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https://twitter.com/KeystoneHPSR
Building the HPSR Community Building HPSR Capacity
KEYSTONE
Inaugural KEYSTONE Course on Health Policy and Systems Research 2015
Health Policy & Systems Research Frameworks – 2
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Health Policy & Systems Research Frameworks – 2
(Research questions)
Kabir Sheikh
24 Feb 2015
KEYSTONE
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Generating and framing HPSR
questions
IHPSR Presentation 4
www.hpsa-africa.org
@hpsa_africa
www.slideshare.net/hpsa_africa
Introduction to Health Policy and Systems Research
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Four key steps in HPSR1. Identify research focus
(problem/concern/opportunity) and question
2. Design study 3. Ensure quality and rigour4. Apply ethical principles
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Key issues in this session
• Starting points for HPSR questions• Different kinds of HPSR questions • What is a ‘good’ HPSR question• How to generate substantively
relevant questions
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• The question drives the study
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Generating questions• Starting points = focus/terrain of health policy
& health systems– consider level (macro/meso/micro/cross-
level)• And consider
– What are research users’ ideas?– What past work?– Disciplinary perspectives?
• Thinking about purpose of research: normative vs exploratory/ descriptive/ explanatory questions
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Start with the problem/concern/opportunity
and aim to inform decision-making
by policy and system actors
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Whose ideas?
Research question
Community group
Patient group
District manager
Hospital managerNational
managerInternational agency
Researcher
Same issue, different questions?
Different issues & questions?
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What wider knowledge?• Look at international experience
(replicate don’t duplicate) – importance of literature review: add
to the literature! • Use theory (relevant empirical
and theoretical resources)
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Why do you want to do your study/What do you want to do in your study?
Do you want to • test an intervention• measure impacts or understandings• understand a phenomenon• act in a situation to improve it
what you want to do may say something about your understanding of knowledge and action
this understanding is the foundation of your study
From CHEPSAA
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What is the study ‘purpose’?
Normative/evaluative: Seeks to generate/identify norms, best practices,’gold standard’ interventionsExploratory: To find out what is happening, especially in little understood situationsDescriptive: To give accurate profile of people, events, situationsExplanatory: To explain patterns relating to phenomenon being researched; To identify relationships between aspects of phenomenonEmancipatory: To create opportunities and the will to engage in social actionRobson, 2002; Thomas, Chataway & Wuyts, 1998; Yin, 2009
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NormativeImpact?Is it best?What is best practice?
ExploratoryWhat+? (new insights)
DescriptiveWho? What? Where? How many? How much?
ExplanatoryWhy and how?
Action/ participatory research
From purpose to question form
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From purpose to question ...Purpose Why adopt
that purpose?
Questions
Normative(positivist)
To generate ‘best’ practice ideas
• Does intervention x work?• Which intervention for issue y is
most effective?Exploratory(realist/relativist)
To find out what is happening, when little is known
• What categories of information are used in decision-making?
• What are the social processes, including power relations, influencing actors’ understandings and experiences, and shaping impacts of interventions?
Descriptive(positivist/ realist)
To give accurate profile of people, events, situation
• What is the quality of care in place q?
• What is the level of health worker motivation in place z?
• What are stakeholder positions on policy A?
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Purpose Why adopt that purpose?
Questions
Explanatory (some control over events)(positivist)
To explain relationships, assuming fairly linear causality
• Do managers influence facility performance? How?
Exploratory/Explanatory;Explanatory(little control over events)(relativist/realist)
To identify and explain relationships, assuming complex causality
• How and why does management influence facility performance?
• When and under what circumstances does management influence facility performance?
Emancipatory(critical perspective)
Draw on expertise of practitionersEncourage practice changes
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Problem: unequal availability of doctors
How can we make doctors
stay on in villages?
Why do most
doctors leave?
Why do some
doctors stay on?Can we
replace doctors with
other workers?
Can they provide quality
services?
Evaluative
Strategic / normative Diagnostic Exploratory
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Need more balance in questions asked
• Past emphasis on normative/evaluative work and ‘generalisable’ answers
• More work on exploratory and explanatory questions considering socio-cultural-political understandings of health systems
Sheikh et al., 2011
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Sheikh et al., 2011
Level of analysis
Macro (architecture)
Meso (organisation/ intervention)
Micro(individual)
Normative/evaluative
How can political parties be effectively involved in a country’s process of planning universal coverage?
What are the reasons for the low efficiency of community governance structures that administer a decentralised fund scheme?
Does individual coaching offer better support to health system managers than individual training?
Exploratory/ explanatory
What norms underpin effective oversight by communities?
How do ‘pay for performance’ arrangements interact with local accountability structures?
Why do front-line providers frequently diverge from recommended clinical guidelines?
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What makes a ‘good’ HPSR question?
Adapted from Robson, 2002• Substantively relevant: worthwhile, non-
trivial questions, worthy of the effort to be expended +
• Clear: unambiguous and easily understood +• Specific: sufficiently specific to be clear about
what constitutes an answer + • Answerable: can see what data are needed
to answer it and how those data will be collected +
• Interconnected: questions are related in some meaningful way, forming a coherent whole
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What makes a ‘good’ HPSR question? (continued)
Adapted from Robson, 2002
• Substantively relevant – How questions are generated >> will build
on what is known not duplicate it, will assist system development in a particular context
• Clear, specific, answerable, interconnected– How questions are framed/worded >> pay
attention to the details: scope (time, place, people), concepts
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Generating substantively relevant
questions• Talk to people in the system of
focus– What do they know and understand?– What do they see as important and
useful? – What do they identify as knowledge
gaps?
• Review the literature– What knowledge has already been
generated locally, internationally?
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Types of literature reviews
Go find the resources – lots out there!
Also qualitative
review & synthesis!
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Review basics1. Identify the review question or focus2. Frame the area you are searching (year, area or
topic)3. Search for primary studies and theoretical papers
(using databases, search engines, or a particular publication)
4. Select papers – inclusion/exclusion criteria; quality appraisal (assess relevance & rigour of what you find)
5. Collect the key items or extract the data6. Review papers & data7. Synthesis (make meaning, pull together a coherent
argument)
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‘Critical Appraisal’• The art of providing a reasonable evaluation of a text by
breaking it down and studying its parts• To be critical does not necessarily mean to criticise in a
negative manner• Requires you to question the information and opinions in a
text and present a reasonable analysis• ‘Analysis’ means to evaluate the strengths and weaknesses
of the text (or research report), based on clear criteria – and with an understanding of the text’s purpose, the intended audience and why it is structured in the way it is
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