Realist review for better evidence base for HIV and AIDS

[Dr Rajesh Gopal]

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

Participants: - Representatives from different organizations based in

1. Rwanda

2. Kenya

3. Ethiopia

4. Mexico

5. Vietnam and

6. India

Venue: - Lloyd Hotel,Amsterdam,Netherlands

Dates: - 14^th to 17^th 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.