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KEYSTONE / Module 4 / Slideshow 2 / Health Policy & System Research Frameworks - 2


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KEYSTONE HPSR Initiative // Module 4: Health Policy & Systems Research frameworks // Slideshow 2: Health Policy & Systems Research Frameworks - 2
This is the second slideshow of Module 4: Health Policy and Systems Research frameworks, of the KEYSTONE Teaching and Learning Resources for Health Policy and Systems Research

To access video sessions and slides for all modules copy and past the following link in your browser:

Module 4: Health Policy & Systems Research frameworks
Health systems are knowable and researchable and their study calls for a range of inputs from different disciplines. Different questions and different understandings of health system problems lend themselves to different and complementary research approaches under the HPSR umbrella. Evolving concepts of ethics and rigour in HPSR are also delineated and knowledge translation as being integrated and continuous with the production of knowledge in HPSR is also considered.

There are 3 slideshow in this module.

Module 4: Health Policy & Systems Research frameworks
-Module 4 Slideshow 1: Health Policy and Systems Research Frameworks -1
-Module 4 Slideshow 2: Health Policy and Systems Research Frameworks - 2
-Module 4 Slideshow 3: Health Policy and Systems Research Frameworks - 3

The other modules in this series are:
Module 1: Introducing Health Systems & Health Policy
Module 2: Social justice, equity & gender
Module 3: System complexity
Module 5: Economic analysis
Module 6: Policy analysis
Module 7: Realist evaluation
Module 8: Systems thinking
Module 9: Ethnography
Module 10: Implementation research
Module 11: Participatory action research
Module 12: Knowledge translation
Module 13: Preparing a Research Plan

KEYSTONE is a collective initiative of several Indian health policy and systems research (HPSR) organizations to strengthen national capacity in HPSR towards addressing critical needs of health systems and policy development. KEYSTONE is convened by the Public Health Foundation of India in its role as Nodal Institute of the Alliance for Health Policy and Systems Research (AHPSR).

The inaugural KEYSTONE short course was conducted in New Delhi from 23 February – 5 March 2015. In the process of delivering the inaugural course, a suite of teaching and learning materials were developed under Creative Commons license, and are being made available as open access resources. The KEYSTONE teaching and learning resources include 38 videos and 32 slide presentations organized into 13 modules. These materials cover foundational concepts, common approaches used in HPSR, and guidance for preparing a research plan.

These resources were created and are made available through support and funding from the Alliance for Health Policy & Systems Research (AHPSR), WHO for the KEYSTONE initiative.

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KEYSTONE / Module 4 / Slideshow 2 / Health Policy & System Research Frameworks - 2

  1. 1. Building the HPSR CommunityBuilding HPSR Capacity KEYSTONE Inaugural KEYSTONE Course on Health Policy and Systems Research 2015 Health Policy & Systems Research Frameworks – 2
  2. 2. Health Policy & Systems Research Frameworks – 2 (Research questions) Kabir Sheikh 24 Feb 2015 KEYSTONE
  3. 3. Generating and framing HPSR questions IHPSR Presentation 4 @hpsa_africa Introduction to Health Policy and Systems Research
  4. 4. Four key steps in HPSR 1. Identify research focus (problem/concern/opportunity) and question 2. Design study 3. Ensure quality and rigour 4. Apply ethical principles
  5. 5. 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
  6. 6. • The question drives the study
  7. 7. 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
  8. 8. Start with the problem/concern/opportunity and aim to inform decision-making by policy and system actors
  9. 9. Whose ideas? Research question Community group Patient group District manager Hospital manager National manager International agency Researcher Same issue, different questions? Different issues & questions?
  10. 10. 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)
  11. 11. 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
  12. 12. What is the study ‘purpose’? Normative/evaluative: Seeks to generate/identify norms, best practices,’gold standard’ interventions Exploratory: To find out what is happening, especially in little understood situations Descriptive: To give accurate profile of people, events, situations Explanatory: To explain patterns relating to phenomenon being researched; To identify relationships between aspects of phenomenon Emancipatory: To create opportunities and the will to engage in social action Robson, 2002; Thomas, Chataway & Wuyts, 1998; Yin, 2009
  13. 13. Normative Impact? Is it best? What is best practice? Exploratory What+? (new insights) Descriptive Who? What? Where? How many? How much? Explanatory Why and how? Action/ participatory research From purpose to question form
  14. 14. 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?
  15. 15. 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 practitioners Encourage practice changes
  16. 16. 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
  17. 17. 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
  18. 18. 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?
  19. 19. 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
  20. 20. 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
  21. 21. 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?
  22. 22. Types of literature reviews Go find the resources – lots out there! Also qualitative review & synthesis!
  23. 23. Review basics 1. Identify the review question or focus 2. 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 data 6. Review papers & data 7. Synthesis (make meaning, pull together a coherent argument)
  24. 24. ‘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
  25. 25. Open Access Policy KEYSTONE commits itself to the principle of open access to knowledge. In keeping with this, we strongly support open access and use of materials that we created for the course. While some of the material is in fact original, we have drawn from the large body of knowledge already available under open licenses that promote sharing and dissemination. In keeping with this spirit, we hereby provide all our materials (wherever they are already not copyrighted elsewhere as indicated) under Creative Commons Attribution-NonCommercial 4.0 International License. To view a copy of this license visit This work is ‘Open Access,’ published under a creative commons license which means that you are free to copy, distribute, display, and use the materials as long as you clearly attribute the work to the KEYSTONE course (suggested attribution: Copyright KEYSTONE Health Policy & Systems Research Initiative, Public Health Foundation of India and KEYSTONE Partners, 2015), that you do not use this work for any commercial gain in any form and that you in no way alter, transform or build on the work outside of its use in normal academic scholarship without express permission of the author and the publisher of this volume. Furthermore, for any reuse or distribution, you must make clear to others the license terms of this work. This means that you can: read and store this document free of charge distribute it for personal use free of charge print sections of the work for personal use read or use parts or whole of the work in a context where no financial transactions take place gain financially from the work in anyway sell the work or seek monies in relation to the distribution of the work use the work in any commercial activity of any kind distribute in or through a commercial body (with the exception of academic usage within educational institutions such as schools and universities However, you cannot: