Re: Meeting at Royal Tropical Institute (KIT), Amsterdam.

[Guest guest]

Dear Dr Gopal,

Re: /message/11998

Thansk for the offer to share the realist perspective and the news about the

portal.

Keep us informed and help us as well the one who need to see things

differently. Would appreciate if you can load up some ppts or docs from the

experience.

Thanks

 

Dr Sanjeev Kumar

New Delhi India

e-mail: <sanjeevbcc@...>

[Guest guest]

As per the request please find a report of the meeting at Lloyd

Hotel,Amsterdam, Netherlands

 

Re: /message/12001

Name of the meeting: -Expert Meeting on Realist Enquiry and Provider Client

Encounters

 

Participants: -Representatives from different organizations based

 

1. Rwanda

2. Kenya

3. Ethiopia

4. Mexico

5. Vietnam and

6. India

 

Venue: -Lloyd Hotel,Amsterdam, Netherlands

Dates: -  14th to 17th September, 2010

 

The representatives deliberated in the meeting along with the faculty members

from the Royal Tropical Institute (KIT) on the application of realist

review/enquiry based on provider client encounters in healthcare/service

delivery systems in the developing countries.

 

The participants fine-tuned the new research approach/methodology of realist

review which appears to be effective in the area of work on HIV and AIDS

with complete consideration of the circumstances and the overall context

(in preference to the routine studies and

traditional systematic reviews and meta-analysis with deliberate removal of all

confounding variables through specific efforts in the research design itself)

say for interventions for specific groups like the Men who have Sex with

Men(MSM) or the People living with HIV(PLHIV).

 

Participants from different countries elaborated the following health system

interventions:

 

* Performance-base financing (Rwanda)

* Public Health Insurance (Mexico)

* Community health care provision (Kenya)

* Regular public and private care provision (Vietnam)

* Health services for specific target group (MSM) (Gujarat, India)

 

The sessions were designed to discuss ways of using a realistic enquiry method

to study provider client encounters within health systems in order to analyze

and discuss process between providers and client and gain insight in factors of

influence on health worker performance and on patient’s experiences with care

[Provider Client Encounter (PCE) framework] and to strengthen the capacities of

all to use a theory driven assessment of performances of providers and services

and its appreciation by clients.

 

The participants including the GSACS representative suggested a  multi-country

research from a realist perspective on community intermediaries based on the

provider client encounters –say peer educator/provider in case of MSM

interventions. Other community intermediaries in different counties like health

care workers (paid or honorary), ‘citizen brokers’ of Mexico etc. may be

considered accordingly.

It was a good learning experience for all the experts/participants who

deliberated on applicability of the same to generate more evidence to

realistically guide evidence-based-planning for designing/strengthening the

interventions.

 

The proposed studies will identify how provider performance and client

perceptions on quality of care are interrelated, what contextual factors and

which elements in the health system interventions or their broader contexts are

crucial to positively or negatively impact on performance of providers.

The studies will help to investigate which mechanism were triggered that lead

to certain behaviour of providers and of clients and their interactions.

Some of the details of realist enquiry/review are as below:-

 

Relevance of the realist enquiry for public health practitioners and researchers

 

Public health interventions are complex interventions located within complex

health and social systems. However, most current research and evaluation methods

in public health do not sufficiently take into account this complexity and tend

to look at outcomes alone, trying to answer whether interventions work.

Therefore these are not conclusive enough to assist policy makers and planners

to choose appropriate interventions. In addition the interventions logic is

often not made sufficiently explicit, compromising the understanding of how

interventions worked.

 

This is so because they often do not take enough account of either the context

in which the interventions took place or the mechanisms according to which the

interventions worked.

The space, place and context in which health services are provided are

influenced by the organization structures and policies which provide

institutional care setting and influence the way health workers are planned,

trained and managed.

 

Certain factors in the institutional care setting do have positive or negative

impact on health care worker performance.

 

Broader contextual factors forming the socio “politico cultural context and

involvement of stakeholders significantly influence performance.

 

How provider performance and clients perceptions in quality of care (QOC) are

inter-related, what contextual factors and which elements in the health systems

interventions or their broader contexts are crucial to positively and negativity

impact on performance of provider.

 

Realist enquiry:

 

Realist enquiry intends to answer the question: " What is it about this programme

that works for whom in what circumstances " , in other words: which mechanisms

cause which outcome under which circumstances.

Realist enquiry has an explanatory focus and aims to unravel mechanisms of

change. The interaction of an intervention with a specific context triggers

reaction which causes certain outcomes to occur. These interactions are called

" Context-Mechanism-Outcome

(CMO) " configurations. Contexts are the circumstances within which public health

interventions are implemented and include the organizational, socio-economic,

cultural and political conditions, but also the stakeholders involved, their

interests and convictions regarding change and the process of implementation.

Mechanisms are reactions, triggered by the intervention within a certain

context, which lead to change.

Evidence building using a realist perspective implies researching

CMO-configurations by:

Making the programme theory that underlies the choice of a certain

intervention, explicit, i.e. the assumptions regarding expected outcome of an

intervention and how this will be achieved.

Conducting research on implemented interventions to collect

evidence about this programme theory.

Research based on a realist perspective can use both qualitative and

quantitative data collection techniques.

 

Dr Rajesh Gopal

e-mail: <dr_rajeshg@...>