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Introduction to Health Policy and Systems Research

Facilitator’s Guide

This is a document developed by members of the CHEPSAA project.

CHEPSAA (Consortium for Health Policy and Systems Analysis in Africa) is a project funded by the European Union which aims to extend sustainable African capacity to produce and use high quality health policy and systems research by harnessing synergies among a Consortium of African and European universities with relevant expertise.

This document is an output from a project funded by the European Commission (EC) FP7-Africa (Grant no. 265482). The views expressed are not necessarily those of the EC.

CHEPSAA: Introduction to Health Policy and Systems Research – Facilitator’s Guide December 2014

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December 2014

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Citation of this work must follow normal academic conventions.A suggested citation is: CHEPSAA. Introduction to Health Policy and Systems Research: Facilitator’s Guide. CHEPSAA (Consortium for Health Policy & Systems Analysis in Africa) 2014, www.hpsa-africa.org

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Contents


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Overview of the course page 5IntroductionOverall course aim Logic of the courseApproach to teaching and learningManaging group workPresentationsCourse readingsResources

Learning outcomes and threshold concepts page 10Course outline page 12

Course sessions1 Introductions page 151.1 Multiple perspectives within the class and within HPSR1.2 What is a health system and why is it important?1.3 Ways of understanding, and strengthening, a health system2 Starting points: the focus and field of HPSR page 212.1 Revisiting: health systems and how to strengthen them2.2 What is the focus and field of HPSR?3 HPSR questions and perspectives page 273.1 Asking HPSR questions3.2 Recognising multiple perspectives4 Introduction to HPSR protocol and design page 324.1 Reviewing HPSR protocols4.2 HPSR study design – an overview5 HPSR design: turning questions into projects page 365.1 Examining protocol designs5.2 Common HPSR designs6 Rigour, trustworthiness and generalisable claims page 396.1 Ensuring rigour7 Topic to design: HPSR paper critique page 427.1 One HPSR research topic, different design options8 Developing an HPSR protocol outline page 458.1 Framing the issue, developing the question and design9 Pitching the idea page 479.1 Presenting and assessing an HPSR protocol10 Influencing health policy and practice page 5010.1 Strengthening evidence-informed health policy-making 10.2 Personal reflection 10.3 Course wrap-up and evaluation

Annex 1: Suggested timetable for a five-day introduction to HPSR short course page 54Annex 2: Course assessment and assignment guide page 55Annex 3: Reading list page 63Annex 4: An example of an HPSR protocol for review in Activity 6 (Sessions 4–6) page 73Annex 5: An example of a table for making a summary of an HPSR protocol (Activity 6, Sessions 4–6) page 82


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Complementary resources The handouts are available as a set of Word files. The PowerPoint slides for the presentations are available for download from the CHEPSAA website: www.hpsa-africa.org.

HandoutsHandout 1: Course overviewHandout 2: Health systems and services: A local TB service delivery case Handout 3: HPSR protocol reviewHandout 4: HPSR strategies – approaches to rigourHandout 5: A guide for the HPSR paper critiqueHandout 6: Develop an HPSR strategy and designHandout 7: Building practitioner–researcher engagementHandout 8: Personal reflectionHandout 9: Course evaluation

PresentationsPresentation 1: Why are we running this course?Presentation 2: What is a health system? What is health system strengthening?Presentation 3: HPSR? What is health policy and systems research?Presentation 4: Generating and framing HPSR questionsPresentation 5: Recognising your starting pointsPresentation 6: Study design: from questions to projectsPresentation 7: Planning HPSR studies: key issues for specific designsPresentation 8: Rigour and ethicsPresentation 9: Influencing policy and practicePresentation 10: IHPSR wrap-up


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Overview of the course IntroductionThis course provides an introduction to the practice of health policy and systems research (HPSR). It is intended for all those interested in health systems – whether or not they are likely to go on to become full-time researchers, to do research in other positions, to commission research or to seek evidence from research studies to inform decision-making.

The course seeks to sensitise participants to some of the fundamental starting points for HPSR and its conceptual and methodological foundations.

The course is intended primarily as a Master’s level introductory course, offered within a broader Master’s programme, such as an MPH (Master’s in Public Health). Its target audiences are, therefore, varied and include those interested in a future HPSR career, either coming from other research areas or as new researchers, health systems practitioners and managers, and those likely to work in non-governmental organisations. Such participants bring to the course an interesting mix of experiences, disciplinary backgrounds and future aspirations, including diversity in the extent and nature of their experience of health policy and systems.

The course as presented in this guide is structured around ten, three-hour sessions – a total of 30 hours of contact time. However, the length of time given to various activities and sessions can be adapted, whilst retaining the core logic of the course. For example, the course could be run as an intensive short course that is spread over five days (see Annex 1). A longer course could also allow for the inclusion of additional sessions on the principles of qualitative and quantitative data collection and analysis. Alternatively, it could be complemented by other courses focused on these principles.

Overall course aimBy the end of the course participants are expected to be able, confidently, to identify substantively relevant HPSR questions, to select appropriate research strategies for addressing these questions in specific contexts and to think through approaches that support the use of research evidence in decision-making. The course is framed within the understanding that HPSR is rooted in real-world problems, and requires constant consideration of the ties between policy-making and research.


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Logic of the course Each of the 10 contact sessions in the course is designed to take 3 hours (allowing for a 15 minute break within each). You will have to adjust the sessions if your timetable does not allow this amount of contact time. However, you would ideally keep the core logic of the course intact. This logic is shown in the sequence of core themes given below.

Introductions: Why HPSR?Starting points

What is a health system? What is health system strengthening? What is health policy? What are the boundaries of HPSR?

What is HPSR? Identifying HPSR issues and framing HPSR questionsFrom question to research strategy and study designUnderstanding HPSR (critique and rigour)

Using research to influence policy and practice

Approach to teaching and learning This course takes an outcomes-based approach to education that involves identifying clear learning outcomes that can be shown and assessed at the end of the learning programme. Participants need to know what they are expected to work towards at the beginning of the course. The key learning outcomes and threshold concepts (key underpinning ideas) for the course are listed at the end of this section of the guide.

See Annex 2 for suggested assessment tasks that build on course activities and that are designed to show evidence of learners’ achievment of learning outcomes. It is useful to construct these tasks to allow iterative learning.

This module also follows a constructivist approach to learning which is based on the understanding that learners are not ‘empty vessels’ to be filled with ‘knowledge’, but that their understanding of new information is built upon and shaped by their existing knowledge, skills, values and attitudes. Therefore, many of the activities in the module have been designed to encourage participants to think through issues for themselves before providing them with new information or theory. In this way learning can be more effective as participants relate the ideas and concepts to their own experience and existing knowledge. This also means that input needs to be adapted by the facilitator to suit the needs of particular learning groups.

In addition, the course follows an active-learning approach as the individual or group activities allow participants to apply what they have learnt and grapple with some of the complexities of HPSR.

It is worth emphasising to participants that the activities provide valuable learning opportunities and the more time and effort they put into them the more they will gain from the learning experience.

Active participationThis course is primarily for people who may go on to be health researchers, managers or advocates, premised on the notion that all health system actors can conduct research and have critical insights on the issues of focus in HPSR. Therefore, active participation in all


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course activities is central to the learning experience, and this includes opportunities for students to listen to each other and to participate in, and facilitate, small group activities. Through these activities participants engage with each other’s different experiences and perspectives and so directly confront the multi-disciplinary challenges of HPSR and experience the value of considering multiple perspectives.

Managing group workIf possible choose a venue that allows participants to move into, and work in, small groups around separate tables. A presentation theatre setting is not conducive to group work, participation or discussion, and does not allow you to move around the groups to give guidance.

The ideal size for most group activities is four to six participants. For some activities, such as thinking pairs, groups of two to three participants are more appropriate.

Some of the group activities require leadership to encourage participation from all group members and to ensure that tasks are completed in time. Create opportunities for as many participants as possible to lead such processes. Provide some guidance and ideas for small group facilitation to support this. A rich array of material is available on the Internet that can be used, and it might also be possible to include some informal or formal peer review of facilitation skills within the course.

Some useful strategies for the group work activities within the course are suggested below.

Where appropriate, reform the groups during the course to allow participants to engage with different individuals, and to give different group leaders an opportunity to practise their facilitation skills.

In every group activity, suggest that roles are clearly identified beforehand (e.g. group facilitator/chair, group scribe, presenters).

Provide a brief guideline on effective group facilitation at the beginning of the course (e.g. ensuring everyone is heard, how to manage strong voices, dealing with different disciplinary perspectives).

If the timing allows, group leaders can be prepared/given warning of the work required in advance (e.g. given an outline of the activity, and time to read the resource materials carefully beforehand).

Observe the groups as they work, and provide guidance as needed, for example:

o If one person dominates the group: ask questions to encourage other participants to contribute.

o If the group gets ‘stuck’ on one issue: ask questions to encourage them to think of other issues, prompt them to move on.

o Remind participants to record their ideas or the consensus reached.

o Remind the groups of the time and help them to pace themselves, for example: ‘Use the last 10 minutes to focus on question X or plan your presentation’.

Note: The development of a research strategy and funders’ pitch (Activities 8 and 9, Sessions 8 and 9) needs particularly careful group facilitation. We suggest that participants who show an ability to manage group work are selected to lead the groups for these activities.


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Copyright lawRemember that permission to distribute photocopies of any journal articles or chapters from books must be obtained from the relevant copyright holders.

Presentations During the power point presentations (PPTs), asking relevant questions can help to draw out what participants already think about certain issues or terms. In this way new information can be provided in a way that helps to either reinforce participants’ understanding or correct any misunderstandings they may have. Questions can also be used to encourage participants to apply their knowledge and to assess their understanding of new concepts and theories.

However, if time is short it is easy to let a lecture-mode of imparting knowledge dominate. To avoid this, use the activities to guide discussion and draw out key themes or concepts, and be flexible in when, and how, theoretical input is given. A key challenge of this style of teaching is time-management, which involves the ability to keep the discussions to the point and manage the group dynamics (i.e. encouraging contributions from quieter participants and avoiding discussions being dominated by the more vocal participants).

Course readingsThis course is designed to be taught utilising the Alliance Reader (reference below) as its core reading. Course facilitators should be familiar with this document, particularly Parts 1 and 2 (pp. 1–60), before organising the course.

Gilson L, ed. (2012). Health policy and systems research: a methodology reader. Alliance for Health Policy and Systems Research, World Health Organization. (Entire reader available for download at: http://www.who.int/alliance-hpsr/resources/reader/en/index.html)

Other textbooks of particular value for this course Fulop N et al., eds (2001). Studying the organisation and delivery of health services: research methods. London, Routledge.

Robson C (2002). Real world research: a resource for social scientists and practitioner–researchers, 2nd ed. Oxford, Blackwell Publishing.

Thomas A, Chataway J, Wuyts M, eds (1998). Finding out fast: investigative skills for policy and development. London, Thousand Oaks, New Dehli, Sage Publications (pp. 307–332).

See also the reading list given in Annex 3, from which facilitators can select readings for participants’ self-study sessions or to use as examples in specific activities, as appropriate.

Resources In addition to this facilitator’s guide, the materials for this course include:

Handouts, available as separate Word files. The handouts are numbered in the order in which they are given to participants during the course.

Suggestions for assessment (Annex 2)

A list of readings (Annex 3)

PowerPoint slides for input sessions, available electronically.


At the start of each session, recap and make links back to the previous session to help participants see the logic of the course.At the end of each session, review and summarise to help clarify and reinforce what has been covered.

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How well did it go?After each session, you may find it useful to record any issues that participants found difficult or points that need to be clarified later in the course. Also note anything that you thought worked particularly well. This can inform future courses.

You may need to adapt these resources as appropriate to suit the needs of your participants.

For each session you will also need flip-chart (or newsprint/large sheets of paper) and marker pens to record key points during discussions. It is helpful if these are displayed on the walls and left for participants to refer to as needed during the course.


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Learning outcomes and threshold conceptsCourse learning outcomesThis course has 11 learning outcomes. While not all sessions address all of the outcomes, most of them weave through the majority of the sessions, albeit with different weightings in each session.

By the end of the course participants are expected to be able to:

1. Identify researchable health policy and systems issues, including those focused on action to strengthen health systems and the processes of policy change.

2. Formulate substantively relevant health policy or health systems research questions, by drawing on relevant empirical work, practice knowledge, and theoretical insights.

3. Be familiar with the range of research purposes, questions and strategies used within HPSR.

4. Identify appropriate research strategies and study designs for different HPSR issues, purposes and question types.

5. Show awareness of critical issues in, and approaches to, ensuring rigour in HPSR.

6. Be aware of critical ethical issues for HPSR.

7. Be able to source HPSR materials and critically appraise HPSR empirical papers.

8. Appreciate the value of multiple perspectives (positional and disciplinary) in conducting HPSR.

9. Have some understanding of how the complex and socially constructed nature of health policy and health systems is addressed in HPSR methodology.

10. Plan activities that support the use of research evidence for and in decision-making, through researcher–policy maker/practitioner engagement.

11. Recognise that personal skills, such as reflexivity, listening and facilitation, are critical to being a health policy and systems researcher.

Threshold conceptsA number of threshold concepts (key underpinning ideas) have been identified for this course, as listed below.

Health policies and systemsA. Health policies and systems are socially constructed; they exist within contexts and

histories.

B. Health policy and policy processes are always political.

C. Health systems consist of ‘hardware’ and ‘software’.

D. Actors (and their interests, values and power) are key to understanding policy.

E. People are at the centre of the health system, driven by values and contexts.

F. Policy comes alive through practice.

G. The health system is knowable and changeable.

H. Managing policy processes requires political awareness.


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HPSRA. HPSR is intentionally multidisciplinary and embraces multiple perspectives.

B. Substantive relevance is critical for the development of sound and ethical HPSR questions.

C. Phenomena that cannot be quantitatively measured are important to health policy and systems and can be researched.

D. The precise wording of HPSR questions is important.

E. Health care services/interventions/programmes provide a lens through which to investigate policy and systems issues in HPSR (i.e. they are not the primary focus of the research).

F. Exploratory and explanatory research (that deepens our understanding of health policy and system phenomena) offers policy-relevant insight.

G. Flexible study designs are the most appropriate design for some HPSR phenomena.

H. Good (i.e. sound) research design requires that the study design fits the question, issues and purpose.

I. There is no hierarchy of study design in terms of quality and rigour in HPSR; and quality and rigour are always important.

J. Researcher curiosity, attentiveness and reflexivity are the basis of rigorous HPSR.

K. Analytic generalisability is legitimate.

L. Theoretical ideas and concepts have value (as a guide for study design and analysis in HPSR).

M. The researcher is the primary research instrument.

N. Ethical HPSR requires the responsible use of power and accountability.

O. The HPSR researcher is a policy activist.

Threshold skills/competencies for the researcher that are addressed in this course include:

1. Recognising where the boundaries of HPSR lie and the types of issues that are addressed (what is HPSR).

2. Conducting a literature review (becoming familiar with the field).

3. Framing various types of HPSR research questions.

4. The ability to identify a range of research strategies and study designs.

5. Knowing ‘the’ appropriate research strategy and study designs to use to address different types of HPSR issues and questions.

6. Critical analysis (knowing what is rigorous and relevant).

7. Being familiar/comfortable with different perspectives, and able to work with and across them.

8. Facilitation of small groups.


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Course outline Note: see Annex 1 for a suggestion of how the course can be run over five days.

Course sessions and topics Threshold concepts

1 IntroductionsThis session serves to introduce participants to each other and orient them to the course, so they know what to expect. Participants are encouraged to think of HPSR as a multisectoral and multidisciplinary effort, with multiple, equally valuable perspectives.

1.1 Multiple perspectives within the class and within HPSR Activity 1: Identify diversity within the class Presentation 1: Why are we running this course? Course overview integrated with presentation1.2 What is a health system and why is it important? Activity 2: The Martian Game1.3 Ways of understanding, and strengthening, a health system Presentation 2: What is a health system? What is

health system strengthening?

2 Starting points: the focus and field of HPSRThis session continues to introduce the idea of systems strengthening, and broadly scope the field and fuzzy boundaries of HPSR – making the distinction between health systems research and health services research

2.1 Revisiting: health systems and how to strengthen them Discussion to consolidate learning from Session 1 Activity 3: Health systems and services: A local TB

service delivery case2.2 What is the focus and field of HPSR? Presentation 3: HPSR? What is health policy and

systems research? Activity 4: Pin the tail on the fuzzy boundaries of

HPSR

Health policies and systemsA. Health policies and systems are socially

constructed; they exist within contexts and histories

B. Health policy and policy processes are always political

C. Health systems consist of ‘hardware’ and ‘software’

D. Actors (and their interests, values and power) are key to understanding policy

E. People are at the centre of the health system, driven by values and contexts

F. Policy comes alive through practice

G. The health system is knowable and changeable

H. Managing policy processes requires political awareness

3 HPSR questions and perspectivesIn this session participants begin to engage with the details of HPSR as a practice – the session introduces the importance of the research question (framing the issue).

3.1 Asking HPSR questions Presentation 4: Generating and framing HPSR

questions Activity 5: Tightening HPSR questions3.2 Recognising multiple perspectives Presentation 5: Recognising your starting points Reflective quiz integrated with presentation

HPSRA. HPSR is intentionally multidisciplinary and

embraces multiple perspectives

B. Substantive relevance is critical for the development of sound and ethical HPSR questions

C. Phenomena that cannot be quantitatively measured are important to health policy and systems and can be researched

D. The precise wording of HPSR questions is important


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E. Health care services/interventions/programmes provide a lens through which to investigate policy and systems issues in HPSR (i.e. they are not the primary focus of the research)

4 Introduction to HPSR protocol and designThis session addresses how different perspectives influence HPSR (how the problems are understood, the questions are framed).

4.1 Reviewing HPSR protocols Activity 6: HPSR protocol review – Part 1: focus,

purpose and question4.2 HPSR study design – an overview Presentation 6: Study design: from questions to

projects

HPSRH. Good (i.e. sound) research design requires

that the study design fits the question, issues and purpose

5 HPSR design: turning questions into projectsParticipants continue to engage with the details of HPSR as a practice. The session introduces different forms of HPSR approaches, and emphasises the link from purpose to question to design.

5.1 Examining protocol designs Activity 6: HPSR protocol review – Part 2:

research strategy and design5.2 Common HPSR designs Presentation 7: Planning HPSR studies: key issues

for specific designs

HPSRE. Health care

services/interventions/programmes provide a lens through which to investigate policy and systems issues in HPSR (i.e. they are not the primary focus of the research)

F. Exploratory and explanatory research (that deepens our understanding of health policy and system phenomena) offers policy-relevant insight

G. Flexible study designs are the most appropriate design for some HPSR phenomena

H. Good (i.e. sound) research design requires that the study design fits the question, issues and purpose

L. Theoretical ideas and concepts have value (as a guide for study design and analysis in HPSR)

6 Rigour, trustworthiness and generalisable claimsParticipants begin to engage with approaches to critique HPSR and understand issues of rigour and generalisable claims. A key message is that different approaches have different rigour issues to observe or be aware of.

6.1 Ensuring rigour Presentation 8: Rigour and ethics Activity 6: HPSR protocol review – Part 3: rigour

and ethics

HPSRI. There is no hierarchy of study design in

terms of quality and rigour in HPSR; and quality and rigour are always important

J. Researcher curiosity, attentiveness and reflexivity are the basis of rigorous HPSR

K. Analytic generalisability is legitimate

N. Ethical HPSR requires the responsible use of power and accountability

7 Topic to design: HPSR paper critiqueThis session begins a second, practical process to allow participants to engage with a particular topic and consider HPSR methodological issues. It is a




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holistic session designed to allow participants to put their learning from previous sessions into practice. It enables the building of critical analysis skills, and demonstrates the value of multiple perspectives/approaches in considering similar issues.7.1 One HPSR research topic, different design options Activity 7: Critical appraisal of HPSR papers Participants’ begin their self-study reading in

preparation for Sessions 8 and 9



I. There is no hierarchy of study design in terms of quality and rigour in HPSR; and quality and rigour are always important

K. Analytic generalisability is legitimate

L. Theoretical ideas and concepts have value (as a guide for study design and analysis in HPSR)

8 Developing an HPSR protocol outlineIn this session participants go through the entire process of framing an issue, developing a question and matching a design to it. This is framed as developing a pitch for a funder.

8.1 Framing the issue, developing the question and design Activity 8: Part 1 – Develop an HPSR strategy and

design

9 Pitching the ideaParticipants practise their communication skills as they present their research ideas and answer questions to defend their HPSR protocol. The session also provides an opportunity for them to apply their understanding of what makes a strong HPSR project as they assess other groups’ protocols during the funders’ panel.

9.1 Presenting and assessing an HPSR protocol Activity 8: Part 2 – Prepare a funders’ pitch Activity 9: A funders’ panel




C. Phenomena that cannot be quantitatively measured are important to health policy and systems and can be researched

D. The precise wording of HPSR questions is important

E. Health care services/interventions/programmes provide a lens through which to investigate policy and systems issues in HPSR (i.e. they are not the primary focus of the research)


10 Influencing health policy and practiceThis session returns to the focus on research as engagement – looking at project, organisational and personal strategies that can support research use in decision-making and build practitioner–researcher engagement.

10.1 Strengthening evidence-informed health policy-making Presentation 9: Influencing policy and practice Activity 10: Organisational strategies for building

practitioner–researcher engagement10.2 Personal reflection Activity 11: Myself as a researcher …10.3 Course wrap-up and evaluation Presentation 10: IHPSR wrap-up Course evaluation

HPSRM. The researcher is the primary research

instrument

N. Ethical HPSR requires the responsible use of power and accountability

O. The HPSR researcher is a policy activist


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Session 1Introductions

As an introduction to the course, this session serves: to introduce participants to each other; to orient participants to the course, so they know what to expect; and to encourage participants to think of health policy and systems research – as a multisectoral and multidisciplinary effort, with multiple, equally valuable perspectives.

Topics and activities1.1 Multiple perspectives within the class and within HPSR

• Activity 1: Identify diversity within the class (30 min)• Presentation 1: Why are we running this course? (35 min)• Course overview integrated with presentation

1.2 What is a health system and why is it important? • Activity 2: The Martian Game (45 min)

1.3 Ways of understanding, and strengthening, a health system • Presentation 2: What is a health system? What is health system strengthening? (55 min)

Resources

Presentations 1 and 2 PPT Handout 1: Course overview Guiding questions writen on flip chart paper (Activity 1) Large sheets of paper and marker pens for each group, prestick or tape (Activity 2)

Background readingAlliance Reader: Part 1, Sections 1–2 (to prepare for Activity 2); Part 1 Sections 3–5 (for Session

1.3)

1.1 Multiple perspectives within the class and within HPSR Key concepts in the course are that people are at the heart of every health system, and health systems are complex and socially constructed. Therefore, it is useful to start the course with activities that not only encourage participants to begin to think about these ideas, and their own place within the health system, but also to loosen the barriers between participants so that they can learn from each other during the course, whatever their past experiences.

In this session, we would like participants to begin to consider not only where they fit within the health system, but also the ‘lenses’ they bring to seeing and understanding the health system. Participants’ perspectives may be influenced by their experience of the health system, where they work in the system, their discipline or practitioner–researcher role.


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Activity 1: Identify diversity within the class Time: 30 minutes (20 min introductions; 10 min discussion)Aim: To introduce the range of experience among course participants.

Ask participants to introduce themselves, guided by the questions below. Write up the questions on the board/flip chart before the activity. To make it less intimidating for participants, introduce yourself first, giving examples of the type of information to share.

Guiding questions What is your name?

What is your relationship to the health system? (e.g. researcher, practitioner, patient – include the level, such as facility, provincial, national policy, and country or region)

What is your particular field of practice or disciplinary background/experience? (in your example, do not only focus on academic background or disciplines, but encourage participants to share a variety of examples)

What kind of research have you done in the past? (give examples to encourage a very broad interpretation of ‘research’, such as managerial/ practice-based ‘investigation’)

During the introductions: As participants introduce themselves, make a note of the different groups that emerge (this could be on flip chart). For example, the different disciplines or work experience, such as clinical experience or district level management. Mentally ‘cluster’ participants into relevant groups (they will work in these groups in Activity 2). If the range of work experience does not provide enough groups, then create others based on country/region, age or gender. The main point is to ensure that later some discussion can be held around how a particular perspective of a group might influence their interpretation of an HPSR issue.

After the introductions: Facilitate a brief discussion, informed by participants’ introductions, about ‘What is research – and why do it?’ The aim is to show that ‘research’ is not only for academic or clinical purposes but also something that can inform the everyday managerial decision-making and thinking that goes on within the health system.

Probe – ask specifically about participants’ past experiences of research, and their understanding of what ‘research’ means, if this was not clear from the introductions.

Presentation 1: Why are we running this course? Purpose and rationalePresentation 1 seeks to motivate participants through sharing a common understanding of why health systems and HPSR matter. It also presents the aims, learning outcomes and key concepts of the course so that participants know what to expect.

Outline The importance of health systems – to individuals and society

The importance of HPSR and its role in improving/strengthening health systems

The key steps in the development of HPSR as a recognised research field

Course aims, learning outcomes and threshold concepts

Threshold skills for HPSR


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Part 1: Rationale for the focus on HPSR (about 5 min)Show the first few slides of Presentation 1 to give a brief rationale for focusing on health systems and HPSR. The issues will all be addressed in more detail later, so only use them here to frame the course.

Part 2: Course overview (about 15 min)Move on to the next few slides in Presentation 1. Hand out the course overview document (Handout 1), which you will need to complete so that it explains not only the learning outcomes and course outline with threshold concepts but also the timetable, assignments and logistics of the course. Briefly look through the document with the class.

Learning outcomes, threshold concepts (about 15 min)End Session 1.1 with the slides from Presentation 1 that show learning outcomes for the course and HPSR threshold concepts and skills. The intention here is not to explain each concept in detail but to show some of the logic of the course in order to manage participants’ expectations.

1.2 What is a health system and why is it important? Participants are expected to have some familiarity with health systems thinking, and ideally they would already have taken the CHEPSAA Introduction to Complex Health Systems course and/or Introduction to Health Policy Analysis course. However, there needs to be some introductory content about health systems to ensure that everyone is on the same page. Activity 2 is an opportunity to provide this in an interesting way.

Activity 2: The Martian Game Time: About 45 minutes (30 min for the game; 15 min for the debriefing discussion).

In groups – cluster participants into groups of people with similar work experience or background – based on their introductions (see Activity 1).

Aim: The idea of this activity is to get people talking to each other, discussing different experiences and perspectives, and then to try to tease out some common dimensions and elements to form a ‘picture’ of a health system. The picture can be in any form, e.g. a diagram (perhaps an organogram) or a cartoon. It might tell a story (such as a patient’s experience of a health system), or depict key but hidden elements of a health system (such as relations and context) or focus on a particular country. Any approach is acceptable!

Explain the instructions in a way that encourages participants to think beyond one particular health system – to get them thinking from a fresh perspective. This is also important if the groups include people with different experiences. Key steps in the process are outlined below, with suggested instructions.

Step 1: Each group draws a ‘picture’ of a health system Explain the instructions, for example: Imagine you are meeting a visitor from Mars, who wants to know about the health

system on Earth. Your group needs to draw a picture that explains to the Martian what a health system is.

As a group, you will need to think about your different experiences and identify the common, key features of a health system as you know it and have experienced it. You will then need to show these in a graphic way.

Draw the picture on one large sheet of flip chart paper.


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Step 2: Each group presents their picture to the class. Class discussion.Ask each group to display their picture on the wall. They need to tell the rest of the class about their picture – in no more than 5 minutes. They provide a rationale and narrative for their picture, focusing on these key questions:

What did you seek to show? Why those particular issues/aspects?

What type of experiences or perspectives informed the picture?

As they listen to the other groups, ask participants to think about:

the similarities and differences across the pictures

how other groups’ pictures differ from their own

what ideas/elements they gained from the other groups’ pictures to add to their own understanding.

After each presentation, identify some key issues to comment on (see below). Also look for similarities and differences between groups.

After 2 or 3 presentations, try to get some feedback from the whole class about what they are learning from their comparison of the pictures. Link their ideas to your own comments, to help participants to see connections between points.

Some key issues for comment/discussion (Presentation 2 will reflect these again) The recognition that the health system encompasses more than the delivery of health

services or health facilities (specifically mention funding, human resources, policy, management, etc.).

The use of a patient perspective (perhaps focused on service delivery in particular, with recognition of providers, and referral systems, but not much acknowledgement of system functions such as funding, human resources, drug supply).

The role of actors within health systems, and those who are identified as key actors.

The importance of relationships and interactions among, for example, health system components, facilities and people.

The hidden influences of contextual factors, such as history, sociocultural norms and practices, organisational culture.

International and national influences over national and local health system settings and functioning.

The use of linear, mechanical/structured models in the pictures, versus fluid, relational or more conceptual understandings.

The acknowledgement of complexity, and what complexity means – perhaps reflected in people and relationships, various inputs combining in unclear ways, feedback loops, potential for unintended consequences, etc.

The dynamic nature of systems and the extent to which that is reflected in the pictures.

Specific identification of policy issues, ideas, actors – highlighting the relevance of policy to health systems (including the nature of policy as process, as encompassing what people do and do not understand and what actions they take).

The similarities and differences between groups:

o The fact that there are similarities and differences indicates that there are multiple perspectives on what health systems are. It demonstrates that we have different ways of understanding health systems and different experiences of them.


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o Consider whether the hidden influence of disciplinary perspectives on the pictures is evident (e.g. an economics perspective versus a sociological/anthropological versus a political science perspective). To what extent does this reflect the particular experiences and perspectives of the people in each group?

o Then, link the above points to the fact that all such differences show the socially constructed nature of health systems, and influence how to do research on systems and system issues. (This can then be picked up again in the discussion of different paradigms of knowledge and research strategies of preference.)

Note: You will need to refer to the group pictures in Session 2, so either arrange for them to be kept on the walls, or take a photograph of them to show as a PPT slide.

1.3 Ways of understanding, and strengthening, a health system Presentation 2: What is a health system? What is health system strengthening?Purpose and rationaleThe purpose of this presentation is to give an overview of current thinking about a health system – what it is and how its various components influence the system as a whole. It also outlines some examples of interventions or polices that help to strengthen (improve the performance of) health systems. Some of these ideas may have been mentioned previously, however this presentation provides an opportunity to draw the ideas together and develop a common understanding so participants are all ‘on the same page’ for Session 2.

Outline Definition of a health system

Conceptual frameworks that help us to think about health systems

Different levels of health systems

The ‘hardware’ and ‘software’ components of health systems

The place of people and relationships within health systems

The historical, political, economic and global influences over health systems and how they develop over time

The influence of perceptions, opinions and views over health systems, and polices and their implementation

Interventions for improving health systems and the importance of health policies

The difference between a whole system focus in strengthening health systems and a disease programme or health care intervention focus

Research-as-action: HPSR as a form of health system intervention

After the presentation, answer any questions and facilitate a discussion about the points raised.

Handout the course reading list (see Annex 3), and the readings for discussion in Session 2 for participants’ self-study (see below).


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Self-study for participantsParticipants read the readings below to consolidate their learning from Session 1 and prepare for the discussion at the beginning of Session 2.

Readings for discussion in Session 2

Sheikh K et al. (2011). Building the field of health policy and systems research: framing the questions. PLoS Medicine, 8(8): e1001073.

Alliance Reader, Part 1, Sections 1–3


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Session 2Starting points: the focus and field of HPSR

This session continues to introduce the idea of systems strengthening, and broadly scope the field and fuzzy boundaries of HPSR – making the distinction between health systems research and health services research.

Topics and activities2.1 Revisiting: health systems and how to strengthen them

• Discussion to consolidate learning from Session 1 (25 mins)• Activity 3: Health systems and services: A local TB service delivery case (60mins)

2.2 What is the focus and field of HPSR? • Presentation 3: HPSR? What is health policy and systems research? (25 mins)• Activity 4: Pin the tail on the fuzzy boundaries of HPSR (55 mins)

Resources

Presentation 3 PPT Handout 2: Health systems and services: A local TB service delivery case (Activity 3) The pictures developed during The Martian Game (Session 1, Activity 2), or a photograph of

them as a slide (Activity 3) A wall chart with the diagram that can be used in Activity 4, large post-it notes, a marker

pen, a blindfold (Activity 4)

Background readingAlliance Reader: Part 1, Sections 6–7 (for Session 2.2)

2.1 Revisiting: health systems and how to strengthen them Discussion to consolidate learning from Session 1Facilitate a discussion based on the readings set at the end of Session 1 (Sheikh et al., 2011; Alliance Reader, Part 1: Sections 1–3). The readings are intended to allow participants to think more about the issues introduced during Session 1 and consolidate their thinking. Have the Presentation 2 slides available in case you need to refer to any of them again.

Here is a suggestion for how to begin the discussion:

Looking back at our drawings of health systems, how do the readings add to your understanding or picture of a health system?

What have you learned from the readings? What questions do you have?

Note: if there is time, you could run this as a time-limited paired exercise to encourage reflection and to allow participants to engage with each other. A plenary brainstorm or ‘shout out’ could then follow to share ideas and allow clarification.


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Activity 3: Health systems and services: A local TB service delivery case Time: 60 minutes (10 min individual reading; 30 min group discussion; 20 min plenary discussion)

In groups

Aims: The focus of this activity is on understanding the distinguishing features of a ‘systems’ focus to strengthen service delivery, in contrast to one that focuses primarily on strengthening a particular disease control programme, health service, or health care intervention. It builds on participants’ learning from Presentation 2, and aims to help participants to:

analyse a system issue

identify system-level actions to improve the system

identify potential research topics.

Participants will draw on conceptual frameworks of health systems introduced in the ‘Introduction to Complex Health Systems’ course (and Presentation 2).

Give each participant a copy of Handout 2. Make sure the groups are clear about what they have to do, and provide assistance if needed.

The exercise is based on a real world South African example, which considers some of the challenges faced in managing TB services in a local setting. Having read the case study, participants are asked to consider three questions in their groups.

Question 1 How do different health system components interact to undermine TB service delivery

in Orange District?

Note: To save time you could ask groups to use only one of the templates provided or get different groups to use different templates.

Question 2 Given your analysis, which possible system-level actions might support service

delivery improvement in the future?

Question 3 What issues might be important to research in order to understand better the

current situation and/or support system and service improvement in the future?

To draw out overarching lessons from the exercise, facilitate a plenary discussion. Given time constraints it is probably best to take each question in turn. It might be appropriate to get full responses from one or two groups and then ask others groups what they would add to those ideas. It might also be possible to ask whether or not they agree with the first groups’ ideas.

Tips for the plenary discussion

The first question (Q1) is simply intended to get participants to use a systems lens in the activity.

Plenary discussion should primarily focus on question 2 (Q2) to encourage a common understanding of a systems lens and the issues and actions it highlights.


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During the Q2 responses, allow specific discussion of what a ‘systems’ focus to strengthening service delivery entails, in contrast to one that focuses primarily on strengthening a particular disease control programme/health service, picking up on Presentation 2 and the prior readings for this session. This should be the central focus of discussions. (If possible, also tease out the links to understanding policy as a process, the politics of policy change.)

Q3 should build on Q2 responses and allow an initial discussion of systems-related research issues; that is, a focus on the underlying system constraints, enablers and opportunities of seeing TB services as a tracer for understanding, or strengthening, the broader system. In this way, the discussion provides a foundation for Presentation 3 and Activity 4.

If time is short it is possible to ask only one or two groups to identify their issues/topics for research and hold over all other discussion relating to Q3 for Activity 4 (‘pin the tail on the fuzzy boundaries’). Note that the issues raised might be framed as questions, which is fine; but then pick some up again in the later discussion of how to frame HPSR questions.

2.2 What is the focus and field of HPSR? Presentation 3: HPSR? What is health policy and systems research? Purpose and rationalePresentation 3 aims to give a sense of the field of HPSR and to explain why the boundaries are ‘fuzzy’ (i.e. difficult to define precisely). It also highlights some of the differences between HPSR and other forms of health research, such as clinical science. An understanding of the broad scope and nature of HPSR is important in identifying appropriate research issues and questions, and thinking about the methodology that is appropriate for a particular research question.

Outline Definitions and defining features of HPSR

The scope and nature of HPSR:

o why the boundaries are ‘fuzzy’. How the focus of HPSR is different from other forms of health research

o the importance of opinions, perceptions, beliefs and personal experience to health policy and systems, and so related research; of phenomena that cannot easily be ‘counted’ and measured

o levels of the system (macro, meso, micro) – introduced in Presentation 2, but this time in relation to research

Methodology and the fact that there is no methodological ‘gold standard’, the approach has to match the question

Recap the logic of the HPSR process – from a real world problem to question to strategy/design – and the need for rigour and application of ethical principles


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Activity 4: Pin the tail on the fuzzy boundaries of HPSR Time: 55 min (20 min for the game; 35 min for the plenary discussion)

In groups – the same groups in which participants worked for Activity 3 (Health systems and services: A local TB service delivery case)

Aims: This activity aims to build awareness of the defining features of a health systems perspective and the slight ‘fuzziness’ of the boundaries of HPSR (therefore topics and issues have to be carefully considered and negotiated). It also serves to regenerate some energy after a fairly content-heavy presentation.

In this activity, groups identify issues that are/are not relevant to HPSR. They then determine where, within the broad field of health and social sciences, a particular issue would ‘fit’. This is done in a fun way, as one participant is blindfolded and guided as to where to place their issue on a diagram (as below).

Suggestions for guiding the process

1. Give each group one large post-it note. Ask each group to write down, using 5-10 words, one of the research issues they identified from the experience of Orange District in Activity 3. Allow a few minutes for the groups to discuss which issue they will choose.

As a whole, the class needs to draw out some issues that are relevant to HPSR and others that are not. So you may like to specifically ask half the groups to identify an issue that they judge falls within the HPSR field, and the other half to identify an issue that they think falls outside HPSR.

o For an issue that participants think is HPSR they need to consider whether it is more on the epidemiological and clinical sciences, policy and practice or social science edge of the field.

o For an issue that participants think is not HPSR they need to consider whether it lies in the epidemiological and clinical sciences, policy and practice or social sciences fields.


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Note: It is the discussion and negotiation that is important in this activity, not the notes themselves. Make it clear that the activity is not about getting a ‘right’ answer but about thinking through the focus of HPSR – context and purpose, the keys to understanding, and HPSR requires constant reflective action.

2. When all the notes are ready, each group nominates one person in their group to be blindfolded. The blindfolded person stands in front of the wall chart/diagram (see below) and has to put the note on the chart. The other members of the group give directions (such as up, down, left or right, hot or cold) to guide her/him to put the note in the appropriate place on the chart.

Note: if this part of the activity does not suit the dignity of the class participants or the culture of the course, leave the blindfolding out and merely talk about appropriate places to put the notes.

Plenary discussion

Facilitate a discussion about the notes. Begin by asking each group to say what is on their post-it, where and why they have placed it on the HPSR diagram.

If there is not enough time for a report back from each group, you could simply focus discussion on some notes that provide a basis for wider discussion, including any that are contestable or reflect misunderstandings. Add your own examples as appropriate.

Possible examples for this discussion include:

As HPSR issues:

o ‘facility and staff barriers enabling or constraining integration of HIV and TB services’; or

o ‘factors influencing staff motivation within TB services’.

As non-HPSR issues:

o ‘clinical trial on a new TB or HIV drug’ (a clinical and epidemiological issue); or

o ‘re-allocating staff to support implementation of HIV and TB integration’ (a managerial issue); or

o ‘understanding how masculinity shapes health seeking behaviour for TB or HIV/AIDS’ (a social science issue).

During the discussion, you may move notes in and out of the circles/areas on the diagram to illustrate different examples of what would be typical HPSR or not. Use some extra post-it notes to write any new examples that come up during the discussion.

End the activity by re-capping some key issues (see below).

Some key issues to clarify

The difference between topics falling into the core HPSR area and those falling into each of the three other areas.

The differences between important contributing disciplines (e.g. health economics, social sciences, policy analysis).

The differences between HPSR and research focussed on specific health programmes, health services or health care interventions (recognising that health service research does fall within HPSR), including:


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o adopting a programme/service focus as a tracer for HPSR (consider whether the programme issue is identified as a way to understand a broader health policy or systems issue, or whether it is the primary object of concern);

o a focus on programme/service issues that have system-wide effects and so are important system issues (e.g. the needs of HIV antiretroviral therapy provision).

The diversity and nature of health policy and systems issues, which include opinions and perceptions, and variation in the extent to which they are measurable (reflecting the socially constructed nature of health systems, and the value of various research strategies in this field).

In preparation for other sessions ...If possible, display the wall chart and the notes for the entire course. You can then return to them during later sessions as the discussion continues, adding new topics and issues.

If it is not possible to leave the chart up, take a photograph of it so participants can be reminded of it later in the course.


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Session 3HPSR questions and perspectives

This session begins to engage with the details of HPSR as a practice – introducing the importance of the research question (framing the issue).

Topics and activities3.1 Asking HPSR questions

• Presentation 4: Generating and framing HPSR questions (45–60 min)• Activity 5: Tightening HPSR questions (55 min)

3.2 Recognising multiple perspectives• Presentation 5: Recognising your starting points (25 min)• Reflective quiz integrated with presentation (25 min)

Resources

Presentations 4 and 5 PPT A piece of paper for each group on which you have written a fairly generic HPSR question

that arose during Session 2 (Activity 5) Guiding questions/criteria written on flip chart paper or shown as a PPT slide (Activity 5)

Background readingAlliance Reader: Part 2, Section 1 (for Session 3.1); Part 1, Section 7 (for Session 3.2)

3.1 Asking HPSR questions Presentation 4: Generating and framing HPSR questions Purpose and rationalePresentation 4 outlines different types of research questions and suggests different ways of thinking about the questions that could be asked. It highlights the principles to consider when developing a sound HPSR question and understanding ‘substantively relevant’ HPSR questions. It provides a useful guide for the work ahead.

Outline The research question drives the study

Consider your starting points – the focus/terrain and who is asking the question

Start with the problem/concern/opportunity and aim to inform decision-making by policy and system actors

Consider whose ideas are being investigated/explored, what is already known about the issue (review the literature, avoid duplication, use theory)

Which disciplinary perspectives will be drawn on?

What is the purpose of the study? (e.g. normative/evaluative, exploratory, descriptive, explanatory, emancipatory)


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The purpose helps to shape the type of question to be asked (give examples of different types of questions)

The need for more work on exploratory and explanatory questions

What makes a ‘sound’ HPSR question (in any field) (based on real world problems, substantively relevant, clear, specific, answerable, interconnected)

The importance of how HPSR questions are generated and framed/worded

How to generate substantively relevant questions in HPSR (this is particularly important, and includes the importance of engaging with people working inside the health system and how to do a scoping literature review)

During the presentation

Keep participants engaged by making links back to the questions that were generated, or could have been generated, during earlier sessions. For example:

The introductory activity that identified diversity within the class (Activity 1). Consider how the different views of researchers contribute multiple perspectives to HPSR and various ways of thinking about and interpreting substantive relevance (what is important and what is worth doing).

The Martian Game (Activity 2, Session 1). You could ask participants: How would your view/picture of health systems influence your questions? (For example, if you saw it as a mechanistic or complex, adaptive system).

The TB case study (Activity 3, Session 2) showed how HPSR tries to understand health systems, and the kind of questions that are needed for health system strengthening.

Activity 4, ‘pin the tail on the fuzzy boundaries …’ showed how different disciplinary perspectives influence the types of questions that researchers ask.

Remember to use examples of questions that reflect on different types of HPSR issues and phenomena, specifically those that are more easily and less easily ‘measured’. Include examples of weak and sound research questions (using Robson, 2002). Consider the importance of the wording and framing of questions, and give good and bad examples –using Robson, 2002.

At relevant points during the presentation, pause and ask participants to reflect, individually or in pairs, on what has been said.

Activity 5: Tightening HPSR questions Time: 55 min (20 min group discussion; 35 min plenary)

In groups – they could be different groups from Activity 4

Aim: This activity is simply intended to emphasise two points (a) that the wording and framing of a question is very important, and (b) that a loosely framed question can suggest many different things to different people.

Note: If you do not have time for the group work in this activity, you can write one or two examples on the board/flip chart and ask participants to suggest how they would tighten them.

Give each group a piece of paper on which you have written a fairly generic but poorly framed HPSR question that arose during Session 2. The question must have some concepts that require thought about how they would be operationalised or addressed in the


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research, e.g. the type of data that would be collected, from whom, and what analysis would be required. Although each group is given the same question, do not tell them that beforehand.

Here’s an example of a poorly framed question that may arise from the scenario in Activity 3 (A local TB service delivery case): How can TB services be improved in Orange District?

The weakness of this question lies partly in its breadth and lack of focus, making it a poor guide for the research to be conducted. Different people might address it in different ways. It’s really more of a managerial question than a research question. It also makes the TB programme the object of research rather than a lens through which to understand the health system or experience of implementing change within it.

Suggested instructions for the group

You have been handed a research question that came up in the last session. You have been awarded a grant to do this research.

Please assess your question against the following five guiding criteria, and reframe it to make it stronger. You have 20 minutes for this. Then you will be asked to read out your research question to the class.

Guiding questions for the groups’ reference (displayed on flipchart or as a PPT slide)

Is this question clear, specific and answerable?

Is this question substantively relevant? (to the best of your knowledge)

What level of health system does the question address? (macro, meso, micro)

What can you tell about the scope of the research? (place, people, breadth of focus)

Are there any concepts that require operationalisation? (i.e. those that will need to be defined clearly and specific approaches developed to assess, measure, and inquire into them)

Plenary discussion

Ask each group to read out their reframed question. Write them up on flip chart (or ask participants to do so). Then compare the questions. Some key points to emphasise and questions to ask during the discussion are suggested below.

Broadly framed questions are open to different interpretations by different people.

Macro-level questions are not inevitably loosely framed.

Each word has meaning in the question.

Is this question substantively relevant? (If ‘yes’ it means it is worthwhile, not trivial, worthy of the effort to be expended, the research will build on what is known and not duplicate it, it will assist health system development in a particular context.)

Is this question clear, specific and answerable? (The wording and framing of the question is important here. It needs to be unambiguous and easily understood; sufficiently specific to be clear about what constitutes an answer; you can see what data are needed to answer it and how those data will be collected.)

Are there any concepts that require operationalisation? (i.e. those that will need to be defined clearly and specific approaches developed to assess, measure, and inquire into them)

3.2 Recognising multiple perspectives


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Presentation 5: Recognising your starting points Purpose and rationaleThis presentation introduces different epistemologies and generally aims to raise awareness of the fact that your perspectives will influence how you see health policy and systems problems, the questions you ask, and the kind of research you do. It aims to help participants to see that they have particular ways of understanding the world; that these understandings shape the issues they think are important to investigate and the research approaches they choose; and that they need to work with people who see things differently.

Outline HPSR is undertaken by people with different backgrounds and experiences

HPSR is intentionally multidisciplinary

There are different ways of thinking about health systems, and knowledge – what it means, how it is developed/constructed

Different paradigms of knowledge highlight different health policy and systems issues and phenomena, and related research questions

It is important to be aware of your personal disciplinary and knowledge starting points

An ‘epistemological self-diagnosis’ is integrated with the presentation as a quiz. You can ask participants to make a note of their answers and then have a ‘show of hands’ for final scores

Your personal disciplinary and knowledge starting points influence the questions you ask, and the research approaches with which you feel comfortable

During the presentation, draw in ideas from participants. Speak to the presentation and ask questions to get people thinking and reflecting about their own perspectives, use examples from previous sessions (see ideas below). You could ask them to consider certain issues in ‘buzz pairs’, vote by a show of hands or by moving to different parts of the room. You could also use new technologies that allow on-line voting by cell phone, for example.

Some ideas for engaging participants with Presentation 5

Refer back to the introductory session (Activity 1, Session 1.1), and the diverse ‘groups’ or perspectives in the class.

Ask the participants to indicate whether they see health systems as machines or social/political constructions – and make the link to earlier discussions (e.g. The Martian Game).

Encourage participants to think about whether health policy and health systems are written in stone or vary according to the meanings made of them (i.e. the way in which they are interpreted).

Try to get people thinking about the role of the researcher – from truth gatherer to interpreter and meaning maker.

Ask people to think about what types of HPSR practice they would prefer not to do – or that someone else in the room would be better at doing.

Link the knowledge paradigm positions to the (forms of) questions already asked in previous sessions (e.g. Activity 4 – ‘pin the tail …’).


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The learning so far …By the end of this session, participants will have an understanding of what HPSR is and how it differs from other fields of research; the range of research methods and tools that may be used in HPSR; and the importance of framing substantively relevant research questions. They have also reflected on different perspectives, including their own, and how these influence the research process. The next few sessions in the course are designed to help participants to put all this together as they go on to identify key elements in real HPSR studies and then, in Sessions 8 and 9 to develop their own study. The sessions are structured in a way that mirrors the four key steps in HPSR, both consolidating and adding to what participants have learned so far.

Prepare for Sessions 4–6Prepare a set of HPSR protocols on different topics, see Activity 6 for more details. (An example of a protocol is given in Annex 4.) Also make notes for each protocol that you select. These will be useful for your reference during the group discussions, and will form additional information sheets to give to participants at the end of the relevant sessions. See Annex 5 for a suggested grid for these notes.

Allocate participants into topic groups. They will work in these groups for Sessions 4, 5 and 6.You could also give participants their relevant protocol and Handout 3 to read as their self-study exercise.

Self-study for participantsParticipants read their group’s protocol and Handout 3 in preparation for Session 4.

See also Annex 2 for an idea for an individual assignment related to formulating and refining research questions.


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Session 4Introduction to HPSR protocol and design

This session addresses how different perspectives influence HPSR (how the problems are understood, the questions are framed).

Topics and activities4.1 Reviewing HPSR protocols

• Activity 6: HPSR protocol review – Part 1 (focus, purpose and question) (1 h 50 min)

4.2 HPSR study design – an overview • Presentation 6: Study design: from questions to projects (55 min)

Resources

Handout 3: HPSR protocol review (Activity 6), one copy per participant Flip chart paper and marker pens for each group (Activity 6) Research protocols (a different protocol for each group) (Activity 6) The notes you have compiled for each protocol – for your reference during the group

discussions, and to hand out to participants for additional information at the end of the activity

Presentation 6 PPT

Background readingPapers relevant to your selected HPSR protocols and their output literature. Alliance Reader, Part 2, Section 2 (for Session 4.2)

4.1 Reviewing HPSR protocols

Activity 6, a review of HPSR protocols, is in three parts and forms the main focus of Sessions 4, 5 and 6. It engages participants with the HPSR process through real, practical examples. The activity allows participants to apply understandings developed in earlier and related sessions, through critical appraisal of real-world HPSR protocols. In this process they also gain understanding of the key elements of a protocol. Facilitated discussion across protocols gives insight into a range of research questions, strategies and study designs; and how protocol formats differ between funders.

Activity 6 builds the foundation for Activity 8 (Sessions 8 and 9) during which participants develop their own HPSR protocol.

Note: this course is designed so that it can be refreshed with new protocols, perhaps selecting protocols with country-specific relevance. Through the CHEPSAA network you can not only find


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some relevant protocols to use but also share the ones that you have found with others – so helping to enrich our learning resources. Please share with us via www.hpsa-africa.orgActivity 6: HPSR protocol review – Part 1Time: 1 hour 50 min (10 min individual reading; 15 min pair discussion; 60 min group discussion; 25 min plenary discussion)

In groups – participants will work in the same groups for Sessions 5 and 6

Aims: The aim of the first part of Activity 6 is for participants to identify the issue of focus, purpose, and research question in an HPSR protocol, as well as briefly to consider the types of conclusions intended to be drawn out from the work (generalisable claims).

Preparation Identify a few real world protocols to use in this activity – ones that have been funded and that demonstrate a range of HPSR issues, questions, research strategies and study designs. For example, you could include protocols that: • are conducted as Master’s studies as well as ones of larger scope; • address more measurable as well as less measurable phenomena; • cover both health policy process and health systems topics; • represent a range of research purposes, including descriptive work; • demonstrate fixed and flexible research strategies;• demonstrate study designs that are particularly important for HPSR such as case study, mixed methods, action research; • use different disciplinary starting points.

Make sure that you are familiar with each protocol and their output literature. Prepare ‘answers’ for the protocol’s research questions for the plenary discussions. (See Annex 4 for an example of a protocol, and Annex 5 for a template for your summary notes.)

Suggestions for organising the group work process

Allocate a different research protocol to each group. Give each participant a copy of Handout 3 and their relevant protocol, if not done already at the end of Session 3.

Briefly introduce each protocol so that everyone has some sense of what the other groups are working on – mention the title, focus and country.

Key points to emphasise at the start of Activity 6

Participants will work with these protocols several times over the next three sessions.

They are real HPSR protocols – thank you to the providers – so the focus is on learning from them not redesigning them (think ‘critical appraisal’ not ‘critique’).

Different research questions have resulted in different study designs – and that is the key thing you are looking to learn from this activity.

Explain the key tasks For Activity 6, Part 1 participants will read their group’s protocol individually, before working in pairs or threes within their larger group to:

identify the purpose, question and perspective of the protocol, and consider what is presented as the substantive relevance of the study;


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consider the types of conclusions the researchers apparently want to draw (for example, conclusions that are generalisable, or that develop theory, or that have no apparent intention to draw conclusions that go beyond the study setting/population …).

Then the whole group needs to work together to:

summarise the purpose and question of the study;

discuss whether they are comfortable that the study’s substantive relevance is adequately justified, and why/why not.

Allow about an hour for the group discussion, then ask them to write up key issues on flip chart paper for display.

Plenary discussion

Facilitate a discussion across the protocols – keep track of time and make sure that each group has time to report back.

Ask each group to report briefly on the protocol they reviewed.

Ask for clarification/queries on each summary from the whole class.

After all the groups have reported back:

o clarify the different topic areas and phenomena of focus in the protocols, including why these address topical HPSR concerns (i.e. identify the features that make the issues ‘fit’ in the HPSR field);

o note any differences in purpose or perspective between the protocols;

o highlight features of the question, including key concepts that need to be operationalised in the protocol;

o clarify how ‘substantive relevance’ is justified for each protocol (and if the groups found their protocols persuasive in this regard);

o gently introduce the idea of different kinds of generalisable claims (i.e. statistical versus analytic generalisations). This idea will be introduced again later, the intention here is only to begin the discussion about the kinds of results that the research is seeking.

Finally, address any other queries or concerns.

4.2 HPSR study design – an overviewPresentation 6: Study design: from questions to projects Purpose and rationalePresentation 6 provides an overview of how to think about study design in HPSR – the second key step in HPSR, after identifying the research question. It introduces the three main categories of research strategy – fixed, flexible and mixed – as well as related study designs, and the role of theory in HPSR. It’s main aim is to show how the research question influences the strategy and design adopted, so building on Session 3 and preparing for Session 5 which looks at study design in more detail.

Outline From purpose to question to overall strategy

Research strategies include fixed, flexible and mixed methods


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Examples of specific fixed and flexible study designs

The appropriate strategy to select for a particular research question is based on the issues and phenomena of focus, and the overall research purpose

The selection of research strategy and specific design is influenced by your epistemological position

Fixed designs are appropriate when you can define and operationalise core phenomena in advance, so you can test hypotheses (be deductive), and when you want to assess and measure at scale – they can support descriptive, explanatory and normative work

Flexible designs are appropriate when the phenomena of inquiry are unclear in advance, or when opinions and views are the subject of inquiry, and when it is appropriate to allow the study design to develop in response to early stages of inquiry – they can support exploratory, descriptive and/or explanatory work and are predominantly inductive in nature

Mixed method design intentionally combines elements of fixed and flexible strategies and data collection methods, to deepen and extend insights and allow various forms of validation

Theory and conceptual frameworks are used to generate hypotheses, shape inquiry and investigate complex causality; but may also be derived from flexible design studies – and form the generalisable claims derived from these studies

Note: The issues introduced in Presentation 6 will be revisited in Session 5.2 and illustrated with specific examples from the protocols participants review in Activity 6.

Ending Session 4Ask participants to keep their copies of the research protocols, and Handout 3, and bring them to the next session.

Keep records of the key ‘outputs’ of this session for reference in Sessions 5 and 6. For example, flip chart notes of each group’s protocol issue (e.g. community health workers), purpose and question. You could capture these as PowerPoint slides, or take photos of the flip charts to present as slides.

Ideas for course assessmentAn activity based on reading abstracts could be used as an assignment to allow self-study around these issues. Another idea based on commenting and reflecting on an HPSR paper is given in Annex 2.


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Session 5HPSR design: turning questions into projects

This session continues to engage with the details of HPSR as a practice – introducing different forms of HPSR approaches, and emphasising the link from purpose to question to design.

Topics and activities5.1 Examining protocol designs

• Activity 6: HPSR protocol review – Part 2: research strategy and design (1 h 25 min)

5.2 Common HPSR designs • Presentation 7: Planning HPSR studies: key issues for specific designs (1 h 20 min) integrated with group reflection and discussion

Resources

Handout 3, research protocols, relevant flip chart notes of the groups’ work in Session 4, and your own summary of the protocols

Presentation 7 PPT

Background readingAlliance Reader: Part 2, Steps 1 and 2

5.1 Examining protocol designsActivity 6: HPSR protocol review – Part 2 Time: 85 min (10 min individual reading; 45 min group work; 30 min plenary discussion)

In groups – same groups as for Session 4.1

Aim: The aim of Part 2 of the protocol review is for participants to focus on the research strategy – its design and methods.

Preparation Review each protocol again and reflect on your prepared summary of the key elements of the strategy/issues (for reference during the plenary discussion after the group work). Be ready to discuss the surprising, interesting and concerning issues with the class.

Introducing the group work

Remind participants that in the previous session, they considered the issue, purpose and question of their HPSR protocol. In this session, they will build on that work as they consider specific elements of study design. Refer them to the questions in Table 2 in Handout 3.

If necessary, ask participants to spend the first 10 minutes or so re-reading the relevant portions of the protocol on their own, making notes in the grid as needed, before working


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together as a group to discuss the questions in more detail.

Observing the group workDuring the group discussions, specific questions about data collection, analysis approaches and differences between fixed, flexible and mixed method research strategies may arise. Members of the group may need to share knowledge and experience with each other. It may also be useful to stop discussions from time to time to highlight key principles of quantitative or qualitative data collection and analysis, so that discussions can continue.

Questions for participants to consider

What is the overarching research strategy and study design? What are the key elements of the design?

Is there any reference to theory? If so, what theory is used, and how?

What, if any, are the sampling units and approaches?

What data collection methods and tools are proposed?

Is there any reference to the analysis process/approach? If so, what kind of analysis will be undertaken?

Is there any phasing or sequencing of data collection and/or analysis activities in the study? What and why?

What are the most surprising and interesting elements of the strategy?

What queries or concerns do you have about this study?

Plenary discussion

There is unlikely to be enough time for each group to give a report back. Therefore, you could ask two groups to report back and then draw out the similarities and differences, compare and contrast elements across protocols. Alternatively, you could take each question in turn and ask a relevant group to say what they found, and then ask the other groups for any different or similar points.

You could prepare a completed grid (based on Handout 3, Table 2) for each of the protocols and give copies to participants and then ask them to highlight any differences that they found in relation to the protocol they reviewed.

Clarify issues raised by each group and consider if any key issues are missing. Summarise key issues to think about for each type of research strategy.

Key points to clarify/emphasise during the discussion

How ‘purpose’ is reflected in the research strategy and study design.

The differences between fixed, flexible and mixed method designs in terms of the type of issues they address, the questions of focus and overall design features, such as sequencing of activities.

The similarities and differences in approach when similar study designs (such as case study design) are used for different protocols.

A few key principles of qualitative and quantitative data collection and analysis.

Any particular questions and concerns raised by the groups.


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5.2 Common HPSR designs Presentation 7: Planning HPSR studies: key issues for specific designs Purpose and rationaleBuilding on Presentation 6, this presentation and discussion highlights key issues for some of the common, or popular, study designs used in HPSR and the key challenges of each. For example, cross-sectional design, case study, participatory action research.

Outline Focus on specific study designs, for each design highlight/discuss:

Its defining features (e.g. in terms of data collection and analysis) (What is it?)

Examples of issues that been explored using that design approach, the suitability of the design for particular types of research purpose and question (Why use it?)

Particular challenges or issues related to the design (What to watch out for/beware of?)

Integrate the presentation with opportunities for participants to link key points from the presentation with the study designs in the protocols they reviewed or with abstracts of relevant papers. After you have presented key issues related to a specific design, ask participants to discuss the key design features of the protocol/abstract they have considered in relation to the points raised in the presentation. Have a plenary discussion to share participants’ reflections before moving on with the presentation.

See also Handout 4 for particular research strategies and their approach to rigour, and the Alliance Reader, Part 4.


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Session 6Rigour, trustworthiness and generalisable claims

In this session, participants begin to engage with approaches to critique HPSR and understand issues of rigour and generalisable claims. A key message is that different approaches have different rigour issues to observe or be aware of.

Topics and activities6.1 Ensuring rigour

• Presentation 8: Rigour and ethics (50 min with discussion)• Activity 6: HPSR protocol review – Part 3: rigour and ethics (1 h 55 min)

Resources

Presentation 8 PPT

Protocols for each group and Handout 3 (as per Sessions 4 and 5) Relevant flip chart notes from Sessions 4 and 5 Handout 4: HPSR strategies – approaches to rigour Note: Check that Handout 4 covers the strategies/approaches relevant to the protocols that you

selected for Activity 6, and adapt it as needed. You need to include the key issues, with key readings, for each type of strategy considered in the protocols.

Background readingAlliance Reader: Part 2, Step 3

6.1 Ensuring rigourPresentation 8: Rigour and ethics Purpose and rationaleThis presentation introduces participants to the last two steps in the HPSR process: ensure quality and rigour, and apply ethical principles. Ensuring quality is important for all research. The aim here is to outline the different rigour or trustworthiness issues to consider for different types of HPSR strategy and design.

Outline Being rigorous in HPSR always involves active questioning and checking,

conceptualising and reconceptualising, crafting interpretive judgements and researcher reflexivity

The attributes the researcher needs to bring to the research – an enquiring mind, listening skills, flexibility, an understanding of the issues and a lack of bias

How to assess or determine validity/trustworthiness in fixed and flexible designs – the types of questions to ask, strategies that enhance validity and rigour. No one approach is more trustworthy than another – but different approaches have different strengths, and different principles of judgement must be used when reading/using different study research strategies/study designs


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Validity in case study work and critical case study issues

Analytic/theoretical generalisation

Interpretative analysis

Role of theory in ensuring rigour

An overview of ethical issues/principles in HPSR – questionable practices in HPSR, what to avoid

Examples of HPSR ethical challenges and other related HPSR issues

A key message to emphasise during the presentation is that in assessing research rigour, different principles of judgement apply to different research strategies. Provide examples and make links to the rigour issues raised in previous sessions, such as Session 3 that looked at multiple perspectives in HPSR. Also ask participants to give examples from the studies they have read.

Activity 6: HPSR protocol review – Part 3 Time: 1 hour 55 minutes (10 min individual reading and reflection; 45 min discussion within groups; 60 min plenary discussion)

In groups – same groups as for Sessions 4 and 5

Aim: This final part of Activity 6 allows participants to reflect on the extent to which the research design in their group’s protocol has sufficient safeguards to ensure rigour and trustworthiness.

Introducing the group work

As previously, ask participants to begin with some quiet reflection on their own, as they look again at their group’s protocol and reflect on the steps of rigour built into the work proposed and the protocol’s potential to support credible insights, conclusions and generalisable claims.

Refer participants to Table 3 in Handout 3 for questions to guide their thinking. They can make notes on the grid in preparation for their group discussion.

After about 10 or 15 minutes, participants begin to discuss their ideas with others in their group. They need to consider:

the key steps of rigour emphasised in the protocol

any surprising or interesting elements of the approaches used to ensure rigour

any queries or concerns they have about the approaches used to ensure rigour

whether they judge that the protocol will support credible insights, conclusions and/or the types of generalisable claims it predicts.

Remind them to record their main points on flip chart paper, which they can display on the wall for future reference.

Members of the group may need to share knowledge and experience with each other. It may also be useful to stop discussions from time to time to highlight key principles of quantitative or qualitative data collection and analysis, to allow discussions to continue.


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Plenary discussion

Ask each group to highlight 2 or 3 key interesting, worrying or surprising elements of the approach used in their protocol and discuss them in plenary.

Facilitate a discussion to draw out key issues, across the protocols. Clarify the similarities and differences in the ways in which the different protocols approached rigour, making links back to their study designs and their different perspectives. Be ready to encourage discussion of the issues you introduced in the presentation.

There may well be time here to discuss again, in greater depth, some key differences in the approaches applied in different protocols. Consider differences in data collection and analysis between fixed, flexible and mixed method research strategies, due to different data forms. Also consider how to judge the rigour and trustworthiness of different types of studies.

Give participants Handout 4 ‘HPSR strategies – approaches to rigour’

Note: Adapt Handout 4 as needed, as it must cover the design strategies relevant to the protocols with which participants work. You need to include the key issues, with key readings, for each type of strategy/design considered in the protocols.

Self-study for participantsGive participants the research papers for Activity 7: Paper critique. They need to read these in preparation for Session 7. (See Handout 5 for some examples.)

Prepare for Sessions 7–9You will need to allocate participants to groups according to the topic of their research paper (see ‘Preparation’ in Session 7.1 for more details). They will work on the same topics for Sessions 8 and 9. You will also need to adapt Handout 5 to match the topics and papers you select.


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Session 7Topic to design: HPSR paper critique

This session begins a second, practical process to allow participants to engage with a particular topic and consider HPSR methodological issues. It is a holistic session designed to allow participants to put their learning from previous sessions into practice. It enables the building of critical analysis skills, and demonstrates the value of multiple perspectives/approaches in considering similar issues.

Topics and activity7.1 One HPSR research topic, different design options

• Activity 7: Critical appraisal of HPSR papers (2 h 15 min)

• Participants’ begin their self-study reading in preparation for Sessions 8 and 9 (30 min)

Resources

Copies of relevant research papers (one paper per participant) Handout 5: A guide for the HPSR paper critique

Background readingResearch papers selected for the activity and related articles

7.1 One HPSR research topic, different design optionsActivity 7: Critical appraisal of HPSR papers Time: 135 minutes (5 min individual recap; 40 min pair discussion (same paper); 45 min groups of three discussion (different papers, same topic); 45 min plenary discussion)

In pairs or groups of three

Aim: This activity aims to encourage participants to apply what they have learned so far about HPSR as they critically appraise actual research papers.

Preparation: Identify topic options and allocate groups

We suggest you focus on HPSR topics for which there are several different empirical examples that apply different research strategies and study designs, and which clearly demonstrate a health policy and systems focus and lens. If possible, these topics should be different from topics chosen for the protocol review (Sessions 4 to 6) in order to broaden participants’ knowledge of the HPSR field. Examples of such topics are:• quality of care• community accountability• decentralisation• health worker motivation.


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For each topic, identify three papers that each use a different research design. Handout 5 provides some examples for two topics (a) health worker motivation and (b) community accountability.

Within each topic, two people (or three, if numbers are uneven) will read the same paper. You may have two groups that address the same topic, depending on the size of your class and number of prepared topics.

Make sure that you are familiar with all the papers, and their similarities and differences, for example see the completed table for papers in Handout 5 (Part B).

Give participants Handout 5 Part A, which provides a guide for key elements to identify in their paper.

The activity begins with individuals recapping their paper. They then work in pairs to identify key aspects of the study and complete the handout grid. Then, each participant works with two others who have read different papers on the same topic. They share and discuss their analysis. A plenary discussion draws together ideas across the papers/topics.As you observe the groups’ discussions, help participants to stay focused on the task by asking questions such as:

Why is this strategy/approach used and what does it add to the broader topic?

What other approaches might the researchers have considered?

Example of instructions to guide the group work process

1. Individual reading/recap (5 min): Take a few minutes to remind yourself about your paper. (Participants should have read the paper earlier in preparation for this session.)

2. Pair discussion – focusing on the same paper (40 min): Within your topic group, find another person who has read the same paper as you. Work together to identify key aspects of the study. Key questions to consider are:

What is the focus/issue/problem?

What is the purpose of the study?

What is the research question?

What is the research strategy and design?

Is the strategy appropriate for the question? Do you judge the overall study to have sufficient rigour? Is there a claim that is made and is that claim justified?

Record your ideas in the relevant sections of the grid in Handout 5. You will each need to make your own notes on this.

3. Discussion in groups of three (45 min): Leave your partner, and find two other people from your topic group who have read different papers. Report back to them about the paper that you read, and the key aspects you identified. Listen to their reports. Discuss any interesting issues that arise across the papers. For example:

How do different research designs generate different types of insights?

In what ways do the papers complement each other/contribute to our understanding of the topic as a whole/what do they illuminate about the topic of focus?

Plenary discussion


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Give participants a prepared grid of key details across all papers for reference (Handout 5 Part B is an example). Taking each paper in turn, ask the topic groups if they have anything to add. However, be careful not to lose participants’ attention by dwelling solely on one topic or paper for too long. Draw out some cross-cutting issues to widen the discussion to include those who studied the other papers/topics.

Emphasise the fact that three studies/papers are focused on the same broad topic, yet each have different approaches and designs. This is why it is important to match your research question to the study design.

Ending Session 7Prepare participants for their self-study task and for Sessions 8 and 9Allow about 30 minutes at the end of Session 7 to lay a foundation for the work to come in Session 8, when participants will develop their own research strategy. Give out Handout 6 and introduce Activities 8 and 9, so they know what to expect. To save time in Session 8 you could also explain more of the process for Activity 8.

Organise participants into groups of six (seven or eight if the numbers are uneven), based on the topic of the papers appraised in Activity 7. In this way, each group contains people who have focused on the same topic, yet read about different research designs. Participants will work in the same groups for Sessions 8 and 9.

Ask participants to spend 10 minutes or so individually to reflect on previous activities and think about possible research issues/questions relevant to their group’s topic. Then, hand out the relevant literature reviews so they can begin their background reading – to extend into their self-study session (see below).

Note: You may like to prepare the topic group leaders for the group work in Sessions 8 and 9, e.g. make sure they have time to do the background reading, share tips for group facilitation.

Self-study for participantsParticipants to read around their topic in preparation for developing their own research strategy in Sessions 8 and 9. At the minimum they need to read the literature review and the abstracts of the papers on their reading list (see Annex 3). They begin to identify issues that they think would make substantively relevant research questions in specific contexts.


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Session 8Developing an HPSR protocol outline

This session requires students to walk through the entire process of framing an issue, developing a question and matching a design to it. This is framed as developing a pitch for a funder.

Topic and activity8.1 Framing the issue, developing the question and design

• Activity 8: Part 1 – Develop an HPSR strategy and design (2 h 45 min)

Resources

Handout 6: Develop an HPSR strategy and design Space for group work: depending on your physical setting, groups can work in one room

together or can spread out among various smaller rooms

8.1 Framing the issue, developing the question and designActivity 8: Part 1 – Develop an HPSR strategy and designTime: 165 min (120 min develop an idea for a research study – from issue, to question to design; 30 min consider the details; 15 min begin to think about presenting the funder’s pitch for Session 9)

In groups – based on the topic of papers appraised in Session 7 (Activity 7)

End of course assignment: Participants’ work during this activity will lay the foundation for their summative assessment assignment, in which they write up their HPSR strategy in more detail. (See Annex 2 for an outline of the assignment.)

In Activity 8, participants continue to work on the same topic that they began exploring in Session 7. Their task is to develop an outline of a research strategy for their topic. This involves clarifying the issue, developing a question and research design.

Give each participant a copy of Handout 6 (although you may prefer to do this at the end of Session 7), and briefly explain the process (see below). Each group will need to elect a group leader to help guide the process. They will also need to record the key points from their discussions to refer to when they present their funders’ pitch in Session 9.)

Note: Small group facilitation is important in this activity. If necessary, provide the group leader with a page outlining some tips for effective group facilitation (ensuring that everyone is heard, how to manage dominant voices, etc.).

Suggested instructions for the groups

Your task is to develop an outline for a research study – an HPSR protocol (Part 1 of Handout 6). Spend most of your time (about 2 hours) on the first two steps in Handout 6,


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and allow about 30 minutes for step 3:

1. Clarify a new key issue or problem

Identify the key issue or problem that you want to focus on within the broad topic area and decide on the particular setting in which the research will take place.

2. Develop an HPSR question

Identify the purpose of your study and frame an HPSR question (you may frame sub-questions, but it is not necessary). Consider whether it is a micro/meso/macro question (or which combination of these). Be able to explain and justify the substantive relevance of your research question.

3. Develop an overall research strategy and design

Decide on an appropriate overall strategy and design (e.g. fixed or flexible strategy, then case study, cross-sectional survey, etc). Then, start thinking about the details of the study design. Pay particular attention to thinking carefully about how you will appropriately investigate the issues and phenomena that are central to your topic and question. Think also about the type of insights that will be generated or the types of generalisable claims that will be made (if any), and what steps of rigour you will apply to ensure the credibility and validity of these insights/claims. You will each work on it in more detail for your end of course assignment.

Spend the last 10–15 minutes of this session to recap/consolidate your ideas and begin to think about how you would present your strategy to a potential funder. What key points would you include in your pitch? You will have more time to develop this in Session 9. It may help to look at the assessment criteria on page 5 of Handout 6 – so you know what other groups are going to be looking for in your presentation.

Note: The groups will need to watch their time carefully during this activity. As you observe their work, help them to move on in their discussions and avoid getting stuck in describing the details of the plan.


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Session 9Pitching the idea

In this session participants practise their communication skills as they present their research ideas and answer questions to defend their HPSR protocol. It also provides an opportunity for them to apply their understanding of what makes a strong HPSR project as they assess other groups’ protocols during the funders’ panel.

Topic and activity9.1 Presenting and assessing an HPSR protocol

• Activity 8: Part 2 – Prepare a funders’ pitch (50 min)• Activity 9: A funders’ panel (1 h 55 min)

Resources

Handout 6: Develop an HPSR strategy and design Pieces of paper for each participant to make their votes

9.1 Presenting and assessing an HPSR protocolActivity 8: Part 2 – Prepare a funders’ pitch Time: 45-50 min

In groups – same groups as for Session 8

Aim: This activity provides an opportunity for participants to clarify the key features of their HPSR protocol and prepare their presentation.

Participants develop the presentation of their HPSR protocol, as in Part 2 of Handout 6. Remind them that they also need to be prepared to defend their protocol and answer a question about it from one of the other groups. At the start of this session, it may be useful to remind participants of the funders’ assessment criteria (see below).

After they have prepared their presentations, notify each group which other group they will ‘question’ during the funders’ panel.

Funders’ assessment criteria

The funders’ panel will use the following criteria to assess each presentation:

Is the issue identified clear, relevant and important?

Do you judge this research to be substantively relevant? (i.e. Is it, overall, ‘worth doing’ given past research on the issue and when balancing ‘importance’ against ‘cost’ to funders and study participants?)

Is the research question well framed, and does it respond to the identified issue?

Is the strategy the most appropriate to address the identified question?


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Will the proposed approach generate trustworthy and credible data on the key issues and phenomena of focus? (This requires participants to include a broad overview of the types of data they will collect and the sources of those data.)

However, the final assessment will be based on the core question:

Would you fund this research?

Note: It is the coherence of the strategy and its focus that is important and needs to shine through in the presentations. The detail can be added later (as part of the end of course assignment).

Activity 9: A funders’ panelTime: 115 min, but adapt to the number of groups (e.g. allow about 8 min for each group’s presentation, plus a few minutes for their defence, plus some time for the funders’ panel wrap and final voting)

Aims: This activity allows participants to practise their communication and presentation skills. They also apply what they have learned so far in the course to make a judgement about other group’s protocols.

In the funders’ panel each group will present their pitch to the others in the class who act as funders. After their presentation, each group has a chance to respond to 1–2 questions before the full panel makes its final judgement.

One other group will be primarily responsible for leading the questions posed to each presenting group. However, each member of the full funders’ panel will make a final judgement on each proposal, based on the assessment criteria in Handout 6. They will vote in a secret ballot. The successful group will be the one that gathers the highest total number of ‘yes’ judgements.

Note: Participants cannot vote for their own group!

Suggestion for organising the funders’ panel and voting process

If you have many groups, the following steps can facilitate the process.

1. Pause after three groups have made their presentation. Allow the relevant groups to reflect and determine a question to ask.

2. Taking each presenting group in turn, ask them to defend their protocol (answer the question posed by another group). The other participants can make their own notes as they assess that particular group.

3. Make any brief, initial comments that you think are helpful, comparing across the groups, see ‘Funders’ panel wrap’ below for ideas.

Repeat steps 1–3 for the next three groups.

4. Participants make their final judgements after all the groups have made their presentations – ‘Yes I would fund this project’ or ‘No, I would not fund it’. Using a small piece of paper for each group, each participant writes the name/number of a group and ‘yes’ or ‘no’ on the paper. They can put these in the ‘ballot box’ so you can count the votes and announce the winner (if there are too many votes to count in this session, leave the announcement for Session 10).


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Funders’ panel wrap-up

After the scores have been collected (but before they are announced), present some overarching points about each protocol. (Alternatively, this could be done at the start of Session 10.) Consider both the substance of the presentation and its style.

Regarding the substance, consider each of the funders’ panel assessment criteria and, in particular:

Is the ‘research design fit for purpose’? Consider its substantive relevance but also whether the broad research purpose proposed is appropriate, given previous research work and experience on the topic, and whether the design will allow the purpose to be achieved.

Was the research question appropriate, and appropriately operationalised?

Given the question and issues of focus, will appropriate data be collected, from appropriate sources?

Give some brief feedback on each protocol. Draw out interesting/unusual/strong points from across protocols, and highlight key weaknesses. Emphasise points that have come up in discussions during the course.

Ending Session 9Introduce the end of course assignment (see Annex 2). Participants’ group presentations provide the basis for this – with one more element to be explored further in Session 10 (how to enhance the uptake of the research findings). It is now up to individuals to describe the research project in more detail, with reference to the relevant readings.

The self-study suggestion below will help participants to prepare for Session 10.

Self-study for participantsParticipants consider how they would enhance the uptake of research findings from their project.

In addition, participants read:

Sheikh K, George A, Gilson L (2014). People-centred science: strengthening the practice of health policy and systems research. Health Research Policy and Systems, 12:19.

Other relevant readings include:

Green A, Bennett S, eds (2007). Sound choices: enhancing capacity for evidence-informed health policy. Alliance for Health Policy and Systems Research, Geneva, World Health Organization.

WHO (2012). Changing mindsets: strategy on health policy and systems research. Geneva, World Health Organization.


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Session 10Influencing health policy and practice

This session returns to the focus on research as engagement – looking at project, organisational and personal strategies that can support research use in decision-making and build practitioner–researcher engagement.

Topics and activities10.1 Strengthening evidence-informed health policy-making

• Presentation 9: Influencing policy and practice (45 min)• Activity 10: Organisational strategies for building practitioner–researcher engagement (40 min)

10.2 Personal reflection • Activity 11: Myself as a researcher … (50 min)

10.3 Course wrap-up and evaluation • Presentation 10: IHPSR wrap-up (30 min)• Course evaluation

Resources

Presentations 9 and 10 PPTs Handout 7: Building practitioner–researcher engagement (Activity 10) Handout 8: Personal reflection (Activity 11) Handout 9: Course evaluation

10.1 Strengthening evidence-informed health policy-makingPresentation 9: Influencing policy and practicePurpose and rationaleThis presentation outlines some of the ideas and challenges of translating research into policy and practice. It builds on what participants know about the nature of HPSR and makes the final link back to the relevance of such research for improving health systems through influencing/informing policy and practice.

Outline Should researchers actively seek to influence policy?

Ideas/models about the policy-making process and research and other influences over it

How can you judge whether or not research has influenced policy?

Why research does not influence policy

Brainstorm session: planning HPSR to support policy-making

How to enhance the uptake/dissemination of research findings (communication of findings and results, thinking beyond projects)


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One of the slides in Presentation 9 invites participants to brainstorm their ideas in response to the question:

What should you think about when planning a research project, to support policy engagement and influence?

Ask participants to suggest some ideas to enhance the uptake of research findings drawn from the protocols they reviewed (in Sessions 4–6). Then ask them to think about what elements/approaches they could include for the research strategy their group developed. This could take the form of a brainstorm, with participants calling out ideas. It also prepares participants for the end of course assignment.

You could then show the slide that offers some guiding questions to help enhance the uptake of findings from a research study (see below). It forms a checklist of issues to consider in relation to particular projects.

Note: Alternatively, you could ask participants to look back at the protocol they reviewed and consider the brainstorm question as an assignment before this Session. They would then come prepared with ideas to contribute at this point in the presentation.

After the brainstorm, continue with the presentation and discussion of the importance of thinking beyond individual projects to creating an organisational environment that fosters connections between evidence and policy-making, researchers and managers, through wider networks.

Some guiding questions to help enhance the uptake of findings from a research study (from Presentation 9)

Stakeholder engagement Who are the critical stakeholders in the study?

How might the research design take into consideration the needs of end users?

How could you encourage on-going engagement with stakeholders throughout the project?

Capacity building Does your team have the capacity to communicate research effectively?

Will an assessment be made of external capacity to make use of research results?

What sort of capacity building approaches might be proposed?

Does the programme team have the capacity to implement their capacity building strategy?

Communicating Will you carry out research synthesis during the inception phase and/or later?

Will outputs be published in peer review journals? Will you make the outputs open access?

Is there a plan to package and communicate findings to non-specialist audiences?


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Activity 10: Organisational strategies for building practitioner–researcher engagement Time: 40 min (20 min for discussion in pairs/threes; 20 min plenary discussion)

In pairs – or groups of three

Aim: This activity aims to encourage participants to begin to think about their own organisation/place of work and what they can do to strengthen practitioner–researcher engagement.

Give each participant a copy of Handout 7. With their partner/s, participants share their ideas about what they think can be done within their own organisation/work setting/level of health system or country to strengthen evidence-informed policy making.

They also review the box ‘Actions required of key actors’ from Sound Choices (Green & Bennett, 2007), and consider which of those ideas would be appropriate/not appropriate for their organisation.

Plenary discussion

Taking each question in turn, ask participants to call out their ideas in a brainstorm – but focus on different types of organisations in sequence, e.g. people working at district level, or national departments, those from non-governmental organisations or funding organisations.

Capture the ideas, grouped according to type of organisations, on flip chart.

10.2 Personal reflection Activity 11: Myself as a researcher … Time: 50 min (40 min individual reflection; 10 min plenary discussion)

Individual activity

Aim: This activity aims to encourage participants to begin a process of self-reflection about themselves as researchers or people who engage with research findings. There is potential for them to make such reflection a regular part of their work, in order to strengthen their practice and understanding of HPSR and its role in strengthening health systems.

Suggested instructions for participants

Take some time to think about yourself as a researcher and your approach to HPSR. Reflexivity is an important element in the research process.

Reflect on your prior reading of the paper by Sheikh, George & Gilson (2014), and its implications for your personal research practice. Think carefully about the particular perspectives and skills that you bring to HPSR and where your comfort zones and boundaries are.

Some questions to guide your reflection are given in Handout 8. Try to consider the different elements of HPSR research in relation to your particular interests, skills and experience and perspectives. For example: a. the issues that particularly interest youb. research strategies


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c. generalisable claims d. approaches to ensuring rigour e. practitioner–research engagement.

Plenary discussion

Facilitate a plenary discussion to draw out the key insights participants gained from Sheikh, George & Gilson (2014). Then ask them to share some ideas of what it means for how they work – what understandings/skills they would like to develop, what they would like to learn and do in the future.

This discussion could also include specific consideration of the ethics of HPSR, referring back to Presentation 8 (‘Rigour and ethics’), and addressing issues such as: a. substantive relevance as an ethical issueb. the action imperative c. power relationships d. practical issues such as time demands e. working with and through fieldworkers.

10.3 Course wrap-up and evaluationPresentation 10: IHPSR wrap-up Purpose and rationaleThis closing presentation provides a summary of what has been covered on the course. It serves to remind participants of key concepts and link back to the key threshold concepts and skills identified in Session 1.

Outline Aims and nature of HPSR

The importance of being systematic, principled and ethical

The HPSR process from issue and question to research design to policy engagement

Key issues and questions from a systems perspective

Key features/elements of HPSR (e.g. substantive relevance, valuing multiple perspectives, being rigorous/trustworthy)

Threshold concepts and skills

Course evaluation Give each participant a copy of the course evaluation form (Handout 9) for them to complete before they leave.

To get a sense of the overall response, when they have completed the forms do three quick rounds during which each participant shares something that:

they enjoyed during the course (1st round)

they learned (2nd round), and

could have been better (3rd round).


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Annex 1 Suggested timetable for a five-day introduction to HPSR short course

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY9.00 – 10.30 Session 1 & 2: Introductions

and starting points: the focus and field of HPSR(Why are we running this course? What is a health system and why is it important?)Activity: The Martian Game

Session 3: HPSR questions and perspectivesPresentation: Generating and framing HPSR questionsActivity: Tightening HPSR questions

Session 5: HPSR design: turning questions into projectsBrief recap on overview from previous dayActivity: HPSR protocol review –Part 2: research strategy and design

Sessions 8 & 9: Developing an HPSR protocol outline and pitching the ideaActivity: Develop an HPSR strategy and design Part 1: Develop your research strategy

Session 10: Influencing health policy and practicePresentation: Influencing policy and practiceActivity: Organisational strategies for building practitioner–researcher engagement

Tea11.00 – 13.00

Presentation: What is a health system? What is health system strengthening?Activity: Health systems and services: A local TB service delivery case

Session 4: Introduction to HPSR protocol and designActivity: HPSR protocol review –Part 1: focus, purpose and questionPresentation: Study design: from questions to projects

Presentation: Planning HPSR studies: key issues for specific designs

Session 6: Rigour, trustworthiness, generalisable claimsPresentation: Rigour and ethicsActivity: HPSR protocol review – Part 3: rigour and ethics

Group work continued, moving into Part 2 of the activity – Prepare a funders’ pitch

Facilitator checks to ensure that the groups have moved on toPart 2 of the activity in the last 45 min

Course wrap up and evaluation:Presentation: IHPSR wrap-upActivity: Myself as a researcher …

Lunch14.00 – 16.00

Presentation: What is HPSR?Activity: Pin the tail on the fuzzy boundaries of HPSR

Presentation: Recognising your starting pointsReflective quiz integrated with presentation

Session 7: Topic to design: HPSR paper critiqueActivity: Critical appraisal of HPSR papers

Activity: A funders’ panelGroup presentations, discussion and individual voting

Course evaluation


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Annex 2 Course assessment and assignment guide One approach to assessment is to have two assignments for formative assessment to be completed during the first half of the course that provide a foundation for Sessions 8 and 9 (‘Developing an HPSR protocol outline’ and ‘Pitching the idea’). Together these assignments could be allocated 40% of the total course mark. Two examples of such assignments are given in this annex – one based on formulating research questions and the other based on a critical analysis/appraisal of an HPSR paper.

The formative assessments could then be complemented by a summative assessment linked to the group work in Sessions 8 and 9. For example, a group work mark (allocated 10% of the total course mark) could be awarded for the funders’ pitch presentation (Session 9); and the group work could be the basis for individual assignments (allocated 50% of the total course mark). These individual assignments could involve the further development of the group’s protocol outline, including consideration of a research uptake/communication plan as discussed in Session 10. An example of guidance notes for such a summative assessment is given in this annex.

Alternatively, the summative assignment could be a formal exam – such as an ‘open book’ exam focussed on writing up a protocol on a different topic from that covered in the group assignment. The group assignment would then still prepare the student/learner for the exam. As an open book exam, learners would be given the exam ‘question’ in advance to do some preparation, they would be allowed to bring some preparatory notes to the exam room, but be required to write under exam conditions.


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Assignment 1 Formulating HPSR questionsSuggested guidelines for participants, to be amended as needed.

Note: Due date: [provide date and time, link to Session xx] (late submission penalties will apply) Required length: Part 1: 3–5 pages, Part 2: 2 pages. Single space, font size 11 or 12 point. Note that all assignments will be routinely run through ‘Turnitin’, to check for plagiarism

www.turnitin.com There is no single correct answer for this assignment, and while we strongly encourage you

to read the course material we also want to discourage you from trying to search the internet or other sources for ‘perfect’ questions. We are principally interested in understanding how you re-work the ideas and concepts of the course and the problems the article presents through your lens of experience, interests and capabilities. (In all assignments, demonstration of broader reading will be rewarded.)

Please use a consistent referencing style when necessary. We will give you individual feedback within two weeks of submission.

Pre-reading1. The case scenario on TB in Orange District (Handout 2)

2. Handouts and readings from Sessions 1–3 of the course

Part 1: Drafting HPSR questions This is a formative assessment task that is not marked. Your course facilitator will give you feedback on the framing of your question, in the light of which you can carry on to the full assignment.

Re-read the scenario provided in Handout 2 describing the health system and TB-related concerns in Orange District.

1. Drawing from this, generate three ‘good’ health policy and systems (HPS) research questions – one micro, one macro and one meso. These could be questions focussed on better understanding the situation and how to intervene in it, and/or questions about the interventions proposed. (Ensure that each question meets Robson’s criteria of a good research question – that is: clear, specific, answerable, interconnected, and substantively relevant).

2. For each of your questions, briefly:

a. Describe the main HPS issue (problem or opportunity) that the question addresses, using details drawn from the scenario.

b. State whether, in your opinion, the question is normative/evaluative, exploratory, descriptive, explanatory or what combination of these purposes. Give reasons for your judgement


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Part 2: Refining your questions 1. Choose two of the three questions you initially formulated.

2. For each question, do some wider reading around the topic of focus to understand the broader international experience on the issues of focus (read at least three papers per question).

3. Refine each question, in the light of your reading and the feedback you received from your course facilitator.

4. For your assignment, write out each refined question (number them question 1 and question 2). For each question:

Justify the question and its underlying purpose, by explaining its relevance to the TB scenario and, using the papers you have read, to health policy and systems more generally – in terms of its contribution to current knowledge.

Write a maximum of one page for each question.

Evaluation criteriaThis assignment represents 15% of the total course mark and will be marked using the criteria given below, linked to the course learning outcomes.

Related learning outcomes

Assessment criteria Mark

LO1 Identified two refined research questions that address researchable health policy and systems issues

10 marks

LO2, 7 For each research question, wrote a narrative that justifies and explains the substantive relevance of the question with appropriate reference to the TB scenario and additional, relevant, papers

30 marks

LO11 Originality and thoughtfulness (reflexivity)

Overall academic literacy

Spelling and grammar mostly correct, uses appropriate referencing conventions, correct word length; evidence of extra reading around subject matter

4 marks

6 marks

Total 50 marks


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Assignment 2 HPSR paper commentary and reflectionSuggested guidelines for participants, to be amended as needed.

Note: Due date: [add date and time, link to Session x] Read the paper you have selected prior to the allocated session. Hand in a written response to the questions below on or before the date of the session

(late submission penalties will apply). Note that all assignments will be routinely run through ‘Turnitin’, to check for plagiarism www.turnitin.com

Be ready to contribute to the class discussion around the issues considered below. You will be given individual feedback within two weeks of handing in your written work. Single space, font size 11 or 12. Please use a recognisable and consistent academic

referencing style. The writing should be predominantly narrative in style, although not excluding bullet points, diagrams, etc.

Please note that this assignment is intended to give you the opportunity to ‘analyse critically’ an HPSR paper – as we believe this is an important competency for HPSR.

Critical analysis is the art of providing a reasonable evaluation of a situation/text by breaking it down and studying its parts. In this case, to be critical does not mean to criticise in a negative manner. Rather it requires you to question the information and opinions in a text and present a reasonable analysis of the paper.

Analysis means to evaluate the strengths and weaknesses of the paper, based on clear criteria – and with an understanding of the paper’s purpose, the intended audience and why it is structured the way it is.

A critical analysis of a research report/paper is assisted by broader reading around that topic – to strengthen your argument.

Part 1: Write a brief paper summary (bulleted notes are acceptable; useful for class discussion)

1. What is/are the research question/s or research objectives (whether explicit or implicit) of the study, as presented in the paper?

2. What appears to be the research purpose?

3. What overall research strategy or design is adopted?

4. Briefly, what data collection methods and analysis approaches are used?

5. What generalisable claims does the paper make, if any?

Part 2: Write a narrative critical analysis (your reflection on the paper)Provide a narrative critical analysis of your selected paper (approx. 3–4 pages), that addresses the following questions:

1. What three key insights do you derive from the paper about the issue of focus?

2. In terms of the study conducted, in your view:


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a. Is the research strategy or design adopted appropriate for the question and underlying purpose? Why/why not? (consider both issues in your response)

b. What are the key strengths and weaknesses of the study in terms of research rigour and ethical practice? (Consider ALL these aspects: study design, data collection and analysis, including, if appropriate, the use/non-use of a conceptual framework.)

c. How persuasive are the generalisable claims that are made in the paper, and what strengthens or weakens their persuasiveness?

Evaluation criteria This assignment represents 25% of the total course mark and will be marked using the criteria below, linked to the course learning outcomes.

Related learning outcomes Assessment criteria Mark

LO3, 4, 9 Shows understanding of the research strategy and design applied in the study presented in the paper, considering the nature of the health policy and systems issue(s) of focus and their relevance for purpose and question

10 marks

LO5, 8 Shows understanding of critical issues in rigour relevant to the study presented in the paper considered, recognising the particular perspectives underlying the study

10 marks

LO6 Shows understanding of key ethical issues for HPSR 5 marks

LO7, 8 Bulleted notes show clear reading of paper; and wrote a balanced critical analysis (e.g. considers strengths and weaknesses of study as presented in paper, considers paper in light of wider, relevant experience, appropriately considers the particular perspectives underlying the study)

15 marks

LO11 Shows some originality and thoughtfulness 6 marks

Overall academic literacy Spelling and grammar mostly correct, uses appropriate referencing conventions, correct word length

4 marks

Total 50 marks


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End of course assignment, summative assessmentDescribe your research strategy and designNote: Due date: [add date and time] The writing should be predominantly narrative in style, although not excluding bullet

points, diagrams, etc. Total number of pages: 10–12, format: single line spacing, font 11 or 12 (or 3000 words,

excluding references) You will be required to make a plagiarism declaration and all assignments will be routinely

run through ‘Turnitin’ www.turnitin.com The assignment will be returned to you by [add date]

Doing good quality Health Policy and Systems Research (HPSR) demands an understanding of what research strategy is appropriate to the questions of focus. The strategy is neither primarily a study design nor a method, but instead represents an overarching approach to conducting the research that includes consideration of the most appropriate methods of data collection and sampling strategy for the research purpose and questions.

Assignment taskYour task is to describe a coherent and focused research strategy and design, based on the outline of the HPSR protocol your group developed during Sessions 8 and 9.

The objective is to deepen your understanding of HPSR and to show your understanding of key concepts covered in the course. As a summative assessment, it aims to show that you have met most of the intended course learning outcomes.

Structure your work around the following headings/issues: Background and introduction Briefly outline the issue or problem that you want to focus on within the broad topic

area of your research.

Provide relevant details of the particular setting/context in which the research will take place.

Brief literature review Give a brief overview of at least five relevant published research papers within your

topic area.

Research purpose and question Clarify the purpose of your research.

State your research question.

Identify the focus of the question as micro/meso/macro/combination.

Explain the substantive relevance of your research – why it is worth doing given both the setting in which it will take place and other research already done in the field.

Research strategy and design Describe the key elements of your strategy/study design, including:

o the scope and timing of the work;


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o overall description of research strategy and design including whether it is fixed, flexible or mixed methods, other key details relevant to your design – sequencing in data collection approaches, etc.;

o any conceptual framework used to guide the study;

o key units of analysis and approach to sampling;

o types of data that will be gathered, and from what/who;

o the broad forms of data analysis you will apply, whether or not any data sets will be combined and why;

o strategies for ensuring validity and rigour of data collection and analysis, and to enhance the credibility of any generalisable claims;

o justify why you have chosen this particular strategy/design over other possibilities.

Enhancing the uptake of findings from the research Explain how you intend to communicate the findings of your research, justifying your

approach.

Ethics Outline the key ethical challenges of this work and how you will address them.

References List all the sources of information/papers reviewed that you have drawn on to write

this protocol. Use one, appropriate referencing convention.

Evaluation criteria This assignment represents 50% of the total course mark and will be marked using the criteria below, linked to the course learning outcomes.

Related learning outcomes

Assessment criteria Mark

LO1 Identified a researchable health policy and systems issue 5 marks

LO2, 7 Formulated a substantively relevant health policy or health systems research question, by drawing, appropriately, on relevant empirical work, practice knowledge, and theoretical insights

20 marks

LO3, 4, 8, 9 Identified a research strategy and study design that is appropriate to investigate the issues and phenomena that are central to the issue and question, showing an understanding of the complex and socially constructed nature of health policy and systems issues

30 marks

LO5 Showed awareness of critical issues in, and approaches to, ensuring rigour for this question/study

10 marks

LO6 Showed an awareness of critical ethical issues for this question/study 10 marks


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LO10 Showed ability to plan appropriate activities that support the use of research evidence for and in decision-making

5 marks

LO11 Argumentation and originality: Report presents clear and logical chains of reasoning, drawing

appropriately on relevant theory and credible empirical evidence Relevant theory and concepts applied critically in analysis and

explained clearly Demonstrates ‘own voice’ and thoughtfulness (reflexivity) in

responses

15 marks

Overall academic literacy

Demonstrates academic literacy: Spelling and grammar mostly correct Uses appropriate referencing conventions Within maximum number of pages

5 marks

Total 100 marks


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Annex 3 Reading listBelow we provide suggestions of readings for different topics covered by the course, but anticipate that a shorter list would be provided to students. However, this course has a high reading requirement which is considered necessary to understand the nature of the field.

Some readings have webpage (URL) addresses and others have a DOI name (digital object identifier), just copy and paste them into your browser. If the DOI number does not automatically take you to the reading, go to: http://dx.doi.org/ and paste the DOI number in the dialogue box. If for some reason neither the link nor the URL lead you to the document, search for it through Google or Pubmed.

Core texts for this courseGilson L, ed. (2012). Health policy and systems research: a methodology reader. Alliance for Health Policy and Systems Research, World Health Organization. Entire reader is available for download at http://www.who.int/alliance-hpsr/resources/reader/en/index.html

Note that several of the readings listed below are included in the full version of the Reader, so you may be able to obtain them by accessing the Reader directly.

Robson C (2002). Real world research: a resource for social scientists and practitioner–researchers, 2nd ed. Oxford, Blackwell Publishing.

WHO (2012). Changing mindsets: strategy on health policy and systems research. Geneva, World Health Organization. Download at: http://www.who.int/alliance-hpsr/alliancehpsr_changingmindsets_strategyhpsr.pdf

Additional research texts useful for this courseBabbie E, Mouton J (2001). The practice of social research. Cape Town, Oxford University Press.

Fulop N et al. (2001). Issues in studying the organisation and delivery of health services. In: Fulop, N et al., eds. Studying the organisation and delivery of health services: research methods. London, Routledge.

Thomas A, Chataway J, Wuyts M, eds (1998). Finding out fast: investigative skills for policy and development. London, Thousand Oaks, New Dehli, Sage Publications.

Health systems and health systems’ strengtheningEssentialPages 1–29 of: Gilson L, ed. (2012). Health policy and systems research: a methodology reader. Alliance for Health Policy and Systems Research, World Health Organization. Download at http://www.who.int/alliance-hpsr/resources/reader/en/index.html


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http://dx.doi.org/

Patcharanarumol W et al. (2011). Why and how did Thailand achieve good health at low cost? In: Balabanova, D et al., eds. Good health at low cost 25 years on. London, London School of Hygiene and Tropical Medicine: 193–234.

AdditionalBalabanova D et al., eds (2011). Good health at low cost 25 years on. London, London School of Hygiene and Tropical Medicine.

de Savigny D, Adam T, eds (2009). Systems thinking for health systems strengthening. Geneva, World Health Organization. (http://www.who.int/alliance-hpsr/resources/9789241563895/en/index.html)

Frenk J (1994). Dimensions of health system reform. Health Policy, 27:19–34.

Frenk J (2010). The global health system: strengthening national health systems as the next step for global progress. PLoS Medicine, 7(1): e1000089. doi:10.1371/journal.pmed.1000089

Frenz P, and Vega J (2010). Universal health coverage with equity: what we know, don’t know and need to know. Background paper for the global symposium on health systems research, 16–19 November 2010, Montreux, Switzerland. Download at: http://www.hsr-symposium.org/images/stories/9coverage_with_equity.pdf (See especially pages 11–18, 27–36.)

Travis P et al. (2004). Overcoming health-systems constraints to achieve the Millennium Development Goals. Lancet, 364:900–06. doi:10.1016/S0140-6736(04)16987-0

Van Olmen J et al. (2010). Analysing health systems to make them stronger. Studies in Health Services Organisation & Policy, 27. Download at: http://www.strengtheninghealthsystems.be/doc/SHSO&P27_HS%20ANALYSIS_FINAL.pdf

Pages iv-vii, 1-30 of: WHO (2007). Everybody’s business: strengthening health systems to improve health outcomes: WHO’s framework for action. Geneva, World Health Organization. (Download at: http://www.who.int/entity/healthsystems/strategy/everybodys_business.pdf)

Health policy and systems research EssentialGilson L et al. (2011) Building the field of health policy and systems research: social science matters. PLoS Medicine 8(8): e1001079. doi:10.1371/journal.pmed.1001079

Pages 30–52 of: Gilson L, ed. (2012). Health policy and systems research: a methodology reader. Alliance for Health Policy and Systems Research, World Health Organization. Download at http://www.who.int/alliance-hpsr/resources/reader/en/index.html

Chapters 1, 3, 4, 5 & 6 of: Robson C (2002). Real world research: a resource for social scientists and practitioner–researchers, 2nd ed. Oxford, Blackwell Publishing.


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Sheikh K et al. (2011). Building the field of health policy and systems research: framing the questions. PLoS Medicine 8(8): e1001073. doi:10.1371/journal.pmed.1001073

AdditionalChapter 1 of: Fulop N et al., eds (2001). Issues in studying the organisation and delivery of health services. In: Fulop, N. et al., eds. Studying the organisation and delivery of health services: research methods. London, Routledge.

Gilson L, Raphaely N (2008). The terrain of health policy analysis in low and middle income countries: a review of published literature 1994–2007. Health Policy and Planning, 23(5):294–307.

Green A, Bennett S, eds. (2007). Sound choices: enhancing capacity for evidence-informed health policy. Alliance for Health Policy and Systems Research, Geneva, World Health Organization.

Hoffman SJ et al. (2012). Background paper on conceptual issues related to health systems research to inform a WHO Global Strategy on Health Systems Research. A working paper in progress. Download at: http://www.who.int/alliance-hpsr/alliancehpsr_backgroundpaperhsrstrat1.pdf

Kemmis S, McTaggart (2005). Participatory action research: communicative action and the public sphere. In: Denzin NK & Lincoln YS (eds) The SAGE handbook of qualitative research (3rd ed.) London, SAGE Publications.

Koon AD et al. (2013). Embedding health policy and systems research into decision-making processes in low- and middle-income countries. Health Research Policy and Systems. doi:10.1186/1478-4505-11-30

Lavis JN, Ross SE, Hurley JE (2002). Examining the Role of Health Services Research in Public Policymaking. Milbank Quarterly, 80(1):125–154. http://dx.doi.org/10.1111/1468-0009.00005

Mills A et al. (2008). What do we mean by rigorous health-systems research? Lancet 2008;372:1527–9. PMID:18984174

Peters DH et al. (2013). Implementation research: what it is and how to do it. British Medical Journal (347): f6753. doi: http://dx.doi.org/10.1136/bmj.f6753

Sanders D, Haines A (2006). Implementation research is needed to achieve international health goals. PLoS Medicine, 3(6): e186. doi:10.1371/journal.pmed.0030186

Sheikh K, George A, Gilson L (2014). People-centred science: strengthening the practice of health policy and systems research. Health Research Policy and Systems, 12:19.

Walt G (1994). How far does research influence policy? The European Journal of Public Health, Jan, 4(4):233–235. doi: 10.1093/eurpub/4.4.233


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Research and study designs ** indicates a paper about the research design rather than a paper reporting an empirical

study

Fixed design Ayieko P et al. (2011). A multifaceted intervention to implement guidelines and improve admission paediatric care in Kenyan district hospitals: a cluster randomized trial. PLoS Medicine 8(4): e1001018. doi: 10.1371/journal.pmed.1001018

Blaauw D et al. (2010). Policy interventions that attract nurses to rural areas: a multicountry discrete choice experiment. Bulletin of the World Health Organization, 88:350–356. doi:10.2471/BLT.09.072918

** English M et al. (2008). Health systems research in a low-income country: easier said than done. Archives of Diseases in Childhood, 93:540–544. Download at: http://dx.doi.org/10.1136/adc.2007.126466

English M et al. (2011). Explaining the effects of a multifaceted intervention to improve inpatient care in rural Kenyan hospitals – interpretation based on retrospective examination of data from participant observation, quantitative and qualitative studies. Implementation Science, 6:124. http://www.implementationscience.com/content/6/1/124. Download at: http://hiv.ucsf.edu/docs/kenya_cfir.pdf

Houweling TAJ et al. (2007). Huge poor–rich inequalities in maternity care: an international comparative study of maternity and child care in developing countries. Bulletin of the World Health Organization, 85(10):745–754. Download at: http://www.who.int/bulletin/volumes/85/10/06-038588/en/#

Kurowski C et al. (2007). Scaling up priority health interventions in Tanzania: the human resources challenge. Health Policy and Planning, 22(3):113–127. doi: 10.1093/heapol/czm012

Macinko J et al. (2007). Going to scale with community-based primary care: an analysis of the family health programme and infant mortality in Brazil. Social Science & Medicine, doi.org:10.1016:j.socscimed.2007.06.028

Masanja H et al. (2008). Child survival gains in Tanzania: analysis of data from demographic and health surveys. Lancet, 371:1276–1283. doi: 10.1016/S0140-6736(08)60562-0

Flexible design **Denzin NK, Lincoln YS (1998). Introduction: entering the field of qualitative research. In: Denzin NK, Lincoln YS, eds. Collecting and interpreting qualitative materials. Thousand Oaks, California, Sage Publications: 1–34.

** Pope C, Mays N (2009). Critical reflections on the rise of qualitative research (research methods and reporting). British Medical Journal, 339(b3425):737–739.

Riewpaiboon W et al. (2005). Private obstetric practice in a public hospital: mythical trust in obstetric care. Social Science & Medicine, 61:1408–1417.


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Sheikh K, Porter J (2010). Discursive gaps in the implementation of public health policy guidelines in India: The case of HIV testing. Social Science & Medicine, 71(11):2005–2013.

Mixed method design** Creswell JW, Plano-Clark VL (2007). Designing and conducting mixed methods research. Thousand Oaks, California, Sage Publications.

Long Q et al. (2008). Barriers to accessing TB diagnosis for rural-to-urban migrants with chronic cough in Chongqing, China: a mixed methods study. BMC Health Services Research, 8:202.

** Moffatt S et al. (2006). Using quantitative and qualitative data in health services research – what happens when mixed method findings conflict? BMC Health Services Research, 6:28.

Morrow M et al. (2009). Pathways to malaria persistence in remote central Vietnam: a mixed-method study of health care and the community. BMC Public Health, 9:85.

** O’Cathain A, Murphy E, Nicholl J. (2008). The quality of mixed methods studies in health services research. Journal of Health Services Research & Policy, 13:92–8.

** Ozawa S, Pongpirul K (2014). 10 best resources on … mixed methods research in health systems. Health Policy and Planning, 29(3):323–327. doi:10.1093/heapol/czt019

Ranson MK, Jayaswal R, Mills AJ (2011). Strategies for coping with the costs of inpatient care: a mixed methods study of urban and rural poor in Vadodara District, Gujarat, India. Health Policy and Planning, (27)4: 326–338.

** Sandelowski M (2000). Combining qualitative and quantitative sampling, data collection, and analysis techniques in mixed-method studies. Research in Nursing & Health, 23:246–255. doi: 10.1002/1098-240X(200006)23:3<246::AID-NUR9>3.0.CO;2-H

Cross-sectional studies Glassman A et al. (1999). Political analysis of health reform in the Dominican Republic. Health Policy and Planning 14(2):115–126. (Demonstrates the use of PolicyMaker, a computer-assisted political analysis tool to study health policy reform in the Dominican Republic and draw out guidance for policy makers.)

Ramanadhan et al. (2010). Network-based social capital and capacity-building programs: an example from Ethiopia. Human Resources for Health, 8:17. (Demonstrates the application of social network analysis, an unusual and interesting analytic approach for HPSR, to evaluate the impact of health management training in Ethiopia.)

Rwashana AS, Williams DW, Neema S (2009). System dynamics approach to immunization healthcare issues in developing countries: a case study of Uganda. Health Informatics Journal, 15(2):95–107. doi: 10.1177/1460458209102971 (Demonstrates the use of systems theory to explain uptake of immunization in Uganda, drawing on causal loop diagram methodology to model the relationships in a complex system.)

Participatory action research


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Aragón AO, Macedo JCG (2010). A ‘Systemic Theories of Change’ approach for purposeful capacity development. Institute of Development Studies. IDS Bulletin, 41(3), 87–99. doi: 10.1111/j.1759-5436.2010.00140.x

** Chambers R (1994). Participatory rural appraisal (PRA): challenges, potentials and paradigm. World Development, 22(10):1437–1454.

Elloker S et al. (2012). Crises, routines and innovations: the complexities and possibilities of sub-district management. South African Health Review. Durban, Health Systems Trust: 161–176. Download at: http://www.health-e.org.za/wp-content/uploads/2013/04/SAHR2012_13_lowres_1.pdf

** Khresheh R, Barclay L (2007). Practice–research engagement (PRE): Jordanian experience in three Ministry of Health hospitals. Action Research, 5:123. http://dx.doi.org/10.1177/1476750307077313

Khresheh R, Barclay L (2008). Implementation of a new birth record in three hospitals in Jordan: a study of health system improvement. Health Policy and Planning, 23:76–82. Download at: http://www.sihealthpolicy.org/wp-content/uploads/2013/06/Implementation-of-a-new-birth-record-in-three-hospitals-in-Jordan.pdf

** Loewenson R et al. (2010) Experiences of participatory action research in building people centred health systems and approaches to universal coverage. Report of the Sessions at the Global Symposium on Health Systems Research, Montreux, Switzerland. Training and Research Support Centre (TARSC), Regional Network for Equity in Health in East and Southern Africa (EQUINET), Centro de Estudios para la Equidad y Gobernanza en los Sistemas de Salud (CEGS), and SATHI-CEHAT, Harare. Download at: http://www.equinetafrica.org/bibl/docs/GSHSR%20PRA%20report%20Dec%202010.pdf

Luckett S, Grossenbacher K (2003). A critical systems intervention to improve the implementation of a district health system in KwaZulu-Natal. Systems Research and Behavioural Science, 20:147–162.

** Meyer J (2001). Action research. In: Fulop N et al., eds. Studying the organisation and delivery of health services: research methods. London, Routledge: 172–187.

Case study Atkinson S et al. (2000). Going down to local: incorporating social organisation and political culture into assessments of decentralised health care. Social Science & Medicine, 51(4): 619–636.

Goudge J et al. (2009). Affordability, availability and acceptability barriers to health care for the chronically ill: Longitudinal case studies from South Africa. BMC Health Services Research (9):75. doi: 10.1186/1472-6963-9-75

Lee K et al. (1998). Family planning policies and programmes in eight low income countries: A comparative policy analysis. Social Science and Medicine, 47(7): 949–959. doi:10.1016/S0277-9536(98)00168-3


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Murray SF, Elston MA (2005). The promotion of private health insurance and its implications for the social organisation of health care: a case study of private sector obstetric practice in Chile. Sociology of Health and Illness, 27(6):701–721.

Mutemwa RI (2006). HMIS and decision-making in Zambia: re-thinking information solutions for district health management in decentralised health systems. Health Policy and Planning, 21(1):40–52. doi:10.1093/heapol/czj003

Rolfe B et al. (2008). The crisis in human resources for health care and the potential of a ‘retired’ workforce: case study of the independent midwifery sector in Tanzania. Health Policy and Planning, 23(2):137–149. doi:10.1093/heapol/czm049

** Russell S (2005). Illuminating cases: understanding the economic burden of illness through case study household research. Health Policy and Planning, 20(5):277–289. doi:10.1093/heapol/czi035

Russell S, Gilson L (2006). Are health services protecting the livelihoods of the urban poor in Sri Lanka? Findings from two low-income areas of Colombo. Social Science & Medicine, 63(7):1732–1744. http://dx.doi.org/10.1016/j.socscimed.2006.04.017

** Thomas A, Chataway J (1998). Challenging cases. In: Thomas A, Chataway J, Wuyts M, eds. Finding out fast: investigative skills for policy and development. London, Thousand Oaks, New Dehli, Sage Publications: 307–332.

Shiffman J, Stanton C, Salazar AP (2004). The emergence of political priority for safe motherhood in Honduras. Health Policy and Planning, 19(6): 380–390.

** Yin RK (2009). Introduction and designing case studies. In: Yin RK, Case study research: design and methods, 4th ed. Thousand Oaks, USA, Sage.

Ethics Emanuel EJ et al. (2004). What makes clinical research in developing countries ethical? The Journal of Infectious Diseases, Mar 1,189(5):930–937.

Hyder A et al. (2014). The ethics of health systems research in low- and middle-income countries: A call to action. Global Public Health, 9(9):1008–1022. doi: 10.1080/17441692.2014.931998

Molyneux CS et al. (2009) Conducting health-related social science research in low income settings: ethical dilemmas faced in Kenya and South Africa. Journal of International Development, 21(2):309–326.

Some specific topics in HPSR Health worker motivationConceptual/reviewDieleman M, Gerretsen B, Van Der Wilt, GJ (2009). Human resource management interventions to improve health workers' performance in low and middle income countries: a realist review. Health Research Policy and Systems. 7(7). doi: 10.1186/1478-4505-7-7 Download at:


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http://www.health-policy-systems.com/content/pdf/1478-4505-7-7.pdf

Franco LM, Bennett S, Kanfer R (2002). Health sector reform and public sector health worker motivation: a conceptual framework. Social Science & Medicine, 54, 1255–1266. http://dx.doi.org/10.1016/S0277-9536(01)00094-6

Willis-Shattuck M et al. (2008). Motivation and retention of health workers in developing countries: a systematic review. BMC Health Services Research. 8(1):247. doi: 10.1186/1472-6963-8-247 Download at: http://www.biomedcentral.com/content/pdf/1472-6963-8-247.pdf

Empirical examplesBlaauw D et al. (2010). Policy interventions that attract nurses to rural areas: a multicountry discrete choice experiment. Bulletin of the World Health Organization, 88:350–356. doi: 10.2471/BLT.09.072918

Chandler C et al. (2009). Motivation, money and respect: a mixed-method study of Tanzanian non-physician clinicians. Social Science & Medicine, 68: 2078–2088. doi:10.1016/j.socscimed.2009.03.007

George A (2009). ‘By papers and pens, you can only do so much’: views about accountability and human resource management from Indian government health administrators and workers. International Journal of Health Planning and Management, 24 (3):205–224. doi: 10.1002/hpm.986

Gilson L et al. (2004). Exploring the influence of workplace trust over health worker performance. Preliminary National Overview Report: South Africa. Prepared for the Health Economics and Financing Programme, London School of Hygiene and Tropical Medicine, UK. Download at: http://www.dfid.gov.uk/r4d/PDF/Outputs/HealthEcFin_KP/WP06_04.pdf

Leonard KL, Masatu, MC (2010). Professionalism and the know-do gap: exploring intrinsic motivation among health workers in Tanzania. Health Economics, 19:1461–1477. doi: 10.1002/hec.1564

Macfarlane F et al. (2011). A new workforce in the making? A case study of strategic human resource management in a whole-system change effort in healthcare. Journal of Health Organization and Management, 25(1):5 –72. doi: 10.1108/14777261111116824 Download at: http://www.emeraldinsight.com/journals.htm?articleid=1915439

Peters DH et al. (2010). Job satisfaction and motivation of health workers in public and private sectors: Cross-sectional analysis from two Indian states. Human Resources for Health, 8:27. doi: 10.1186/1478-4491-8-27

Community accountabilityConceptual/reviewBrinkerhoff, D (2004). Accountability and health systems: toward conceptual clarity and policy relevance. Health Policy and Planning, 19(6):371–379. doi: 10.1093/heapol/czh052


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McCoy D, Hall J, Ridge M. (2012). A systematic review of the literature for evidence on health facility committees in low- and middle-income countries. Health Policy and Planning, 27:449–466. doi: 10.1093/heapol/czr077

Molyneux S et al. (2012). Community accountability at peripheral health facilities: a review of the empirical literature and development of a conceptual framework. Health Policy and Planning 27(7).

Empirical examplesBjorkman M, Svensson J (2009). Power to the people: evidence from a randomized field experiment on community-based monitoring in Uganda. The Quarterly Journal of Economics, 124(2):735–769. http://www.mitpressjournals.org.ezproxy.uct.ac.za/doi/pdf/10.1162/qjec.2009.124.2.735

Boulle T et al. (2008). Promoting partnership between communities and frontline health workers: Strengthening community HC’s in South Africa (PRA paper No. 8). Harare: EQUINET. Download at:http://www.equinetafrica.org/bibl/docs/CDU PRArep Final.pdf

Cleary SM, Molyneux S, Gilson L (2013). Resources, attitudes and culture: an understanding of the factors that influence the functioning of accountability mechanisms in primary health care settings. BMC Health Services Research, 13. doi: 10.1186/1472-6963-13-320 Download at: http://researchonline.lshtm.ac.uk/1300563/1/1472-6963-13-320.pdf

Goodman C et al. (2011). Health facility committees and facility management – exploring the nature and depth of their roles in Coast Province, Kenya. BMC Health Services Research, 11:229. http://www.biomedcentral.com/1472–6963/11/229

Haricharan HJ (2012). Extending participation: Challenges of health committees as meaningful structures for community participation. Learning Network Report. Download at: http://salearningnetwork.weebly.com/uploads/6/5/0/1/6501954/hanne_report_on_health_committees.pdf

Loewenson R, Rusike I, Zulu M (2005). The impact of Health Centre Committees on health outcomes in Zimbabwe. Plenary paper presented at Global Forum for Health Research, Forum 9: Poverty, equity and health research Conference, Mumbai, India, 12–16 September 2005. Download at: http://www.equinetafrica.org/bibl/docs/LOEgov092005.pdf

Uzochukwu BSC (2011). Trust, accountability and performance in health facility committees in Orumba South local government area, Anambra State, Nigeria. Download at: http://www.crehs.lshtm.ac.uk/nigeria_accountability_hr_14june2011.pdf

Decentralisation Conceptual/reviewBossert T (1998). Analyzing the decentralization of health systems in developing countries: decision space, innovation and performance. Social Science & Medicine, 47(10), 1513–1527.


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http://researchonline.lshtm.ac.uk/view/creators/1159.html

Mills A (1994). Decentralization and accountability in the health sector from an international perspective: what are the choices? Public Administration and Development, 14(3), 281–292.

Mitchell A, Bossert TJ (2010). Decentralisation, Governance and Health-System Performance: 'Where You Stand Depends on Where You Sit'. Development Policy Review, Nov. 28(6):669–691.

Empirical examplesAtkinson S et al. (2000). Going down to local: incorporating social organisation and political culture into assessments of decentralised health care. Social Science & Medicine, 51(4):619–636. doi: 10.1016/S0277-9536(00)00005-8 (in the Alliance Reader)

Avelino G, Barberia LG, Biderman C (2014). Governance in managing public health resources in Brazilian municipalities. Health Policy and Planning, 29(6):694–702. doi: 10.1093/heapol/czt003

Bossert TJ, Beauvais JC (2002). Decentralization of health systems in Ghana, Zambia, Uganda and the Philippines: a comparative analysis of decision space. Health Policy and Planning, 17(1), 14–31. doi: 10.1093/heapol/17.1.14

Khaleghian P (2004). Decentralization and public services: the case of immunization. Social Science & Medicine. July, 59(1):163–83. doi: 10.1016/j.socscimed.2003.10.013

Munga MA et al. (2009). The decentralisation–centralisation dilemma: recruitment and distribution of health workers in remote districts of Tanzania. BMC International Health and Human Rights. 9:9. doi: 10.1186/1472-698X-9-9

Some Internet resources for HPSRCHEPSAA: http://www.hpsa-africa.org/

Consortium for Research on Equitable Health Systems – LSHTM: http://www.crehs.lshtm.ac.uk

Development Research Uptake in sub-Saharan Africa: http://www.drussa.net/

EQUINET: http://equinetafrica.org

Future Health Systems: http://www.futurehealthsystems.org/index.htm

WHO website on health systems: http://who.int/healthsystems/en/

Health Systems Global: Third Global Symposium, Cape Town, SA, 30Sept–03Oct 2014: http://hsr2014.healthsystemsresearch.org/

McMaster Health Systems Evidence: http://www.healthsystemsevidence.org

The Alliance for Health Policy and Systems Research: http://www.who.int/alliance-hpsr/en/

USAID Health Systems 2020: http://www.healthsystems2020.org


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Annex 4 An example of an HPSR protocol for review in Activity 6 (Sessions 4–6)This protocol has been edited for use as a teaching case - not for further circulation or publication

Exploring the concept of power in the implementation of South Africa’s new community health worker policy – a case study from

Chris Hani District in the Eastern Cape ProvincePolicy Analysis Mentoring Programme - EQUINET

Background and IntroductionThe past few years have seen a renewed interest in the use of community health workers to address a growing human resource crisis in many developing countries (Lehmann, Friedman and Sanders 2004; WHO 2006). This interest is reflected in the recent work of the Joint Learning Initiative on health human resources (JLI 2004) and the latest World Health Report (WHO 2006).

In South Africa the Department of Health has been developing and implementing a new Community Health Worker Policy since 2003, aimed at institutionalising community health workers and bringing uniformity to a great diversity of and fragmentation in community health worker schemes (Friedman 2006). The policy makes provision for the appointment of generalist community health workers, who are to be paid a stipend by respective provinces through appointed NGOs and who, attached to primary care facilities, will perform a wide range of community based care and support functions. The policy has been in implementation for some three years, but so far little is know about its implementation process, its successes and challenges.

In this project the School of Public Health at the University of the Western Cape proposes to investigate how the “arrival” of the new CHW policy has been implemented in Chris Hani District in the Eastern Cape Province. In particular we propose to examine how the policy as has interacted with and impacted on existing CHW practices, using a case study approach with a small number of facilities in Chris Hani District, and exploring specifically how power dynamics are shaping policy implementation.

The School of Public Health has been working in Chris Hani District in the Eastern Cape province for a number of years, conducting research on staff retention, the impact of the HIV/AIDS pandemic on personnel in primary care clinics and staffing arrangements for HIV care. In the context of this research we anecdotally encountered but never systematically studied the implementation of the new CHW policy from a health services perspective. Anecdotal evidence and observation suggest that in and around many primary care clinics CHW schemes had developed over the years, often informally and with a wide range of governance arrangements. The new policy which stipulates that a particular number of CHWs should be appointed (and paid) per facility and thus seeks to establish uniformity, has interacted with existing arrangements in different ways. While it has been seen as an opportunity by many, it also appears to have created considerable tension in facilities which had services from a larger number of CHWs in the past: who is formally appointed and who is not? What should happen to other CHWs? Who is responsible for the appointed CHWs? These are some of the questions we want to explore in this study.


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The interaction between new policies and established practices is a phenomenon which very frequently accompanies change processes. Much less frequently do we explore and understand how this interaction takes place and how it shapes and impacts on policy implementation outcomes, often in unintended ways. In this study we work on the assumption that a lack of understanding of and attention to the contextual dynamics of policy implementation contributes to the much bemoaned policy-implementation gap. The study aims to highlight the importance of understanding how policy and practice interact, and how power shapes this interaction, and to illustrate and analyse, using a case study approach, how this interaction unfolds. A specific aims is also to furthermore explore how equity targets which are central to health policy planning in South Africa, are affected by the interaction of policy implementation and established practice, intentionally or unintentionally. These insights should be of benefit to policy makers and academics alike.

Literature review The literature on the role of community health workers in low-income countries was recently comprehensively reviewed by the author (Lehmann and Sanders 2006). It is significant that, with few exceptions, the body of literature on the subject is overwhelmingly descriptive, detailing roles and activities, and in some cases discussing the success and failure in national health systems.

There is little in the international or local literature which speaks directly to the focus of this research study on power and its relation to policy implementation processes. The literature does, however, discuss power relations and particularly the vulnerability and fragility of CHW programmes in most health systems, as well as the potential of CHW programmes to contribute to equity gains in resource-poor communities.

With regard to the latter, there is widespread agreement in the literature that CHWs can make a valuable contribution to community development and, more specifically, can improve access to and coverage of communities with basic health services. There is robust evidence that CHWs can undertake actions that lead to improved health outcomes (Bhattacharyya et al. 2001; Haines et al. forthcoming; Pegurri, Fox-Rushby and Damian 2005). However, although they can implement effective interventions, they do not consistently provide services likely to have substantial health impact and the quality of services they provide is sometimes poor. It is emphasised that, for CHWs to be able to make an effective contribution, they need to be carefully selected, appropriately trained and, very importantly, adequately and continuously supported. Large-scale CHW systems require substantial increases in support for training, management, supervision, and logistics (Ande, Oladepo and Brieger 2004; Bhattacharyya et al. 2001; Gilroy and Winch 2006; Gilson et al. 1989; Ofosu-Amaah 1983). We will explore how training and support have been perceived and addressed by actors in the policy implementation process in this study and how this has impacted on equity gains or losses.

With regard to the role of power in initiating and implementing CHW programmes, the literature focuses on the role of community participation and relations of CHWs with formal health services.

Virtually the entire literature emphasises the importance of community ownership and participation as a pre-condition for thriving programmes. At the same time it is widely acknowledged that a considerable gulf exists between the ideal of programmes driven and owned by communities and programme realities. It is further agreed that while there are few success stories of lasting community participation, sustainability and impact of programmes require the ownership and active participation of communities as a non-negotiable pre-condition (Bhattacharyya et al. 2001; Gilson et al. 1989; Mathews, van der


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Walt and Barron 1994; Quillian 1993). Case studies suggest that this is easier to achieve in small-scale programmes which are initiated within and by communities, often with assistance from a NGO or a church group. Examples of these can be found right through the history of CHW programmes, e.g. in the Philippines in the 1970s (Barcelon and Hardon 1990), in India in the 1970s and 80s (Kaithathara 1990), in Kenya in the 1980s and 90s (AKHS not dated), in Belize since the mid-1990s (Council 2004). There is also experience that active participation of communities in health and social action, including CHW programmes, is more likely to occur and be sustained in conditions of popular mobilisation such as in the aftermath of a liberation struggle or after the replacement of military or repressive regimes by popular governments (Cufino Svitone et al. 2000; Garfield 1993; Sanders 1992).

In most of these cases substantial and time-consuming investments were made in a) securing participation of communities and b) involving them in all aspects of the programme, including the identification of priorities and project planning. In other words, community mobilisation precedes and accompanies the establishment of CHW programmes (AKHS not dated).

National or state-wide programmes are usually initiated from the centre (China, India, Brazil, Indonesia, Ghana, to name but a few). While in these cases, too, community participation is explicitly part of the agenda, for a number of reasons, it is much more difficult to achieve. Rifkin argues that a key reason is “that community participation has been conceived in a paradigm which views community participation as a magic bullet to solve problems rooted both in health and political power. For this reason, it is necessary to use a different paradigm which views community participation as an iterative learning process allowing for a more eclectic approach to be taken. Viewing community participation in this way will enable more realistic expectations to be made” (Rifkin 1996).

Whether and how communities had and took the opportunity to participation in shaping the way in which the new CHW policy was implemented in Chris Hani District and what mechanisms were put in place to facilitate community participation will be a key question in this study.

A second crucial relationship discussed in the literature is the interaction between CHWs and formal health services. The literature suggests that in many cases these interactions are being affected by the way that programmes are being introduced: CHW programmes are often advocated for by enthusiasts with local experience persuading policy makers to scale up initiatives and implement programmes on a large scale (Gilson et al. 1989). This frequently results in the implementation of inadequately thought-through schemes without the full participation of health personnel at the local level. In many programmes, even those personnel who come into most contact with CHWs, usually nurses, are not involved in the planning, implementation, monitoring and evaluation of such programmes. The result is that health service personnel feel little ownership for the programme and lend little support to these initiatives. The situation is aggravated by the fact that as a rule professional health workers are socialized into the hierarchical framework of disease-oriented medical care systems and have a poorly developed concept of primary health care. Health professionals often perceive CHWs as lowly aides (Walt 1992; WHO 1989, 1990) who should be deployed as assistants within health facilities, often completely misunderstanding their health promoting and enabling role within communities. A sense of superiority of health personnel has been observed as a problem in several cases (Sanders 1992). Attitudes to CHWs inevitably suffer as a result.


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In the present study we will not only look at the relationships between CHWs and health professionals, but will broaden the scope to investigate the relations of all key actors involved in the policy implementation process.

The history of South African CHW programmes has been best documented by Irwin Friedman in various issues of the South African Health Review (mostly recently see (Friedman 2006).

The policy documents in the early 1990s, most notably the ANC Health Plan, identified CWHs as an important resource for PHC implementation. “They were viewed as catalysts for community development, who could mobilise people around issues such as the need for clean water, sanitation, waste disposal, safe playgrounds and parks. (…) It was envisaged that they would form an integral part of the decentralised health services, and be compensated, either by the Government, or the local community” (Friedman 2003).

The initial enthusiasm waned somewhat in the late 1990s, and support for CHW programmes, which are mostly run by NGOs, remained uneven, although CHW programmes continued to be run in most provinces. “The net result has been a diverse group of single-purpose workers being recruited to work in communities, industry and institutions with little prospect of career development. They are also not well coordinated among themselves or with the general health sector” (Friedman 2006).

It is this diversity, amongst other things, which the new policy, which started as a ministerial initiative in 2003, intends to address.

Friedman summarises the purpose of the policy and the intended roles of CHWs as follows: “CHWs are defined as community-based generalist health workers with a basic level of

competence in health promotion, primary health care, health resource networking and coordination.

CHWs should provide a limited range of services within the scope of their competence.

They should also, in terms of their engagement with communities and households, determine health needs and facilitate the improvement of services.

In situations where single-purpose community health workers (such as DOT supporters or VCT counsellors) operate, CHWs should improve the effectiveness of these and simplify life for community members by coordinating these activities.

CHWs will receive a stipend, but will not be government employees and will be employed through civil society initiatives.

The preferred model is a Government / NGO partnership where Government provides grants to NGOs, which employ the CHWs. This might vary according to local conditions.

Although voluntarism will continue to be encouraged, volunteers should not be employed more than a few hours a week without remuneration. Volunteers also should not be misled into believing that they will necessarily get paid work.

A Clinic Committee / Community Health Committee should provide a governance mechanism.

There should be community participation in the selection and recruitment of CHWs” (Friedman 2006).


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This project will not address the detail of the purpose and content of the policy. Instead it will focus on how the policy is being translated into practice at the local level, and how it has affected key actors and interacted with existing community health workers schemes.

The role of power in policy implementation will be specifically explored, following the growing realisation that power dynamics and relations are central to both policy development and implementation (Hyden, 2006; SIDA 2005, 2006). We will work from an understanding that power does not only find expression as acts of oppression and dominance, but is being exercised along a continuum, from dominance to resistance. Expressions of power to be explored include, apart from acts of formal domination or resistance, non-decision-making where decisions are required, structuring routines and discourses to support or counteract policies, sharing or withholding relevant information. (Buse, Mays and Walt 2005; Collinson 2005). Most of these elements can be used by actors as elements of dominance or resistance, depending on the location of the actor.

Research questionHow do power relations and dynamics shape the implementation of the CHW policy in selected facilities in the Chris Hani in the Eastern Cape province?

Objectives 1. To assess and document what CHW arrangements existed in the chosen facilities prior

to the new policy

2. To describe and document the changes brought about by the new CHW policy

2.1. To explore how key actors understand the new CHW policy

2.2. To trace the policy implementation process through engagement with key actors and documents

2.3. To outline the impact of the new policy on quality and accessibility of health care in the selected sites and on key actors

3. To assess how power dynamics have impacted on the process of implementing the new policy and its outcomes.

3.1. To map power relations between key actors.

3.2. To investigate whether and how key actors have been involved in discussing and implementing the new policy

3.3. To explore sources and forms of power exercised by actors and their impact on the policy implementation process

3.4. To explore which strategies actors employed to impact on content, process or other actors

3.5. To analyse and document how policy practice was shaped by the above factors

4. To assess contextual factors impacting on the implementation process

5. To explore whether and where different actions in the policy development and implementation process might have led to strategically different results.

6. To develop an understanding which aspects in the design and particularly the implementation of the policy support or counteract equity aims or equity gains (i.e., increased or reduced numbers of CHWs; changes in coverage; changes in the scope or quality of service delivery through CHWs).


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MethodologyAt the centre of this project lies the question how power relations and dynamics have influenced and are influencing the implementation of the CHW policy in Chris Hani District and equity concerns have been affected by the policy implementation. Secondarily, however, and as a basis for the exploration of power, we will develop a narrative of community health worker practices in the district, focussing on practices before and after the introduction of the new policy, changes brought about by the policy and key actors’ perceptions of these changes.

Methodologically, the study will be qualitative in character and inductive, using a grounded theory approach (Strauss and Corbin 1998). We will make use of “thick description” and some ethnographic methods, such as ethnographic fieldnotes (Emerson, Fretz and Shaw 1995). Time constraints, however, will prevent us from conducting a full ethnographic study.

Exploration of powerIn exploring power relations use will be made of a number of different conceptual tools.

The policy triangle will be used to map how key actors are located in relation to the national and local context of the policy, its content and how the policy process unfolded (Buse et al. 2005).

A categorisation of power along a continuum from power through domination to power through resistance, developed by the CHP, will be used and tested to develop a textured understanding of ways in which power is demonstrated and exercised. Categories of power will also be explored with all actors during interviews.

The investigation of power relations and interaction between key actors will be deepened by conducting force field and stakeholder analyses which will explore in depth key actors’ roles and interests in the implementation of the policy and their relations with each other (Brugha and Varvasovszky 2000; Varvasovszky and Brugha 2000).

Key actors in the policy implementation process have been identified as follows: Eastern Cape Department of Health (EC DoH)

Non-governmental organisation(s) tasked with policy implementation (NGO)

Local Service Area, i.e. sub-district (LSA) management (explore who exactly: LSA manager; dedicated programme manager; other?)

Facility managers

Community Health Committee

CHWs working in the area under both the old and new schemes.

For each of these actors or group of actors their sources of power will be explored, in terms of access to knowledge/information; opportunity to make themselves heard and participate in processes; access to resources; hierarchy (Collinson 2005; Hyden 2006; SIDA 2006).

The diagram below represents a first assessment of how key actors are connected in relation to the implementation of the CHW policy.


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Actor relationships:

Each of the relationships will be explored in terms of what forms of power are being used, to what end and with what effect.

Lastly, we will use elements from Greenhalgh et al.’s work on “diffusion of innovation in service organisations” (Greenhalgh et al. 2004). Their paper, based on an extensive literature review, considers the determinants of success or failure in implementing innovations in organisations, including structural, organisational and personal determinants. The categories they developed lend themselves well to further assess all four aspects of the policy triangle, i.e. actors, context, content and process. They will be used to develop a deeper understanding of the factors impacting on policy implementation and how they impact on the inter-play of power among actors.

SamplingA particular health district was chosen for this study because we have been working in the area for a number of years, have an established research infrastructure and good working relationships with relevant actors. We will work with one of two local service areas (LSA), as both of have been identified as learning sites by the district.

We will select a sample of three to four facilities within one of the LSAs, considering practicalities such as whether or not we have worked with and have knowledge of a facility, i.e., giving preference to facilities known to us, but also ensuring a geographical spread to ensure that we investigate remote as well as very remote facilities (i.e. facilities within 20km of an urban centre or district hospital and facilities as far away as 200km from an urban centre or district hospital).

Within selected facilities and their surrounding communities we will interview the facility managers, the chairperson or designated representative of the community health committee, as well as six to ten CHWs, making sure that we interview CHWs who were part of old CHW schemes and those who are appointed as part of the new policy.

Data CollectionThe key method of data collection will be in-depth narrative interviews (Forst et al. 2004; Spradley 1979), aimed at eliciting “a less imposed and therefore more valid account of the informant's perspective” (Forst et al. 2004). While interview guides will be developed to serve as a guide and memory to the interviewer (see appendix), the interviews with all actors will be unstructured, as interviewees will be encouraged to “tell the story” of community health workers before and after the implementation of the new policy and the impact of the new policy from their perspective and in their own words.


ECDoH

LSA management

NGO

Facility Manager

CHWs

CHCs

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During the entire data collection process we will keep detailed field notes and write analytic memos to document our own observations of events, behaviours and contexts (Emerson et al. 1995; Marshall and Rossman 2006).

A further option will be to conduct a series of focus group discussions in which concepts of power in relation to the implementation of the CHW policy will be explored. The aim would be two-fold: firstly to explore participants’ understanding of the policy and how power relations unfolded in more depth and detail. And secondly, to provide some input and reflective space for participants in which they have the opportunity to make sense and meaning of events in their lives. Whether this approach is feasible will have to be assessed as the research process unfolds, as it only makes sense to use this route with a receptive audience.

Data analysisAs is common in qualitative research, data will be analysed throughout the research process to allow for an on-going refinement of research questions and understanding by the researchers.

Key methods used will include the triangulation of emerging stories and their analysis for common and conflicting views and narratives and contestations. We will use pattern and discourse analyses to explore themes and language used to describe policy implementation and the unfolding of power relations (Marshall and Rossman 2006; Miles and Huberman 1994; Strauss and Corbin 1998). We will map actor relationships and the forcefields created by these relationships by conducting a stakeholder analysis (Brugha and Varvasovszky 2000; Varvasovszky and Brugha 2000).

The bringing together of these analyses should lead to an in-depth understanding of the context within which the CHW policy was implemented, how it was perceived by key stakeholders and how it impacted on local contexts and how power relations shaped and possibly were shaped by the implementation of the policy. Against the background of a health systems orientation which aims to improve equity in health services in the country, the study results will shed light on the question whether the implementation of the CHW policy has improved or reduced equity gains in terms of access to and quality of health services for those most in need.

ReferencesAKHS. not dated. “Sustaining community-based health initiatives”. Best practices in community based health initiatives. Policy brief no. 3. A. K. H. Services, Mombasa.Ande, O., O. Oladepo, and W. R. Brieger. 2004. “Comparison of knowledge on diarrheal disease management between two types of community-based distributors in Oyo State, Nigeria.” Health Educ Res 19(1):110-3.Barcelon, M. A. and A. Hardon. 1990. “The community based health care program of the rural missionaries of the Philippines.” In Implementing primary health care, edited by P. a. J. C. Streefland, pp. 129 - 40. Amsterdam: Royal Tropical Institute.Bhattacharyya, K., P. Winch, K. LeBan, and M. Tien. 2001. “Community Health Worker incentives and disincentives: how they affect motivation, retention and sustainability”. Arlington, Virginia: BASICS/USAID.Brugha, R. and Z. Varvasovszky. 2000. “Stakeholder analysis: a review.” Health Policy Plan 15(3):239-46.Buse, K., N. Mays, and G. Walt. 2005. Making Health Policy. Maidenhead: Open University Press.Collinson, D. 2005. “Strategies of resistance. Power, knowledge and subjectivity in the workplace.” In Resistance and power in organizations, edited by J. M. Jermier, D. Knights, and W. R. Nord, London/New York: Routledge.Council, P. 2004. Linking reproductive health to social power: community health workers in Belize and Pakistan. New York: Population Council.Cufino Svitone, E., R. Garfield, M. I. Vasconcelos, and V. Araujo Craveiro. 2000. “Primary health care lessons from the northeast of Brazil: the Agentes de Saude Program.” Rev Panam Salud Publica 7(5):293-302.Emerson, R., R. Fretz, and L. Shaw. 1995. Writing Ethnographic Fieldnotes. Chicago: University of Chicago Press.


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Forst, L., S. Lacey, H. Y. Chen, R. Jimenez, S. Bauer, S. Skinner, R. Alvarado, L. Nickels, J. Zanoni, R. Petrea, and L. Conroy. 2004. “Effectiveness of community health workers for promoting use of safety eyewear by Latino farm workers.” Am J Ind Med 46(6):607-13.Friedman, I. 2003. “Community Based Health Workers.” In South African Health Review 2002, edited by I. e. al., Durban: Health Systems Trust.Friedman, I. 2006. “CHWs.” In South African Health Review 2005, edited by P. Ijumba, Durban: Health Systems Trust.Garfield, R. 1993. “Nicaragua: health under three regimes.” In Reaching health for all, edited by J. E. Rohde, M. Chatterjee, and D. Morley, pp. 267-95. Oxford: Oxford University Press.Gilroy, K. E. and P. Winch. 2006. Management of sick children by community health workers. Intervention models and programme examples. Geneva: WHO/UNICEF.Gilson, L., G. Walt, K. Heggenhougen, L. Owuor-Omondi, M. Perera, D. Ross, and L. Salazar. 1989. “National community health worker programs: how can they be strengthened?” J Public Health Policy 10(4):518-32.Greenhalgh, T., G. Robert, F. Macfarlane, P. Bate, and O. Kyriakidou. 2004. “Diffusion of innovations in service organizations: systematic review and recommendations.” Milbank Q 82(4):581-629.Haines, A., D. Sanders, U. Lehmann, A. K. Rowe, J. Lawn, S. Jan, D. G. Walker, and Z. Bhutta. forthcoming. “Achieving child survival goals: potential contribution of community health workers ” Lancet.Hyden, G. “Why do things happen the way they do? A power analysis of Tanzania”.Hyden, G. Year. “Beyond governance: bringing power into policy analysis.” In Paper presented to the Danida/GEPPA Conference on ”Power, Politics and Change in Weak States”edited by, pp. Copenhagen.JLI. 2004. Human resources for health. Overcoming the crisis: Global health Initiative/Harvard University Press.Kaithathara, S. 1990. “Experiences with community health and village health workers in rural India.” In Implementing Primary Health Care, edited by P. J. C. Streefland, Amsterdam: Royal Tropical Institute.Lehmann, U., I. Friedman, and D. Sanders. 2004. “Review of the utilisation and effectiveness of community-based health workers in Africa”. Working paper of the Joint Learning Initiative.Lehmann, U. and D. Sanders. 2006. “Community Health Workers - what do we know about them?” WHO, Geneva.Marshall, C. and G. B. Rossman. 2006. Designing qualitative research. Thousand Oaks: Sage Publication.Mathews, C., H. van der Walt, and P. Barron. 1994. “A shotgun marriage--community health workers and government health services. Qualitative evaluation of a community health worker project in Khayelitsha.” S Afr Med J 84(10):659-63.Miles, M. B. and A. M. Huberman. 1994. Qualitative data analysis : an expanded sourcebook Thousand Oaks, Calif. ; London: Sage Publishers.Ofosu-Amaah, V. 1983. “National experience in the use of community health workers. A review of current issues and problems.” WHO Offset Publ 71:1-49.Pegurri, E., J. A. Fox-Rushby, and W. Damian. 2005. “The effects and costs of expanding the coverage of immunisation services in developing countries: a systematic literature review.” Vaccine 23(13):1624-35.Quillian, J. P. 1993. “Community health workers and primary health care in Honduras.” J Am Acad Nurse Pract 5(5):219-25.Rifkin, S. B. 1996. “Paradigms lost: toward a new understanding of community participation in health programmes.” Acta Trop 61(2):79-92.Sanders, D. 1992. “The state of democratization in primary health care: community participation and the village health worker programme in Zimbabwe.” In The community health worker. Effective programmes for developing countries, edited by S. e. Frankel, pp. 178-219. Oxford: Oxford University Press.SIDA. 2005. “Methods of Analysing Power – A Workshop Report”.SIDA. 2006. “Power Analysis - Experiences and Challenges ”. D. o. D. a. S. Development.Spradley, J. 1979. The Ethnographic Interview. Fort Worth, Fla.: Harcourt Brace Jovanovich College.Strauss, A. and J. Corbin. 1998. Basics of qualitative research : techniques and procedures for developing grounded theory. Thousand Oaks: Sage Publications.Varvasovszky, Z. and R. Brugha. 2000. “A stakeholder analysis.” Health Policy Plan 15(3):338-45.Walt, G. 1992. Community health workers in national programmes. Just another pair of hands? Milton Keynes: Open University Press.WHO. 1989. Strengthening the performance of community health workers in primary health care. Report of a WHO Study Group. Geneva: World Health Organization WHO Technical Report Series No 780.WHO. Year. “Strengthening the performance of community health workers:.” In edited by, pp.:World Health Organization, Geneva.WHO. 2006. The world health report 2006: working together for health. Geneva: World Health Organzation.


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Annex 5 An example of a table for making a summary of an HPSR protocol (Activity 6, Sessions 4–6)

Note: You will need to be familiar with the protocols selected for Activity 6 and be ready to lead discussions about the key elements/features across the protocols. This example is for guidance only as you compile your own notes for reference.

Title of protocol or research study

Focus

Country

Purpose

Question

Strategy

Theory

Analysis

Rigour issues

Generalisable claims?

Policy engagement?


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Documents

Web viewThe handouts are available as a set of Word ... Handout 1: Course ... and skills that you bring to HPSR and where your comfort zones and