Document(s) 5 of 27

1. The development of health systems research
2. What is health systems research?
3. Participants in health systems research
4. Guidelines for health systems research

I. THE DEVELOPMENT OF HEALTH SYSTEMS RESEARCH

Why did HSR develop?

By adopting of the philosophy and strategies for Health For All, politicians and health staff at all levels are committed to ensuring that all people will attain a level of health that enables them to participate actively in the social and economic life of the community in which they live.

Although research has made major contributions to health by providing knowledge of the causes of diseases and by developing the technology to cure and prevent disease and promote health, Health For All is far from being achieved.

Why is there still so much disease that could have been prevented or cured? Because health services by themselves cannot control all of the factors that influence health. Poverty and political systems which either widen or narrow the gap between rich and poor and which promote or neglect the education of girls, for example, influence the health of people. Drought and wars may bring malnutrition and disease with which the health services can hardly cope. While communicable diseases such as smallpox and, to some extent, leprosy may be gradually conquered due to improved environmental conditions and extra effort on the part of the health services, new diseases such as HIV/AIDS may appear which upset the whole health care system and society at large.

This complex of environmental factors – geographical, socio-economic, cultural, political, demographic, epidemiological – not only influences the health of people, it also affects the health services. Countries suffering from poor economics, wars and drought usually have poorly functioning health services as well.

Still, even within less favourable environments, some services function better than others. A very important factor is the quality of information on which policy makers base their decisions. Very often this information is vague or missing. Then decisions on interventions can be completely off track, which means that money is wasted. Basic questions which health policy makers need answered include, for example:

— What are the health needs of (different groups of) people, not only according to health professionals but also according to the people themselves? Can shared priorities be agreed upon?

— To what extent do the present health interventions cover these priority needs? Are the interventions acceptable to the people in terms of culture and cost, especially to the poor? Are they provided as cost-effectively as possible?

— Given the resources we have, could we cover more needs, or more people, in a more cost-effective way? Is it possible to introduce or expand cost-sharing through insurance, to reduce the risk of unexpected high costs, in particular for the economically vulnerable? Could co-operation with the private/NGO sector be improved? Could donor agencies help solve well-defined bottlenecks in the system?

— Is it possible to better control the environmental factors which influence health and health care? Can other sectors help (education, agriculture, public works/roads, etc.)? (See Figure 2.1.)

These questions cannot be answered without collecting more information through research. That is why, since the end of the 1970’s, Health Systems Research (HSR) has been developed.

Figure 2.1: Environmental and health system factors influencing attainment of Health For All

II. WHAT IS HEALTH SYSTEMS RESEARCH?

What is research?

Characteristics of research:

• It demands a clear statement of the problem.
• It requires clear objectives and a plan (it is not aimlessly looking for something in the hopes that you will come across a solution).
• It builds on existing data, using both positive and negative findings.
• New data should be systematically collected and analysed to answer the original research objectives.

Health research serves two major purposes:

First, basic research is necessary to generate new knowledge and technologies to deal with major unresolved health problems. Second, applied research is necessary to identify priority problems and to design and evaluate policies and programmes that will deliver the greatest health benefits, making optimal use of available resources.

During the past two (or even three) decades there has been a rapid evolution of concepts and research approaches to support managerial aspects of health development. Many of these have been described by specific terms such as operations/operational research, health services research, health management research, applied research and decision-linked research. Each of these has made crucial contributions to the development of HSR (WHO 1990).

What is meant by a health system?

There are different interpretations of what a health system is. Some give a narrow definition and only consider the different levels of the public health care services as a health system (see Figure 2.2.)

Figure 2.2: Public health care system

The inclusion of the district council, district development committee and village development committee indicates, however, that some 25 years after Alma Ata* it has been widely recognised that local administration and other sectors than the health sector alone carry responsibility for the health of the people in a village, district or region.

Many HSR researchers have a wider perception of health systems. They also include the private sector. The private sector has many possible components:

• Non-governmental organization (NGO) care, provided by churches, Red Cross, local NGOs, etc.
• Medical practice by private doctors, nurses, or by quacks who provide injections and drugs without medical training.
• The pharmaceutical sector (licensed pharmacies or unlicensed sellers).
• The large ‘non-biomedical’ professionalised healing systems (Ayurvedic, Chinese, Unani, homeopathic, chiropractic, etc.)
• Traditional (or folk) medicine, with traditional birth attendants, herbalists and diviners, who may either identify natural or supernatural causes of disease (witchcraft, angry ancestors) and treat patients accordingly.

The Primary Health Care (PHC) approach has broadened the horizon of medical care providers considerably. PHC put individuals and communities in the centre of attention. Individuals providing self-care (what mothers and other relatives do to keep children and themselves healthy) and

* The WHO/UNICEF/World Council of Churches conference, which in 1978 laid the foundation for the worldwide Primary Health Care approach.

traditional/folk healers were accepted as important potential allies of health staff. So were personnel from other sectors, which could support health, for example, through the construction of roads, the improvement of education, water, sanitation, and through income generation.

Figure 2.3: A broadly defined health system

Figure 2.3 presents the widest possible definition of a health system, including all public and private sectors/institutions which directly influence and support the health of people, embedded in the wider environmental context that was described in Figure 2.1.

This figure would take different shapes in different societies, but everywhere individuals form part of a network of family and community members who are concerned about their health. This network prescribes or advises how to prevent illness and what to do in case of ill health. In many societies, mothers and grand mothers are key figures in early childcare. They determine nutritional and hygiene practices, alert children to dangers, provide care in case of disease, and teach children the basics of self-care.

At the other end of the spectrum, a public authority is responsible for the well being of all people inhabiting its territory. Nowadays governments of states organise public health care and, to some extent, regulate private health care initiatives. Through other social services (e.g., education, social welfare), through laws and taxes and police and army, governments are supposed to assure their citizens the resources to survive and live in peace. Since time immemorial this has been the duty of rulers, although each society has developed its own ways of ensuring ‘health for all’.

When in the 1980s many countries were struck by chronic economic crises, the World Bank advocated structural adjustment programmes to reorganise the economies, which relied on market mechanisms rather than on state control with subsidies and protection. The health and educational sectors were inevitably affected and went through a series of reforms that hit the consumer hard. The World Health Organization recognised the need for health reforms, but under the condition that these would leave the goal of HEALTH FOR ALL in tact. It therefore focussed attention on fairness of the system, which should also be affordable to the poor, and at the same time stressed that the system should be responsive to the need of patients for human, respectful treatment (see Figure 2.4).

Figure 2.4: Objectives and functions of the health system

Functions the health system performs      Objectives of the system

Health is expressed as life expectancy by the WHO, taking into account the time lived with a disability of any kind (also due to chronic disease and old age). In the highly industrialised countries of Western Europe, for example, the average life expectancy of men is 74 years, of which 6.5 years are with disability; for women it is 80.8 and 7 years, respectively. In Africa in areas most struck by AIDS, men live now on average only 45.6 years, of which 7.6 years are with disability; for women the respective means are 48 and 8 years. Responsiveness to patients’ human needs would mean respecting the patient’s dignity and autonomy and reducing the fear and shame that sickness brings with it. Fairness ideally means financial protection for everyone by payment according to financial capacity. This can best be assured by pre-payment through an insurance system, with fees according to capacity. The insurance revenues are then pooled and costs of care paid from the pool, so that in fact the rich help to cover the treatment of the poor. Unfortunately, such a system is hard to organise in the least developed countries where rural areas harbour mainly poor, but WHO counts on international solidarity and donor agencies for contributions.

The health system comprises both public and private health services but, for the time being, no agricultural, educational or other sectors, however relevant. The first urgency is the performance of the health system, which should be as good as possible, given the available means. To reach that aim, WHO set some criteria. Ministries of Health should weigh the public health importance of proposed health actions, set priorities, and thoroughly investigate the cost-effectiveness of different possible interventions to select the highest value for the money. In terms of resources, they should strive for a balance between investments, the use made of these investments and their maintenance. For example, if staff members are highly trained but their knowledge is under-utilised, or if buildings, equipment and means of transport cannot be maintained, these investments are highly wasteful. Likewise the services don’t function well if there is no money left for consumables such as essential medicines. The patients then have to buy medicines on the private market, out of their pockets and at unnecessary high costs, which the poor cannot afford. Good oversight is required to achieve an optimal balance among the different expenses, and it is one of the aims of HSR to provide the policy makers with the relevant data.

Good oversight and ‘stewartship’ is also required to develop a fair financing system. The Ministry of Health is usually the appropriate institution to collect money from taxes and donor agencies to finance the health care system. In the 1980’s it became clear that even PHC services could never function adequately with the required coverage (health for ALL) without a contribution from the clients. User fees were introduced in countries that hitherto had provided care free of cost, but this appeared to hit the poor out of proportion despite exemption rules. Hence WHO proposes a more structural solution by introducing prepayment through insurance and pooling of resources, which is beneficial for the poor.

Although the MOH, in many developing countries, is still the principal provider of health care, if it is to achieve the most cost-effective care, it has to consider the use of the private sector and contract services out in cases where this would be cheaper. Consequently, the MOH has to set standards of care and control for deviation in the private sector as well as the public. To have oversight and control is one of the major present day challenges for Ministries of Health.

Specific questions for specific levels of service

HSR is not only of use to policy makers; at each level managers may have questions that require further research.

Health policy makers may, for example, want to know:

• What are the prospects for voluntary community-based insurance? What would acceptabl contributions for different income groups? Should the pooling of resources take place on a community or national basis?
• How can user-fees be used as an instrument to direct demands for care to the appropriate level?

Managers at district/provincial level may raise questions such as:

• Why is neonatal mortality in certain districts much higher than in other districts?

Hospital directors may ask:

• Why do we have such a high rate of complications during child birth? Are the first-line services available and adequate? Are our own services adequate? Are mothers coming late for delivery and, if so, why?

Managers at village level (village health committees) may want to know:

• How can we assist women with little or no education so that they can effectively recognise the symptoms of pneumonia and go in time to the health centre with their children?
• How much community labour will be required to manage the new water system?

(Please add your own examples.)

We must be aware that problems at one level of the health system are usually connected with problems or deficiencies at other levels (see Figure 2.2). HSR should address problems from the differingperspectives of all those who are, directly or indirectly, involved. Otherwise we run the risk of coming up with results which only partly explain the problem and which are therefore insufficient to solve it.

III. PARTICIPANTS IN HSR

It is evident that many issues in health are interrelated and interact with issues in other sectors, such as production, education, the condition of wells or roads, and broader environmental factors. Research in health systems must recognise this. The research skills that are required may need to come from a variety of disciplines, e.g., public health/medicine, health economics, behavioural and social sciences, and agriculture. Therefore HSR is multi-disciplinary in nature.

Even simple research that is conducted at the operational level may require research skills from different disciplines to provide sufficient and relevant information to support decision-making. Therefore, training in HSR includes relevant aspects from various research disciplines.

Researchers who work in HSR will have to work in a trans-disciplinary way, which means working together as a team throughout all phases of the research. In the process, they need to acquire a basic understanding of the concepts and approaches as well as the potential and limitations of research techniques used in sister disciplines.

Who should be involved in HSR?

The participatory nature of health systems research is one of its major characteristics. To ensure that the research is relevant and appropriate, everyone directly concerned with a particular health or health care problem should be involved in the research project(s) focused on it. This may include policymakers, managers from the health and other public services involved, health care providers and the community itself. Their involvement is critical if the research activities are to make a difference:

• If decision-makers are only involved after completion of the study, the report may just be shelved.
• If staff of health and other public services are only involved in data collection and not in the development of the proposal or in data analysis, they may not be motivated to collect accurate data or carry out the recommendations.
• If the community is only requested to respond to a questionnaire, the recommendations from the study may not be acceptable.
• If professional researchers are not involved in the implementation of recommendations, they may have little concern for the feasibility of the recommendations.

The roles that various types of participants will play in the research project will depend on the level and complexity of the particular study as well as its area of focus. Some projects are very complex and may need expertise from several levels, sectors and disciplines. Others may focus on simpler problems and require a more modest set-up. Health personnel may even play a major role in simple studies focusing on practical problems in their own working situations, although their projects may require assistance from researchers with skills in relevant disciplines.

IV. GUIDELINES FOR HSR

Bearing in mind that HSR is undertaken primarily to provide information to support decision-making that can improve the functioning of the health system, we summarise by suggesting some essential guidelines for success:

1. HSR should focus on priority problems in health care.
2. It should be action-oriented, i.e., aimed at developing solutions.
3. An integrated multi-disciplinary approach is required, i.e., research approaches from many disciplines are needed since health is affected by the broader context of socio-economic development.
4. The research should be participatory in nature, involving all parties concerned (from policymakers to community members) in all stages of the project.
5. Studies should be scheduled in such a way that results will be available when needed for key decisions; research must be timely. Otherwise, it loses its purpose.
6. Emphasis should be placed on comparatively simple, short-term research designs that are likely to yield practical results relatively quickly. Simple but effective research designs are difficult to develop but much more likely to yield useful results when needed.
7. The principle of cost-effectiveness is important in the selection of research projects. Program management and operational research should focus, to a large extent, on low-cost studies that can be undertaken by management and service personnel in the course of daily activities. (There is a need for larger studies as well, however, which may require outside funding and full-time research staff.)
8. Results should be presented in formats most useful for administrators, decision-makers and the community. Each report should include:
   • A clear presentation of results with a summary of the major findings adapted to the interests of the party being targeted by the research.
   • Honest discussion of practical or methodological problems that could have affected the findings.
   • Alternative courses of action that could follow from the results and the advantages and drawbacks of each, formulated with inputs from all parties concerned.

   8. Evaluation of the research undertaken should concentrate on its ability to influence policy, improve services and ultimately lead to better health, rather than on the number of papers published.

Trainer’s Notes

Module 2: INTRODUCTION TO HEALTH SYSTEMS RESEARCH

Adapting the presentation to the participants

It is recommended that the content and focus of the module be adapted to the level and interests of the participants. For example:

1. Review the background of participants (e.g., primary health care, clinical medicine, research, policy-making, or community leadership).
2. Based on this review, select suitable examples related to the background of participants to illustrate each concept.

   Remember that understanding of abstract concepts is facilitated if participants can relate them to their own experiences.

3. The focus and scope of this module can be varied in accordance with the expected future roles of participants in the research teams.

   If participants are fairly specialised personnel from a single discipline or from just a couple of disciplines, it would be useful to focus on the multi-disciplinary aspect of HSR and the types of information that disciplines other than those represented in the workshop can provide. For example, if workshop participants are hospital managers and clinicians, it may be most useful to illustrate the uses of research input from behavioural science for HSR; if participants are behavioural scientists such as health education officers and sociologists, it may be most useful to emphasize the importance of input from management sciences, health economics and clinical epidemiology.

4. When presenting figures, use different overhead sheets for the different components. For example, the health system (Figure 2.3) could be presented on four superimposed sheets.

   

5. Ask participants to give examples of topics suitable for HSR from their own working environment.
6. Ask whether they have participated in evaluations or other regular research activities. Demystify the concept of HSR. Identify in what stages of the research they have participated and whether the participation was optimal.
7. Try to draw out the points mentioned in the guidelines from the participants themselves. By the end of the introductory session they should be able to come up witsome of the points on their own.

Proposed pre-workshop reading (to be sent to participants before the workshop)

World Health Organisation (1990) Health systems research: Background document at the World Health Assembly. Geneva: WHO. A43/Technical Discussions/3.

Proposed additional reading (to be available in the course library)

Bobadilla JL (1998) Searching for essential health services in low- and middle-income countries. Washington DC: Inter-American Development Bank.

Joint Project on Health Systems Research for the Southern African Region (1994) Summaries of Health Systems Research Reports 1988-1993. Harare, WHO Sub-regional Office III (now AFRO).

Joint Project on Health Systems Research for the Southern African Region (1997) Health Systems Research: Does it make a difference? Update 1996 (3^rd edition) WHO: Geneva.

Joint Project on Health Systems Research for the Southern African Region. Series Health Systems Research: It can make a difference.

Volume 1: Availability, provision and use of drugs (1994)

Volume 2: Factors associated with maternal mortality (1994)

Volume 3: Under utilisation of TB services in Southern Africa. Exemplary research protocol, research results and their implementation (1996)

Volume 4: Factors influencing the functioning of primary health care at village level (1996)

Murray CJL, Kreuser J, Whang W (1994) Cost-effectiveness analysis and policy choices investing in health systems. In: Murray CJL, Lopez A. Global comparative assessments in the health sector: disease burden, expenditures and intervention packages. Geneva: World Health Organization.

Scrimshaw SCM, Hurtado E (1987) Rapid assessment procedures for nutrition and primary health care. Anthropological approaches to improving program effectiveness. Tokyo: United Nations University and Los Angeles CA: Latin America Centre, University of California.

Taylor CE (1984) The uses of health systems research. World Health Organisation: Geneva. Public Health Paper 78.

World Health Organization (2000) The World Health Report. Health systems: improving performance. Geneva: WHO.

World Health Organisation (1988) Health systems research in action: case studies from Botswana, Columbia, Indonesia, Malaysia, the Netherlands, Norway, and the United States of America. Geneva: WHO.

World Health Organization, Programme on Health Systems Research and Development (1991) From research to decision making. Geneva: WHO.

Document(s) 5 of 27