Elsevier

Social Science & Medicine

Volume 133, May 2015, Pages 159-167
Social Science & Medicine

Review
Anchoring contextual analysis in health policy and systems research: A narrative review of contextual factors influencing health committees in low and middle income countries

https://doi.org/10.1016/j.socscimed.2015.03.049Get rights and content

Highlights

  • Context is key to understanding health committees as health systems phenomena.

  • Contextual analysis supports better research and its translation to action.

  • Studies from 1996 to 2013 on health committees in low and middle income countries.

  • Context is dynamically interdependent with the health committees it influences.

  • We map key contextual spheres and cross-cutting issues affecting health committees.

Abstract

Health committees, councils or boards (HCs) mediate between communities and health services in many health systems. Despite their widespread prevalence, HC functions vary due to their diversity and complexity, not least because of their context specific nature. We undertook a narrative review to better understand the contextual features relevant to HCs, drawing from Scopus and the internet. We found 390 English language articles from journals and grey literature since 1996 on health committees, councils and boards. After screening with inclusion and exclusion criteria, we focused on 44 articles. Through an iterative process of exploring previous attempts at understanding context in health policy and systems research (HPSR) and the HC literature, we developed a conceptual framework that delineates these contextual factors into four overlapping spheres (community, health facilities, health administration, society) with cross-cutting issues (awareness, trust, benefits, resources, legal mandates, capacity-building, the role of political parties, non-governmental organizations, markets, media, social movements and inequalities). While many attempts at describing context in HPSR result in empty arenas, generic lists or amorphous detail, we suggest anchoring an understanding of context to a conceptual framework specific to the phenomena of interest. By doing so, our review distinguishes between contextual elements that are relatively well understood and those that are not. In addition, our review found that contextual elements are dynamic and porous in nature, influencing HCs but also being influenced by them due to the permeability of HCs. While reforms focus on tangible HC inputs and outputs (training, guidelines, number of meetings held), our review of contextual factors highlights the dynamic relationships and broader structural elements that facilitate and/or hinder the role of health committees in health systems. Such an understanding of context points to its contingent and malleable nature, links it to theorizing in HPSR, and clarifies areas for investigation and action.

Introduction

Health committees (HCs) are one of the better documented mechanisms in an incipient empirical evidence base on community accountability in health systems (Molyneux et al., 2012). In many countries, they are a familiar fixture of health systems, and can be effective in improving quality and coverage of health care, as well as improving health (McCoy et al., 2012). Despite their widespread prevalence, their contributions vary due to their diversity in formation, roles, resources and mandates. One part of unlocking their potential to engage communities and improve health care quality and coverage lies in better understanding their contextual location within health systems and societies. To further such understanding, in this article we explore how context is understood in health systems and policy research (HPSR) and from that basis present findings from our literature review on HC contextual factors.

Emphasis on understanding context in HPSR (Walt and Gilson, 1994) is part of what distinguishes it as a social science subject (Sheikh et al., 2011). Context, according to the Oxford dictionary, is defined as “the circumstances that form the setting for an event, statement, or idea, and in terms of which it can be fully understood and assessed” (OED, 2014). Rather than being an afterthought, contextual analysis enables the meaning and inner workings of our main variable of interest to be better illuminated (Collins et al., 1999). It also functions outwards, by encouraging us to examine a broader range of relationships that may influence our outcome of interest, potentially changing our unit of analysis or focus of intervention. As a core part of research, understanding context is vital to generalizing findings, whether this is from statistical representation, analytical generalization or case-by-case transferability (Polit and Tatano Beck, 2010).

While the purpose of research is to create generalized knowledge that is abstract, in HPSR it is ultimately applied in specific circumstances, with consequences, whether intended or not, on a range of social actors and the power relations that connect them (Flores et al., 2014). As ‘nothing happens in a vacuum’, contextual analysis in health systems enables us to better grasp whether specific reforms are appropriate, feasible and sustainable (Collins et al., 1999, IFAD, 2009). There is growing recognition that traditional evaluation methodologies can no longer ignore contextual variables (Victora et al., 2011) as real world settings vary with time and location (Collins et al., 2007, Timmermans, 2013) with multiple pathways of influence (Timmermans, 2013), far beyond the control of investigators. More fundamentally, realist perspectives have approached programs as social and dynamic processes best understood and evaluated by asking “what works for whom and in what context?” (Pawson and Tilley, 1997).

The re-emergence of the importance of contextual analysis is represented in HPSR in varied ways (Ssengooba et al., 2007, Mbindyo and Gilson, 2009, Zaidi et al., 2012, De Savigny et al., 2012, Belaid and Ridde, 2014, Smith, 2014). Yet in many conceptual frameworks, context is primarily an empty arena surrounding the health systems phenomena of interest. It is all encompassing but ephemeral. One consequence of such depictions is that it implies an air of inevitability, an assumption that contextual features are not actionable or are beyond human intervention. At the other extreme is the production of generic lists, such as the PESTLE (Political, Economic, Social, Technological, Legal, Environmental) tool used in business planning. Others are more specific to health reforms (Collins et al., 2007) or policy analysis (Leichter, 1979). A key limitation of these approaches is that they can reify static categories, which in turn limit our understanding.

Collins et al. (1999) caution against making context an end in itself, removed from the subjectivities of the actors involved, the messiness of real life and its inter-relationships. In this sense, while context is typically seen as external to the variable of interest, in open or ecological systems (Bronfenbrenner, 1979) contextual factors are malleable and shaped by the interventions they influence (Marchal et al., 2012). Pawson and Tilley (1997) similarly remind us that context is more than just locality; it embodies social systems integrating individuals, inter-relationships, institutions and infrastructure in dynamic ways. An appreciation of intersectionality—how different social hierarchies combine in unpredictable and interactive ways (Hankivsky, 2012)—is also relevant to understanding context in this way. Similarly, conceptual mapping is another way of demonstrating the interconnectedness between multiple factors operating at different levels (Tiberghien et al., 2011).

These more dynamic ways of examining contextual features are not without their limitations. Introducing complexity can lead to excessively lengthy and amorphous analyses, making it difficult to determine which variables are more influential and demand greater consideration. It can also be challenging for researchers to understand where to draw the boundaries of contextual exploration.

Rather than rely on empty arenas, generic lists or amorphous detail, our approach to understanding context follows realist perspectives of evaluation that emphasize the development of program theories to guide exploration (Pawson and Tilley, 1997, Marchal et al., 2012). Based on an iterative exploration of how context is understood in HPSR and the HC literature, our conceptualization of how contextual features interact with HCs considers the dynamic relationships and linkages that constitute health systems. We present our work not as a definitive way of understanding context as an end in itself, but as an approach to anchoring it to our phenomena of interest. After detailing our narrative review process, we present our derived conceptual framework and organize our review findings accordingly.

Section snippets

Search strategy

Between June and August 2013 we searched the online database Scopus, which includes all PubMed and Embase content from 1996 onward, for peer-reviewed journal articles in English containing the concept of health committees, as detailed in Table 1. Concurrently, we searched grey literature online (www.google.com) for reports on HCs using the same terms listed earlier and also searched websites of 16 organizations and web-archives known to specialize in the subject. Ethical approval was not

Findings

As presented in Fig. 2, we mapped the following four overlapping and porous contextual spheres critical for HCs role in health systems: (1) community, (2) health facilities, (3) health administration and (4) society. While each sphere plays a different role in the health system, we identified cross-cutting issues within these spheres: awareness, trust, benefits, resources, legal mandates, capacity-building, the role of political parties, non-governmental organizations, markets, media, social

Discussion

We mapped four main contextual spheres of influence over HCs: community, facility, health administration and society. Depending on the specific HC in question, community members, health workers, health administrators and elected representatives are not just external influences, but can be members of the HC. The boundaries between external contextual features and the phenomena of interest (the HC) were thus often porous, as are the boundaries between external contextual spheres. For example,

Conclusion

Understanding the inter-related and dynamic contextual features of HCs enables us to better understand how HCs function and the reasons for their variability. It allows us to identify various entry points for strengthening their roles, as well as to recognize how they themselves can influence the contextual features around them to create better enabling conditions for their work. Such an understanding of context points to its contingent and malleable nature, links it to theorizing in HPSR, and

Acknowledgments

This work was supported by a grant from the World Health Organization's Alliance for Health Policy and Systems Research and Canada's International Development Research Centre. The authors are also grateful to Marjolein Dieleman for her assistance.

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