HOW TO WRITE RESEARCH PROPOSAL

Designing and Conducting Health Systems Research Projects Part I:  Proposal Development and Fieldwork                     Module 1   COURSE ORIENTATION

 

 

 

How will the research proposal be developed?

 

A number of basic steps have to be taken when developing a research proposal. These steps are presented in the flowchart below.

 

This flowchart appears on the back of each of the pages which mark the beginning of modules 3-18.  Each time the flowchart appears, the step in the proposal development process that the module addresses is indicated by double lines around the box.

Flowchart: Steps in the development of a health systems research proposal

 

Questions you must ask	Steps you will take	Important elements of each step
Selection, analysis and statement of the research problem
What is the problem and why should it be studied?		-       problem identification -       prioritising problem -       analysis -       justification
Literature review   What information is available?		-       literature and other available information
Formulation of objectives   Why do we want to carry out the research? What do we hope to achieve?		-       general and specific objectives -       hypotheses
Research methodology   What additional data do we need to meet our research objectives? How are we going to collect this information?		-       variables -       types of study -       data collection techniques -       sampling -       plan for data collection -       plan for data processing and analysis -       ethical considerations -       pre-test or pilot study
Work plan   Who will do what, and when?		-       human resources -       timetable
Budget   What resources do we need to carry out the study? What resources do we have?		-       material support and equipment -       money
Plan for project administration and utilization of results   How will the project be administered? How will utilisation of results be ensured?		-       administration -       monitoring -       identification of potential users
Proposal summary   How will we present our proposal to relevant authorities, community and the funding agencies?		-       briefing sessions and lobbying

N.B.  Development of a research process is a cyclical process. The double-headed arrows indicate that the process is never linear.

It should be stressed that designing a research proposal is not a linear but a cyclical process. Throughout the course there will therefore be opportunities to review and, when the need arises, to revise parts of the proposal that have already been drafted. When developing the research methodology, for example, the teams may find that the objectives and even the statement of the problem need to be revised to be made more specific. When finalising the work plan and budget, the teams may determine that the research design, for financial reasons, may need to be revised so the project is more modest and thus less costly.

 

By the end of the first part of the course, each group will have developed a research proposal with the following chapters: (For details, see Module 18.)

 

 

EXECUTIVE SUMMARY

 

1. INTRODUCTION

 

1.1     Background information                    Literature review may be

1.2     Statement of the problem                 partially or fully integrated in 1.1 and 1.2

1.3     Literature review

 

2. OBJECTIVES

 

3. METHODOLOGY

 

3.1     Study type, variables, data collection techniques

3.2     Sampling

3.3     Plan for data collection

3.4     Plan for data processing and analysis

3.5     Ethical considerations

3.6     Pre-test

 

4. WORK PLAN (including description of project staff)

 

5. BUDGET (including explanatory note on major budget posts)

 

6. PLAN FOR ADMINISTRATION, MONITORING, AND UTILIZATION OF RESULTS

 

References

 

List of abbreviations (if applicable)

 

Data collection instruments (annexed)

 

                                                                                                                                                

I.      THE DEVELOPMENT OF HEALTH SYSTEMS RESEARCH

 

 

Why did HSR develop?

By adopting of the philosophy and strategies for Health For All, politicians and health staff at all levels are committed to ensuring that all people will attain a level of health that enables them to participate actively in the social and economic life of the community in which they live.

Whereas research has made major contributions to health by providing knowledge on the causes of diseases and by developing the technology to cure and prevent disease and promote health, Health For All is far from being achieved.

Why is there still so much disease that could have been prevented or cured? Because health services by themselves cannot control the many factors that influence ill health. Poverty, political systems which either widen or narrow the gap between rich and poor and which promote or neglect the education of girls, for example, influence the health of people. Drought and wars may bring malnutrition and disease with which the health services can hardly cope. While communicable diseases such as leprosy and smallpox may be gradually conquered due to improved environmental conditions and extra effort on the part of the health services, new diseases such as HIV/AIDS may appear which upset the whole health care system and society at large.

This complex of environmental factors – geographical, socio-economic, cultural, political, demographic, epidemiological – not only influences the health of people, it also affects the health services. Countries suffering from poor economics, wars and drought, usually have poorly functioning health services.

Still even within less favourable environments, some services function better than others. A very important factor is the quality of information on which policy makers base their decisions. Very often this information is vague or missing. Then decisions on interventions can be completely off track, which means that money is wasted. Basic questions on which health policy makers need information are:

-           What are the health needs of (different groups of) people, not only according to health professionals but also according to the people themselves?

-           To what extent do health interventions cover these (different) needs? Are the interventions acceptable to the people in terms of culture and cost? Are they provided as cost-effective as possible?

-           Given the resources we have, can we cover more needs, more people, in a more cost-effective way? Is it possible to obtain more resources to benefit the health of the people, by lobbying for more funds from the government or from external donor agencies? By better co-operation with the private/NGO sector? By involving the community more intensively (sharing of responsibility and cost)?

-           Is it possible to better control the environmental factors, which influence health and health care? Can other sectors help (education, agriculture, public works/roads, etc.).

(See Figure 2.1.)

 

These questions cannot be answered without collecting more information through research. That is why, in the 1970’s, Health Systems Research (HSR) was developed.

 

Figure 2.1: Environmental and health system factors influencing attainment of Health For All

 

 

 

 

 

 

 

 

 

 

 

II          WHAT IS HEALTH SYSTEMS RESEARCH?

 

 

What is research?

 

RESEARCH is the systematic collection, analysis and interpretation of data to answer a certain question or solve a problem

 

Characteristics of research:

 

·            It demands a clear statement of the problem.

·            It requires clear objectives and a plan (it is not aimlessly looking for something in the hopes that you will come across a solution).

·            It builds on existing data, using both positive and negative findings.

·            New data should be systematically collected and analysed to answer the original research objectives.

 

Health research serves two major purposes:

 

First, basic research is necessary to generate new knowledge and technologies to deal with major unresolved health problems. Second, applied research is necessary to identify priority problems and to design and evaluate policies and programmes that will deliver the greatest health benefits, making optimal use of available resources.

 

During the past two (or even three) decades, there has been a rapid evolution of concepts and research approaches to support managerial aspects of health development.  Many of these have been described by specific terms such as operations/operational research, health services research, health management research, applied research and decision-linked research. Each of these has made crucial contributions to the development of HSR (WHO 1990).

 

HEALTH SYSTEMS RESEARCH is ultimately concerned with improving the health of people and communities, by enhancing the efficiency and effectiveness of the health system as an integral part of the overall process of socio-economic development, with full involvement of all partners.

 

 

What is meant by a health system?

 

There are different interpretations of what a health system is. Some give a narrow definition and only consider the different levels of the public health care services as a health system (see figure 2.2.)

 

 

Figure 2.2:             Public health care system

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The inclusion of the district council, district development committee and village development committee indicates, however, that some 20 years after Alma Ata* it has been widely recognised that local administration and other sectors than the health sector alone carry responsibility for the health of the people in a village, district or region. Similarly, district health committees, health centre committees and village health committees should guarantee that the users of health services have a say in how these services are organised. Whether and how all these bodies function together as a health system is of course an important issue in health systems research.

 

Yet, many HSR researchers have a wider perception of health systems. They also include the private sector. The private sector has many possible components:

 

·            Non-governmental (NGO) care provided by churches, Red Cross, local NGOs, etc.

·            Medical practice by private doctors, nurses, or by quacks who provide injections and drugs without medical training.

·            The pharmaceutical sector (licensed pharmacies or unlicensed sellers).

·            The large ‘non-biomedical’ professionalised healing systems (Ayurvedic, Chinese, Unani, homeopathic, chiropractic, etc.).

·            Traditional (or folk) medicine, with traditional birth attendants, herbalists and diviners, who may either identify natural or supernatural causes of disease (witchcraft, angry ancestors) and treat patients accordingly.

 

The Primary Health Care (PHC) approach has broadened the horizon of medical care providers considerably. PHC put individuals and communities in the centre of the attention. Self-care (what mothers and other relatives do to keep children and themselves healthy) and traditional/folk healers were accepted as important potential allies of health staff. So were other sectors, which could support health, for example, through the construction of roads, the improvement of education, water, sanitation, and through income generation.

 

PHC was a global approach, technically and financially supported by international organisations, much the same as the current world-wide health reforms have been influenced by World Bank-driven policies.

 

Figure 2.3 presents the widest possible definition of a health system, including all public and private sectors/institutions which directly influence and support the health of people, embedded in the wider environmental context that was described in Figure 2.1.

 

This figure will take different shapes in different societies, but everywhere individuals will form part of a network of family and community members who are concerned about their health. This network will prescribe or advise how to prevent illness and what to do in case of ill health.

 

In many societies, mothers and grand mothers are key figures in early childcare. They determine nutritional and hygiene practices, alert children to dangers, provide care in case of disease, and socialise children in the basics of self-care.

 

At the other end of the spectrum, a public authority is responsible for the well being of all people inhabiting its territory. Nowadays governments of states organise public health care and to some extent regulate private health care initiatives. Through other social services (e.g., education, social welfare), through laws and taxes and police and army, governments are supposed to assure their citizens at least a minimum of resources to survive and live in peace. Since times immemorial this has been the duty of rulers, though each society has developed its own ways of ensuring ‘health for all’.

 

For example, in many countries, chiefs traditionally carried out remedial rituals when drought, epidemics or other calamities afflicted the country. They acted as judges in conflicts, cared for destitute persons and headed the army.

 

In between the individual and the state there may be many different caretakers of health and well-being, varying from herbalists, bonesetters, traditional birth attendants, diviners and faith healers or priests to private medical doctors, nurses and specialists. The question of WHO does WHAT, WHY, HOW and WHEN in case of ill health – which is basic in HSR – may therefore have many answers.

 

Figure 2.3:      A broadly defined health system

 

 

 

An important determinant of health behaviour is culture. Both community members and different types of healers, even those with a university degree in medicine will be influenced by cultural perceptions of what are the symptoms, causes and preferred treatments for specific diseases. If symptoms are connected with ancestors or witches (supernatural causes) then one can expect that diviners will be consulted. They have to find out who causes the problems and what should be done to appease the angry ancestor or the witch. For diseases generally attributed to a natural cause (e.g., cough, flu, infections) patients may use self-care, a herbalist or the health services. As symptoms deteriorate, however, patients and their supporting network may switch their perceptions on causes and on preferred treatment. In case of persistent, serious symptoms they may try many different treatments.

 

The health system presented in Figure 2.3 can serve as a tool to gain an overview of the many different factors that influence health as well as health seeking behaviour. Apart from cultural perceptions the availability, accessibility and perceived quality of different health care options are important factors influencing people’s choice of where to go for care

 

The public health services should be aware of the other options for health care people use, as some of these options may be allies. Self-care, for example, is often overlooked as a possible ‘partner’ in public health. It is also wise to look at the availability, accessibility and quality of the public health care system, in comparison to other health care options. Are the health services there were people need them, covering their needs, in a user-friendly way, at a cost they can pay? Figures 2.1 and 2.2 will help to analyse the public health care system from those points of view.

 

 

Selectivity versus comprehensiveness in HSR

 

Because HSR is problem-oriented it should be selective and concentrate on those factors that will help to explain and solve the problem being examined. It is very seldom that all components of the health system will be included in one study, although HSR studies rarely limit themselves to one component only.

 

Even within the narrower field of the health services, HSR focuses on specific topics, depending on who experiences the problem and at what management level.

 

Health policy makers may, for example, want to know:

 

·            How high (or low) should user fees be for specific health services in order to prevent a drop in utilisation by those who need the services most?

 

Managers at district/provincial level may raise questions such as:

 

·            Why is neonatal mortality in certain districts much higher than in other districts?

 

Hospital directors may ask:

 

·            Why do we observe such a high rate of complications in deliveries?  Are the first-line services sufficiently available and adequate? Are our own services adequate? Are mothers coming late for delivery and, if so, why?

 

Managers at village level (village health committees and village health workers) may want to know:

 

·            Why are our village health posts under-utilised?

 

·            How can we assist illiterate women so that they can effectively prevent and treat diarrhoea?

 

Community leaders may want to know:

 

·            What will be the effects of a cost-recovery program on drug costs and availability of drugs?

 

·            How much community labour will be required to manage the new water system?

 

(Please add your own examples.)

 

 

The major objective of HSR is to provide health managers at all levels, as well as community members, with the relevant information they need to make decisions on health-related problems they are facing.

 

 

We must be aware that problems at one level of the health system are usually connected with problems or deficiencies at other levels (See Figure 2.2). HSR should address problems from the different perspectives of all those who are, directly or indirectly, involved. Otherwise we run the risk of coming up with results which only partly explain the problem, and which are therefore insufficient to solve it.

 

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