Health Systems Research An Overview

Dr. Deoki Nandan

MD (SPM),F.I.S.C.D, F.I.A.P.S.M, F.I.P.H.A, M.N.A.M.S, F.A.M.S, F.N.A.R.C.H.I

Director National Institute of Health and Family Welfare, Ministry of Health, Munirka, New Delhi - 110067 Introduction Research in health 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 an 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 viz geographical, socio-economic, cultural, political, demographic, and 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. WHAT IS HEALTH SYSTEMS RESEARCH? HSR is ultimately concerned with improving the health of people and communities, by enhancing the efficiency and effectiveness of the health system as an integral part of the overall process of socio-economic development, with full involvement of all partners. 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 is the most effective strategy to reduce infant mortality? How to improve community involvement in implementation of health programmes Managers at district level may raise questions such as: Why is neonatal mortality in certain districts much higher than in other districts? Hospital Administrators may ask:

Why does a hospital report a high rate of complications during child birth? Village Health & Sanitation Committees (VHSC) may want to know:

How can we assist illiterate women so that they can effectively recognize the symptoms of pneumonia and go in time to the health centre with their children?

The major objective of HSR is to provide health managers and administrators at all levels, as well as community members, with the relevant information they need to make decisions on health-related problems they are facing. We must be aware that problems at one level of the health system are usually connected with problems or deficiencies at other levels. HSR should address problems from the differing perspectives 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. 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 multidisciplinary 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. Some essential guidelines for success include:

HSR should focus on priority problems in health care. It should be action-oriented and aimed at developing solutions. 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 socioeconomic development. The research should be participatory in nature, involving all parties concerned (from policymakers to community members) in all stages of the project. 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. 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. 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.

HSR can be done through both quantitative and qualitative approach. Most common approach is quantitative, but recently there has been a shift in focus to qualitative approach. Qualitative research focuses on communitys health-related behaviors, health-related perceptions, structure and processes of institutional functioning, interaction between different categories of personnel, interaction of care-providers with common man etc. Ethical issues are also important in qualitative research. Ethical issue addresses questions on:

How does the research represent the needs and views of the marginalized within the study group as against the dominant groups? How does the research represent the needs and views of lay people (which may include the communitys dominant view but not the minority view within the community) as against the technocratic view? How does the researcher mediate between the possible positive and negative consequences of the liberal technocratic perspective and of the study groups perspective?

NEED FOR CAPACITY BUILDING Rapid Appraisal of Health Interventions (RAHI) - A National Institute of Health and Family Welfare Initiative: Programme managers/service providers are invariably busy with conduct of activities. However they do acknowledge need for data supported inputs for improving programme performance, which will also foster culture of evidence-based decision-making. There is need to develop a critical mass of institutions to generate programme relevant information at local/regional level. By strengthening capacities of these institutions on rapid appraisal methodologies, not only the state programme managers will benefit in having a local research institution which can carry out rapid appraisals of important health interventions being carried out as per their needs on time to time basis, but also help to create a sustained training activity in these institutions for budding researcher who would like to pursue a career in public health. NIHFW, through its wide umbrella of Public Health Education and Research Consortium (PHERC)-Network and Partnership has initiated efforts to strengthen the capacities of PSM department of medical colleges and other training institutions on rapid appraisal of health interventions and through sharing of information. In this direction, UNFPA in collaboration with NIHFW has supported 24 health systems research projects in 6 poor performance states during phase I & II. The research questions for the projects were generated at the local level. The objective of this project was to accelerate programme implementation in identified states through organizing timely and appropriate research inputs for addressing priority implementation problems. During the 3rd phase of RAHI, the Institute has undertaken rapid appraisal of health interventions under NRHM through joint effort with PSM department of medical colleges and other training institutions in low performing states including Uttarakhand and J & K. Some other major initiatives in this direction taken by the authors/presenters have been:

A Community Based Maternal and Child Health Nutrition Project (MCHN project) Management context Qualitative Research in the status of Pulse Polio Immunization- Process Evaluation Programme Context. Qualitative & Quantitative in Injection Safety Practices: A Program to Improve Injection Practices in the Country - Policy Context.