is a yearly calculation of expenditure from the fund and under-spends can be carried forward to the next insurance year. The Social Pooling Fund is mainly from the employer's contribution and is used when the IAF has been depleted, and out-of-pocket expenditure (deductibles) has exceeded a pre-set percentage of annual income . However, the SPF in most urban centres is only used to cover inpatient related expenditures. For using the SPF, co-payments between the insurance agency and the insured individual are established, although the co-payment percentage split between insurance agency and insured individual varies from city to city. A cost ceiling for using SPF is also set up, beyond which all medical costs are borne by the insured individual until next financial year. A few cities, like Shanghai, have developed so-called supplemental health insurance schemes which are designed to cover costs that go over the ceiling level.In the GIS-LIS there is an almost total refund for care provided. In the BHIS, premiums are calculated based on a percentage of individual income although the percentage may vary between cities. Deductibles, co-payment arrangements and ceilings have been established. The premium funds are divided into two tiers – the In the GIS-LIS system there is almost no restriction on the types of health care services and prescriptions provided. In the BHIS, health facilities are designated for use by the members. At the same time the insurance agency has also indicated the types of services and drugs that can be reimbursed/covered by the BHIS. Any services and drugs that are not listed are paid for by the individuals concerned. A fixed fee-for-service has also been introduced.In the GIS-LIS system, joining the schemes has been almost automatic for employees of an organisation linked to the insurance system. Although enterprises are required to participate in the BHIS, it was not made mandatory and some enterprises have chosen to stay away from the new scheme. Enterprises that are economically better-off and/or have a younger demographic profile among the employees have been more likely to stay out of BHIS, while there are some organisations that cannot afford the premiums ,13. For Although not directly related to the 1997 reform, other non-commercial and commercial insurance schemes have been established since the 1990s by both the public and private sectors to cover medical and health needs of the insured. For example, many insurance companies have worked with schools to develop schemes covering inpatient care for the children in primary and secondary schools in different cities. Private enterprises and companies, including joint ventures, have often tended to buy specific health insurance packages from these insurance companies. Overall, they tend to provide limited health care coverage for the insured and are complementary to the mainstream/principal insurance schemes such as GIS-LIS and BHIS. Although in-depth understanding of these health insurances schemes is presently lacking, it may be assumed that there is diversity in terms of the background of the insurance companies, as well as the nature and operation of the insurance schemes managed by them.Three National Health Services Surveys (NHSS) have been conducted in China for both urban and rural areas in June/July 1993, June/July 1998 and September/October 2003 (the postponement was due to SARS epidemic). These surveys were organised and directed by the Centre for Health Statistics and Information, Ministry of Health. This paper uses only the data generated from household questionnaire interviews carried out among the urban population in the 1998 and 2003 surveys. GIS-LIS and BHIS only operate in the urban areas and the BHIS only began to be implemented nationwide in 1998.The survey sample was decided using multi-stage stratified random sampling procedures and methods in order to achieve maximum representation of the demographic and socio-economic characteristics of the whole population. All the cities in the country were grouped into 5 levels/groups according to 10 socio-economic, education, demographic and health indicators. These included employment rates in different types of industries, percentages of population under 14 and above 65, literacy rate, gross birth and death rates, infant mortality rate, per capita products of industry and agriculture and percentage of population with junior high school education. The cities ranked at the first level demonstrated higher social and economic development and the best health indicators, while those ranked at the fifth level demonstrated the opposite [All three NHSSs used the same sampling strategy and procedure. A comparison analysis test was conducted between the sample population and the data generated from the population census of 2000, confirming a high representation of the sample population in relation to the whole. The sample cities, households and population sizes in the surveys of 1998 and 2003 are presented in Table In the third NHSS, the households participating in the questionnaire interviews were randomly selected from the same sample residential committees that were used for the first and second NHSS . The surAnalysis for this specific paper included data on coverage in relation to participation in health insurance, employment status, income level, age and gender. With respect to income groups, this paper has used the methods of Gao et al . The totQuality control measures used in the NHSS included establishing a management structure and data reporting system, consultation meetings for the survey design and finalising survey tools, organising the training for the survey supervisors and interviewers and conducting pilot surveys.Measures for the quality control of data collection included revisits to a sample of 5% of households by survey supervisors to check the accuracy of data collected by interviewers. During the second visit, fourteen key indicators/questions were asked to check the consistency of the information collected: being visited by an interviewer and duration of the visit, hospitalisation in the past one year, distance to the nearest health facilities, use of ambulance/emergency services, current monthly household income and expenditure. The range of matching rates of the key indicators between the first and second visits was 91–97%.There were however important methodological issues to contend with. As the information collected by the NHSSs was self reported, there was an issue of recall accuracy of the information provided by the respondents. The use of proxy respondents in the absence of scheduled respondents may also challenge information accuracy. The use of local community doctors to conduct interviews meant that their knowledge of the local socio-economic, cultural and geographic context would facilitate the process of the survey. On the other hand, it might have introduced some bias as respondents might have feared that giving out information threatened confidentiality. Nevertheless, the reliability of the data derived from NHSS can be assured by the high matching rates of the key indicators between the first and second visits to the 5% households participated the surveys.As noted above, this paper seeks to understand the impact of the 1997 urban health insurance reform on insurance coverage. Particular attention is given to the three government-run health insurance schemes . These three government-run schemes will be referred to as mainstream health insurance schemes in the following text and tables.From the data displayed in Table Both non-commercial and commercial schemes have increased their share of the insured population between 1998 and 2003. The urban population covered by non-commercial insurance schemes increased from 7.8% in 1998 to 10.6% in 2003, while commercial schemes rose from 3.3% to 5.6% in the same period. Despite the increase, however, there has been little change to the overall figures for the insured and uninsured amongst the total surveyed urban population. In addition, the proportion of the urban population without any insurance cover increased slightly between 1998 and 2003. This means that nearly half of the urban population surveyed had no insurance protection at all against illness and injuries.Table Although the interpretation of the data in the table needs to take into account population increases in the different groups, it is noticeable that the percentage coverage of mainstream insurance falls for all age groups in the five year period. The age groups 0–14 and 15–24 increased their overall insurance coverage in the period (p < 0.01), while the other five age groups all showed a percentage increase in those without any insurance coverage.The mainstream insurance schemes are all employment-based and the BHIS operates for both the public and private sectors. However, being in employment does not lead automatically to participation in an insurance scheme. Table Table All income levels experienced increases in coverage by both non-commercial and commercial health insurance schemes between 1998 and 2003. Although income group 1 showed only a marginal increase in non-commercial health insurance coverage between 1998 and 2003, in comparison with other income groups, the group showed a more significant increase in commercial insurance coverage in the same period.Table Other types of non-governmental insurance schemes, however, show more balanced gender participation with little change over time.The data indicated in this paper shows that the social health insurance system is not meeting one of its key aims, that of increasing coverage. Coverage through mainstream insurance has actually decreased and the increase in commercial and other non-commercial insurance fails to increase overall coverage. Although the data from tables At first sight, the merging of the two older insurance systems into the new BHIS appears to seek a new integration and consolidation of the system. The third NHSS showed that 55.2% of the urban population were covered by a number of health insurance schemes, within which BHIS was the most dominant. The merger of the GIS and LIS into BHIS has certainly gone ahead and the previous mainstream systems are now minority insurers. A closer look at the emerging system however, suggests a continuation and deepening of the diversity in insurance systems.Firstly, there has been a fall in mainstream health insurance which has occurred along with increased diversity in the insurance sector. The non-state insurance sector has expanded. Although there has been a transfer and integration of two old schemes (GIS and LIS) to the new one (BHIS), the transformation is still not complete and GIS and LIS remain in operation. For example, some central government agencies and several provincial government agencies have not participated in the BHIS simply because government civil servants would prefer to continue to enjoy almost free medical care under GIS. This adds to the appearance of diversity in the insurance system. A key issue here is the extent to which the reform does or does not promote risk pooling and achieve cross-group subsidy. Although all enterprises are required to cover the health insurance needs of their employees, participation in the new BHIS is more voluntary, rather than mandatory. Enterprises have the option to take part or stay away, based on their judgement of economic gains/losses. In a study conducted in Shandong province, Meng et al  found th"Focus group discussions with enterprise managers and employees revealed that they assessed potential benefits and costs when deciding whether to join the municipal health insurance scheme."Some enterprises had not yet decided to join the BHIS as they just could not afford the payment of premiums for their employees and retirees. Others thought that it would be better to remain with LIS for the reasons related to financial contributions and benefit packages . InteresThe insurance reform has increased the risk pooling capacity to a higher degree, i.e. from individual enterprise-based to municipal-wide. In spite of the increased pooling size, the new scheme has not achieved a satisfactory level of solidarity. In fact, like the old schemes, the new scheme has maintained more or less the same eligibility criteria based on employment. This can potentially reduce the basis for wider horizontal and vertical subsidy between the rich and poor, young and old, and the sick and healthy.Secondly, BHIS operates through a decentralised system in which local government plays an important part. Although there is a national framework for the operation of the BHIS, it also operates through a decentralised system in which local government plays a role in setting the rules and regulations of the system. On the one hand, this decentralisation of the system can have an impact on service provision and lead, for example, to different staff salary and benefits packages in different districts/regions at different stages of economic development . On the The economic reform from the 1980s onwards has brought with it a rapid process of economic growth and urbanisation in China. Major changes have taken place in the mechanisms and composition of the labour market. The selectiveness of the BHIS may be closely linked to these changes.Firstly, since the economic reform in the 1980s, enterprises have been given more autonomy in managing their staff. For example, increasing numbers of staff have been employed on short-term contracts . Governm"...discrimination in the labour market against women (...) reduces their health insurance entitlements, either because schemes are unable to offer benefits to laid – off or early retired workers or because individuals on short term or temporary contracts have reduced insurance entitlements."Secondly, rapid economic expansion in urban areas has created massive rural to urban movement in the labour force. Consequently this has formed a new population group of non-registered migrants residing in urban areas . Accordi"The precise number of this 'floating' population is uncertain, but is thought to be at least double estimates. This population is not covered by any social insurance system. Whether they have any insurance status at all is determined solely by their employer, if they have been fortunate enough to secure a job."Thirdly, the gender differences in insurance coverage need to be understood in the context of gender differences in employment. This study showed that the urban female population in China are distinctly disadvantaged in insurance coverage. Given that the BHIS is employment-based, this may be looked at from the angle of the employment status of women in urban areas. In 2002, only 38% of total employees in urban units were female . In spitFourthly, the mainstream health insurance schemes are, more accurately, institutional and employment-based and therefore do not cover the self-employed. This rule does not seem to coincide with the changing employment features in urban areas. From 1996 to 2000, people in self-employment in urban settings increased from 17.09 to 21.36 million , some muFifthly, unemployment in urban areas increased from 3.1% in 2000  to 4% inLastly, this paper also points to an imbalance in the relationship between the employer/owner of the enterprises and their employees. We have already noted that the process of economic reform from the 1980s onwards, owners/employers have been granted increased management authority in the running of enterprises. There is no guarantee that this authority is being used in the interests of the employees. At the same time, trade unions and workers congresses in China exert little influence in industrial relations and decision making on workers' benefits including health insurance coverage. This is largely due to their poor capacity in lobbying for policy change within and across enterprises, and the reluctance of and resistance from government and enterprises to granting trade unions independent status in representing workers ,29. AgaiAs noted above, the NHSSs revealed the growth of urban population coverage by other types of health insurance schemes outside the mainstream insurance schemes. The commercial insurance schemes are of recent origin and may well continue to grow as part of a general shift to private forms of production and exchange in China. The 2003 NHSS data showed that the coverage rate by commercial insurance varied a great deal between cities , probablThe non-commercial (and non-mainstream) medical insurance schemes are diverse and complex. They are largely made up of non-profit-making arrangements set up by different government departments, public institutions, or enterprises to cover certain medical care needs of different groups. Included here are Medicaid schemes for the urban poor, catastrophic disease insurance schemes, collective health insurance, insurance arrangements made by schools or enterprises for students/employees, as well as rural collective medical insurance by migrant workers working in urban areas . There iRecent policy development and discussion has turned to the issue of integrating non-commercial health insurance schemes into the mainstream medical insurance scheme, or broadening the eligibility for mainstream health insurance schemes to uninsured vulnerable groups. The policy document issued by the State Council in 2006 stated that eligible migrant workers should be included into basic medical insurance schemes . In ShanFurther research is needed to compare the different insurance schemes currently operating in China in terms of, for example, financial protection, service/benefit coverage, and levels of acceptability and satisfaction among the insured. This research should take into account the contextual settings in which the different schemes have been established and operated. It is important that such research should inform the further developments of social health insurance policy in China. Further policy relevant research is also needed into how different options of insurance administration impact on efficiency. For example, merging different non-commercial health insurance schemes and including dependent children and spouses into employees' insurance scheme could be analysed.Based on a comparison between two NHSSs, this paper has drawn attention to the changing face of health insurance in China. In addition to the increasing diversity in insurance systems, it has also drawn attention to the growing inequity in insurance coverage between 1998 and 2003. The rapid economic development and the reduction in poverty that has taken place in recent years have contrasted with restrictions in coverage and critical issues around the inequity generated within the system.Unless appropriate action is taken, it is quite possible that the forms of gender, age, income and employment disparities indicated will continue to increase. The discussion suggests the need to look at state involvement in two possible areas. Firstly, there is a need to consider establishing and managing insurance schemes particularly for the vulnerable groups, such as low-income and short-contract employees. The development of public insurance schemes benefiting disadvantaged groups including women and the poor in urban settings, such as the medical finance assistance scheme, is still in its infancy. They have only been piloted in a handful cities , althougSecondly, there is the option of legislation and regulatory control to widen access to joining the BHIS. As the implementation of the new health insurance scheme has not been made mandatory for all the institutions and enterprises , selectiThere is clearly a need for research to monitor and evaluate the impact of new forms of health insurance. Results analysed in this paper are certainly cause for concern. In conducting research, this paper suggests four important characteristics to be taken into account. Firstly, the research has to cover the broader aspects of health insurance systems, going beyond the subject matter of this paper. For example, further work needs to be done in such vital areas as financing and the relative impact financial changes place on different groups and changes in benefit coverage. It would be useful to assess and compare the level of benefit coverage and financial burden on different groups under different health insurance schemes including BHIS, the old systems (GIS-LIS) and other non-commercial schemes. The impact on member access to health care in the light of the different forms of user charging and the individualised nature of the insurance accounts needs to be understood. Secondly, the data in this paper is aggregated to represent national trends. On several occasions this paper has pointed to the regional and local diversities to be found in the new system. It is important that research takes up this challenge of demonstrating how differences in both the regulatory norms of the insurance systems and the differences in the local economic and social contexts can have an impact on the outcome of insurance reform. It is quite possible that the decentralised system of BHIS insurance management is a step to further inequity. Thirdly, the research needs to recognise the complexity in identifying causal relations between insurance reform and impact on health care. There are a wide range of contextual and contradictory factors determining the type and level of health care provided to different social groups. Insurance reform is one among a wide range of factors to consider. Research needs to unravel how insurance reform relates to these other factors and impacts on such factors as the type of care and the level of equity. Lastly, further research needs to integrate both qualitative and qualitative methods. This is important for developing complex patters of causal explanations between insurance reform and such issues as coverage, access and cost containment.The authors declare that they have no competing interests.LX contributed significantly to the conception of the paper, analysis and interpretation of data, and participated in revising the paper for important intellectual content, also participated in the conduct and management of the National Health Service Survey in 2003;YW contributed significantly to the conception and drafts of the paper, analysing and interpreting data, and revising the paper;CDC carried out revising the paper critically for important intellectual content and gave the final approval of the version to be published;ST contributed to the conception of the paper, data analysis, and revising it critically for important intellectual content.All the authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


The ability of health organizations in developing countries to expand access to quality services depends in large part on organizational and human capacity. Capacity building includes professional development of staff, as well as efforts to create working environments conducive to high levels of performance. The current study evaluated an approach to public-private partnership where corporate volunteers give technical assistance to improve organizational and staff performance. From 2003 to 2005, the Pfizer Global Health Fellows program sent 72 employees to work with organizations in 19 countries. This evaluation was designed to assess program impact.The researchers administered a survey to 60 Fellows and 48 Pfizer Supervisors. In addition, the team conducted over 100 interviews with partner organization staff and other key informants during site visits in Uganda, Kenya, Ghana, South Africa and India, the five countries where 60% of Fellows were placed.Over three-quarters of Fellowships appear to have imparted skills or enhanced operations of NGOs in HIV/AIDS and other health programs. Overall, 79% of Fellows reported meeting all or most technical assistance goals. Partner organization staff reported that the Fellows provided training to clinical and research personnel; strengthened laboratory, pharmacy, financial control, and human resource management systems; and helped expand Partner organization networks. Local staff also reported the Program changed their work habits and attitudes. The evaluation identified problems in defining goals of Fellowships and matching Organizations with Fellows. Capacity building success also appears related to size and sophistication of partner organization.Public expectations have grown regarding the role corporations should play in improving health systems in developing countries. Corporate philanthropy programs based on "donations" of personnel can help build the organizational and human capacity of frontline agencies delivering health services. More attention is needed to measure and compare outcomes of international volunteering programs, and to identify appropriate strategies for expansion. As international donors expand global financing in response to the HIV-AIDS pandemic and in support of the Millennium Development Goals, issues of human and organizational capacity are becoming increasingly important . GovernmThe private business sector is recognized as an important stakeholder in international development, especially in the health sector. Public-private partnerships are being pursued as a way to leverage ideas, resources, and capabilities to achieve public health goals . Most coIn workshops organized by the Global Health Initiative of the World Economic Forum to discuss how business can help strengthen service delivery capacity in Sub-Saharan Africa, management was identified as a key challenge amenable to solutions sought in partnership with business . One typIn 2005, Boston University's Center for International Health and Development was asked by the U.S. Agency for International Development (USAID) and Pfizer Corporation to undertake an evaluation of Pfizer's international volunteering program. From 2003 to 2005, Pfizer's Global Health Fellows (GHF) Program placed 72 employees in organizations based in 19 countries. The goal of the program was to promote better health by improving the service delivery capacity of local partners in poor countries. The Boston University research team sought to determine the impact of Pfizer's international volunteering program on the organizations receiving assistance, and to document lessons learned for public-private collaboration in capacity building.Pfizer's Global Health Fellows Program matches qualified and interested Pfizer staff with assignments in local partner organizations in the developing world. The Program identifies potential local partners and Fellowship assignments through intermediary non-governmental organizations (NGOs) such as Health Volunteers Overseas (HVO) and American Jewish World Services (AJWS). Pfizer also works directly with large international NGOs such as Family Health International, Médecins du Monde, and other partner organizations such as the Uganda Infectious Disease Institute.Twice a year, Pfizer employees apply for selection as Fellows through a competitive process. The approval of a fellow's supervisor must be obtained in order for them to participate in the program, which implies that the Fellow's work will be covered while overseas. The Pfizer work unit Supervisor is not responsible for the matching process or program impact, though Supervisors communicate with Fellows during the Fellowship.Partner Organizations review Fellowship candidates for a defined assignment, and select a Fellow from the candidate pool. Fellows receive pre-departure training and information concerning health issues, security, cultural competence, and GHF Program procedures. They also are encouraged to contact the Partner Organization to discuss their scope of work prior to arrival.Assignments average three to six months. The fellow's salary and benefits are charged to her/his Pfizer work unit, while living allowance and travel are paid by Pfizer Corporate Philanthropy, which also pays a small allowance to the Partner Organization for supervision. Subject to approval, the Fellow may also use up to $500 to cover material costs for local projects.Figure Conducted between October 2005 to January 2006, the evaluation sought to answer the following questions:▪ How do Fellowships affect the Partner Organizations with which Fellows are placed? How does the Fellowship Program build institutional and professional capacity?The evaluation also examined how the Fellowships affect participating Pfizer employees and their work units, and examined the effect of the Global Health Fellows Program on Pfizer's reputation and corporate activities (findings presented elsewhere) . This arThe evaluation team used both qualitative and quantitative methods to collect data. Two approaches were used: a survey for eliciting information from Fellows and Pfizer Supervisors, and structured in depth interviews to gather information from Partner Organizations. The diversity of respondents within Partner Organizations  made it difficult to use the survey approach. We also wanted to explore perceptions of program goals and impact in more detail through the in-depth interviews with Partner respondents. The study design was approved by the Boston University Medical Campus Institutional Review Board.We surveyed Fellows (both returned and current as of January 2006) and the Pfizer Supervisors of Fellows. We attempted to contact all 72 Fellows and 69 Supervisors who had participated in the program as of October 2005, including those who had subsequently left the company. Our response rates were 83% (60) for Fellows and 70% (48) for Supervisors. Fifteen of the 33 non-respondents did not answer repeated e-mails and phone messages, 14 had missing contact information, and 4 were interviewed too late to be included in the analysis. About 72% of Fellows interviewed were female, which is the same percentage as in the total population of Fellows. Interviews were conducted in person or by telephone. The survey questions were arranged by phase of fellowship  with questions to elicit suggestions and comments, and to record interviewer observations. Confidentiality was assured by using codes to identify respondents, and by masking identifying detail from qualitative responses.Fellows were asked questions about preparation, goals and scope of work, achievements, and impact of the program on themselves, the Partner Organization, their Pfizer workgroup, and the company as a whole. Supervisors of Fellows were asked about reasons for approving the Fellowship, preparation, how work was covered in the Fellow's absence, and the impact of the program on the Fellow, the Pfizer workgroup, and the company. Partner Organization respondents were asked about goals and scope of work, achievements, and the impact of the program on the Partner Organization, and their impressions of the company.Qualitative data from the surveys were entered into NVivo 2.0 software. NVivo is a computer program that allows for more complex categorization of large sets of qualitative data than when done manually. Domain analysis was subsequently conducted by a research team member and assistant. Quantitative data were analyzed using Microsoft Excel and SAS v9.1 to produce frequency tables and means where appropriate. Data were stratified by round of Fellowship and current versus returned Fellows to elicit trends.Researchers also interviewed personnel from Partner Organizations in Kenya, Uganda, Ghana, South Africa, and India – countries which represented 60% of Fellowships. We interviewed the manager of the Organization where each Fellow was placed, the Fellow's immediate Supervisor, and co-workers. In a limited number of cases, we were able to interview local recipients of the services the Fellow was attempting to improve. For many Fellowships, we visited the work site and in some cases reviewed the systems changes resulting from the Fellow's recommendations.In total, the research team conducted over 100 NGO Partner interviews. Members of the evaluation team wrote notes from each interview, and all references to individual Fellows were coded using the same coding system used to identify Fellow interviews. In order to encourage full disclosure, respondents were promised that feedback on individual Fellows would not be shared with the Fellow or with Pfizer except as part of our aggregate findings. The interview notes were shared with all five members of the study team. Where appropriate, respondent's impressions of Fellowship accomplishments were compared with statements made by the Fellows. This comparison has informed our general conclusions, but no specific contrasts are shown in our results in order to maintain confidentiality.The evaluation team met after completion of all field interviews to formulate general conclusions from the interview material. In our discussions, we developed categories for grouping Fellowships, based on level of skill/judgment applied by the Fellow and the level of impact on the host organization and the services it provides. This process is described in more detail in the Results section.Knowledge transfer was an overriding theme in Fellows' statements of their professional goals, while on a personal basis many Fellows noted a desire to "do good", serve the poor, and to grow personally. Fellows described their intention to make a positive impact on the Partner through transferring their expertise. Fellows also described what they believed were their Partner Organization's goals, which the research team grouped into six broad categories, shown in Table Nine Fellows (15%) mentioned that the Partner goals were undefined or left entirely to the Fellow to develop, and 21 Fellows (35%) described how the goals were redefined or expanded during the Fellowship. For example, one Fellow remarked, "Once they realized I could do more they asked me to help with research. I wrote grant proposals and one was approved." Another stated "I sat down and said, 'I think I can do more' and wrote a whole set of goals ... and I added indicators for success."On the other end of the spectrum were Fellowships that were overly ambitious, with too many tasks specified for the time and resources available or skill capacity of the Fellow. One Fellow was given a "laundry list that would have taken someone three years," while another mentioned partner goals changed "on a daily basis". Four Fellows mentioned that they narrowed the scope of the goals during the Fellowship.The diversity in Fellowship goals made it difficult to evaluate the Fellowships against a common standard. Instead, we focused on documenting Fellows' perceptions of goal accomplishment, perceived effects of the Fellowship expressed by Partners, and observed effects or documentation available during our site visits.First, we asked Fellows to report on how well they thought they had achieved Partner Organization goals ;▪ stronger technical or management capacity of the Partner Organization (i.e. enabling a new activity or improving existing activities).As shown in the next section, data collected from NGO respondents supported these findings.Interviews with respondents at Partner Organizations provided examples of how Fellows helped organizations develop greater professional pride, confidence and self-efficacy, a "systems way of thinking" and business approach to management, and new technical skills. NGO perceived benefits from the Fellowships are discussed in three areas: skills transfer, operational improvements, and attitudes.According to Partner Organization respondents, Pfizer Fellows transferred skills in the areas of medical practice, nursing, pharmacology, laboratory science, computer technology, facility and equipment maintenance, financial systems, epidemiology and biostatistics, marketing, program evaluation, and design and management of clinical research trials. These skills were transmitted in a variety of ways. Some Fellows were assigned to academic institutions, where they helped local faculty with curriculum development and actually taught classes and seminars on topics not previously covered. Others provided on the job training, often as part of an assignment to develop a particular product or operational improvement. Fellows sometimes taught computer skills by showing counterparts how to use an office application such as PowerPoint for their work, or by teaching a statistics application.On the clinical research side, Fellows helped to write research grant proposals, design clinical trials, and train staff in proper trial procedures. For example, respondents in one Partner Organization attributed a newfound ability to compete for grants (demonstrated by two grants submitted and one funded) to the work of a Fellow. In another organization, a Fellow set up clinical trial management systems that organized and streamlined work, and could easily be modified to accommodate different study protocols in the future.Turning to operational improvements in administrative and clinical care systems, most Partner Organization respondents readily cited operational changes that came from the work of the Fellows. Often the Fellow worked with an individual or team, using a combination of technical knowledge and management techniques to design and implement changes. For example, in a large, private non-profit teaching hospital, a sequence of two Fellows with extensive pharmacy operating experience worked with senior pharmacy staff to design a new system for recording drug procurement transactions; a drug pricing system with lower mark-ups on expensive drugs to make these more affordable to some seriously ill patients; and staffing changes based on standard productivity measures to reduce waiting time and increase client through-put. The Fellows also helped pharmacy staff to work with the Information Technology department to integrate necessary changes into the hospital's computerized systems. The Pharmacy Director described the effect of the new procedures: "I used to spend up to four hours a day signing documents. I brought them with me to meetings. When I signed one pile, it was replaced by another. Now it is reduced to nearly nothing. [The Fellow] has freed me to develop the Department." Examples of other operational changes are shown in Table A wide variety of work products were produced by the Fellows, including standard operating procedures, policy manuals, problem analysis documents , and treatment protocols. In some cases, these depended on the Fellow's professional expertise. At one Partner, codification of procedures enabled the Organization to apply for formal accreditation for its services. Some Partner Organizations were able for the first time to address issues (such as development of a public relations strategy) because the Fellow provided the first available expertise in this area.In other cases, the product was not dependent on a unique skill. The Fellow had the time and writing ability to prepare documents within the professional competence of existing staff, but which NGO personnel did not have the time to prepare. Fellows also taught counterparts how to write better reports. "I learned how to write a report systematically....this is a format we can use for all our work," said one counterpart.In a few cases, a Fellow provided energetic volunteer assistance, relatively unrelated to the Fellow's expertise, in carrying out the mission of the Partner Organization. The Fellow's determination and hard work enabled the Organization to improve or expand its service while the Fellow was present. For example, one volunteer organized local artists to decorate drab pediatric wards with bright murals. Another organized a major community clean-up operation, even raising some of the funds for equipment. The community was still cleaner than usual six months after the Fellow's departure. However, with no clean up tools regularly available, it may be difficult to maintain the community spirit the Fellow engendered.Finally, although the impact is more difficult to quantify, Partner Organization personnel offered examples of ways in which Fellows changed attitudes and stimulated new approaches to problem solving. For example,Fellows demonstrated the value of networking and reaching out to development partners. To better serve an impoverished rural population, one Fellow suggested that the NGO approach the local government health department to urge expansion of in-village HIV counselling and testing. These negotiations led the government to take action and dedicate resources to in-village VCT, rather than forcing villagers to individually incur transport costs to reach the urban VCT center. In another country, a Fellow introduced NGO staff to a government office which had grant revenue and was looking for projects to fund, while also connecting the NGO to a local University looking for opportunities to involve student and faculty volunteers in community service projects.Fellows convinced Organizations of the need to measure and continuously evaluate interventions, with Fellows actually working to draw up evaluation plans. Fellows suggested ways to measure the impact of social marketing programs, and to assess productivity and objectively assess staff performance. One respondent explained, " [The Fellow] analyzed work efficiency. We didn't know how to manage our own productivity before. We did not know how to justify new staff. Now we can justify.....Definitely, the changes will be lasting."Fellows stimulated initiative in their counterparts. One respondent said " [The Fellow] taught us to be responsible. We used to wait for higher authority to tell us what to do. [The Fellow] told us that the whole responsibility should be ours. Our talents, feelings, ideas can be brought out in our work.... Now, we don't postpone things so much, and it helps to avoid having things clump up. When we start something, we finish it."Fellows encouraged counterparts to work in teams, and to plan and monitor their own work. Work organization often improved as a result of the Fellows' example. An employee in one organization noted: "I learned time management. We would have a plan that said when we were to do things, and then we did them according to the plan. That wasn't the way we worked before."A few Fellowships ran into problems because of personality clashes, lack of effort on the part of the Fellow, and culture shock. These problems may be mitigated through careful selection, training, and matching of Fellows to Organizations. Other problems generally contributing to the lack of success in achieving Fellowship goals included:▪ The Fellow did not have the skill set expected by the host organization;▪ The Terms of Reference for the Fellowship were vague or inaccurate;▪ Critical prerequisites–computer software or hardware, or a key counterpart–were not available when the Fellow arrived;▪ Access to critical counterparts in the organization was too limited. The chosen counterpart may have been too high or too low in the organization;▪ Counterparts were not able to prioritize the Fellow's assignment. This may have been a result of excessive routine work load, poor motivation, or the failure to involve the work unit in defining the need for a Fellow;▪ The Partner Organization did not have the management or financial flexibility to implement the Fellow's recommendations.A key question of concern to Pfizer and USAID was whether the Global Health Fellows Program was having an impact on service expansion in the countries and organizations where it was working. To answer this question, the research team attempted to define a typology delineating three main levels of Fellowship impact. The typology is presented in Table By reviewing data from Fellows, Supervisors, and (in the five countries visited) Partner Organizations, the research team was able to place most Fellowship assignments within this typology. As the typology model was created at the end of the study, we did not measure the constructs explicitly during the research process; consequently, the model's reliability is not yet established. Despite this limitation, we present the typology to illustrate a potential avenue for empirical evaluation of corporate volunteering programs in the future.A change in operations based on the Fellow's work, and which facilitated the sustained expansion of services, was classified as Type 3. Thirty-one percent of Pfizer Fellowships fell into this category. For example, one Fellow's work resulted in an increase in the volume of CD4 tests  performed by the Partner Organization, from 100 to 300 a day, while simultaneously increasing test quality and reliability. At another Partner Organization, a Fellow created an accounting software application for revenue reporting which saved staff six working hours per week while accommodating a tripling in the amount of revenues recorded.Fellowships were classified as Type 2 if they involved transfer of skills and expertise through teaching, or the development of documents such as clinical protocols. These capacity building activities were perceived as important building blocks toward service expansion, although for these Fellowships there was less evidence that expansion had occurred yet. Almost half of Fellowships (48%) were categorized as Type 2.A volunteer effort not based on the special skill and expertise of the Pfizer employee, and not transferring scarce skills to the Partner, was classified as Type 1.Thirteen percent of Fellowships fell into Type 1, while an additional 8% of Fellowships lacked sufficient data for classification.The research team found an increased number of Type 3 Fellowships in later rounds of the program, although the difference was not statistically significant. If real, such a difference could reflect the increased attention to defining specific goals and objectives for the Fellow's scope of work early in the assignment, which involved more communication with Partner Organization staff prior to the Fellow's arrival. When comparing current versus returned Fellows, we did not observe differences in Fellowship type, and there were no significant differences between Fellowship performance according to the region of the world where the Fellow worked. We did note an association between Fellowship length and performance, with longer Fellowships scoring higher. While the association did not reach statistical significance, this finding seems important. A possible confounder could be program timing: more of the shorter length Fellowships were held in the first year of the GHF program, when the program design and management systems were still being refined.The evaluation results raise important operational, strategic, and methodological questions. Operational issues are addressed first, followed by a discussion of more general strategic questions concerning the design of international corporate volunteering programs. The last section discusses methodological concerns, and suggests steps needed to improve future design and implementation of programs.Corporations seeking to contribute resources to global health and development through public-private partnerships using corporate volunteering should consider lessons learned from the Pfizer experience. For example, the Pfizer program demonstrates the need to define Fellowship assignments with specific technical assistance goals and tasks, in order to make the best match between volunteer employees and the Partner Organizations. Prerequisites for assignments (including necessary software or staff) should be in place before Fellows are sent, and assigned counterparts must have sufficient time and decision making authority to support the Fellowship goals.As other researchers have noted, philanthropic partnerships in the developing world need to be sure that volunteers are prepared for different cultural and social decision making processes, language differences, and unfamiliar bureaucracy . Pfizer The research team was surprised by the large percentage of women participants in the Pfizer program, a figure disproportionate to Pfizer's distribution of professionals eligible for participation. Pfizer staff could not give reasons for this discrepancy, but it may be because women are more likely to participate in any type of volunteering effort . In addiConsideration of gender imbalance leads to more strategic considerations of program design. One of these issues is where corporate volunteering programs should be placed in the corporate structure, and their dual role as a corporate social responsibility initiative and a human resources development program. Discussions are currently underway at Pfizer to integrate the GHF program with other management development initiatives, in part to mitigate gender imbalance but also to increase the sustainability of the program by making it less reliant on the support of any particular corporate "champions". Pfizer is also considering adding some shorter-term volunteering opportunities in order to appeal to higher level managers and executives who cannot be away from their job responsibilities for longer periods. The higher-level volunteers would be placed in relatively complex local organizations which have previously hosted Fellows for longer periods and shown capacity to integrate technical assistance effectively. This approach would maximize the probability of high impact assignments within the shorter time frame.Another strategic issue raised by the evaluation results is program design. The study raises the question of whether Pfizer's strategy of tailored technical assistance working with myriad local Partner Organizations is the best corporate investment in building human resource capacity in developing countries. A key factor in operation of Pfizer's corporate volunteering program has been the lack of a "cookie cutter" approach to technical assistance. Pfizer chose not to "project-ize" the Fellowship assistance by defining strategic results areas in advance. Instead, the program identifies local partners and starts from where they are, addressing the unique needs of each individual organization. This strategy creates management challenges. As the Partner Organizations vary in size, mission, ownership, and years of experience, this means each Fellowship may set unique goals, apply different approaches, and engage in different activities with varying outputs. While Pfizer has made efforts to encourage internal sharing of technical approaches and dissemination of lessons learned, there is still a risk of Fellows "reinventing the wheel" in developing new systems when these exist in similar programs with which the volunteer was not familiar.An alternative strategy to improve program effectiveness is to focus on a more homogeneous set of partnerships or technical assistance goals. Research sponsored through the Brookings Initiative's Initiative on International Volunteering may provide some guidance in this regard. The Brookings Initiative's Corporate Engagement Working Group has commissioned a white paper on international corporate volunteering in an effort to document best practices for selection and deployment of volunteers and evaluation of program impact. Initial findings suggest that some companies are focusing capacity-building assistance on specific types of organizations or interventions. For example, the multinational medical technology company BD (Becton Dickinson Corporation) worked in collaboration with the Zambian Catholic Medical Mission Board to field 10 corporate volunteers for a two-week assignment in 2005 and 2006 ,24. The More controversial is the challenge of deciding which organizations to support through corporate volunteering. Sending a succession of Fellows to well-managed, relatively complex organizations that have made effective use of previous Fellowships may increase impact; yet smaller organizations also need capacity building help, especially since these organizations can play an integral role in achieving goals of equity and access for marginal populations. One possible strategy to include smaller organizations might be to encourage the creation of networks of Partner Organizations within a given area or country, allowing large and small organizations to share management tools and encouraging collaborative improvement efforts.A final question concerns the types of evaluation tools and methods which are needed to measure the sustained impact on the organizations receiving assistance. The GHF program experience suggests a need to sensitize employee volunteers to the benefits of measuring program impact and documenting results. A follow-on research study funded by the United States Agency for International Development (USAID) Global Health Office and Pfizer is designed to collect measures of capacity building impact, including more extensive development of an impact typology such as the one presented here. The study will also measure factors which may influence program impact, including Fellow characteristics, Partner Organization level of development, and features of the Fellowship itself .Future evaluations might also try to systematically survey all groups  and pose questions in such a way that they cross-refer. This would allow comparison of perceptions of impact. Discrepancies might help identify specific ways to improve the matching between Fellows and Partners, and better coordinate the collaborations and mutual expectations.What did Pfizer get out of the program, and what benefits might other corporations obtain by adopting public-private partnerships based on corporate international volunteering? In recent years, public expectations have grown regarding the role business should be playing in global health. People expect private companies to be involved in increasing access to services as a duty of corporate citizenship. Observers have noted that companies can use philanthropy as a way to rebuild eroding trust and establish the public acceptance needed to stabilize their marketplace ,25. InteThe evaluation found that the Program had a positive impact on the Fellows themselves, their professional development, and the pride and satisfaction of the Fellows' work groups at Pfizer. Fellows reported believing that their experience dealing with sometimes inadequate resources, uncertainty, and cultural differences will make them better, more flexible managers. They expect the Fellowship will give an advantage in future assignments and promotions. Seventy-seven percent of Fellows felt the effect on their professional development was positive. Pfizer's commitment to the GHF Program made the Fellows (and their co-workers) proud to be a Pfizer employee. These findings are described in more detail elsewhere .This evaluation has several limitations. First, while we made several attempts to contact Pfizer Fellows who had subsequently left the company, we were only able to contact one out of the nine Fellows no longer employed by Pfizer. It is possible that these Fellows had different experiences from those who are still at Pfizer, though it is unlikely that this has affected the information reported by Partner Organizations. Secondly, the evaluation was only able to conduct site visits in five countries, including 60% of Fellowship experiences. The experiences of Partner Organizations not visited may be different. In addition, although efforts were made to assure informants that responses were confidential and anonymous, it is possible that some respondents were reluctant to share criticism. Finally, our typology of Fellowship impacts was created retrospectively and must be interpreted with caution. Further research is needed to test the reliability of this typology.Pfizer provided partial funding for this study, as described in the Competing Interests section. Pfizer staff did not have editorial control or review the manuscript before submission, mitigating the potential for bias in reporting results.Public-private partnerships and corporate philanthropy have significant resources to leverage toward expanding health services in developing countries. In recent years, corporate philanthropy has shifted to "interdependent philanthropy", with the dual goal of addressing social problems while also furthering the company's strategic interests and expanding core business . StrengtPfizer Corporation provided 50% of the funding for the study. The research was also supported by federal funding through the United States Agency for International Development, as described in the Acknowledgements. At the time of the study, FF, TV, SR, and KM were full-time employees of Boston University, while PC was a consultant to Boston University. Pfizer staff did not have any editorial control on the manuscript and did not see a copy prior to submission. Pfizer funding did not pay for the preparation of the manuscript.TV participated in study design, administered surveys, conducted site visits in India, analyzed site visit data, and led the writing of the manuscript. SR participated in study design, administered surveys, conducted site visits in Ghana, performed qualitative data analysis, and helped to write the manuscript. KM administered surveys, coordinated the study, and performed statistical analysis. PC participated in study design, administered surveys, and conducted site visits in South Africa and Kenya. FF conceptualized the study, participated in its design, administered surveys, conducted site visits in Kenya and Uganda, analyzed site visit data, and helped to write the manuscript. All authors read and approved the final manuscript.


There is little evidence linking adverse reproductive effects to exposure to specific pesticides during pregnancy.In February 2005, three infants with congenital anomalies were identified in Collier County, Florida, who were born within 8 weeks of one another and whose mothers worked for the same tomato grower. The mothers worked on the grower’s Florida farms in 2004 before transferring to its North Carolina farms. All three worked during the period of organogenesis in fields recently treated with several pesticides. The Florida and North Carolina farms were inspected by regulatory agencies, and in each state a large number of violations were identified and record fines were levied.Despite the suggestive evidence, a causal link could not be established between pesticide exposures and the birth defects in the three infants. Nonetheless, the prenatal pesticide exposures experienced by the mothers of the three infants is cause for concern. Farmworkers need greater protections against pesticides. These include increased efforts to publicize and comply with both the U.S. Environmental Protections Agency’s Worker Protection Standard and pesticide label requirements, enhanced procedures to ensure pesticide applicator competency, and recommendations to growers to adopt work practices to reduce pesticide exposures.The findings from this report reinforce the need to reduce pesticide exposures among farmworkers. In addition, they support the need for epidemiologic studies to examine the role of pesticide exposure in the etiology of congenital anomalies. In February 2005, the Healthy Start program in the Collier County Health Department (CCHD) in Florida identified three infants with congenital anomalies who were born within 8 weeks of one another and determined that all three mothers had worked for the same tomato grower . All thrThe CCHD searched the Healthy Start program records for other birth defects cases born between December 2004 and February 2005 and whose parents had the potential for exposure to agricultural pesticides. No additional cases were identified. Medical records on the three mothers and their infants were obtained and reviewed by the CCHD and the state health departments in Florida and North Carolina. Charles A. Williams, a clinical geneticist and professor of pediatrics and genetics at the University of Florida, College of Medicine  reviewed case summaries obtained from the medical records and provided the descriptions of the birth defects. Exposure information was obtained from NCDACS and the Florida Department of Agriculture and Consumer Services (FLDACS), which obtained pesticide application and worker assignment records from the grower. Additionally, each of the mothers and fathers were interviewed in early 2005 by CCHD. The mothers of case 1 and case 2 were also interviewed in 2006 by NCDHHS.Because of the imprecision of the conception date, there is also imprecision in the calendar days that correspond to the maximal sensitivity period for any given birth defect. As the window of maximal sensitivity shifts, the number of days involving pesticide exposure may also change. Therefore, a range of days is provided to reflect the minimum and maximum number of days of pesticide exposure during the maximal sensitivity period. In addition, because workers often worked in several agricultural fields on a given day and because the specific hours worked in each field were not available, days of pesticide exposure were categorized into “probable days” and “possible days.” Probable days are those days when the mother was scheduled to work in a field that had a restricted entry interval (REI) in effect the entire day. Possible days consist of days when the mother was scheduled to work in a field that had an REI that was in effect for only a portion of the day. On possible days, it is conceivable that the mother did not work in the field when the REI was in effect. This would be the case if she worked only before the pesticide application occurred, or only after the REI had expired. According to the Worker Protection Standard (WPS), after the application of any pesticide on an agricultural establishment, the agricultural employer shall not allow or direct any worker to enter or to remain in the treated area before the REI has expired, unless the worker is provided appropriate personal protective equipment (PPE) . There iInformation on the three cases is provided in This infant was born with tetra-amelia  . The parThis infant was born with mild Pierre Robin syndrome . The father of this child has micrognathia. During gestational days  14–57, this child’s mother worked in violation of the REI for up to 8 days. On seven of these days, the pesticides applied to the fields where the mother worked included methamidophos. In addition, on gestational days 7 and 10, the mother worked in fields when an REI was possibly in effect . The mother has three other living children, none of whom are known to have birth defects. This mother also had one previous stillbirth but without obvious birth defects.This infant had multiple severe malformations including cleft lip and palate, imperforate anus, solitary kidney, vertebral anomalies, dysplastic low-set ears, and ambiguous genitalia. These findings are quite reminiscent of a severe type of the Goldenhar Syndrome . Death occurred at 3 days of age. During gestational days 14–59, the mother worked in violation of REIs for up to 10 days. On eight of these days, the REI for methamidophos was in effect on some of the fields where the mother worked. Abamectin and methylpyrrolidone were applied to some of the fields on two other days, but the mother may have worked in those fields before the applications were made. The mother had two previous pregnancies. One pregnancy 3 years earlier involved a malformed fetus and ended in miscarriage. The mother could not recall her employment or whether she had any toxic exposures during that pregnancy. The other previous pregnancy resulted in a normal child.None of the three mothers reported tobacco or alcohol use, and none reported taking prescription, over-the-counter, or folk medications. Maternal infections  were ruled out as a cause of the birth defects based on data available in the medical records. All three mothers are Mexican, have undocumented U.S. immigrant status , and sought pre-natal care late in their pregnancies. All three mothers reported morning sickness, but none reported to the crew leader or grower that they were acutely poisoned by pesticides while pregnant. Information on housing conditions during the pregnancies was unavailable. Each child’s father was also employed as a farm-worker for the same grower as the three mothers. Unfortunately, information on the three fathers’ pesticide exposures was unavailable.Approximately 956 farmworkers were employed at the Florida location and 500 at the North Carolina location, 20% of whom were women. The identity of the female farm-workers was not provided by the employer. Thus, identification of other workers who gave birth in 2004 or 2005 was not possible.In 2005, the Florida and North Carolina farms were inspected by FLDACS and NCDACS, respectively. A large number of violations were identified, and the grower received among the largest fines ever imposed by these enforcement agencies. Violations identified by both agencies included failure to prevent workers from entering pesticide-treated fields before REI expiration, and failure of pesticide handlers to understand all pesticide label requirements. NCDACS also documented failure to provide drinking water and water for routine washing, whereas FLDACS did not report on the availability of water.Three farmworkers giving birth to infants with birth defects within an 8-week period is cause for concern. In Florida, approximately 3% of live births have major birth defects. There is evidence to suggest that the three observed major birth defects exceed this expected rate. To obtain the observed birth defects rate among these farmworkers, one needs the number of births for the period in question. Unfortunately, there is no accurate information on the fertility rate among female farm-workers employed in Florida. However, based on Collier County, Florida, Hispanic birth rates , it is eThe etiology of most human birth defects cases is unknown . HoweverThere are serious concerns that during the period of organogenesis all three mothers were exposed early in pregnancy to pesticides shown to be teratogenic in animals. Furthermore, some of these exposures may have been high because, according to the grower’s records, the mothers worked in fields in which the REI had not expired.Mancozeb and its metabolite ethylenethiourea (ETU) have been shown to produce limb defects and cleft palate after high oral doses were given to rats . ETU hasThe mother of case 3 has evidence of 8 workdays (4 probable and 4 possible days) of exposure to methamidophos, which has evidence for teratogenicity in mice and rats . On at lThe mother of case 2 had only one probable day working in violation of an REI during the maximal sensitivity period, the fewest number of the three mothers. However, this mother had 8 days possibly involving work in violation of an REI. The one probable day and six of the possible days involved exposure to methamidophos. We are unaware of animal evidence for an association between the birth defects found in case 2 and methamidophos exposure; however, mancozeb and its metabolite ETU have been shown to produce abnormal shortening of the mandible . AlthougSome may question whether this is a true cluster because each of the babies had a different constellation of defects, and none of the pesticides to which the mothers were probably exposed can be linked  to all of the observed defects. However, the differences in the birth defects identified in this cluster may be attributed to the differences in the conception dates, the differences in the work histories of the three mothers, and the large number of chemicals used by the grower. There is evidence to suggest that each mother was exposed to pesticides during the maximal sensitivity period for the organ system/structure that was affected.As demonstrated in All three mothers had the potential for three routes of exposure: dermal, inhalation, and oral. It is not possible to determine which route most contributed to their internal dose of pesticides. Many host, agent, and environmental factors affect the relationship between the potential exposure and the resulting absorbed dose . When thThere is no evidence that the three mothers described in this report experienced toxicity associated with their gestational pesticide exposures. Although many teratogenic exposures also produce adverse effects on the mother, there are exceptions. For example, a study in which rats were administered a dermal dose of 50 mg/kg body weight/day of ETU on days 12 and 13 of gestation produced malformations in all fetuses  but produced no substantial acute effects on the dams . AnotherAlthough evidence of acute pesticide poisoning among the three mothers is absent, limited contemporaneous means were available to identify maternal pesticide toxicity. Their undocumented immigrant status and lack of health insurance limited their access to medical care, as evidenced by the fact that none of the three mothers received prenatal care before the second trimester of pregnancy. Furthermore, because the mothers may not have known the symptoms associated with pesticide toxicity, any such symptoms may have been attributed to their pregnancy. All three mothers reported morning sickness, whose symptoms such as nausea and headache can resemble pesticide poisoning.There are several limitations with this report. Because a complete cohort of the grower’s employees could not be ascertained, it was not possible to fully characterize their birth defect risk. Because some birth defects are not diagnosed for months to years after birth, it is possible that additional undetected birth defects exist among this farmworker cohort. Although the presence of family history for case 2 and the multiple, complex defects for case 3 suggest the likelihood of a genetic etiology, it was not possible to conduct evaluations of genetic causes. Information on pesticide exposure was based on company records, which may be inaccurate. Because pesticide biomonitoring and environmental sampling were not performed, the mothers’ exposures could not be compared with the high doses used in animal testing to produce developmental effects. In addition, all three mothers received late prenatal care, and nutritional supplementation was not begun until after prenatal care commenced. Moreover, previous reports of clusters of birth defects and presumed occupational exposures have, in light of additional evidence, been found to be more complicated problems or related to factors not measured in the original studies . FinallyDespite these limitations and the lack of a clear etiology for the observed birth defects, the case series raises serious concerns that some farmworkers may experience unsafe pesticide exposures when pesticide label directions are not followed . These e