1. Health System Research:
Designs and Methods
Tulsi Ram Bhandari
Ph D Scholar

2. Outlines of presentation
 Introduction
 Development
 Objective
 Areas
 Designs, methods & techniques
 Ethical issues
 Limitations
 Conflict of interest
 conclusion

3. What is research?
 Scientific and systematic search for
information on particular subject/issue.
 Embedded in epistemological position
and theoretical framework.
 Collects essential evidence with the
help of different research methods.

4. What is health system research?
 Part of research/health research,
 Results closely linked to health system,
 Initially, it was known as health service
research,

5. Development of HSR
In 1967, Division of Research in
Epidemiology and Communication
Science (RECS) was established for
research works, under WHO.
In 1972, RECS was restructured into
Division of Strengthening Health
Services (SHS) and Health Services
Research responsibilities were
transferred to Division of SHS.

6. Development cont…
In 1978, Global Advisory Committee on
Medical Research and Sub-committee
on Health Services Research were
formed-
to achieve “Health For All by the year
2000” and
Implement the “Primary Health Care”
approach successfully.

7.  In 1980, WHO recognized and
established Health System Research
with following mandates-
 Promotion, coordination and information
exchange in the practice of HSR,
 Strengthening of national capabilities for
HSR training and development
 Support to substantive research in priority
areas.
Development cont…

8.  In 2000, Health Policy and System Research was
launched to improve the performance of health
systems.
 First time in 2002, under the umbrella of Health
System Research there was initiated a new sub
area Public Health System Research by the
public health system research interest group
(PHSR-IG).
Development cont…

9. Health system ?
It is defined as-
“All the organizations, people
and actions whose primary
intent is to promote, restore or
maintain health.”
(WHO-2000)

10. Definition of HSR
 “the multidisciplinary field of scientific
investigation that studies how social factors,
financing systems, organizational structures
and processes, health technologies, and
personal behaviours affect access to health
care, the quality and cost of health care,
and ultimately our health and well-being. Its
research domains are individuals, families,
organizations, institutions, communities, and
populations.” 6

11. Concern of HSR
Prime concern of HSR is to provide
information for decision-making that
can improve the functioning of the
health system.

12. Concern Areas of HSR5
(2)
(4)
(1) (3)

13. Objective of HSR
…to provide health managers at all
levels, as well as community
members, with the relevant
information they need to make
decisions on health-related issues
and problems they are facing.

14. Importance of HSR
 It is needed to-
 Strengthen the health care.
 Work with real field problems
 Use variety of research disciplines
 Apply practical scientific knowledge for
improving health care and health status.

15. Steps/process of HSR
Define research
problem
Literature
review
Review concepts
& theories
Review previous
findings
Generate research
question/s (?)
Researchdesign
&executiveplan
Execute research
project
Analyze & interpret
results
Submit report
Disseminate
results
Seminar/
workshop
Publication

16. Research Design
It is considered as a "blueprint" for
research, dealing with at least four
problems:
which questions to study,
which data are relevant,
how to collect data, and
how to analyze and interpret the data.

17. Designs: HSR
Non-Intervention
studies
Intervention
studies
Exploratory
studies
Descriptive
studies
Comparative/
Analytical studies
Experimental
studies
Quasi-experimental
studies
Pre-post experimental
studies

18. Exploratory Studies
 It is a small-scale study of relatively
short duration, which is carried out
when little is known about a situation or
a problem.
 It may include description as well as
comparison.
 Approach the problem from different
angles at same time (Triangulation).
E.g. piloting studies, small scale
comparative studies

19. Descriptive studies
 It involves describing the characteristics
of a particular situation, event or case,
such as- physical, socio-economic and
cultural, behavioural, etc.
 It can be carried out on a small or larger
scale-
1. Small scale: case studies
2. Large scale: surveys/census
(Note: one time data collection)

20. Comparative or analytical
studies
 It attempts to establish causes or risk
factors for certain problems by comparing
two or more groups, some of which have
or develop the problem and some of which
have not.
 It can be carried out as follows-
1. Cross-sectional comparative studies
2. Case – control studies
3. Cohort studies

21. Cross-sectional comparative
studies
 It is a type of survey focus on describing
as well as comparing groups.
 Researchers wish to determine the role
of independent variable to dependent
variable.
(Note: relationship between variables)

22. Case – control studies
 Investigator compares one group
among whom the problem that he
wishes to investigate is present, and
another group called a control or
comparison group, where the problem is
absent, in order to find out what factors
have contributed to the problem.

23. Case-control design
Population
Cases
Controls
Risk factor
Present
Risk factor
absent
Comparison
Risk factor
Present
Risk factor
absent
PresentPast
(Retrospective study, looking backward)

24. Cohort studies
 In a study, a group of individuals that is
exposed to a risk factor (exposed group)
is compared to a group of individuals not
exposed to the risk factor (non-exposed
group).
 The researcher follows both groups over
time and compares the occurrence of the
problem.

25. Cohort studies design
Population
Exposed to
risk factors
Not exposed
to risk factors
Problem
Present
Problem not
present
Comparison
Problem
Present
Problem not
present
FuturePresent
(Prospective study, looking forward)

26. Experimental Studies
 In this study, individuals are randomly
allocated to at least two groups.
 One group is subject to an intervention,
or experiment, while the other group(s)
is not.
 The outcome of the intervention is
obtained by comparing the two groups.

27. Experimental studies Design
Population
Sampling
Sample
Randomization
Experimental group Control group
Data collection Data collection
Manipulation/intervention No manipulation/placebo
Data collection Data collection
Comparison

28. Quasi-experimental studies
 It is missing either randomisation or the use
of a separate control group.
 However, it always includes the manipulation/
intervention.
Study design
Control group before
Study group
Comparison
Control group after
Study group afterIntervention

29. Study group before
Comparison
Study group afterIntervention
Pretest-posttest experimental studies
 It is quite easy to set up because uses only
one group.
 The situation is analysed by comparing
before and after the intervention.
Study design

30. Design Vs Method
 Design ≠ method of data collection
 Design ≠ quantitative / qualitative
Design?
Systematic plan/procedure under which a study
is carried out.
Method ?
Systematic process of achieving certain ends
with accuracy and efficiency, in an ordered
sequence of fixed steps.

31. Methods in HSR
Methods Tools
Quantitative
Survey/ census: Structured Interview/
self administered questionnaire
Structured interview schedule/
questionnaire
Record review / Service statistics Checklist
Observation Checklist
System analysis/review Combined tools
Secondary data use/analysis Statistical software
Content analysis Combined tools
Meta-analysis, systematic review Statistical software
Social Network Analysis(SNA) Combined tools
Mapping(Process & Service) With GIS map/ sketch map

32. Methods in HSR cont…
Methods ToolsQualitative
Case studies
Guideline/structured
format/conceptual framework
Focus Group Discussion Guideline
In-depth Interview guideline
Participatory observation Checklist/daily diary
Cognitive mapping With GIS map/sketch map
Mixedmethods
(Triangulation)
E.g. FGD+ In-depth
interview+
structured interview
Guidelines + Interview schedule
Projective techniques
Combined with other methods
(FGD, questionnaire, interview)

33. Quantitative
 Explanation,
prediction
 Test theories
 Known variables
 Large sample
 Standardized
instruments
 Often deductive
Qualitative
 Explanation,
description
 Build theories
 Unknown variables
 Small sample
 Observations,
interviews
 Often inductive
Qualitative vs Quantitative
Methods

34. Relationship b/w Qualitative and
quantitative methods in Research
Qualitative
studies
Quantitative
studies
Themes
Understanding problems &
identifying associations with
and between contributing
factors
Operational definition
of variables
Measuring problems &
testing hypotheses about
contributing factors

35. Data Collection Techniques
 Using available information,
 Observing,
 Interviewing,
 Administering written questionnaire,
 Focus group discussion,
 Projective technique,
 Mapping scaling, and
 others

36. Using available information
 Routinely collected data,
 Secondary data: HMIS, NDHS, Census etc
 Unpublished record report,
 Publications
 Grey literature( rarely available published
documents),
 Newspapers,
 Case histories, etc

37. Observing
 Observation of human behaviours,
 Observation of objects
 Types of observation-
 Participatory vs non-participatory
 Open vs conceal
 Observation tool: checklist
 Structural
 Semi-structural

38. Interviewing
 High degree of flexibility: In-depth interview
 Semi-structural interview
 Low degree of flexibility: structural
interview
 Exit interview, supplementary interview, etc
 Interview tools
 Guideline
 Structured schedule

39. Administering
 Ways of administering-
 Sending by mail/email and receiving by
same ways,
 Hand-to-hand delivering and later
collection,
 Gathering respondent and requesting to
response and return immediately.

40. Projective technique (PT)
 Ask the participant to response the
hypothetical or incomplete question.
 E.g.
 Suppose your child suffered from ARI,
what would you do?
 If your wife was to propose that you use
condoms, you would ...
 PT can be combined with other
methods: FGD, questionnaire, interview
etc

41. Mapping and Scaling
 Mapping is a valuable technique for
visually displaying relationships and
resources.
 Process mapping
 Service mapping
 Scaling is a technique that allows
researchers through their respondents
to categorise certain Variables.

42. Systematic/extensive review
 Online available literature review
 Published documents review
 Grey literature review
 Unpublished document/desk review
 Review focused on analytical question,
etc

43. Case studies
 Examine to a great extent in order to
find out and correct possible errors.
 Common used case studies techniques
 Use systemic rapid assessment toolkit
 Use conceptual framework
 Use unstructured questionnaire
 Participatory observation, etc.

44. System Review
 systems review is a technique, used to elicit
the situation (Past and present) of an
organization.
 Common techniques of SR-
 Structural review
 Narrative analysis of selective documents
 Time and motion analysis
 Cost analysis
 Trend analysis
 Demand and supply analysis
 Gaps and surplus analysis
 Disease burden analysis
 Lot Quality Assurance Sampling(LQAS)

45. Program Evaluation
 Common techniques –
 Content analysis: textual analysis
 both qualitative and quantitative studies
 Analysis: objective, scopes, outputs/outcome
 Cost analysis
1. Cost-utility 2. Cost-benefit
3. Cost- effectiveness 4. Cost –minimization
 Budget analysis
 Sources of revenue
 Areas of expenditure

46. Program Evaluation cont…
 Financing analysis
 Government financing in health
 Corporate financing
 Private financing in health
 Per-capita health expenditure
 Catastrophic healthcare/expenditure
 Role of user fees, etc
Health expenditure= government financing +
private expenditure

47. Demand and supply analysis
Supply side intervention Demand side intervention
Institutional Innovation
Financial incentives
Skill development
Improved infrastructure
Providers
Health
Services
Consumers
/users
Empowerment
Awareness
…

48. Social Network Analysis (SNA)
 It is defined as a distinctive set of methods used
for mapping, measuring and analysing the social
relationships between people, groups and
organizations.
 It consists of 3 stages:
 describing the set of actors and members of
the network;
 characterizing the relationships between
actors; and
 analysing the structure of the systems and
generating information…

49. Meta-Analysis
 A systematic method of evaluating
statistical data based on results of
several independent studies of the
same problem.
 Produces a stronger conclusion than
can be provided by any individual study.
 Useful for quantitative as well as
qualitative studies

50. Ethical issues in HSR
 Ethical approval and informed consent,
 Respect of participants,
 Autonomy of individual participants,
 Benefits and risks,
 Dissemination and publication of results,
 Unique human nature and implementation
of protocol
 Conflict of interest, …

51. Limitations of HSR
 Difficult in randomization and equal
participation of subject,
 High turnover: retirement, transfer, change,
etc
 Difficult to match with relevance policy and
community’s expectation,
 Cost and benefits: control and distribution
 Implementation of results with scare
resources
 Donor interest and influence
 Access/permission , publication and
dissemination of results

52. Conflict of Interest in HSR
 Among research team/s and members.
 Financial issues and quality of research.
 Disseminating and publishing of the
results.
 Maintaining the distance and relationship
with participants.
 Conflict with government’s regulations,
policies, programs, interests…

53. Conclusion
 HSR is a new discipline of research/ health
research.
 Health services research, health policy and
system research and public health system
research are very close terms with health
system research.
 Health system research is being influenced
by global politics and investments rather
than its own philosophy.

54. At last…
 First Global Symposium on Health
Systems Research (HSR), Was
organized in Montreux, Switzerland, 16–
19 November 2010
 Second Global Symposium is going to
be organized from 31st Oct. to 3rd Nov.
2012, Beijing, People's Republic of
China.

55. Thank you!

56. Development of HSR
In 1967, Division of Research in
Epidemiology and Communication
Science (RECS) was established for
research works, under WHO.
In 1972, RECS was restructured into
Division of Strengthening Health
Services (SHS) and Health Services
Research responsibilities transferred to
SHS.

57. Development cont…
In 1978, Global Advisory Committee on
Medical Research and Sub-committee
on Health Services Research were
formed-
to achieve “Health for All by the year
2000” and
Implement the “Primary Health Care”
approach successfully.

58.  In 1980, as per the recommendation of
Health Services Research Sub-
committee, WHO had recognized
Health Service Research as a priority
area and established Health System
Research.
Development cont…

59.  In 1980, Health System Research was
considered as an organization with
following mandates-
 Promotion, coordination and information
exchange in the practice of HSR,
 Strengthening of national capabilities for HSR
training and development
 Support to substantive research in priority
areas.
Development cont…

60.  In 1990, Technical Discussions of Forty-
Third World Health Assembly finalized the
following four major themes/issues in
health research-
Health systems research,
Nutrition research,
Research capability strengthening, and
Science, research and health care.
Development cont…

61.  In 2000, Health Policy and Systems Research was
officially launched with the following objectives :
 Stimulate the generation and synthesis of
knowledge, encompassing evidence, tools and
methods
 Facilitate the development of capacity for the
generation, dissemination and use of knowledge
among researchers, policy makers and other
stakeholders
 Promote the dissemination and use of
knowledge to improve the performance of health
systems.
Development cont…

62.  First time in 2002, under the umbrella of
Health System Research there was
initiated a new sub area Public Health
System Research by the public health
system research interest group (PHSR-
IG).
Development cont…

63. Supply and demand barriers to
utilization of health care
...