Building the field of health policy and system research: social science matters

Policy ForumBuilding the Field of Health Policy and Systems Research:Social Science MattersLucy Gilson1,2*, Kara Hanson2, Kabir Sheikh3, Irene Akua Agyepong4, Freddie Ssengooba5, SaraBennett61 School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa, 2 Department of Global Health and Development, London School ofHygiene and Tropical Medicine, London, United Kingdom, 3 Public Health Foundation of India, New Delhi, India, 4 Ghana Health Service/School of Public Health,University of Ghana, Accra, Ghana, 5 School of Public Health, Makerere University, Kampala, Uganda, 6 Health Systems Programme, Johns Hopkins Bloomberg School ofPublic Health, Baltimore, Maryland, United States of AmericaIntroduction tives, as well as shared concerns. Richer PLoS Medicine Series on HPSR methodologies for addressing these con- The first paper in this series on building cerns must then be developed. And, asthe field of Health Policy and Systems Following the First Global Sympo- sium on Health Systems Research in health policies and systems are themselvesResearch (HPSR) in low- and middle- social and political constructions, it isincome countries (LMICs) [1] outlined the Montreux in November 2010, PLoS Medicine commissioned three arti- important to acknowledge the particularscope and questions of the field and value of social science perspectives in the cles on the state-of-the-art in Healthhighlighted the key challenges and oppor- field. Each of these issues is addressed in Policy and Systems Research (HPSR).tunities it is currently facing. This paper Three Policy Forum articles, au- the following sections, and they areexamines more closely one key challenge, thored by a diverse group of global considered further in paper three of thethe risk of disciplinary capture—the im- health academics, critically examine series [4].position of a particular knowledge frame the current challenges to the fieldon the field, privileging some questions and lay out what is needed to build Knowledge Paradigmsand methodologies above others. In capacity in HPSR and support localHPSR the risk of disciplinary capture policy development and health sys- Figure 1 characterises key areas ofcan be seen in the current methodological tems strengthening, especially in difference between the dominant knowl-critique of the field, with consequences for low- and middle-income countries. edge paradigms that underpin the disci-its status and development (especially plines applied within HPSR. The figurewhen expressed by research leaders). Paper 1. Kabir Sheikh and col- deliberately polarises the paradigms to The main criticisms are reported to be: leagues. Building the Field of Health spark debate. Some disciplines are domi-that the context specificity of the research Policy and Systems Research: Fram- nated by a particular paradigm and somemakes generalisation from its findings ing the Questions. are spread across paradigms.difficult; lack of sufficiently clear conclu- The positivist worldview is reflected in Paper 2. Lucy Gilson and colleagues.sions for policy makers; and questionable much clinical, biomedical, and epidemio- Building the Field of Health Policyquality and rigour [2]. Some critique is and Systems Research: Social Sci- logical, and some social science, research.certainly warranted and has come from ence Matters. This view starts from the same position asHPS researchers themselves. However, the natural and physical sciences. Thethis critique also reflects a clash of Paper 3. Sara Bennett and col- phenomena being investigated comprise aknowledge paradigms, between some of leagues. Building the Field of Health set of facts, a single reality that canthose with clinical, biomedical, and epide- Policy and Systems Research: An be observed and measured by themiological backgrounds and those with Agenda for Action. researcher without disturbing them. Thesocial science backgrounds. Yet, as HPSR central aim of research is to detect causalis defined by the topics and questions it mechanisms through the deductive processconsiders rather than a particular disci- of testing hypotheses derived fromplinary approach, it requires engagementacross disciplines; indeed, understanding Citation: Gilson L, Hanson K, Sheikh K, Agyepong IA, Ssengooba F, et al. (2011) Building the Field of Healththe complexity of health policy and Policy and Systems Research: Social Science Matters. PLoS Med 8(8): e1001079. doi:10.1371/jour-systems demands multi- and inter-disci- nal.pmed.1001079plinary inquiry [3]. Published August 23, 2011 To develop the science of HPSR it is, Copyright: ß 2011 Gilson et al. This is an open-access article distributed under the terms of the Creativetherefore, important to start by recognis- Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium,ing the diversity of disciplinary perspec- provided the original author and source are credited. Funding: No specific funding was provided for writing this article.The Policy Forum allows health policy makers Competing Interests: The authors have declared that no competing interests exist.around the world to discuss challenges and Abbreviations: HPSR, Health Policy and Systems Research; LMIC, low- and middle-income country.opportunities for improving health care in theirsocieties. * E-mail: lucy.gilson@uct.ac.za Provenance: Commissioned; externally peer reviewed. PLoS Medicine | www.plosmedicine.org 1 August 2011 | Volume 8 | Issue 8 | e1001079

Summary Points how to strengthen health systems to benefit those being served by them. The N All researchers hold a knowledge paradigm that frames their understanding of complexity of the phenomena being investigated may also generate a willingness reality and of the functions and nature of research. Some disciplines are dominated by a particular paradigm and some are spread across paradigms. to think creatively about how to investigate issues. Therefore, HPS researchers tend N The criticisms that Health Policy and Systems Research (HPSR) is too context not to fall at the extreme ends of the specific, does not offer clear lessons for policy makers, and is not rigorous are partly a reflection of differences in knowledge paradigms between those with spectrum outlined in Figure 1—and this predominantly clinical, biomedical, and epidemiological backgrounds, under- makes multi- and inter-disciplinary work pinned by a positivist paradigm, and those with social science backgrounds more possible. underpinned by a relativist paradigm. Review of existing HPSR work demon- N Health policies and systems are complex social and political phenomena, strates, moreover, that bringing together research from different traditions gener- constructed by human action rather than naturally occurring. Relativist social science perspectives are, therefore, of particular relevance to HPSR as they ates broader and deeper understanding on recognise that all phenomena are in essence constructed through human the issues of focus. Box 1, for example, behaviour and interpretation. shows the breadth of questions that have N Social science insights that can advance the science of HPSR include been addressed around one critical HPS issue for LMICs, user fees; and the approaches to generalising from rich understanding of context; supporting policy learning; and enhancing research rigour and quality. different papers examining the household level impacts of out of pocket payments together provide deeper and richer in-theory and past experience against empir- researchers study human behaviour in sights on these experiences than wouldical facts. At their simplest, such mecha- everyday or natural settings, gener- come from one perspective alone.nisms represent the prediction that ‘‘x will ating qualitative data that are primarilycause y’’ in any other setting. Simple analysed inductively to generate categories Learning from Relativist SocialHPSR hypotheses might include, for and explanations of experience. Such Science Perspectivesexample, ‘‘limited financial incentives analysis also involves interpretation bycause low motivation’’ or ‘‘a lack of health the researcher, in interaction with Health policies and systems are funda-facilities undermines access to health respondents. It may be guided by, and/ mentally shaped by political decision-services.’’ Sometimes such hypotheses are or generate, what is called middle range making, whilst the routines of healthtested through statistical analysis of sec- theory, i.e., ideas about how the world systems are brought alive through theondary data [5]; sometimes studies are works, comprising categories and concepts relationships among the actors involved indesigned to allow hypotheses to be tested derived from analysis, and suggestions managing, delivering, and accessing health[6]. Indeed, the positivist perspective about how they are linked together. care, and engaged in wider action tounderpins the recent rise of experimen- Middle range theory may be tested against promote health, including researcherstal methodology in impact evaluation. evidence through the process of analysis or [11]. In essence, therefore, health policiesAs the emphasis in such studies is on highlights questions and ideas to be and systems are constructed throughmeasuring the magnitude of an interven- considered in future studies. human behaviour and interpretation,tion’s impact, and ensuring that this Relativist HPSR studies focus, for rather than existing independently ofestimate is unbiased, careful attention is example, on how health system actors them. As relativist social science perspec-paid to selecting an appropriate control understand and experience particular ser- tives see all phenomena as at least partiallygroup (randomized or otherwise) and vices or policies [7], and what social and constructed in this way, they have partic-controlling the influence of possible con- political processes, including power rela- ular value in building the methodologicalfounding factors. Much less emphasis is tions, influence them [8,9]. The develop- foundations of HPSR. Three contributionsplaced on understanding how the inter- ment and testing of middle range theory is are discussed here: generalising from richvention works and which contextual or also supported by studies that adopt a contextual understanding; supporting pol-other factors mediate its impact. critical realist position. This knowledge icy learning; and approaches to ensuring Much social science work that is paradigm falls somewhere in the spectrum research rigour.qualitative is located at the relativist end between positivism and relativism, and isof the spectrum. Such research is essen- of growing interest in HPSR [10] (see Taking Account of Context intially based on the understanding that the FEMhealth, http://www.abdn.ac.uk/fem- Drawing out Generalisationsworld around us is subject to human health/). However, these sorts of questions Multiple contextual factors influence theinterpretation. Health policies and systems are still only quite rarely addressed in the working of health systems. Health workerare, therefore, understood to be con- wider HPSR literature [1]. motivation, for example, reflects a range ofstructed and brought alive by social personal, organisational, and societal fac-actors through the meaning they attach to Shared Concerns and the Value tors, including relationships with others,(their interpretations of) their experiences. of Multiple Perspectives and itself influences many aspects of theWhereas positivist researchers focus on provision of health care. Similarly, pa-facts and regularities (that is, causes and Although HPS researchers from differ- tients’ decisions to use services, or adhereeffects), relativist researchers see inter- ent disciplinary traditions have some to treatment advice, are responses to manypretations as the primary subject of difficulty understanding each other’s per- contextual factors: their own understand-inquiry, proposing that different interpre- spectives, they also have some shared ings of illness, and how best to treat it;tations of the same experience represent starting points: a common focus, health advice received from friends and family;multiple realities. In this tradition, policies and systems, and a concern about past experience of health providers; the PLoS Medicine | www.plosmedicine.org 2 August 2011 | Volume 8 | Issue 8 | e1001079

Figure 1. Core differences between knowledge paradigms.doi:10.1371/journal.pmed.1001079.g001availability of cash to cover costs; and the particular experiences situated within their tion (Box 2). The aim in such analysis isgender dynamics influencing household context that allow understanding and not to draw conclusions that can bedecision-making. There are also multiple explanations of the phenomena of focus statistically generalised to a wider studyinterpretations of the same experience as by reference to that context [12]. For population, or that will hold across timedifferent people bring different contexts to example, a study of Brazilian health and place. Instead, analytic generalisationbear on its interpretation. Health workers, system decentralisation, involving anthro- entails the development of general conclu-for example, respond differently to the pological work in three case study areas, sions that, although derived from a limitedsame financial incentive, and patients vary investigated the factors shaping the extent number of particular experiences, providein their response to treatment advice. The of local decision-making actually achieved, theoretical insights that can be put forwardcausal mechanisms underpinning the with consequences for quality of care for consideration, and testing, in other,changes brought about by new health improvement possibilities. A range of similar situations. This includes middlepolicies or health system interventions are, contextual factors were influential, includ- range theory, as outlined earlier, andthus, complex. ing political relationships among layers of theory that offers ideas about the causal As a result, investigation of HPS issues government, the potential of generating mechanisms likely to underpin interven-demands research that seeks to understand tax revenue at the local level, differences tions that achieve their goals.and explain experiences by reference to between rural and urban areas in thethe many layers of their context, whilst opportunities for community participationacknowledging the often quite different in decision-making, and existing patterns Active Support for Policy Learninginterpretations of experience across peo- of political patronage; and these also Health research has traditionally seenple. Reducing relevant contextual factors combined with individual management knowledge generation as essentially ato a set of simple quantifiable measures for styles and health worker commitment to process of adding to the existing stock ofstatistical analysis is, simply, difficult. On the local area [13]. facts and predictions, with researchersthe other hand, case study research, widely In studies with multiple cases, system- acting largely as disinterested scientistsused in organisational and political science atic and deliberate cross-case comparison feeding evidence into the decision-makingwork, supports the ‘‘thick descriptions’’ of supports, moreover, analytic generalisa- process [14]. Learning from that knowl- PLoS Medicine | www.plosmedicine.org 3 August 2011 | Volume 8 | Issue 8 | e1001079

Box 1. Drawing on Different Perspectives to Understand and tacit knowledge in active debate with Explain Experiences of User Fee Policy Change in Low- and policy makers [15]. Thus, some social Middle-Income Countries scientists argue that in addressing problems that matter in their own communi- Assessing household level impacts ties, researchers should pay particular attention to the ways in which values and Positivist perspectives: power shape those problems and responses N What is the impact of out of pocket payments on household poverty levels to them [17], assisting policy actors to negotiate mutually acceptable solutions to across countries? problems, and ensuring that underrepre- # Cross-national statistical analysis [5] (health economics) sented groups are heard [18]. For others, N What is the impact of user fee removal on aggregate patient utilisation and building the possibility of such action into research design is an ethical requirement across different patient socioeconomic groups within one country? and key hallmark of good quality research # Before and after statistical analysis [24] (health economics) [19]. Relativist perspectives: Social science perspectives, therefore, challenge the HPSR community to think N How do pocket payments combine with other influences over health-seeking more deeply about how to support policy behaviour to impact on the dynamics of household poverty? and system change through their research, # Mixed method study involving longitudinal household case studies [22] including how to address the thorny issue (development sociology, health economics) of the boundary between researcher and advocate. For example, what sorts of Explaining policy implementation experiences participatory and action research with Critical realist and relativist perspectives: citizens, health managers, and health workers can support the reflective enquiry N What political forces led to user fee introduction/removal, and why was equity that generates positive change in current neglected as a policy goal? practices? And should and can we initiate # Qualitative study [25] (social anthropology, policy analysis) processes that stimulate public debate about research findings—such as active N How does the process of implementing user fee removal influence health media engagement, debates on public worker morale? platforms, or engagement with civil society # Multiple method study within overarching qualitative approach [26] organisations? (sociology, policy analysis) N How is the process of implementing user fees, in interaction with other policies, Ensuring Research Rigour influenced by wider societal forces? For some traditions of health research, validity and reliability are the hallmarks of # Ethnographic study [27] (anthropology) rigorous research, and are ensured through careful study design, appropriate tool devel-edge then entails the simple transfer of lation sometimes see this process as quite opment and data collection, and correctknowledge from one setting to another linear [16]. approaches to statistical analysis. In contrast,[15]. Even current HPSR debates about However, for a relativist, researchers relativist (qualitative) social science researchthe importance of getting research into contribute to the process of learning as is premised on the understanding that therepolicy and practice and knowledge trans- active participants, using both formal and are multiple realities, reflecting actors’ different understandings of common experiences (Figure 1). These understandings are Box 2. An Example of Analytic Generalisation [28] either seen to have significant influence over A study of the factors underpinning successful family planning programmes the issues of focus or to be the focus of involved work in eight country cases. In each country a rich description of the inquiry. Researchers from this tradition, evolution of programme development over time was developed, based on moreover, aim not just to identify and report qualitative interviews with policy elites and documentary data analysis. such understandings, but instead, through analysis and engagement, to produce their The countries were paired on the basis of similar socioeconomic development, own interpretations of them, explaining why but in each pair one country had a strong and one a weak, family planning and how actors behave and think as they do. programme. Comparison of experience within and across pairs, suggested that For relativist research, the ‘‘trustworthiness governments’ commitment to family planning programmes was influenced by of researchers’’’ interpretations is the key the process of their development and implementation. hallmark of research rigour, implying that the interpretation is widely recognised to More specifically, three factors were identified as likely to underpin successful have value beyond the particular examples family planning programmes: coalitions among elite groups with influence over considered. Such trustworthiness is, in health policy, that support effective programme development; spreading the risk essence, negotiated between researchers associated with the sensitive issue of family planning among groups and over time; and having a clear and stable organisational structure in charge of and research users on the basis of transpar- implementation, as well as adequate funding. These conclusions were the general ent information on study design and the insights put forward for consideration and testing in other settings. processes of data collection, analysis, and interpretation. Table 1 summarises the PLoS Medicine | www.plosmedicine.org 4 August 2011 | Volume 8 | Issue 8 | e1001079

Table 1. Processes for ensuring rigour in case study and qualitative data collection and analysis [20,29]. Principle Example: A study of the influence of trust in workplace relationships over health worker motivation and performance, involving in-depth inquiry in four case studies [30] Prolonged engagement with the subject of inquiry Case study: Although ethnographers may spend years in the field, HPSR tends A period of three to four weeks spent in each case study facility to draw on lengthy and perhaps repeated interviews with respondents, Respondents and/or days and weeks of engagement within a case study site Informal engagement & repeated formal interviews Use of theory Conceptual framework derived from previous work To guide sample selection, data collection and analysis, and to draw into Case study selection based on assumptions drawn from framework (see below) interpretive analysis Theory used in triangulation and negative case analysis (see below) Case selection Four primary health care facilities: two pairs of facility types, & in each pair one well Purposive selection to allow prior theory and initial assumptions and one poorly performing as judged by managers using data on utilization and to be tested or to examine ‘‘average’’ or unusual experience tacit knowledge (to test assumptions that staff in ‘‘well performing’’ facilities have higher levels of motivation and workplace trust) Sampling In small case study facilities, interviewed all available staff; in larger facilities, Of people, places, times, etc., initially, to include as many as possible interviewed a purposive sample of staff from each of the staff groups within the of the factors that might influence the behavior of those people central facility (considering e.g., age, sex, length of time in facility); interviewed random to the topic of focus (subsequently extend in the light of early findings) sample of patients visiting each facility; interviewed all facility supervisors and area Gather views from wide range of perspectives and respondents rather manager than letting one viewpoint dominate Multiple methods (case studies) For each case study site: Two sets of formal interviews with all sampled staff Researcher observation & informal discussion Interviews with patients Interviews with facility supervisors and area managers Triangulation Within cases: Looking for patterns of convergence and divergence by comparing results Initial case reports based on triangulation across all data sets for that case (and across multiple sources of evidence (e.g., across interviewees, and between across analysts in terms of individual staff members’ experience), generating overall interview and other data), between researchers, across methodological judgments about facility-wide experience as well as noting variation in individual approaches, with theory health worker experience Cross-cases: Initial case reports compared with each other to look for common and different experiences across cases, and also compared with theory to look for convergence or divergence Negative case analysis Within cases: Looking for evidence that contradicts your explanations and theory, Triangulation across data identified experiences that contradicted initial and refining them in response to this evidence assumptions (e.g., about the influence of community interactions over motivation, and about the association between low motivation and poor caring behaviour), and identified unexpected influences (e.g., a general sense of powerlessness among health workers) Cross-cases: Cross-site analysis identified facility-level experience that contradicted the initial assumptions underpinning the study (e.g., about the link between high levels of workplace trust, strong health worker motivation, and positive caring behaviour), and identified unexpected conclusions (e.g., about the critical importance of facility- level management over trust and motivation) Report notes weak evidence to support links between levels of workplace trust and client perceptions, but also stronger evidence of links between levels of workplace trust and motivation Peer debriefing and support Preliminary case study reports initially reviewed by other members of the research Review of findings and reports by other researchers team Respondent validation (member checking) Preliminary cross-case analysis fed back for review and comment to study Review of findings and reports by respondents respondents; feedback incorporated into final reports Clear report of methods of data collection and analysis (audit trail) Report provides clear outline of methods and analysis steps as implemented in Keeping a full record of activities that can be opened to others practice (although on reflection, could be fuller and more reflexive) and presenting a full account of how methods evolved to the research audience doi:10.1371/journal.pmed.1001079.t001critical steps researchers must take to ensure particular approaches to research rigour stages of research must always be con-that their analysis is both based on rich relevant to the specific paradigm of ducted with caution. Rigorous investiga-insight into the experience examined and knowledge underpinning any study. How- tion involves the following [19–21]:has been subject to challenge, and to offer a ever, because of the complexity of thetransparent account of their research processto the user. issues investigated, social science perspectives on rigour offer valuable insights for N an active process of questioning and checking in inquiry—asking how and At a minimum, improving the quality of all empirical HPSR. As HPSR is often why things happened and not onlyHPSR requires paying due attention to the more investigation than observation, all what happened, checking answers to PLoS Medicine | www.plosmedicine.org 5 August 2011 | Volume 8 | Issue 8 | e1001079

questions to identify further issues that Finally, although currently rarely con- HPSR, thus, demands we take steps to need to be followed up to deepen ducted in HPSR, mixed-method research build understanding across disciplinary understanding of the experience; in which qualitative and quantitative boundaries, for example, by ensuring thatN a constant process of conceptualising analyses are undertaken sequentially, with one stage of work deliberately feeding into we can speak each other’s languages around generalisability and knowledge and reconceptualising—using ideas and theory to develop an initial understand- the next [22], offer important opportuni- generation; sharing experience of supporting of the problem or situation of focus ties for the triangulation across methods ing policy learning; and clarifying expec- to guide data collection, but using the and knowledge paradigms that can broad- tations of each other’s disciplinary culture. data collected to challenge those ideas en and deepen investigation of health Valuing social science perspectives and and assumptions and when necessary, to policy and systems issues [23]. building interdisciplinary understanding revise your ideas in response to the both represents the cutting edge of HPSR evidence; Conclusions and demonstrates that the field is at aN crafted, interpretative judgements— The current interest in HPSR provides scientific cutting edge. based on enough evidence, particularly about context, to justify the conclu- exciting opportunities for the field, but also Author Contributions sions drawn, as well as deliberate brings the threat of ‘‘disciplinary capture’’ by the clinical, biomedical, and epidemi- Wrote the first draft of the manuscript: LG KH consideration of contradictory evi- KS IA FS SB. Contributed to the writing of the dence (negative case analysis) and ological disciplinary perspectives domi- manuscript: LG KH KS IA FS SB. ICMJE review of initial interpretations by nant in wider health research. Yet, social criteria for authorship read and met: LG KH respondents (member checking); science perspectives are vital to HPSR. KS IA FS SB. Agree with manuscript’s results Health policies and systems are complexN researcher reflexivity—being explicit social and political phenomena, construct- and conclusions: LG KH KS IA FS SB. about how your own assumptions may influence your interpretation, ed by human action rather than naturally and testing them in analysis. occurring. Advancing the science ofReferences1. Sheikh K, Gilson L, Agyepong IA, Hanson K, World Health Organization. Bull World Health 21. Thomas A, Chataway J, Wuyts M, eds (1998) Ssengooba F, Bennett S (2011) Building the field Organ 87(8): 608–613. 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Building the field of health policy and system research: social science matters

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