https://twitter.com/KeystoneHPSR

Building the HPSR Community Building HPSR Capacity

KEYSTONE

Inaugural KEYSTONE Course on Health Policy and Systems Research 2015

Keystone Course: Getting Oriented

KEYSTONE

Keystone Course: Getting Oriented

Kabir Sheikh

23 February 2015

KEYSTONE

WHY KEYSTONE? COURSE AIMS AND OBJECTIVESCOURSE OUTLINE

KEYSTONE

Because health systems matter…

• To individuals

– care and support when sick and vulnerable

– treatment and cure for sickness

• To societies

– part of ‘fabric of society’, not just about sickness/death

(Courtesy CHEPSAA)

KEYSTONE

Because Health Systems are researchable…

• “We use the extended term Health Policy and Systems Research for a field that is often referred to simply as Health Systems Research.”

• “For us, the broader term better captures the terrain of work it encompasses because it explicitly identifies the interconnections between policy and systems, and highlights the social and political nature of the field.”

Note: focus is mainly on LMIC

(Sheikh et al. 2011)

KEYSTONE

Eclectic History

Social scientists seeking to support change in systems

• Health economics

• Sociology

• Political science

• Anthropology

Public health specialists trying to resolve practical concerns

Brian Abel Smith, Anne Mills, Gill Walt, Michael Reich, Eliot Freidson, TN Madan, Roger Jeffery, Charles Leslie, Mark Nichter, etc.

Milton Roemer, Patrick Vaughan, Carl Taylor, Corlien Varkevisser

H(P)SR: A multidisciplinary and

interdiscipinary field

KEYSTONE

Caveats

• Narrow interpretations: HPSR is being interpreted narrowly –in terms of its utility for addressing the constraints of specific health interventions, focusing on hardware more than software, operational over fundamental societal questions

• “Disciplinary capture”: Quantitative and deductive methods, and their corresponding criteria of quality (“E.g. does this study have a randomised design?”), are often applied where qualitative or inductive methods could be more appropriate.

(Sheikh et al. 2011)

KEYSTONE

Because we need to strengthen the field and build capacities…

Recommendations from PLoS Med series (Sheikh et al. 2011, Gilson et al

2011, Bennett et al 2011)

• Focus on HPSR’s role in supporting societal development and self-sufficiency of LMI nations and communities

• More exploratory and fundamental research

• More literacy of and application of rigorous social science

• More institutional capacity building for HPSR in LMIC

KEYSTONE

What is KEYSTONE?

• KEYSTONE is a national initiative to develop new capacities, and channelize latent capacities in multiple disciplines, towards addressing critical needs of health systems and policy development in India

• A collective endeavour of several Indian research organizations, KEYSTONE is convened by the Public Health Foundation of India in its role as a Nodal Institute of the Alliance for Health Policy & Systems Research, WHO.

• Tagline: Building HPSR Capacity. Building the HPSR Community

KEYSTONE

12 partner institutions

KEYSTONE

PROGRAMME THEORY

KEYSTONE

VALUES• Strive for highest attainable quality of research training and research

• Cross-disciplinarity: promote research that addresses pressing health system priorities through application of a range of disciplinary approaches and cross-disciplinary frameworks

• Emphasize the relevance of the training and research for people involved in positive change in systems, through greater interconnectedness and embeddedness in systems

• Community orientation: building relationships, collegiality, cooperation and mutual support across researchers and research organizations

• Place principles of health equity and health justice at the heart of the initiative

• Be attentive to accepted principles of research ethics at all times, while recognizing that the ethics of HPSR is an evolving field

KEYSTONE

Course Objective

• Course aims and objectives: The KEYSTONE course aims to develop individual capacities and channelize latent capacities of participants, for investigating and addressing real-world problems of health systems and policy, through rigorous immersion in current HPSR approaches, frameworks and methodologies

KEYSTONE

Learning Outcomes

By the end of the course participants should be able to

• Formulate relevant health policy and systems research questions,

• Select the appropriate research strategies and approaches for answering these questions

• Think through strategies to support the use of research knowledge in health system decision-making

KEYSTONE

Scope of HPSR

• Distinguished by issues and questions considered, not by a disciplinary base, and includes:

– research focused on health services as well as promotion of health

– concern for global and international issues as well as national and sub-national issues

– research on or of policy – addresses politics of health systems and health systems services

• Promotes work that explicitly seeks to influence policy

Courtesy CHEPSAA

KEYSTONE

Scope & nature of HPSR (continued)

HPSR is not:

• Clinical or basic science

• Only rooted in health economics or focused on financing issues (though both important)

• Focused on disease distribution, causes and interventions (but rather generic organisational & societal‘structures’through which interventions are implemented)

Courtesy CHEPSAA

KEYSTONE

Scope & nature (continued)

Specific services/disease programmes:

• Often a tracer for understanding systems issues e.g. maternal health services; the impact of district strengthening on child health outcomes

• May be researched because they have system wide effectse.g. antiretroviral therapy

• Must think BEYOND the programme/service!

Courtesy CHEPSAA

KEYSTONE

Programmatic and health systems perspectives on tuberculosis (TB) research

Systems goal Disease programme

perspective

Health systems

perspective

Thinking broad (beyond the

disease)

Izoniazid (INH) prophylaxis

for prevention

Secondary prevention for

TB and other common

diseases

Thinking cross-cutting

(underlying functions)

Implementing a TB patient

register

Improvement in information

systems

Thinking scale (e.g. facility

to district, province)

Strengthening facility

Directly Observed

Treatment, Short Course

(DOTS) support systems

Strengthening district

community-based services

Thinking comprehensive

delivery platforms

Running a TB service Building a primary health

care system that is

available, affordable and

acceptable/responsive

Thinking about systems not programmesCourtesy CHEPSAA

KEYSTONE

Threshold Concepts - 1

• The health system is knowable and changeable

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

• The health policy and systems researcher is also part of the health system – and their perspectives influence how issues and research is shaped, and how evidence is utilized

• Health systems are socially constructed; they exist within contexts and histories.

• Health systems are integrative by nature, and consist of complex inter-relationships; we all have a role in the system.

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

(Courtesy CHEPSAA)

KEYSTONE

Threshold Concepts - 2

• HPSR is multi-disciplinary, embracing and valuing science and practice perspectives, as well as different research perspectives

• The substantive relevance of a research study is informed by existing work in the field and in a specific setting, and it is critical to consider in identifying the research purpose and conducting ethical research

• The research purpose may be normative, exploratory, descriptive, explanatory or emancipatory, or some combination of these

• The HPS research question reflects the study’s research purpose and drives the selection of an appropriate research strategy/study design

• HPSR embraces both fixed and flexible research strategies/study designs (including quasi-experimental studies, cross-sectional structured surveys, case study work, mixed method studies, ethnography, cross-sectional qualitative studies, and different forms of longitudinal work)

• There is a flat hierarchy among research strategies within HPSR (no gold standard)• HPSR embraces both statistical and analytical generalizability

(Courtesy CHEPSAA)

KEYSTONE

Threshold skills/competencies for the HPS researcher

• Recognizing where the boundaries are (what is HPSR)

• Literature review (becoming familiar with the field)

• Framing various types of HPSR research questions

• Knowing what research strategy to use to answer different types of HPSR questions

• Recognizing the strengths and weaknesses of different research approaches and tools

• Critical analysis (knowing what is rigorous and relevant)

• Being familiar/comfortable with different perspectives

(Courtesy CHEPSAA)

KEYSTONE

“Horizontals”

“Horizontals” are topic areas of instruction on HPSR, including foundational concepts and common HPSR approaches

1. Foundations

• Health Systems & Health Policy Frameworks

• Social justice, Equity & Gender

• System complexity

• Health Policy & Systems Research (HPSR) Frameworks

• Knowledge translation

KEYSTONE

2. Approaches or Lenses

Different and complementary methodological approaches and lenses in health policy & systems research

• Economic Analysis

• Policy Analysis

• Realist Evaluation

• System Thinking

• Ethnography

• Implementation Research

• Participatory Action Research

KEYSTONE

“Verticals”

Cross-cutting components represent strands of engagement and activity that run through the course

• KEYSTONE Vertical

• Problem Vertical

• Reading Vertical

KEYSTONE

DAY Date 09.00-10.00 10.00-11.30 11.45-13.15 14.00-15.30 15.45-17.15

1 23 Feb Health Systems & Health Policy (HSHP)

Social justice, equity and gender (JEG)

Introduction,

icebreakerHSHP JEG

2 24 Feb Complexity, systems thinking (COM)

Health Policy & Systems Research

frameworks (RF)

Finalize researchable problem

Recap/quiz,

discussion of readings COM RF

3 25 Feb Economic analysis (ECO) Recap/quiz,

discussion of readingsECO

4 26 Feb Policy analysis (POL) Recap/quiz,

discussion of readingsPOL

5 27 Feb Realist evaluation (REAL)

Systems thinking (ST)Recap/quiz,

discussion of readingsREAL ST

28 Feb OFF DAY

6 1 Mar Ethnography (ETH) Recap/quiz,

discussion of readingsETH

7 2 Mar Implementation research (IMP)

Participatory action research (PAR)

Finalize research question & approach

Recap/quiz,

discussion of readingsIMP PAR

8 3 Mar Knowledge translation (KT)

Research plan writingRecap/quiz,

discussion of readingsKT Research plan workshop

9 4 Mar Private work on research plans

10 5 Mar Research plan presentations Presentations Conclusion

Open Access PolicyKEYSTONE commits itself to the principle of open access to knowledge. In keeping with this, we strongly support open access and use of materialsthat we created for the course. While some of the material is in fact original, we have drawn from the large body of knowledge already available underopen licenses that promote sharing and dissemination. In keeping with this spirit, we hereby provide all our materials (wherever they are already notcopyrighted elsewhere as indicated) under Creative Commons Attribution-NonCommercial 4.0 International License. To view a copy of this licensevisit http://creativecommons.org/licenses/by-nc/4.0/

This work is ‘Open Access,’ published under a creative commons license which means that you are free to copy, distribute, display, and use thematerials as long as you clearly attribute the work to the KEYSTONE course (suggested attribution: Copyright KEYSTONE Health Policy & SystemsResearch Initiative, Public Health Foundation of India and KEYSTONE Partners, 2015), that you do not use this work for any commercial gain in anyform and that you in no way alter, transform or build on the work outside of its use in normal academic scholarship without express permission ofthe author and the publisher of this volume. Furthermore, for any reuse or distribution, you must make clear to others the license terms of this work.

This means that you can:

read and store this document free of charge

distribute it for personal use free of charge

print sections of the work for personal use

read or use parts or whole of the work in a context where no financial transactions take place

gain financially from the work in anyway

sell the work or seek monies in relation to the distribution of the work

use the work in any commercial activity of any kind

distribute in or through a commercial body (with the exception of academic usage within educational institutions such as schools and universities

However, you cannot: