Thursday, 31 May 2012

KNOTS blogger

KNOTS blogger


Posted: 31 May 2012 08:00 AM PDT

Participants in the recent STEPS Summer School came to Brighton from all around the world, bringing diverse life experiences and disciplinary perspectives together to learn about, discuss and debate new approaches to research for sustainability.

Much of our discussion focused on the importance of encompassing plurality and diversity in both research and policy processes, and being alert to different framings of any given issue, particularly more marginalised ones.  This got me thinking that it would be interesting to apply these ideas to ourselves (the group of participants at the summer school), and explore the range of perspectives within our group about the activity we are all involved in, namely: carrying out research for sustainability.

At the same time it seemed like a good opportunity to illustrate one of the methods that had been highlighted earlier in the week as a potentially useful tool for 'opening up' policy to a more diverse range of concerns and discourses, 'Q method'.

So, on something of a whim, I volunteered to carry out a Q study with the group and present the results back at the end of the week in a mini-conference organised by the participants. Carrying out a Q study in 3 days was a little experimental for me, and I wasn't even sure it would work: would our views be different enough to reveal anything interesting? Or would the fact we'd all just participated in the same two weeks of talks mean that we'd all just 'regurgitate' perhaps unconsciously what we had been hearing over the summer school?! In the end, thanks to everyone's enthusiastic participation and critical engagement with the exercise, it was a lot of fun, and revealed some interesting things about the diversity within our group despite the fact that we are all ostensibly involved in a similar endeavour.

I'll give a brief background to the method before I describe the results. Q has a long history (it was developed by the psychologist William Stevenson in the 1930's), and in recent years has found favour with a wide variety of researchers from different disciplines (from geography and political ecology to psychology and nursing) who share an interest in exploring different perspectives or framings, or in eliciting minority or marginalised discourses.

In short, the method involves a researcher collecting a number of opinion statements about a given topic and asking a group of participants to sort them onto a scale (e.g. -4 to +4) according to how much or how little they are like their opinions. The resulting sort patterns are then statistically analysed to see whether particular groups of people sort the statements in similar ways.  Resulting clusters of sort patterns (or 'factors') represent more or less shared points of view within the participant group and can be interpreted (usually with the aid of additional comments from participants) and written up as narratives. It's a 'small n' method (generally carried out with a purposive sample of between 20 – 40 participants), so despite its statistical underpinnings, it is also highly interpretative, and lends itself to combination with a variety of other methods both quantitative and qualitative.

The first step in any Q study is defining the area you are interested in exploring. In this case the topic of interest was the diversity of answers to the question: 'what is research for sustainability?' The summer school attendees were all asked to contribute one statement about research for sustainability with which they agreed, and one with which they disagreed.

This generated around 70 statements (to which I added a few more into the mix, based on notes I had scribbled down during sessions with different speakers throughout the week, or questions or comments made by different participants).These statements were then narrowed down to a manageable number, the 'Q sample' (in this case 34 statements) which members of the group were asked to sort onto a 'quasi-normal' distribution shape from -4 to +4 according to how much or how little they were like their opinion. 26 people (including myself) carried out Q sorts, and the results were then statistically analysed for patterns using the free software, PQMethod. Deciding on the number of factors (or perspectives) to extract is a matter of judgement as much as mathematics, and depends to a large extent what you are interested in finding out from your data.  In this case since I was interested in shared perspectives, I decided that only those factors with which at least two individuals were associated would be extracted and considered. Using this criterion, 4 distinct factors emerged from the sorting patterns, with one further factor that was 'bi-polar' i.e. two people who sorted the statements in almost opposite ways.

So what came out, and what could it tell us about the diverse group of participants at the summer school?

With more time to analyse the results one could try to draft short narrative descriptions of the different perspectives, but in this case I'll simply point to some of the areas of similarity and difference revealed by the study, and flag up some questions about particular statements that might serve as useful starting points if one were to interrogate the data further. The original statements that participants were asked to sort are listed in the table below.

In the table above, the statements at the top are the ones where there is a high degree of consensus between the viewpoints (i.e. the statements that were sorted in more similar ways by the group); those at the bottom are those with which there was greater levels of disagreement. 

Below are my thoughts on the answers to some key questions asked. The numbers in brackets are the hypothetical score that each of the idealised perspectives or 'factors' would have awarded this statement in terms of the original distribution -4 to +4). 19 out of the 26 participants loaded on just one factor, while seven people's views were either split between two or more factors, or didn't load on any.  Factor 1 was dominant, with eight people sharing this point of view to a greater or lesser extent, while four people loaded on factor 2, three people loaded on factor 3, two on factor 4 (and one positively and one negatively on factor 5).

At the top of the table, one of the statements which received a unanimously ambivalent zero, or negative 1 score from all of the factors, concerned the issue of impact:

24. Sustainability research needs to be used: ultimately the most important thing is impact (0,0,-1,0,0)

What might this ambivalence stem from?  Is this perhaps an allusion to tensions between calls for all research to make itself above all 'policy relevant', and the need for more critical perspectives?  Or perhaps our group felt that 'impact' was too broad and vague a term?

Our group also appear to share disagreement with statement 13:

13. Sustainability research should prioritise the environment: in the end the planet is everyone's life support system and it has limits. (-1,-1,-2,-1,-2)

This shared disagreement seems to echo debates that occurred earlier on in the summer school about the political implications of a global framing of the environment as a 'life support', and questions raised by various group members about whose views and needs might be disregarded under this framing of the problem.

Given the emphasis of the STEPS centre on 'pathways' to sustainability(sustainabilities?) is it perhaps unsurprising that our group largely agreed with statement 26:

26. It's about throwing light on different possible 'pathways' of development, and not stopping at appreciating them but elaborating their merits and demerits (2,1,3,2,3)

But this statement also engages with the idea that it is possible to judge different pathways ('elaborate their merits…'), pointing to the shared perception in the group of the existence of a normative framework for doing so that exists beyond the framings of the research subjects, and acts to prevent the prevent the researcher becoming paralysed by relativistic tendencies. Exactly what this normative framework might look like might be the subject of another Q study!

Related to this issue, the largely negative response awarded to statement 11, further highlights a shared unease with a wholly relativist worldview in which the only 'good' is advocating on behalf of marginalised groups whatever their particular stance or values:

11. Research for sustainability should work to advocate for all marginal groups even if their values don't fit in neatly with those of the researcher or the broad sustainability agenda. (-1,-3,-1,-2,0)

The question then becomes – how does a researcher make the call to advocate or not on behalf of those they are studying?

Despite the ambivalence around the idea of 'impact', perhaps somewhat paradoxically the broadly positive results awarded to statements 14 and 25 suggest that contributing to 'social change' and encouraging 'mobilisation' are important dimensions or outcomes of research for sustainability:

14. It's about engaging, reflecting and questioning with the overall aim of contributing to social change that respects the environment. (3,4,1,3,4)

25. Sustainability research needs to provide new storylines to encourage mobilisation around more socially and environmentally sustainable goals. (3,3,0,2,3)

Moving further down the table towards areas of disagreement, the issue of values and normativity in science emerges in statement 5, and generates some different responses between the factors:

5. Removing norms and values from science may not ever be fully possible, but doing good science for sustainability is about minimising the personal biases and norms of the researcher. (-3,-3,-3,0,-1)

Does the disagreement expressed by factors 1, 2, 3 and 5 with this statement suggest a view of scienc e in which norms and biases are inevitable? Or is what is emerging here about differing understandings about the normativity inherent in the idea of sustainability? Would this statement have been sorted differently had it just been about 'doing good science' rather than 'good science for sustainability'?

Returning once again to the sticky issue of ethical relativism, some disagreement started to emerge around statement 12:

12. One person's environmental degradation is another person's improved livelihood or decreased disease risk: degradation is a relative concept and when doing research for sustainability, researchers should not impose their own external framing of the environment, however important they feel it to be. (-1,-2,1,-1,1)

Factor 3 and 5 in particular appear to express greater agreement than the others with this statement, while factor 2 appears most negative about this issue. When read alongside the negative scores awarded to statement 13 (that the environment should be prioritised as it is everyone's life support), the difficulty with either absolute position becomes clear, and as a group we appear uncomfortable and divided about the radically relativist position implied by statement 12, and yet largely against a purely absolutist global framing such as apparent in statement 13.

The geographical focus of research was the subject of statement 8:

8. Research for sustainability should focus primarily on the developing world. (-4,-4,-4,-3, 0)

This was disagreed with strongly by all but one factor.  If interrogating the data further, it might be interesting to ask whose views were represented by this factor, and why this might be.

One of the statements that generated a greater amount of disagreement concerned the issue of ethics:

4. Research for sustainability is about bringing ethics to a global system dominated by capital. (2,-2,-2,1,-3)
Does disagreement about this statement imply a difference of opinion about the extent to which research for sustainability is about ethics per se?  Factor 2 and factor 5 in particular disagree with this statement. We might compare this to the sorting pattern for other questions to try and understand why this is. For example, factor 5 responded positively to statement 28 and negatively to statement 19 – does this suggest that this view is uncomfortable with seeing research for sustainability in terms of ethics, and challenging power, preferring to focus on the role of the researcher as building up knowledge about the world?

Again, a high level of disagreement emerged around statement 6 regarding 'win-win' solutions:

6. It's about finding win-win (socially just and environmentally sustainable) solutions to difficult problems. (-1,4,0,-2,-1)
Factor 2 in particular prioritised this statement above all others while factors 4 and 5 were much more ambivalent about it. Why? This difference appears to go to the heart of a debate which recurred at various moments over the course of the summer school: whether talk of 'win-win' solutions might act to gloss over the existence, in some cases, of real conflicts between more socially-just and environmentally sustainable outcomes, and allow the researcher to conceal with a layer of 'discursive blur' where his or her normative commitments really lay…

Just how 'radical'we as researchers need to be, or what we should aspire to do with our research, also divided the group:

29. Research for sustainability is about enabling the radical transformations required by sustainability agendas. (2,-1,0,-3,4)

And disagreement about exactly what 'radical transformations' might involve could also be inferred from the disagreement around statement 31 which suggests that reducing the ecological footprint by all possible means should be the goal of research for sustainability:

31. Research for sustainability is about reducing the ecological footprint of humanity by all means necessary. (-2,-2,-4,-4,3)

 So there it is. Even among a group of researchers with many shared ideals and commitments to the idea of carrying out 'research for sustainability', a group who had spent two weeks listening to the same talks and taking part in the same debates, there was a diversity of perspectives.  Different views about the ethical and political dimensions of the idea of sustainability, different emphases on the purposes or ideal outcomes of research, different ways in which people negotiate the difficult terrain between commitment to a personal set of ideals and normative values, and an appreciation of the need for research to reveal diversity, and sometimes conflicting voices.

Whatever else we might learn from exploring the particular differences between members of our group in this way, hopefully the exercise served to remind us all that there is no single unassailably 'right' perspective about research for sustainability. We all have to situate ourselves in this critical and contested field through ongoing processes of engagement with difficult debates, trying as best we can to avoid being too contradictory in our positions, and keeping at the forefront of our minds the importance of reflexivity. Thanks a lot to everyone who took part!

Wednesday, 30 May 2012

KNOTS blogger

KNOTS blogger

Blog roundup from iHEA 2011

Posted: 13 Jul 2011 06:16 AM PDT

In addition to Future Health Systems, several other large-scale projects have been sharing their thoughts and reactions to the 8th World Congress on Health Economics (iHEA 2011).

The Center for Health Market Innovations (CHMI) has recently posted two interesting blogs from the event. The first blog provides an overview of some interesting sessions and presentations. They highlight two from FHS:

The second blog is a guest post by Birger Forsberg on a special issue of Health Policy and Planning that looks at the role of the private sector in health. FHS also contributed to this special issue, with an article entitled 'Making health markets work better for poor people: the case of informal providers'.

The SHOPS project posted about their participation in the pre-congress session on Private Sector in Health.

Karen Grepin (NYU) has also been actively sharing her reactions to various iHEA sessions, both on Twitter and on her blog. She too highlights the pre-session symposium on the private sector in health and reviews the special issue of Health Policy and Planning. She notes that all presentations from the symposium are available at Dominic Montagu's (UCSF) website, 'Private Healthcare in Developing Countries'.

Jed Friedman of the World Bank focuses more on pay-for-performance innovations in health systems, citing presentations from Rwanda and the Philippines.

From private sector to health markets

Posted: 10 Jul 2011 08:45 AM PDT


At a plenary discussion during the iHEA pre-congress session on 'the Private Sector in Health', Gerry suggests an important reframing of the terms of engagement. No longer are we talking about working with the private sector, but rather we are now 'engaging with health markets'. In the video below he looks to the future and suggests that we must focus on regulatory frameworks and the shift in the locus of innovation, especially to rapidly growing middle-income countries.

Going to Extremes

Posted: 09 Jul 2011 10:20 AM PDT

BY DR. DAVID BISHAI, Johns Hopkins Bloomberg School of Public Health

In his plenary speech on July 9, 2011 to the iHEA pre-session on Private Sector in Health in Toronto, Tim Evans, Dean of BRAC University of the Health Sciences, laid out the poles of the debate on universal access to health care.

At one extreme there would be model of all medical care financed and delivered by the state. At the other extreme there would be no state intervention in private markets for health insurance and medical care.  What is supposed to happen next, according to the standard script of the dialectic, is a triumphal arrival at the golden middle.

However, something has derailed our arrival there.

Neither pole is especially attractive or realistic.  The discussion should have moved on by now. Why does this unnecessary “either-or” debate go on and on?  In my opinion the explanation lies in the advantages of being provocative.

Passion and enthusiasm are critical parts of the communication of ideas: The heat generated by an  idea is inverse to its distance from the middle.

By “heat”, I mean the ability of an idea to generate the excitement of journal editors, conference organizers, and bloggers.  With heat comes a desire by those in agreement to start movements and finance studies. With heat also come movements and finance by those opposed. In the past the mutual desire for truth would have moved the poles closer together. When provocation doesn’t matter, successive thinkers looking for truth would be disinclined to stray further and further from the mass of thought. These days, straining the pole even further away from the middle can be a winning strategy in the struggle to get attention and support.

The irony is that most people who think about health reform benefit more from discourse on non-polarizing options. Textbook economics treatments of the problems of health care do not support either pole. The welfare theorems suggest that unregulated health care markets will fail to provide adequate quality and will fail to protect the poor. Economists’ professional attraction to market solutions is based on shared recognition that they are seldom trouble-free. The public goods problems in health care (and other sectors) warrant collective action of some sort, but do not automatically support a solution based on 100% collective finance and provision.

This week at the International Health Economics Association, professional economists from around the world will gather to discuss and hone their craft. They mostly realize that health reform will have to be based on solving public goods problems. The toolkit for these solutions will need to include the best features of markets and the best features of enlightened collective action. The best solutions will not be the hottest—they will be squarely in the middle.  Let’s hope the light that shines from them makes up for their lack of heat.

* Editor's note: FHS will be participating in a wide variety of activities at this year's iHEA congress. See a list of activities, and stay tuned for future blogs and updates live from the event.

The scale and scope of private contributions to health systems

Posted: 07 Dec 2010 08:02 AM PST


The private sector provides more than half of the health services in Africa and Asia, measured both by source of financing for health services, and place of health service delivery.  While new data and better mapping of providers are improving the understanding of the scale of private healthcare services in low- and middle-income countries (LMICs), issues of dual public-private employment, undercounting of unregistered practitioners, and public sector distrust remain barriers to a full accounting of the size or the activities of the sector. To encourage filling this knowledge gap, in May 2010, the 63rd World Health Assembly passed a resolution called, “Strengthening the capacity of governments to constructively engage the private sector in providing essential health-care services,” which acknowledged that private providers are a major source of care in most countries, that private provision of services can lead to innovation as well as great challenges,  and that governments in LMICs can more effectively engage with and regulate private providers.

On November 17, 2010 researchers held a session entitled “The scale and scope of private contributions to health systems” as part of the First Global Symposium on Health Systems Research (HSR) - Science to Accelerate Universal Health Coverage hosted by the World Health Organization (WHO) and partners in Montreux, Switzerland to provide updates of current research on the private sector, highlight innovative financing mechanisms, and address future topics for research. The session was conducted as a “fishbowl conversation” to encourage audience participation; the design includes speaker chairs arranged in an inner circle that represents the fishbowl with one chair left empty for any member of the audience to occupy, at any time, at which point an existing member of the fishbowl must voluntarily leave to free a chair.  Speakers represented a growing group of researchers that have met regularly for the last five years to share findings and advances in research methods for studying the private sector from the perspective of public health, epidemiology, health economics, public policy, and management.  They included:

  • Sara Bennett,  Johns Hopkins Bloomberg School of Public Health (chair)
  • Ruth Berg, Abt Associates
  • Gerry Bloom, Institute of Development Studies
  • Tania Boler, Marie Stopes International
  • Kara Hanson, London School of Tropical Medicine and Hygiene
  • Birger Forsberg, Karolinska Instituet
  • Gina Lagomarsino, Results for Development Institute
  • Dominic Montagu, Global Health Group, University of California, San Francisco
  • Stefan Nachuk, Rockefeller Foundation
  • Gustavo Humberto Nigenda Lopez, National Institute of Public Health, Mexico

Speakers were asked to share their individual and institutional experience on innovative financing mechanisms which included: the Affordable Medicines Facility – malaria (AMFm), several national health insurance experiences, and public-private partnerships for regulation and otherwise.  Speakers also addressed communities of practice and other tool-sharing platforms that aim to make advances towards adoption of standardized methods for assessing private practitioners, their patients, and private funding flows using both secondary data sources and primary data collection, including: Social Franchising 4 Health (, the Center for Health Market Innovation (, Strengthening Health Outcomes through the Private Sector (, The Alliance for Health Policy and Systems Research, Future Health Systems, Eldis on health systems, id21, and more by the World Bank and others.

Speakers and audience members suggested the following areas for future research: more anthropological studies around private provider behavior, motivations, and incentives; regulating counterfeit drugs within the private sector; consideration of the human resource aspects of the private sector, including recruitment and training, in their work; payment mechanisms and incentiving patients as well as providers; the increase of “payer” attention to the private sector, including governments; the role of purchasing (financial accounting, standards, etc.); the efficacy of various regulatory partnerships; quality of clinical service delivery; quality of chemical sellers (given that one longitudinal study by KEMRI found no significant difference between quality of chemical shops routinely inspected and those not).

Speakers reported on several upcoming literature reviews underway around the private sector: the Global Health Group at UCSF is conducting a Cochrane Review on health outcomes in publicly-vs-privately provided settings in LMICs and a review with Results for Development and the CHMI on informal providers.  At least one systematic review on voucher programs and health is also in progress.

Throughout the session, speakers also emphasized the economic booms occurring in Asia, and the private health sector growth that has quickly followed and stressed that in many significant amounts of delivery and care are happening outside of the regulatory system, including a prominent informal sector in many countries.  Finally, speakers called for greater transparency around public-private partnerships to ensure efficacy and lesson sharing.

Funding from the Alliance for Health Policy and Systems Research awarded to the Uganda team

Posted: 06 Dec 2010 06:59 AM PST

We are delighted to announce that our Uganda Team has received a grant from The Alliance for Health Policy and Systems Research from their new Implementation Research Platform.

The Platform has been set up to identify common implementation problems, develop and test practical solutions to these problems and determine the best way of introducing these solutions into the health system and implement at scale.

The study will build on Future Health System's research into the use of motor bike transport to improve the uptake of maternal health care. It will look at how two types of interventions, one aimed at increasing access to institutional deliveries and care for complications through vouchers, and the other aimed at improving newborn care and uptake of PMTCT through home visits by community health workers, can be integrated and scaled-up within the existing health system in Uganda. It will also explore the effect of implementing the integrated intervention on the proportion of deliveries that occurs in health facilities, and on neonatal mortality.

You can read more about the work in Uganda on our website.

Blog round up

Posted: 26 Nov 2010 04:36 AM PST


We have all arrived home from the Global Symposium and I've had a little bit of time to browse web coverage to see what news and views filtered out from Montreux into the public realm. Given the conference organisers' desire to archive learning from the meeting and reach out to a wide audience to prompt interest in this area of research it's useful to see what areas captured people's imagination.

Scidevnet have covered the symposium with regular updates from T V Padma their South Asia Regional Coordinator. Issues covered included:

  • The need to increase research capacity in developing countries and encourage collaborative learning and research into policy

  • Researching complex systems

  • Tackling TB and HIV in Ukraine and Russia through a system wide approach

  • The challenge of tackling health financing

  • Gaps in universal health coverage in Sub-Saharan Africa

Meanwhile in their news section Aisling Irwin covers the announcement made in the closing session of the creation of a new international entity under their headline, "Ailing Global Forum for Health Research joins COHRED."

We are big fans of the BMJ and were happy to see our friend and colleague Tracey Koehlmoos of ICDDR,B was providing them with updates. She commented,
"In addition to the plethora of great plenary speakers and interesting sessions, is the real benefit of coming together with so many of my global colleagues. For many of us, we fight the war on poverty and disease from the frontlines in developing countries. Some groups work in relative isolation or grouped on the occasional multi-country study. We often only hear of one another or read one another's research findings through publications.   After exercising early, I sat alone at breakfast the other morning, and within twenty minutes I was surrounded by a large group of South Asian colleagues most of whom had not met previously but we had all heard of one another and some of us had corresponded with one another via e-mail.  It was transformational to sit face to face and talk about our common challenges in the region.  I left the table feeling empowered —and pretty sure that we will figure out a way to work together in near future."

If you see any other good news reporting on the symposium please do let us know…

See Sara on film talking in the plenary at the Global Symposium

Posted: 25 Nov 2010 08:22 AM PST

Exploring the spread and scale up of health interventions and service coverage

Posted: 24 Nov 2010 07:14 AM PST


The Future Health Systems Consortium has invested in a stream of work called, "Beyond Scaling Up: Pathways to universal access." This research has looked at some of the challenges involved in rapid scale up and what can be learnt from successes in this area. Drawing on a background paper, co-authored with Peroline Ainsworth, Gerry Bloom opened a parallel session at the Global Symposium with an overview of learning in this area.

Gerry argued that there are many challenges that might impact upon the scaling up process. Recent years have seen many political commitments to increase access and an improved financing environment for health systems strengthening underpinned by new global organisations. There is a recognition that scaling up means managing change in a dynamic and complex context (where there has been a shift from absolute scarcity to problems with safety, quality and cost with changing patterns of inequality, the introduction of new technologies and institutional arrangements, the rise of patient and citizen movements and mixed systems). Unexpected outcomes and unintended consequences caused by the scaling up process point to the need for systematic knowledge and shared understandings amongst a range of actors.

Ligia PainaLigia Paina and David Peters, Johns Hopkins School of Public Health, suggested that we might be using the wrong models for scaling up – that blue print, linear, one size fits all models are misaligned with the reality of health systems in practice. She explained how health systems are characterised by dynamic change which is rooted in local context. Complex adaptive systems thinking might help us to better understand a failure to scale up. It may explain why we cannot control the behaviour of communities and providers.

Emmanuel SokpoEmmanuel Sokpo and Jeff Mecaskey presented on the experiences of the Partnership for Reviving Routine Immunization in Northern Nigeria (PRRINN) project in northern Nigeria. Their work was rooted in an understanding of the social, political and economic history and context and included a political economy assessment. This assessment:

  • Deepened understanding of the positions of major stakeholders in the state with respect to the socio-political, institutional, structural and historical context as they pertain to the health sector

  • Identified issues which, in a general sense, appear to provide good opportunities for creating 'coalitions of interest' and for levering desired institutional changes

  • Provided input into the prioritisation of key interest groups and/or organisations that can be developed as a 'coalition of interests' to drive change

They found that political competition was largely occurring within the elite and was structured around the power struggles of individuals, and inter-familial tensions played out within the camps of political parties. There are few alternative centres of power and little check on executive power overall, making the programme highly reliant on key individuals. State power and resource control is in the hands of the state government, while those who still retain some influence over ideology are also under the financial influence of the government. In their opinion the link between policy, strategy , planning and implementation of health interventions was broken with more focus on capital inputs than on health outcomes. Finally they discovered that a fragmented primary health care system is convenient arrangement for States and LGAs to share health resources without accountability. This knowledge was invaluable to the successful scale up of their programme.

Wang YunPingZhenzhong Zhang and Wang YunPing, of the China Health Development Research Centre, a government think tank, provided an assessment of the rapid scale up of health insurance in China. She concluded that the success of the schemes rested on:

  • Political commitment and a change in values toward social and economic development. Health used to be a means to economic growth now it is one of the goals.

  • Learning by doing. The schemes were launched incrementally in a gradual move toward reaching the whole population. Work within the Health 8 and other health sector programmes provided a solid foundation of research which helped the Chinese Government move forward. They experimented with pilots which then spread and bridged the gap between research and policy.

  • The scheme was centralised and relatively decentralised. Central Government provided general principles but left space for local policy makers to think about the detail. They employed cross-ministry cooperation.

  • Changing role of communities. Rural residents are no longer passive recipients. Their needs and interests are the concern of the local officers. The government promoted the schemes with positive incentives and information about how they may benefit.

Vera at the SymposiumVera Schattan Coelho, Brazilian Centre for Anaysis and Planning,  reflected on the success of the SUS in Brazil. She explained how it reflected the aspirations of a movement that believed in health for all and was a process where local, federal and national levels worked together for change with the Support of social movements, public health practitioners and left wing parties. Vera explained that when the SUS began the institutions that we needed were not there. At the end of the 1970s the old system really wasn't working and so state innovations started to take place, for example, the Family Health Programme. There was a complete change in the relation between the national and the municipal level and clear contracts were established where the federal state was responsible for the policy but transferred the money to the municipalities and they were responsible for implementing. This happened by degrees not all at once so there was a gradual building of institutional capacity. The social movement, "the health movement", was involved in policy decision making through Councils that included civil society, health providers and Government. When it was discovered that health indicators for indigenous people were much poorer than for the general population minority groups pushed for new programmes targeted at. The indigenous health system was established in 1999. You can read more about this in our briefing. The lesson from this is that within scaling up processes there is a need to balance universalism and also the need for tailored services for some.


Learning by doing and applying our learning: What are the strategies and institutional options?

Posted: 23 Nov 2010 06:39 AM PST


Learning by doing sounds a nebulous concept but actually it is crucial in health systems development. If we can't understand the process of intervening in the system and the positive and negative outcomes of our actions how can we improve the work that we are doing? The last decade has seen a rapid increase in the number of institutions such as learning platforms, health observatories, and think tanks. But at the same time, there is a lack of clarity in the difference between them, as well as their pros and cons.

This Future Health Systems Consortium session at the Global Symposium included presentations from the Asian Observatory on Health Systems, The Zambian Forum for Health Research, Health Intervention and Technical Assessment Program (HITAP) Thailand and The China National Health Development Research Center. It tried to better understand the work that they are doing as well as the challenges that they face.

Blogs we like: The Center for Health Market Innovations

Posted: 23 Nov 2010 12:12 AM PST


Sitting in the Global Symposium marketplace is a good way of finding more about other projects and the people that make them tick. We were lucky to have the Center for Health Market Innovations as our neighbour. Rose, their Program Officer, has been kind enough to link to our blog. You should check them out, this is what they say about their blog:

The Center for Health Market Innovations (CHMI) blog features news about promising new programs, innovative collaborations, relevant resource articles, and editorial pieces authored by members of the CHMI community. These editorial pieces are intended to further conversations about health market trends, national health policies, and improving health care for the poor. We encourage you to participate in this dialogue in the comments section or suggesting a post to rreis at

New Consortium launched at the Symposium: REBUILD

Posted: 22 Nov 2010 08:24 AM PST


Tim explaining the soft launchIn countries affected by political and social conflict, health systems often break down and emergency assistance provided by humanitarian organisations often constitutes the main source of care. As recovery begins, so should the process of rebuilding health systems but little is known about how effective different approaches are in practice. Health systems research has tended to neglect these contexts, because it may be more difficult to carry out studies in unstable environments and relevant capacity is often weak.

New Directions in Health-Environment Research: Implications for Health Systems

Posted: 22 Nov 2010 06:27 AM PST


Michael chairing the sessionI chair a session on New Directions in Health-Environment Research: Implications for Health Systems. A bit off the beam of the Global Symposium's thrust: one of 13 concurrent sessions, perhaps 20 people attend.

Setting the stage, I describe the methodological challenges researchers are tackling to uncover how environmental change, of different kinds, is creating health risks; in identifying developmental processes that are loosening structures of risk and in clarifying how health and other sectors can collaborate to realize these opportunities.    

The first case describes an "unnatural experiment", the 2001-03 famine and its impact on the evolution of HIV in Malawi. Using existing data, I show how hunger profoundly affected the distribution of HIV and of people by pushing people into survival sex and distress migration. The data also show that hunger was less severe, maize price less volatile and migration and change in HIV prevalence less marked where people had access to robust crops like cassava, alongside the maize staple. Cassava appears to be providing a "prevention dividend".

Networking at the Global Symposium

Posted: 21 Nov 2010 07:55 AM PST

Whilst we were very busy at the conference the Future Health Systems Consortium also found some time to catch up with old friends and to meet new ones.


[gallery orderby="rand"]

From Montreux – the First Global Symposium on Health Systems Research

Posted: 21 Nov 2010 06:21 AM PST


You know you're a discipline or a significant sub-discipline when you can organize and find funding for a global symposium. Twelve hundred participants from umpteen countries also testify to the self-awareness that marks a field. And the Symposium's theme is fittingly ambitious: Science to Accelerate Universal Health Coverage.

Charlie Chaplin is in town but can't make it to the Symposium. He's buried just down the road. But I wonder what his Little Tramp, bowler-hatted and down-at-heels, would make of it. Would he be considered part of the System? Am I? My interest is in the determinants of disease in the turbulent social, economic and natural environment and what that understanding can contribute especially to prevention.

Applause for the rapporteurs

Posted: 19 Nov 2010 05:15 AM PST

There are many individuals that help to make a conference of the size and complexity of the Global Symposium run smoothly. The Future Health Systems Consortium is lucky to have a smart and dedicated group of note takers who are pushing out summaries from our sessions in between delivering papers and networking.

In particular many thanks to Adrijana Corluka for helping us out with the session on Improving Health Service Delivery and Ligia Paina for the Learning by Doing write up.

More on this later…

Catalysing political will to build health systems research capacity

Posted: 19 Nov 2010 02:55 AM PST


Sara in plenarySara Bennett, from Johns Hopkins School of Public Health, gave a rousing plenary speech on the final day of the Global Symposium. She argued that all stakeholders – policy makers, service providers, the leaders of research organisations, funders and health development partners - need to come together to support capacity development for health systems research. Health systems research capacity development can be seen as worthy but dull and it may not be compelling to donors. Yet there are a lot of exciting innovations in research capacity development occurring in low and middle income countries.

Sexy, maybe. Fun, definitely!

Posted: 18 Nov 2010 12:49 AM PST


In response to Nandini's question can research make health systems sexier?  I guess it can it all depends on the researchers line of thought. I have been part of the Future Health Systems Consortium for five years and believe me I have realised that health systems research can be lots of fun! You must be wondering why. This particular consortium allows you to be creative and innovative. Nobody tells you what to research on, you decide what is relevant for you and you think of innovative ways to solve the problems that plague health systems in developing countries. This is a big lesson for developing countries we need to start thinking and doing what we think is best for us in our context. During this Global symposium, the issue of context is coming out strongly context matters in health systems research. We know our context best we should get into the driver's seat.

Two quotations will stay with me after all is said and done at this conference. The one by Davis Miles "don't play what's there play what's not there." I look forward to researching on health systems topics that are still a puzzle. As part of the safe deliveries study, we are piloting a study that gives mothers access to delivery and postnatal care services in Eastern Uganda using vouchers.  Institutional deliveries have increased tremendously! Great but the question remains how can you scale up this initiative in a resource constrained country?

The second quotation is by Abbas Bhuia "Leave a mark in the field where you are researching." I guess not only a mark of excellent research but a mark that you have made a difference in the lives of the people in that community.

A post on posters

Posted: 17 Nov 2010 02:05 PM PST


Time after time at international conferences I am amazed that people don't pay more attention to poster presentations. Often they provide a clear and coherent argument and compelling graphics and images which are far more effective than many oral sessions. You can keep a copy and refer back to them. What's more - when your energy is lagging due to conference overload you can count on them to be concise and to the point!

So I'm going to draw your attention to 2 poster presentations that are being given here at the Global Symposium by Future Health Systems Consortium researchers. The first is on "Experiences of Implementing a Demand Side Financing Scheme for Maternal Health Services in Eastern Uganda." It explains how the team are studying demand (vouchers for transport and maternal services) and supply side initiatives (training health workers and provision of essential equipment, drugs and supplies) to explore how we can improve the uptake of maternal health services. The second is "Exploring health researchers' perceptions of policymaking in Argentina: A qualitative study." This research took the form of semi-structured, indepth interviews with 20 key informants, representing sites in the Federal City of Buenos Aires and the provinces of Salta, Jujuy, Tucuman, Santiagodel Estero and Catamarca, in Argentina's north west region.

I'm not going to tell you what they concluded. You'll have to download the posters to find out... 


Would you like an injection with that Happy Meal?

Posted: 17 Nov 2010 01:23 PM PST


I started my career in education, transitioned to corporate training, and then navigated into public health. But with each professional shift – not much seems particularly different. Universal Education and Universal Healthcare; supply/demand principles at Johns Hopkins Hospital and supply/demand principles at Mars Corporation; and increased salaries for teachers, nurses, or accountants doesn't always translate to better test scores, fewer infections, or less bankruptcy. 

So when yesterday's session on social franchising began with a reference to McDonalds – I sat up straight. I like the intersection of seemingly disparate fields. 

Future Health Systems' Researchers Enjoying the Symposium

Posted: 17 Nov 2010 06:59 AM PST

Sabina Faiz RashidOladimeji Oladepo and Hafiz RahmanAbbas Bhuiya

Tuesday, 29 May 2012

KNOTS blogger

KNOTS blogger

New DFID Human Development Resource Centre website now live

Posted: 29 May 2012 05:58 AM PDT

New Human Development Resource Centre website shares unique collection of resources on health, nutrition and education.

FHS Bangladesh launch new book: Doctoring the village doctors

Posted: 14 May 2012 08:28 AM PDT

Experts gather at ICDDR,B for the launch of the book Doctoring the Village Doctor

FHS Bangladesh partner, ICDDR,B, have recently released a new book chronicling their experience working with village doctors in rural Bangladesh to improve care for the poor. Entitled, Doctoring the Village Doctors: Giving Attention Where it is Due, it has been welcomed by experts as an important contribution to an underexplored area.

Bangladesh faces an estimated shortage of 60,000 physicians, 280,000 nurses and 483,000 technologists, according to the Bangladesh Health Watch. Poorly trained ‘informal’ providers known as village doctors usually fill that gap – especially in rural areas.

In efforts to improve the overall health system of the country, these informal providers are often overlooked. But ICDDR,B has been working with village doctors in Chakaria for several years now to help improve these services. They’ve implemented a range of interventions, including the establishment of a franchise of doctors known as ShastyaSena. And they’ve seen some improvement, but perhaps less than they had hoped.

According to Hilary Standing, Emeritus Professor at the Institute of Development Studies,

The authors lay out the results and the challenges that the intervention brought in trying to improve basic health care provision for the rural poor. They are candid about its limitations and successes and they outline the next exciting steps that are being take to build on the lessons from this round of intervention.

The book was launched last month at an event organised at ICDDR,B with the Center for Health Market Innovations. The event brought together lessons from several studies on the role of informal providers in health service provision in India, Nigeria and Bangladesh. The book was also recently reviewed by Bangladesh’s largest English-language newspaper, The Daily Star.

Hardcopies of the book are available from ICDDR,B in Dhaka for BDT350.00. Online copies are available free of charge.

Monday, 28 May 2012

KNOTS blogger

KNOTS blogger

New DFID Human Development Resources Centre website now live

Posted: 28 May 2012 06:26 AM PDT

New Human Development Resource Centre website shares unique collection of resources on health, nutrition and education. These represent research in action, responding directly to development programming and policy needs, and shared for the benefit of the wider community.

What if the world’s poorest obtain most development services from the ‘market’?

Posted: 28 May 2012 05:52 AM PDT


[Editors note: This blog post originally appeared on IDS's Governance and Development blog, and has been reproduced on the FHS website with permission.]


Much energy is spent on debating whether services such as health, education and veterinary medicine, should be provided by the public or private sectors. But the answer to this question turns out to be irrelevant for most of the globe’s poorest.

Who pays for services in Low and Middle Income Countries?
Most of the severely disadvantaged people in the world live in poorly governed states in South Asia, China and Africa. In these and many other Low and Middle Income Countries (LMICs) formal and informal user-fees are pervasive in the public as well as the private sectors.  

True, much of Latin America, Taiwan, Malaysia, Thailand, Sri Lanka and Botswana have established effective government-run systems for health and other services that are not reliant on market relations, but these are not the places where most of the ‘poorest of the poor’ live.

Generally, someone who needs curative medical treatment, education, or veterinary care in most other LMICs will have to pay someone for it. For example:

  • In India less than 25% of rural health services are provided by government (and even with the latter usually involves informal payments). Likewise the non-state sector provides the overwhelming majority of curative services in Bangladesh.
  • Animal health services in tropical Africa moved from overwhelmingly free government provision before 1980 to almost universally compensated services by 1990, as is also true in India. Even when ‘free’ primary education is found in these countries, most often it involves payments for uniforms, supplies, and instructor tutoring.

So the distinction between ‘public’ and ‘private’ is more one of ownership and supervision, not of whether money is being exchanged. A market is present in both the ‘government’ and ‘private’ service sectors in these countries. It is more useful to look at variations in the market than in the formal attributes of the providers.

Are the poor getting what they are trying to pay for?
None of this is to say, that the poor don’t deserve subsidised services; they do. But sometimes subsidies benefit civil servants, rather than the poor. For example, government veterinary staff in India actually charge informally the same prices as private practitioners.

And even when the subsidies do reduce the costs to the poor, almost always payments by the recipients are not eliminated. Given this continuing reality, it is important to ask if the poor are getting what they are trying to pay for.

The poor living in poorly governed LMICs can and do invest modestly in the purchase of needed services and can be seen buying from higher cost providers. This is particularly true in the face of catastrophic events, especially if they have land or some other collateral asset. Nonetheless the quality of services offered to the poor in poorly governed LMICs is frequently seriously deficient.  

Tackling inequality of information on quality of services
The poor have more knowledge about the quality of the services on which they rely than is generally recognised. But in the purchase of professional services, those who are selling their expertise know more than their customers. When institutions are available to help overcome this information inequality, people are able to get better value from their purchases and are willing to buy more. This is called solving the problem of ‘information asymmetry.

In poorly governed societies a development priority is to build a set of institutions that enable quality in competence, effort and accountability to be rewarded in providers and signalled to consumers. In societies with high levels of governance, the state usually plays a central role in providing institutional solutions to the problems of information asymmetry.

In most countries with low levels of governance and poorly developed paths for public sector improvement it is unrealistic and counter-productive to expect government to be the sole provider of individualisable (‘private’) health and development services for the poor.

Granted, even in these settings the state will often want to play a role in planning institutional solutions by non-governmental actors to ensure the provision of services that have important ‘externalities’ (such as disease prevention, surveillance and control) with collective benefits.

But what might those solutions to the ‘information asymmetry’ problem in the delivery of essential individualisable services be? In a subsequent blog post I will scan the development literature for the lessons that emerge. 

For now, I stress that the world’s poorest are having to buy key development services from markets in both the public and private sectors and that those markets are unlikely to disappear any time soon. We therefore need to make those markets work to improve the quality and utility of what the poor are going to purchase. 

This blog draws on a paper currently under consideration with WORLD DEVELOPMENT -- Institutional Solutions to the Asymmetric Information Problem in Services for the Poor by David Leonard, Gerald Bloom, Kara Hanson, Juan O’Farrell, and Neil Spicer.