KEYSTONE HPSR Initiative // Module 4: Health Policy & Systems Research frameworks // Slideshow 2: Health Policy & Systems Research Frameworks - 2 This is the second slideshow of Module 4: Health Policy and Systems Research frameworks, of the KEYSTONE Teaching and Learning Resources for Health Policy and Systems Research To access video sessions and slides for all modules copy and past the following link in your browser: http://bit.ly/25vVVp1 Module 4: Health Policy & Systems Research frameworks Health systems are knowable and researchable and their study calls for a range of inputs from different disciplines. Different questions and different understandings of health system problems lend themselves to different and complementary research approaches under the HPSR umbrella. Evolving concepts of ethics and rigour in HPSR are also delineated and knowledge translation as being integrated and continuous with the production of knowledge in HPSR is also considered. There are 3 slideshow in this module. Module 4: Health Policy & Systems Research frameworks -Module 4 Slideshow 1: Health Policy and Systems Research Frameworks -1 -Module 4 Slideshow 2: Health Policy and Systems Research Frameworks - 2 -Module 4 Slideshow 3: Health Policy and Systems Research Frameworks - 3 The other modules in this series are: Module 1: Introducing Health Systems & Health Policy Module 2: Social justice, equity & gender Module 3: System complexity Module 5: Economic analysis Module 6: Policy analysis Module 7: Realist evaluation Module 8: Systems thinking Module 9: Ethnography Module 10: Implementation research Module 11: Participatory action research Module 12: Knowledge translation Module 13: Preparing a Research Plan KEYSTONE is a collective initiative of several Indian health policy and systems research (HPSR) organizations to strengthen national capacity in HPSR towards addressing critical needs of health systems and policy development. KEYSTONE is convened by the Public Health Foundation of India in its role as Nodal Institute of the Alliance for Health Policy and Systems Research (AHPSR). The inaugural KEYSTONE short course was conducted in New Delhi from 23 February – 5 March 2015. In the process of delivering the inaugural course, a suite of teaching and learning materials were developed under Creative Commons license, and are being made available as open access resources. The KEYSTONE teaching and learning resources include 38 videos and 32 slide presentations organized into 13 modules. These materials cover foundational concepts, common approaches used in HPSR, and guidance for preparing a research plan. These resources were created and are made available through support and funding from the Alliance for Health Policy & Systems Research (AHPSR), WHO for the KEYSTONE initiative.

1. https://twitter.com/KeystoneHPSR
Building the HPSR CommunityBuilding HPSR Capacity
KEYSTONE
Inaugural KEYSTONE Course on Health Policy and Systems Research 2015
Health Policy & Systems Research Frameworks – 2

2. Health Policy & Systems
Research Frameworks – 2
(Research questions)
Kabir Sheikh
24 Feb 2015
KEYSTONE

3. Generating and
framing HPSR
questions
IHPSR Presentation 4
www.hpsa-africa.org
@hpsa_africa
www.slideshare.net/hpsa_africa
Introduction to Health Policy and
Systems Research

4. Four key steps in HPSR
1. Identify research focus
(problem/concern/opportunity) and
question
2. Design study
3. Ensure quality and rigour
4. Apply ethical principles

5. Key issues in this session
• Starting points for HPSR questions
• Different kinds of HPSR questions
• What is a ‘good’ HPSR question
• How to generate substantively relevant
questions

6. • The question drives the study

7. Generating questions
• Starting points = focus/terrain of health policy &
health systems
– consider level (macro/meso/micro/cross-level)
• And consider
– What are research users’ ideas?
– What past work?
– Disciplinary perspectives?
• Thinking about purpose of research: normative vs
exploratory/ descriptive/ explanatory questions

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

9. Whose ideas?
Research
question
Community
group
Patient
group
District
manager
Hospital
manager
National
manager
International
agency
Researcher
Same issue,
different
questions?
Different
issues &
questions?

10. What wider knowledge?
• Look at international experience
(replicate don’t duplicate)
– importance of literature review: add to
the literature!
• Use theory (relevant empirical and
theoretical resources)

11. Why do you want to do your
study/
What do you want to do in your
study?Do you want to
• test an intervention
• measure impacts or understandings
• understand a phenomenon
• act in a situation to improve it
 what you want to do may say something about
your understanding of knowledge and action
 this understanding is the foundation of your study
From CHEPSAA

12. What is the study
‘purpose’?
Normative/evaluative: Seeks to generate/identify norms, best
practices,’gold standard’ interventions
Exploratory: To find out what is happening, especially in little
understood situations
Descriptive: To give accurate profile of people, events, situations
Explanatory: To explain patterns relating to phenomenon being
researched; To identify relationships between aspects of
phenomenon
Emancipatory: To create opportunities and the will to engage in
social action
Robson, 2002; Thomas, Chataway & Wuyts, 1998; Yin, 2009

13. Normative
Impact?
Is it best?
What is
best
practice?
Exploratory
What+? (new
insights)
Descriptive
Who? What?
Where?
How many?
How much?
Explanatory
Why and how?
Action/
participatory
research
From purpose to
question form

14. From purpose to question ...
Purpose Why adopt that
purpose?
Questions
Normative
(positivist)
To generate
‘best’ practice
ideas
• Does intervention x work?
• Which intervention for issue y is most
effective?
Exploratory
(realist/
relativist)
To find out what
is happening,
when little is
known
• What categories of information are
used in decision-making?
• What are the social processes,
including power relations, influencing
actors’ understandings and
experiences, and shaping impacts of
interventions?
Descriptive
(positivist/
realist)
To give accurate
profile of people,
events, situation
• What is the quality of care in place q?
• What is the level of health worker
motivation in place z?
• What are stakeholder positions on
policy A?

15. Purpose Why adopt that
purpose?
Questions
Explanatory
(some control
over events)
(positivist)
To explain
relationships,
assuming fairly
linear causality
• Do managers influence
facility performance? How?
Exploratory/
Explanatory;
Explanatory
(little control
over events)
(relativist/realist
)
To identify and
explain
relationships,
assuming complex
causality
• How and why does
management influence facility
performance?
• When and under what
circumstances does
management influence facility
performance?
Emancipatory
(critical
perspective)
Draw on expertise
of practitioners
Encourage practice
changes

16. Problem: unequal availability of
doctors
How can we
make doctors
stay on in
villages?
Why do most
doctors
leave?
Why do some
doctors stay
on?
Can we
replace
doctors with
other
workers?
Can they
provide quality
services?
Evaluative
Strategic / normative Diagnostic Exploratory

17. Need more balance in
questions asked
• Past emphasis on normative/evaluative work
and ‘generalisable’ answers
• More work on exploratory and explanatory
questions considering socio-cultural-political
understandings of health systems
Sheikh et al., 2011

18. Sheikh et al., 2011
Level of
analysis
Macro
(architecture)
Meso (organisation/
intervention)
Micro
(individual)
Normative/
evaluative
How can political
parties be effectively
involved in a country’s
process of planning
universal coverage?
What are the reasons
for the low efficiency
of community
governance structures
that administer a
decentralised fund
scheme?
Does individual
coaching offer
better support to
health system
managers than
individual training?
Exploratory/
explanatory
What norms underpin
effective oversight by
communities?
How do ‘pay for
performance’
arrangements interact
with local
accountability
structures?
Why do front-line
providers frequently
diverge from
recommended
clinical guidelines?

19. What makes a ‘good’ HPSR question?
Adapted from Robson, 2002
• Substantively relevant: worthwhile, non-trivial
questions, worthy of the effort to be expended +
• Clear: unambiguous and easily understood +
• Specific: sufficiently specific to be clear about what
constitutes an answer +
• Answerable: can see what data are needed to
answer it and how those data will be collected +
• Interconnected: questions are related in some
meaningful way, forming a coherent whole

20. What makes a ‘good’ HPSR question? (continued)
Adapted from Robson, 2002
• Substantively relevant
– How questions are generated >> will build on what
is known not duplicate it, will assist system
development in a particular context
• Clear, specific, answerable, interconnected
– How questions are framed/worded >> pay
attention to the details: scope (time, place,
people), concepts

21. Generating substantively
relevant questions
• Talk to people in the system of focus
– What do they know and understand?
– What do they see as important and useful?
– What do they identify as knowledge gaps?
• Review the literature
– What knowledge has already been generated
locally, internationally?

22. Types of literature reviews
Go find the resources – lots out there!
Also
qualitative
review &
synthesis!

23. Review basics
1. Identify the review question or focus
2. Frame the area you are searching (year, area or topic)
3. Search for primary studies and theoretical papers (using
databases, search engines, or a particular publication)
4. Select papers – inclusion/exclusion criteria; quality
appraisal (assess relevance & rigour of what you find)
5. Collect the key items or extract the data
6. Review papers & data
7. Synthesis (make meaning, pull together a coherent
argument)

24. ‘Critical Appraisal’
• The art of providing a reasonable evaluation of a text by
breaking it down and studying its parts
• To be critical does not necessarily mean to criticise in a
negative manner
• Requires you to question the information and opinions in a
text and present a reasonable analysis
• ‘Analysis’ means to evaluate the strengths and weaknesses of
the text (or research report), based on clear criteria – and with
an understanding of the text’s purpose, the intended audience
and why it is structured in the way it is

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