Nuffield Centre for InternationalHealth and Development

Presentation made to University of Leeds students half way through the project

24th October 2014

Where?

CambodiaThe legacy of conflict (partial reconstruction of destroyed

infrastructure, continuing presence of landmines)

Limited education opportunities and poor job prospects

Weak governance and endemic corruption - linked to crony capitalism

A growing economy with high inequality

The Cambodian Health System • Lack of equipment and

pharmaceuticals• Poor or absent facilities in rural

and remote areas• Staff absenteeism & dual

practice• Uncaring even violent staff

behaviour towards patients• Unnecessary procedures• High informal fees (+formal)• Weak coordination and

communication between system levels

• Numerous health policy experiments

NGO Heaven?3,500 according to the Diplomat (2013)

Mind the Gap! Contemporary international health development creates its raison

d’etre through gap creation (McNally, S., HIV in Contemporary Vietnam: An Anthropology of Development. Unpublished PhD Thesis., 2002, Australian National University: Canberra)

How? Problem identification (‘measure’ deficits) Come up with ideal solutions (e.g. WHO recommendations…) Gap – you aren’t meeting the ideal Recommend - policies, institutions and development workers Creates a space for development money and an ‘industry’

So What? A negative discourse Impacts on the way reality is understood. When used by powerful

actors (e.g. World Bank) gains dominance Hindering long term empowerment and development?

Let’s think differently…

Obstetric Referral in the Cambodian Health System – What Works?

4 objectives (Oct 2013 – June 2015)

Investigate positive delivery journeys to and back from public healthcare facilities for pregnant women

Identify existing positive resources in the public system

Adapt and assess whether AI can generate robust research evidence

Enhance Cambodian capacity to undertake qualitative research and use it in policy making

Design Principles

Based on Appreciative Inquiry Qualitative research Experimental (failure is acceptable!) Capacity development included Quality assurance & Policy relevance built in

What is appreciative inquiry?

Appreciative Inquiry

What works now?

Change starts from what you have, not what you don’t have Reveals the strengths of an organisation - use strengths to

improve future performance Internal gaze “Based upon the belief that organizations grow in the

direction of what is studied” (Van Der Haar and Hosking 2004)

Usually a form of participatory action research in five phases

The Positive Path http://www.youtube.com/watch?v=pVBMMJ0RMao&feature=rela

(03.00 – 05.00 ) Providing governmental and non-governmental

organizations in India with an approach to achieve sustainable development in India

Define what you want to change – collaboratively Researcher acts as facilitator, bringing participants together, ensuring all

have a voice and all are heard. Can be done as a plenary, individual interviews, group sessions Participants can document discussion Researcher synthesises that discussion and feedback to group

Discovery – tell stories through AI interviews. Participants interview each other! Positive questions

Please give examples of a time when X operated at its best What did YOU do that made X a success? What enabled that success?

Participants collect stories in notes, flip charts, drawings… Researcher synthesises notes for Dream phase and feeds back to group

Dream - what should our future be? Participants interview each other! Researcher acts as facilitator, making sure that everyone has a voice

and is being heard Participants ask each other positive questions e.g.

If we were to operate at our very best (in the way you have described in the last phase) every minute of every day, what community/organisation/business would we be? What would we look like?

Wouldn’t it be good if ……………(X) happened – complete the sentence Participants collect stories in notes, flip charts, drawings… Researcher synthesises notes for Design phase and feeds back to group

Design – how can we get to that future? Participants collaborate to make a plan Researcher acts as facilitator. Participants as each other positive

questions e.g. What will enable us to operate at our best (using what we have now)? What am I going to do? What are we going to do?

Participants collective generate a plan Researcher synthesises all information into one coherent document or

resource for the group

Destiny – do it. Individual and group commitment to carrying through on the plan

Not problem focused = unbalanced?

Requires active participation by all – what if you can’t get that?

From a traditional project management perspective has no monitoring of the plan after the AI interviews, unless incorporated in the Design phase by participants themselves.

May require traditional power roles, e.g. managers, to relinquish control – will they do it?

Can ignore power relations, e.g. gender, professional, community

Critique

Over-reliance on stories alongside a dearth of other sources of data” (Messerschmidt 2008) = deceived by misplaced causation?

Academic validity of research results have been questionable – possible lack of research rigour in conducting research aspect

Back to the project…

Adapting Appreciative Inquiry

Methods 3 iterations in design Interviews

Pilot conducted May 2014 2 interviews each with

women who gave birth in a public facility Healthcare staff (clinical and managerial) Others who helped women reach a facility (e.g. VHSG)

Main fieldwork (December 2014) 30 interviews with same categories of respondents

Validation Workshop (May 2015) Complete Impact Evaluation (Nov 2015)

Limitations One core method Interviews are only as good as your skills as

an interviewer Interviews are accounts of reality – not about

‘true or not’ Provide justifications and rationales for

action, cannot tell you what people actually did

Talk – language and cultural competence always in question

Pilot SamplingOperational District focal

point

Health Centre manager

(interview)

Midwife (interview)

Women & Village Health Support Group

(interview)

Possibility to snowball

To women (minor variations for other respondents) Tell me about your best delivery journey Why was this the best journey? Compared to other delivery journeys, what did you do that

made this one better than the others? What did other people do that made it different/better? What are the three best things you experienced that you

would want other women to experience in the future ? Imagine a journey for delivery at its best, even better than now

- what does it look like? Describe it in detail.

Pilot Questions

Analysis1. Transcribe all interviews

What happened…2. Translate half into English for review by Uni Leeds3. Code

Give lines of interview a notation Code comprehensively

4. Thematic development Interrogate the text Can the sub codes be collected into ‘bigger’ categories –

researcher interpretation Know your epistemology Know yourself!

Positive experiences were easily retrieved Questions were more easily understood by women/others. Staff found it

difficult Best/dream were difficult concepts for Cambodians

“better” “if an angel granted you a wish of a best journey, what would that picture be”

(women) “contribute your best effort in helping one woman from their heart and soul”

(staff) Issues around consent and confidentiality

Interviews were not always private Information sheet not used Almost no time to consider participation (minutes) Interviewer found it difficult to not lead

Question guide WILL be changed for main fieldwork

Early Results

Sampling Change

Operational District focal

point

Health Centre manager

(interview)

Midwife (interview)

Women & Village Health Support Group

(interview)

Possibility to snowball

Change for main fieldwork

Include Emergency Obstetric Care interviewing

staff at both District and Provincial Hospitals

Include women who went

through referral at all levels

Quality Assurance Purpose

Frame and improve research process RESULTS expected to be contentious so used to

validate the research PROCESS in the eyes of the international research community

Three ways to assure quality… Output led Process led Epistemology led

We took an epistemology led approach

Policy Relevance Project board - plug into the wider policy

environment Ministry of Health, Study province Provincial

Health Department, United Nations Population Fund (Cambodia)

Meet regularly throughout the project

Impact Assessment Why do it?

Describe impacts to different audiences (policy, health development donors, academic, general public)

Short term impact of 2 key project work-streams Research capacity strengthening Policy communications

on the way qualitative research is conducted in Cambodia and on the mind-set of researchers and policy makers.

Process evaluation / reflective focus group Whole research team Policy makers Externally facilitated

Conclusion Rationale for this project

Even in the worst situation something is working… So what?

Build change on what you have, not what you don’t have How?

Potential to influence the next 7 year health sector strategic plan for Cambodia Opportunity to change emergency referral processes

Will it work? Perhaps not! Adapting rather than copying AI - jury still out….

References Appreciative Inquiry Commons http://appreciativeinquiry.case.edu Richer, M, Ritchie J, Marchioni, C 2009. "If We Can't Do More, Let's Do It Differently!":

Using Appreciative Inquiry to Promote Innovative Ideas for Better Healthcare Work Environments Journal of Nursing Management, 17, 947-955

Messerschmidt, D 2008 Evaluating Appreciative Inquiry as an Organizational Transformation Tool: An Assessment from Nepal Human Organization Volume: 67, Issue 4, 454-468

Van Der Haar, D, and D Hosking, 2004 Evaluating Appreciative Inquiry: A Relational Constructionist Perspective Human Relations 57:1017-1036

Ashford, G, and S Patkar, 2001 The Positive Path: Using Appreciative Inquiry in Rural Indian Communities Winnepeg, Manitoba: DFID

Carter, S & Little M 2007 Justifying Knowledge, Justifying Method, Taking Action: Epistemologies, Methodologies, and Methods in Qualitative Research Qualitative Health Research 17(10):1316-1328

Reynolds, J et al 2011 Quality Assurance of Qualitative Research: A Review of the Discourse Health Research Policy and Systems 9(43)

Reynolds, J et al. 2013 Quality Assessment & Strengthening of Qualitative Research: An Example Protocol ACT Consortium