August 2011, PLoS:
1) Framing the Questions: Sheikh et al: http://bit.ly/tHAepF
2) Social Science Matters: Gilson et al: http://bit.ly/uoaiHw
3) An Agenda for Action ; Bennett et al: http://bit.ly/ruW3Ed
Reviewed by Karen Pesse
This series of three articles on Health Policy and System research was commissioned by PLoS following the First Global Symposium on Health System Research held in Montreux one year ago. Although first author is different for each of them, they were actually written by a group of academics coming from high-, as well as middle- and low income countries; thus internal coherence is quite high. Although I personally agree with most what is stated by the authors it must be acknowledged that other, potentially divergent, viewpoints on these matters might have been left out by these articles.
This is especially important since, as recognized in the first article of the series – Framing the Questions by Sheikh et al -, the definition, scope of action and methodological approach of HPSR is still “under construction” and by no means a politically neutral activity. The authors show very neatly that problems affronted by this kind of research are interconnected and most of them have been predominantly addressed by ontological and epistemological paradigms that led to reductionist approaches. HPSR is defined by the scope of topics or research question it addresses, but they can be understood in quite divergent manners: the presentation of three models for conceptualizing health systems and their implications for HPSR is enlightening, and call upon researchers to take an explicit position towards these perspectives. This is also true for the level of analysis and research question defining a study; this aspects need to be carefully considered before attempting any research in this area. Although it could be criticized as too simplistic, I consider the elucidation of main differences between a normative/evaluative and an exploratory/explanatory intent and the table with examples of these very valuable in the article. Also the box discussing limitations of two currently very popular approaches to HPSR (implementation research and impact evaluation) is very much worth reading.
The second paper – Social Science Matters, by Gilson et al – presents a plea for the incorporation of social sciences, its knowledge paradigms, conceptualization and type of question posed to heath systems as well as methodological approaches into the field(s) of work of HPSR; thus addressing one of the challenges identified by the first article of this series; the “disciplinary capture” of this kind of research. It describes, in a very understandable manner, the differences between positivism and relativism (constructivism), and discusses the value of the latter one in terms of generalizing from rich contextual understanding; supporting policy learning; and approaches to ensure research rigor. But at the same time it mentions point of shared interest among both perspectives, recognizing that “bringing together research from different traditions generates broader and deeper understanding on issues to focus”. Examples included in the boxes and the table enlisting principles and examples on how to ensure research rigor are very helpful too.
The last article of the series – An Agenda for Action, by Bennett et al – briefly describes the problems currently faced by HPSR; and proposes and discusses strategies for capacity building in this field of research. Strategies are explained following a “hierarchical model”, starting from systems and environments to make them more supportive for HPSR; passing to organizational capacity building referred mainly to structures and functions of academic institutions; and finalizing with the development of individual competences, with special emphasis on the ability of crossing the boundary of pre-established disciplinary fields. All proposed actions seem very import and with great potential for enhancing HPSR development, but clues on how and when (in what sequence) to implement them are missing.
In summary: a very interesting series for all involved in the implementation of HPSR, and a must for academics engaged in its development as a specific field of research.