Click to add presenter’s name Health Economics Unit University of Cape Town Click to add conference title Click to add conference date & venue Recognising the range of questions and methodological approaches in HPSR Lucy Gilson University of Cape Town and London School of Hygiene and Tropical Medicine Professor Lucy Gilson, 14 Dec 2011

HPSR The terrain The diversity Developing the field Funding development of the field Professor Lucy Gilson, 14 Dec 2011

THE TERRAIN Professor Lucy Gilson, 14 Dec 2011

HPSR seeks to understand what health systems are & how they function what needs to be done to strengthen them how to influence policy agendas on health system development how to develop and implement policies in ways that strengthen health systems Professor Lucy Gilson, 14 Dec 2011

ConstraintDisease-programme issuesHealth system issues Poorly motivated staff Financial incentives to reward delivery of particular priority services Institution of proper performance review systems Creating greater clarity of roles and expectations regarding performance of roles Review of salary structures and promotion procedures Goes beyond assessing & strengthening dedicated disease/condition specific programmes Travis et al Professor Lucy Gilson, 14 Dec 2011

Why include health policy focus? Health policies are deliberate actions to strengthen health systems Policies become effective – if there is enough political support AND – if they take root within health systems Important to understand – the politics of influencing policy agendas – the organizational dynamics of health systems Professor Lucy Gilson, 14 Dec 2011

Health policy Not just an output of decision making but rather the entire process of decision-making Encompasses the – formal documents, guidelines and rules – the decision-making practices of the full range of policy actors that translate the documents into policy-as- experienced Analysis focuses on people, processes, power Professor Lucy Gilson, 14 Dec 2011

Health systems are dynamic & interconnected systems at whose heart are people People governance Information financing service delivery human resources medicines & technology De Savigny & Adams, 2009 ‘It is the multiple relationships and interactions among the building blocks... that convert these blocks into a system’ Professor Lucy Gilson, 14 Dec 2011

Health Policy: Content & Instruments Actors, Power & Politics Institutions, Interests & Ideas Health Systems: Hardware: Structure; Organisation; Technology; Resourcing Software: Actors & Relationships; Values; Norms Policy Change & Health System Development Global & National forces Scope of HPSR Professor Lucy Gilson, 14 Dec 2011

THE DIVERSITY OF HPSR Professor Lucy Gilson, 14 Dec 2011

Different perspectives Epidemiology & Clinical Sciences Policy & Practice Social Sciences HPSR Professor Lucy Gilson, 14 Dec 2011

What are health systems? Machine-like organisations which can be controlled from the top through rules and incentives Complex social and political phenomena, constructed through human action Professor Lucy Gilson, 14 Dec 2011

What is the nature of the social reality being investigated? Epidemiology/Clinical science: There are a set of facts to be gathered (one reality) Social science: Reality is constructed by actors drawing on their ‘contexts’ (different parallel realities) PositivismRelativism Professor Lucy Gilson, 14 Dec 2011

Purposes of research & related questions Normative/evaluative Exploratory/ explanatory What interventions work best? What works for whom under what circumstances? What are the social processes, including power relations, influencing actors’ understandings and experiences, and shaping impacts of interventions? Professor Lucy Gilson, 14 Dec 2011

Knowledge paradigm   PositivismCritical Realism Relativism (interpretivism / social constructionism) Types of questions addressed Is the policy or intervention effective/cost-effective? What works for whom under which conditions? What are the social processes, including power relations, influencing actors’ understandings and experiences? Key research approaches and methods Deductive: Hypothesis driven Emphasis on measurement through surveys, data records & Statistical analysis; some qualitative data Deductive and inductive : theory testing & building Multiple data collection methods; Mixed method studies Inductive: theory building & testing Emphasis on qualitative data collection approaches & Interpretive analysis Professor Lucy Gilson, 14 Dec 2011

Ensuring rigour Positivist: Validity & reliability of data & analysis Relativist: Trustworthiness of interpretive judgements Professor Lucy Gilson, 14 Dec 2011

DEVELOPING THE FIELD Professor Lucy Gilson, 14 Dec 2011

The value of combining perspectives Assessing household level impacts of user fees Survey data & statistical analysis: What is the impact of out of pocket payments on household poverty levels across countries? Qualitative, longitudinal household case studies: How do out of pocket payments combine with other influences over health seeking behavior to impact on the dynamics of household poverty? Professor Lucy Gilson, 14 Dec 2011

Balance in questions asked Past emphasis on normative/evaluative work and ‘generalizable’ answers More work on exploratory & explanatory questions considering socio-cultural-political constructions of health systems (not just health) Sheikh et al Professor Lucy Gilson, 14 Dec 2011

In HPSR Value the range of perspectives and questions No hierarchy of method Professor Lucy Gilson, 14 Dec 2011

Strengthening study design 1.Research focus identified from understanding of – local context AND relevant literature AND relevant theory 2.Clear, answerable research questions 3.Question-driven research strategy 4.Approaches to ensuring research rigour that are relevant to strategy chosen 5.Apply ethical principles Professor Lucy Gilson, 14 Dec 2011

From RQ to research strategy (Yin 2009) Form of RQ Requires behavioural control of events? Focus on contemporary events? Research strategy Who, what, where, how many, how much? NoYes Survey Who, what, where, how many, how much? NoYes/no Archival analysis How, why? Yes Experiment How, why? No History How, why? NoYes Case study Professor Lucy Gilson, 14 Dec 2011

The value of mixed method studies Deliberately combine strategies to expand the scope of studies, and deepen insights e.g: – initial small-scale intensive study to develop detailed understanding of a phenomenon, followed by larger-scale structured survey to generate more extensive understanding of the same phenomenon, using tool developed from the initial study. Professor Lucy Gilson, 14 Dec 2011

Ensuring rigour in HPSR An active process of questioning and checking during the inquiry A constant process of conceptualizing and reconceptualizing Crafting, trustworthy interpretive judgements Researcher reflexivity Professor Lucy Gilson, 14 Dec 2011

Procedural steps in building trustworthiness Prolonged engagement Use of theory Case selection: – Purposive selection to allow prior theory and initial assumptions to be tested or to examine ‘average’ or unusual experience Sampling – Of people, places, times etc, to include as many as possible of the factors that might influence the behavior of those people central to the topic of focus – Gather views from wide range of respondents Multiple methods (case studies) Triangulation Negative case analysis Peer debriefing and support Respondent validation (Member checking) Clear report of methods of data collection and analysis (Audit trail) Professor Lucy Gilson, 14 Dec 2011

FUNDING HPSR DEVELOPMENT Professor Lucy Gilson, 14 Dec 2011

Critical elements Long term, large-scale funding for research programmes – focused on particular contexts/systems & driven by questions; combining empirical, methodological & conceptual work; linked to educational programmes Multi-disciplinary research teams, working collaboratively with other health system actors Opportunities for cross-national work and learning Professor Lucy Gilson, 14 Dec 2011

Working across capacity dimensions Professor Lucy Gilson, 14 Dec 2011

Thank you Professor Lucy Gilson, 14 Dec 2011