Recognizing research paradigms: Session summary

Recognizing research paradigms, methods and impact for people-centred health systems
Plenary session at the Third Global Symposium on Health Systems Research,
Cape Town, 2 October 2014

Let us not ‘harness’ people to the cart – let us enable them to drive it.
Dr René Loewenson, Zimbabwe

Whose knowledge counts?
How do we foreground practitioner experiences in the research process?
How can crowdsourcing bring ‘outsiders’ into the research team?
What new counting and accounting approaches are relevant to people-centred health systems?
What are we doing to nourish people’s role in offering existing and producing new knowledge?

To answer such questions, this session convened a range of research commissioner and user input on perspectives and traditions to strengthen people-centred health systems (P-CHS), and was chaired by Professor Barbara McPake (Director, Nossal Institute for Global Health, University of Melbourne, Australia). James Macinko, New York University Associate Professor of Public Health and Health Policy, listed contributions to quantitative research traditions and new approaches in the use of quantitative data to strengthen P-CHS. Among the lessons learned were how to quantify differences in healthcare costs and quality, understand the burden of disease, and estimate impacts in utilisation and efficiency of health services.

In terms of challenges, impact evaluation is hampered by the weak quality of many empirical analyses because the construction of a counterfactual is needed; this has led to a quest for experimental methods and exploitation of natural experiment techniques (uncontrolled observational studies). While randomised controlled trials (RCTs) do establish causality and solve statistical problems, they are limited in generalisability in that they relate what is found but not why – which may lead to poor or irrelevant policy choices and other unintended consequences such as stigmatisation of vulnerable groups and wasted resources.

Promising technologies for linked datasets and improved data architecture could facilitate bringing data use and interpretation into participatory fora and strengthening analytic capacity for health systems in complementary ways. More productive interaction with data producers and users at all levels would clarify the intent and purpose of the data. Using electronic medical records (EMR) for screening, triage, referral, tracking and sharing has significant potential for improving care at facility and household level. P-CHS can be advanced by integrating implementation science into impact evaluation with expansion into learning and empowerment; incorporating multiple types of evidence and methods; involving under-represented groups; facilitating feedback; forging multisectoral partnerships; conducting meta-analyses to identify grey literature; and running disease surveillance via mobile phones and social media.

Barriers to these efforts include fragmented and low-resourced health systems and a paucity of local health information, infrastructure and capacity. We need long-term district-based data banks, better learning tools and democratisation of data through links to education (specifically to increase numerical literacy), and viable global communities of practice. Dr René Loewenson – Director of the Training and Research Support Centre (TARSC) in Zimbabwe and Steering Committee Member of the Regional Network for Equity in Health in East and Southern Africa (EQUINET) – described how Participatory Action Research (PAR) centralises people within health systems by recognising their agency as co-determinants of health equity. This approach does not exclude other forms of research, but brings knowledge under the control of people so that they move from being objects of studies to being both subjects and active researchers who facilitate building theory from lived experience.

The PAR model collectively organises, validates, problematises and systematises this experience. This process evolves in spirals rather than as a singular event, and the method entails eliciting and accumulating both quantitative and qualitative evidence with diverse and adaptable tools (joint review of individual observations, e.g. picture codes, social mapping, collective questionnaires, seasonal calendars, narratives). The aim of inquiry is to explain, understand and transform reality by implementing, reflecting on and generating knowledge from action.

A pivotal aspect of PAR is that it recognises the power of community members to transform barriers – for individuals directly affected, institutions and social relations – and thus embeds local knowledge into sophisticated health plans, services and standards. It can raise new evidence, questions, thinking, practice, particularly on social determinants, risks, perceptions and potentials of and inequities in health systems. Holistic paradigms with multiple causes and outcomes are seen as relevant for real problems, and communication, mutual respect and trust are strengthened across health systems.

The challenges in this work include addressing research quality, such that it covers issues of reliability, confirmability, internal and external validity, dependability, credibility and transferability. Ethical issues require close management of power relations. PAR is not easy to fit to funding sources and ethical review frameworks. In order to secure space in recognised publications for P-CHS literature, more engagement with journals is needed towards adapting report-writing conventions, and alternative knowledge repository options should be sought.

Visual technologies and cell-phones offer new avenues for PAR application in the form of video and photo documentation, participatory GIS mapping, and social platforms for sharing information to support wider-scale collective validation and analysis. We need to nurture the role of knowledge production by those directly involved through policy dialogue, and enabling and sharing good practice via learning networks and publication.

Also taking part in the following panel discussion were Clara Mbwili-Muleya, District Medical Officer in Zambia’s Ministry of Health; Kumanan Rasanathan, UNICEF Senior Health Specialist; and Bruno Marchal, Assistant Professor in the Institute of Tropical Medicine, Belgium. See here for the discussion.

Page updated: 4 October 2014