- Email: [email protected]
From conflict to cohesion: Involving stakeholders in policy research
Pergamon 0149-7189(95)00027-5
Evaluation and Program Planning. Vol. 18, No. 4. pp. 409415, 1995 Copyright X: 1995 Elsevier Science Ltd Printed m the USA. All rights reserved 0149-7189/95 $9.50+ .OO
FROM CONFLICT TO COHESION: INVOLVING STAKEHOLDERS IN POLICY RESEARCH
JANE
Centre
for Health
E.
and
DOHERTY
Policy. Department
LAETITIA
of Community
Health.
C.
RISPEL
University
of the Witwatersrand
ABSTRACT
INTRODUCTION
formulation of recommendations. The experience from the studies remains pertinent despite the resolution of South Africa’s most obvious power imbalances through the democratic elections of 1994. The first section of the article describes the process we follow in achieving participation, the second highlights the advantages of this approach and the last section describes the difficulties associated with the approach. We conclude by emphasizing the facilitatory role which may be played by independent researchers in times of transition.
The transitional period in South Africa, coupled with the general societal context of uncertainty, suspicion and violence, poses several challenges to policy researchers. While policies which address the inequities of apartheid are urgently needed, the time and resources available for policy formulation are limited. These policies often have to accommodate the views of a range of stakeholders who, at best, have had little prior contact with one another or, at worst, are openly hostile. This article describes our experience as health policy researchers in employing participatory research techniques to partially address these problems. The article makes use of examples from several large studies which were conducted over the past 5 years. All of the studies evaluated primary health care services in disadvantaged communities and were unusual in the extent to which they involved community representatives and health authorities at local, regional and national levels in the
Requests for reprints should Witwatersrand. Johannesburg.
be sent to Jane South Africa.
E. Doherty.
Centre
THE PARTICIPATORY PROCESS
RESEARCH
The need for community participation in planning is widely recognized (Rifkin, 1986; Werner, 1980; Centre for the Study of Health Policy, 1988; Pan-American Health Organisation, 1990; Pate1 and de Beer, 1990;
for Health
409
Policy.
Department
of Community
Health.
University
of the
410
JANE E. DOHERTY
and LAETITIA
Askew. 1991; Hadorn, 1991). The need to achieve the participation of all levels of service provider (in our case. of health workers) is less widely accepted. In its research projects. the Centre for Health Policy is committed to achieving community and health worker participation both on principle and as a matter of practical necessity. Yet facilitating meaningful participation is it difficult process and case studies generally show a gap between theory and actual practice at the operational level (Hadorn. I99 I ). We believe that without the application of a formal strategy the participatory aspect ot our research would fall by the wayside. Obviously participatory research represents only one aspect of the research process: other research methods. both quantitative and qualitative, are also applied. In many instances policy researchers may choose not to apply participatory techniques at all. For example, policy options may be developed within a research unit as a stimulus for debate. However, we believe that participatory techniques are appropriate when research occurs at a service site within a community and results in recommendations which will affect the functioning of the service. Below we describe a generic strategy we have developed over the years to encourage participation.
Identifying the Stakeholders
An important step before accepting a research project is the identification of the stakeholders in the area of study, their interests and their relationships with one another. Generally these stakeholders include community organizations (such as political movements, traditional leaders, civic associations, church groups. women’s groups and professional organizations). different public authorities (such as health-related departments within local, regional. provincial and national structures), sections within individual departments, and the private health sector.
Consultation with Stakeholders
In identifying the major stakeholders it usually becomes apparent that some stakeholders could take exeption to a research project that develops unilateral recommendations. Before the advent of a democratic government in South Africa, most often these stakeholders were community organizations, especially civic structures, which were likely to form the basis of future local governments. However, tensions about areas of jurisdiction and responsibility also existed between different health authorities, such as between ‘homeland’ and nearby ‘white’ authorities or between local authorities and provincial services. It is important to consult with senior representatives of all the major stakeholders who may be affected by recommendations emanating from a research project before the project commences.
C. RISPEL
This draws major stakeholders into the research process and confers legitimacy on the project. Involving Individual Stakeholders in Research Once it is agreed to embark on a research project,
the next step is to set up a process which facilitates the participation of each stakeholder. Because of the sensitivities between different health care providers and between health providers and the community we choose to work at first with each stakeholder individually. This is a necessary but laborious process. lt~tsorluc~tor~~~ Lcttcs rrnd Ir!fiwrwtioll Lc&~t. We initially send out a letter informing the senior leadership or management of our research proposal and requesting an introductory meeting to discuss the research process. Information leaflets that describe the purpose and methods of the research in accessible language are also distributed. Int?fr.odrctor~~Mwting. An in-depth discussion is held with senior managers or leaders to elicit their opinion of the research proposal. The objectives of the introductory meeting are to ensure that the project is understood and supported at a senior level, to gain access to the next level within the organization and to allow people to comment on our proposed methodology. Modifications are made to the research methodology in the light of these discussions. Similar introductory meetings are held with all other structural levels within the organization. Thus. for example, an introductory meeting with a senior nursing services manager results in a similar meeting with area managers. then with clinic managers and then with all categories of clinic staff (both professional and non-professional). Wherever possible these meetings are combined. At the end of each introductory meeting we agree on how the research should proceed. For example, arrangements are made to tour health facilities or conduct record reviews. An appointment is made for a group discussion to gather the views of participants. A questionnaire is given to each participant: this questionnaire may be filled in anonymously. or may simply be used as a framework to prepare for the group discussion. Our telephone numbers are provided should anyone want to contact us privately. In one study a box was provided at various facilities for anonymous comments. Several principles guide this stage of the research process:
In hierarchical structures such as the public health service it is important to follow protocol in accessing lower levels of management. The following points should be emphasized to all participants: participation of both staff and community
From Conflict to Cohesion
l
l
members in the research and development of recommendations is vital; - it is important to involve both current and future providers of health services to ensure that plans are implemented; ~ confidentiality will be maintained (in particular, no opinions will be linked to specific individuals); -~ the results of the project will be widely available. Participants should not be asked to provide answers to research questions at the first meeting. Participants should be given ample time to formulate their responses and to consult with one another. This makes their responses more meaningful and considered. Meetings should be set up at the convenience of participants rather than of researchers. The research process should entail minimum disruption of the daily activities of the participants.
Group Discussions. In the group discussions we try to elicit the views of participants and to involve them in the process of planning. It is important whenever possible to separate senior and junior staff, and professional and non-professional staff, in order to minimize conflicts and to ensure that no group is inhibited from expressing their opinion. We usually meet all interested members of community groupings together. For example, we meet with private doctors attending a regular meeting of their association, or with the health forum of a civic association or church group. As we discuss later, it is particularly difficult to reach the grassroots membership of large community organizations and we usually deal only with their elected representatives. It is a matter of debate whether this represents adequate community participation. The group discussions focus on the problems experienced by the health services, recommendations for service improvement and perceptions of how the integration of different services should occur. In many instances the occasion represents the first time that community members and less senior members of staff are involved in planning services, and often the opportunity is taken to raise issues which do not fail strictly within the brief of the project. The relationship between different levels of management is a typical issue for health workers. while the misappropriation of funds is a typical issue for community members. It is important to document these issues but they have to be handled with great sensitivity. Circulution qf’ Dmfi Findings ,jbr Correction. Findings generated by the participatory process as well as other methods are circulated in draft form, usually only to the representatives of participants. The purpose of circulating the report is to demonstrate how the contribution of participants has been taken into account, to
411
allow participants to correct errors and misperceptions, and to give participants an overview of issues concerning other parts of the health service and the community. The latter function is very important where the historical fragmentation of structures has led to ignorance and confusion. We find it best not to include recommendations in this version of the report. Workshop to Generate Recommendations. A workshop is then held with each stakeholder to generate recommendations. For practical reasons we usually involve only mid-level management and upwards in this process. Recommendations formulated by workshop participants are then balanced against recommendations we have developed ourselves through the more general research process, including the original group discussions. Bringing The Stakeholders Together The process described thus far generates recommendations from within individual organizations. It is important to set a parallel process in motion which eventually brings these organizations together so that contrasting positions can be debated and broad-based solutions can be developed. Project Planning Meetings. We set up project planning meetings or reference groups on which all stakeholders are represented. The purpose of these structures is to provide technical input on how the research process should proceed. Reporting to Estuhlished Negotiating Fora. In the years leading up to the democratic elections in South Africa, numerous negotiating ford were established to guide the transition process. Members of the outgoing regime, and of the liberation movement or progressive civic groupings, were typically represented on these fora. Where a representative forum exists in our research areas we subject our research project to its political guidance. This is important to achieve a degree of political commitment to the outcome of the research process. Workshops to Generate Recommendations. Once the research project has gained political credibility and individual stakeholders have formed a trusting relationship with the researchers, it becomes possible to bring stakeholders together for the formulation of final recommendations. It is important to advance the process to this stage for several reasons. Firstly, joint planning completes the process of familiarising stakeholders with the constraints and possibilities facing one another. Secondly, it enables the identification of common ground and generally weakens old animosities. Thirdly, it allows the ratification of recommendations which have
412
JANE E. DOHERTY
and LAETITIA C. RISPEL
broad-based support. Lastly, it brings together those who have authority to implement recommendations. This process remains important despite the advent of a democratically elected government in South Africa. Very successful workshops were held in one study which involved the services in a ‘homeland’ and the surrounding areas. In another study the relationships between the different stakeholders were not far enough advanced for the researchers to convene a workshop. Instead, the researchers helped to facilitate a workshop which developed out of independent political negotiations between the stakeholders. This workshop constructed a framework within which future planning affecting the stakeholders would occur. A permanent committee was set up by the stakeholders. Amongst other things this committee will respond to recommendations put forward by the research report.
Circulation of the Final Report to all Stakeholders Lastly, a final report is circulated by the researchers to the senior representatives of the major stakeholders. The report ultimately represents the views of the researchers rather than a consensus opinion of the stakeholders, although the participatory research process guarantees a high degree of concordance of views between all the parties. For a period of 2-3 months the final report is available only to the major stakeholders. This gives the stakeholders an opportunity to develop a position on the various recommendations. Thereafter the report becomes a public document.
Diagrammatic Summary Figure 1 summarizes the participatory research process we have described. In order to make the process seem less abstract the figure makes use of an example from one of our research projects. For the sake of simplicity we focus in the example only on the process followed with the major public health service providers, of which there are four. In practice, we also followed the cycle of consultation with other structures, such as the civic association, vertical programmes within the health authorities, other government departments, and the private sector.
ADVANTAGES
OF PARTICIPATORY RESEARCH
The obligation of health authorities to involve communities in the planning of their health services is widely recognised as a matter of principle. However. participatory research and planning may also be recommended on practical grounds.
Introductory
letter,
pamphlet
and meeting
I Senior
service
managers
Clinic
managers
Senior
clinic
I->
4 Ihr
meetings
I---->
3 lhr
meetings
staff
24
Group
Senior
nursing
staff
Junior
nursing
staff
Senior
service
Clinic
managers
/>
staff
I-->
Circulation
of draft
service
and clinic
meetings’ meetings’
recommendations
4 2-3hr
meetings
I
stakeholders
Circulation ‘In
20 I-2hr
report
/---->
Joint planning
major
meetings
2 I-2hr
to generate
managers
All
24 l-2hr
managers
Workshop
Senior
meetings
discussions
,-’ Non-professional
I-2hr
some instances
workshop
3-day
/>
of final
workshop
report
these staff met together
with
the senior staff
Figure 1. The participatory
research process applied to four public health authorities.
Quality of Information The participatory research approach which we have described is a comprehensive technique for gathering accurate information. The combined experience and perspectives of individuals who provide or use the health services provide considerable guidance for planning purposes, especially where quantitative data is unavailable and cannot be gathered. Also, research which is genuinely open and consultative helps to build trust in the researchers and enthusiasm for the research process. This makes the information which is provided to the researchers that much more accurate, complete and constructive. Extensive consultation enables researchers to understand health service issues in a more complex way than their position as ‘outsiders’ would normally allow. Consensus Building A participatory research approach makes the process of planning public and accessible. Opinions are debated, alternatives are considered and constraints on planning are made clear. This process helps to redress the ignorance and distrust created by the practices of apartheid,
From Conflict to Cohesion including the fragmentation of health services. As the process unfolds within a research context it becomes easier to discover common interests and to avoid the adversarial relationships which are common in more political environments. In addition, researchers have relatively more time and resources to dedicate towards formulating issues and developing consensus than do service providers who are submerged by all kinds of other organizational demands. Commitment to the Recommendations It is much more likely that health authorities and community groups will be willing to accept the final recommendations of a research project in which they have participated actively. Importantly. it is more likely that there will be a sense of commitment towards implementation of the recommendations. Development of Capacity Through active participation in research, health workers and community members develop their understanding of research and planning techniques. We feel that participants are empowered to some degree by being encouraged to formulate and express their opinions, especially when they are not normally part of the decision-making hierarchy. The skills that are learned help to extend the contribution of the participants beyond the lifespan of the research project. For example, in the course of one study, certain members of civic associations became familiarized with many of the research issues, thereby increasing their competency in general negotiations. In another study, we arranged for a health worker to be seconded to the research project to develop his skills. In the same study, the process of general consultation stimulated mid-level managers to re-evaluate their own managerial styles. Advocacy Many research findings reflect what is common knowledge within the health services and the community. A research report is able to present this body of experience in an ordered and academic manner. From this perspective the consultative process represents an opportunity for the views of participants to be taken seriously by higher authorities.
CHALLENGES TO PARTlCIPATORY RESEARCH We have argued above for the usefulness of participatory research. We acknowledge, however, that achieving participation is a lengthy and difficult process. It is not always possible to follow the process as methodically as we desire. Below we list the challenges we face as researchers applying the participatory approach.
413
Our point is not that the approach should be abandoned on account of its difficulty, but that researchers need to strategize carefully to make the approach effective. Resource Constraints Time. A participatory approach is time-consuming, not only for the researcher but for the other participants in the process. Some participants, especially managers who have busy services to run, may feel that the process of in-depth group discussions is unnecessary. Sometimes these discussions do not in fact yield new information, although they help to develop a sense of joint ownership of the research process. As policies develop organically out of the research process it is difficult to predict a definable outcome. Often new initiatives evolve out of the process which expand the scope of research and create an added workload for the researchers. As researchers are dependent on participants for the progress of the project it is difficult to keep to strict deadlines for the client who originally commissioned the research. In terms of the policy needs of the country the tension is between developing rapid results that can be used in the transitional process and ensuring that these results are sound and widely supported. Cost. The time spent by researchers employing participatory techniques costs money. In a comprehensive review of primary health care services in the former south-eastern Transvaal we calculated that the financial cost of these techniques was 6.5% of the overall research costs (Doherty, Price & Harris, 1991). When the costs to the services of allowing health workers to participate in the study were added the economic costs rose to 14%. Economic costs will be even higher in studies which rely heavily on participatory techniques, but we doubt that there are cheaper, effective alternatives. It may be difficult to convince clients or funders who are used to consultancies that employ different approaches that their money is being well-spent in this manner. Researcher Fatigue. The stress experienced by researchers in such a research process should not be underestimated. The process involves extensive interaction with numerous individuals and involvement in repetitive meetings, not all of which are exclusively devoted to the purpose of the research. As meetings are held at the convenience of participants considerable evening and weekend work has to be tolerated. Researchers are sometimes confronted with suspicion, at least initially, and throughout the research process have to deal in a diplomatic way with difficult individuals and sensitive situations. The responsibility for fostering good relationships between adversaries weighs heavily on the shoulders of people whose primary function is research and not reconciliation.
414
JANE E. DOHERTY
The Social Conte.ut. In South Africa, community members and health workers often operate under conditions of severe stress. They experience’ poverty, social upheaval, uncertainty about the future, and violence. For example, a clinic in one study experienced 6 burglaries in an 8 week period (Centre for Health Policy, Chris Steel Architects and Rosmarin and Associates, 1994). This affected the morale of staff, with the result that issues of future planning received secondary importance. At times of heightened violence it is often unwise for researchers to pursue their research activities. Health Worker Relutionships. The morale of health workers in the public sector has been low over the past 2 years. Staff are uncertain about which authority will be responsible for primary health care services in the future and fear for their job security. Issues of salaries, promotion, pensions and other benefits generate a lot of concern. There are thus often tensions between different levels of management within the health service and sometimes instances of ‘go slow’ action. The public health sector is also subject to strikes by non-professional staff. Strikes disrupt normal service delivery, and create tensions between professional and non-professional staff. At such times it is often inappropriate for researchers to continue with their programme of research. Researcher Credibility. Part of the rationale for employing participatory research techniques is to deal with the dynamics that exist between and within different power groups. In an environment of confrontation it is important yet difficult for researchers to maintain their credibility with all parties. Individual parties may try to use researchers to further their own political agenda. Alternatively, certain groups may feel that the participatory research process is subversive as it allows the expression of ideas which undermine their power. Researchers even find themselves in difficult positions when they are well-trusted by all parties. For example, we were sometimes requested to give ‘technical inputs’ to community organizations prior to their meetings with health authorities. This created a dilemma for the research team as we were in fact contracted by the health authorities to conduct the research. To prevent ourselves becoming ‘political footballs’ we observe the following procedure. We maintain strict confidentiality as to the source of opinions, but remain completely open and equitable in terms of the process we follow and the information we make available to participants. When very sensitive issues are raised with us and these issues fall outside our project brief we highlight these issues as needing to be addressed but do not intervene further. We also reserve the right to formulate our own final recommendations. In other
and LAETITIA C. RISPEL words, we see the researcher as someone who facilitates consensus but who is not obliged to put forward a consensus opinion. This may cause tension if a recommendation conflicts with the position of one of the participants. Credibilit), qj’ the Reseurch St?,le. The participatory research process generally proves popular with participants. However, in some cases clients may not feel that researchers are in fact experts because, at least initially, they simply gather opinions rather than provide answers. In addition, the participatory process gives the researchers a high profile. Participants begin to trust the researchers and believe that the researchers are ‘on their side.’ However, the researchers have no authority to implement their recommendations, and thus run the risk of discrediting their own research process if implementation does not take place. It is very important to emphasize to all stakeholders that researchers cannot guarantee the implementation of research recommendations. At the same time, it is necessary to provide concrete and achievable recommendations, and to foster the creation of structures that are committed to these recommendations. Methodological The issues listed by researchers approach. But tations.
Problems previously deal with the problems faced employing the participatory research the approach itself has certain limi-
F&e Impressions qf’ Priorities. By insisting on participation the researcher may exaggerate the relative priority accorded to health service issues. The phrasing and emphasis of research questions is particularly important. For example, asking the community to identify their health care needs does not provide a sense of whether there are other more pressing needs. Biased or /nuccurutr Itzftirmution. The opinions expressed by participants in group discussions may not necessarily reflect real situations. In some discussions certain individuals may not feel free to express their opinions. This is particularly the case when more senior or powerful people are present in the discussion. For this reason we try to meet separately with senior and junior personnel. However, in community meetings it is often difficult to extract the opinion of underrepresented groups, such as women or inhabitants of informal settlements. To minimize inaccuracy and bias we try to consult as widely as possible [and in one study met with women from a community-based women’s organization on their own (Marais, Schneider, Price & Doherty, 199 I )], and balance recommendations generated through discussion groups with more objective
From Conflict to Cohesion research measures, such as record reviews or structured interviews in household surveys. Whereas a participatory style of research tries to create a feeling of openness it also precludes the researcher from wielding the authority sometimes available to outside consultants. The researcher has to rely on the goodwill and co-operation of the participants: if the participants are not co-operative the researchers have no mandate to enforce access to information. Accessing Communit>- Members. The cycle of extensive consultation works relatively well within health authorities. This is partly because the research is commissioned by the authorities or directly relevant to their planning process, and partly because the hierarchical nature of these authorities makes it easy to organize meetings with health workers. As many researchers realize it is much more difficult to achieve proper community participation. Once the political hurdle of involving community groups in the research process has been passed, numerous practical problems remain. Community organizations have less access to resources (such as transport and telephones) and usually consist of volunteers who have other occupations: for these reasons it is difficult even to set up meetings. Resource constraints also mean that community organizations have to prioritize issues which they wish to address. Often health issues receive less emphasis than other issues (for example, political representation). We often put great effort into arranging meetings which are eventually poorly attended. Given the disproportionate amount of time that goes into arranging community meetings, and the poor attendance at such meetings, we tend to settle in the end for meetings with community representatives rather than with the membership at large. Another problem we experience with some community meetings is that participants do not always have adequate knowledge or confidence to contribute usefully to the process. On some occasions participants make recommendations which we think are ill-conceived or unrealistic (participants often request narrowly-defined curative and hospital-based services, for example). We thus have to make a judgement as to the success of the consultative exercise before incorporating recommendations. In some cases we offer workshop sessions which outline and explain the issues more fully. This is obviously a problematic approach as it could lead to manipulation of the participatory process by the researchers. Whilst we generally conduct patient exit interviews as part of our research process, we usually find focus group discussions with community members are more productive. Not only do patients represent a biased sample but they seldom provide useful information about the service.
415
CONCLUSION We have argued for a participatory approach to certain kinds of health policy research. We emphasize that this approach should include community members as well as the health services, and should involve all the levels within these organizations. We feel that in transitional periods, such as that currently experienced by South Africa, such an approach is necessary on principle as well as for practical reasons. We feel that policies arising from such a process are more likely to be rational, implementable and enjoy wide political support. The participatory research approach may thus be more efficient in the long run than research which avoids the arduous process of extensive consultation, and is likely to be relevant to sectors other than health.
REFERENCES ASKEW, ticipation
I.D. (1991). Planning and implementing community parin health programmes. In R. Akhtar (Ed.). Heulth care potterm tnd plmtt~iti~~ in dewloping countries. Westport, CT: Greenwood Press. CENTRE FOR HEALTH POLICY. CHRIS STEEL ARCHITECTS, ROSMARIN and ASSOCIATES (I 994). Planning for health facility development at the primary level: The case of Greater Soweto. Paper No. 35. Johannesburg: Centre for Health Policy. CENTRE national
FOR
THE
STUDY
health sewiwfor
Johannesburg:
OF HEALTH
South A,fj.icu. Part
Centre for the Study of Health
POLICY
(1988).
A
1: The case fbr changr.
Policy.
DOHERTY. J., PRICE, M. & HARRIS, J. (1991). Rigour and resources: A comparison of the costs of different types of studies in a comprehensive regional health systems evaluation. Paper presented to the 10th Conference of the Epidemiological Society of South Africa, Cape Town. HADORN. D.C. (1991). The role of public values in setting care priorities. Social &kttw untl Medicine, 32( 7). 773-78 I,
health
MARAIS. S.. SCHNEIDER, H.. PRICE. M. & DOHERTY. J. (199 I). Rwien~ of‘heulth serviws in KaNgwane und the south-eastern Tranwaal.
Volume 5: Report on intersrc~toral
Johannesburg:
Centre for Health
factors
ctffivting
he&h.
Policy.
PATEL. L. & DE BEER. C. (1990). Transforming services: Problems and prospects. Critical Hrulth.
health and welfare 3lj32.
8-I
I.
PAN-AMERICAN
HEALTH ORGANIZATION (1990). Dwelof’ local health .~~:vtem.s:Social purtic~ipulion. Pan-American Health Organisation.
opment und .strengthening
Washington: RIFKIN. World
S.B. (1986). Health planning
Hdth
Forum,
and community
participation.
7. 156-162.
WERNER. D. (1980). Health care and human dignity-a subjective look at community-based rural health programmes in Latin America. Corttuct.57. 2-16.
Evaluation and Program Planning. Vol. 18, No. 4. pp. 409415, 1995 Copyright X: 1995 Elsevier Science Ltd Printed m the USA. All rights reserved 0149-7189/95 $9.50+ .OO
FROM CONFLICT TO COHESION: INVOLVING STAKEHOLDERS IN POLICY RESEARCH
JANE
Centre
for Health
E.
and
DOHERTY
Policy. Department
LAETITIA
of Community
Health.
C.
RISPEL
University
of the Witwatersrand
ABSTRACT
INTRODUCTION
formulation of recommendations. The experience from the studies remains pertinent despite the resolution of South Africa’s most obvious power imbalances through the democratic elections of 1994. The first section of the article describes the process we follow in achieving participation, the second highlights the advantages of this approach and the last section describes the difficulties associated with the approach. We conclude by emphasizing the facilitatory role which may be played by independent researchers in times of transition.
The transitional period in South Africa, coupled with the general societal context of uncertainty, suspicion and violence, poses several challenges to policy researchers. While policies which address the inequities of apartheid are urgently needed, the time and resources available for policy formulation are limited. These policies often have to accommodate the views of a range of stakeholders who, at best, have had little prior contact with one another or, at worst, are openly hostile. This article describes our experience as health policy researchers in employing participatory research techniques to partially address these problems. The article makes use of examples from several large studies which were conducted over the past 5 years. All of the studies evaluated primary health care services in disadvantaged communities and were unusual in the extent to which they involved community representatives and health authorities at local, regional and national levels in the
Requests for reprints should Witwatersrand. Johannesburg.
be sent to Jane South Africa.
E. Doherty.
Centre
THE PARTICIPATORY PROCESS
RESEARCH
The need for community participation in planning is widely recognized (Rifkin, 1986; Werner, 1980; Centre for the Study of Health Policy, 1988; Pan-American Health Organisation, 1990; Pate1 and de Beer, 1990;
for Health
409
Policy.
Department
of Community
Health.
University
of the
410
JANE E. DOHERTY
and LAETITIA
Askew. 1991; Hadorn, 1991). The need to achieve the participation of all levels of service provider (in our case. of health workers) is less widely accepted. In its research projects. the Centre for Health Policy is committed to achieving community and health worker participation both on principle and as a matter of practical necessity. Yet facilitating meaningful participation is it difficult process and case studies generally show a gap between theory and actual practice at the operational level (Hadorn. I99 I ). We believe that without the application of a formal strategy the participatory aspect ot our research would fall by the wayside. Obviously participatory research represents only one aspect of the research process: other research methods. both quantitative and qualitative, are also applied. In many instances policy researchers may choose not to apply participatory techniques at all. For example, policy options may be developed within a research unit as a stimulus for debate. However, we believe that participatory techniques are appropriate when research occurs at a service site within a community and results in recommendations which will affect the functioning of the service. Below we describe a generic strategy we have developed over the years to encourage participation.
Identifying the Stakeholders
An important step before accepting a research project is the identification of the stakeholders in the area of study, their interests and their relationships with one another. Generally these stakeholders include community organizations (such as political movements, traditional leaders, civic associations, church groups. women’s groups and professional organizations). different public authorities (such as health-related departments within local, regional. provincial and national structures), sections within individual departments, and the private health sector.
Consultation with Stakeholders
In identifying the major stakeholders it usually becomes apparent that some stakeholders could take exeption to a research project that develops unilateral recommendations. Before the advent of a democratic government in South Africa, most often these stakeholders were community organizations, especially civic structures, which were likely to form the basis of future local governments. However, tensions about areas of jurisdiction and responsibility also existed between different health authorities, such as between ‘homeland’ and nearby ‘white’ authorities or between local authorities and provincial services. It is important to consult with senior representatives of all the major stakeholders who may be affected by recommendations emanating from a research project before the project commences.
C. RISPEL
This draws major stakeholders into the research process and confers legitimacy on the project. Involving Individual Stakeholders in Research Once it is agreed to embark on a research project,
the next step is to set up a process which facilitates the participation of each stakeholder. Because of the sensitivities between different health care providers and between health providers and the community we choose to work at first with each stakeholder individually. This is a necessary but laborious process. lt~tsorluc~tor~~~ Lcttcs rrnd Ir!fiwrwtioll Lc&~t. We initially send out a letter informing the senior leadership or management of our research proposal and requesting an introductory meeting to discuss the research process. Information leaflets that describe the purpose and methods of the research in accessible language are also distributed. Int?fr.odrctor~~Mwting. An in-depth discussion is held with senior managers or leaders to elicit their opinion of the research proposal. The objectives of the introductory meeting are to ensure that the project is understood and supported at a senior level, to gain access to the next level within the organization and to allow people to comment on our proposed methodology. Modifications are made to the research methodology in the light of these discussions. Similar introductory meetings are held with all other structural levels within the organization. Thus. for example, an introductory meeting with a senior nursing services manager results in a similar meeting with area managers. then with clinic managers and then with all categories of clinic staff (both professional and non-professional). Wherever possible these meetings are combined. At the end of each introductory meeting we agree on how the research should proceed. For example, arrangements are made to tour health facilities or conduct record reviews. An appointment is made for a group discussion to gather the views of participants. A questionnaire is given to each participant: this questionnaire may be filled in anonymously. or may simply be used as a framework to prepare for the group discussion. Our telephone numbers are provided should anyone want to contact us privately. In one study a box was provided at various facilities for anonymous comments. Several principles guide this stage of the research process:
In hierarchical structures such as the public health service it is important to follow protocol in accessing lower levels of management. The following points should be emphasized to all participants: participation of both staff and community
From Conflict to Cohesion
l
l
members in the research and development of recommendations is vital; - it is important to involve both current and future providers of health services to ensure that plans are implemented; ~ confidentiality will be maintained (in particular, no opinions will be linked to specific individuals); -~ the results of the project will be widely available. Participants should not be asked to provide answers to research questions at the first meeting. Participants should be given ample time to formulate their responses and to consult with one another. This makes their responses more meaningful and considered. Meetings should be set up at the convenience of participants rather than of researchers. The research process should entail minimum disruption of the daily activities of the participants.
Group Discussions. In the group discussions we try to elicit the views of participants and to involve them in the process of planning. It is important whenever possible to separate senior and junior staff, and professional and non-professional staff, in order to minimize conflicts and to ensure that no group is inhibited from expressing their opinion. We usually meet all interested members of community groupings together. For example, we meet with private doctors attending a regular meeting of their association, or with the health forum of a civic association or church group. As we discuss later, it is particularly difficult to reach the grassroots membership of large community organizations and we usually deal only with their elected representatives. It is a matter of debate whether this represents adequate community participation. The group discussions focus on the problems experienced by the health services, recommendations for service improvement and perceptions of how the integration of different services should occur. In many instances the occasion represents the first time that community members and less senior members of staff are involved in planning services, and often the opportunity is taken to raise issues which do not fail strictly within the brief of the project. The relationship between different levels of management is a typical issue for health workers. while the misappropriation of funds is a typical issue for community members. It is important to document these issues but they have to be handled with great sensitivity. Circulution qf’ Dmfi Findings ,jbr Correction. Findings generated by the participatory process as well as other methods are circulated in draft form, usually only to the representatives of participants. The purpose of circulating the report is to demonstrate how the contribution of participants has been taken into account, to
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allow participants to correct errors and misperceptions, and to give participants an overview of issues concerning other parts of the health service and the community. The latter function is very important where the historical fragmentation of structures has led to ignorance and confusion. We find it best not to include recommendations in this version of the report. Workshop to Generate Recommendations. A workshop is then held with each stakeholder to generate recommendations. For practical reasons we usually involve only mid-level management and upwards in this process. Recommendations formulated by workshop participants are then balanced against recommendations we have developed ourselves through the more general research process, including the original group discussions. Bringing The Stakeholders Together The process described thus far generates recommendations from within individual organizations. It is important to set a parallel process in motion which eventually brings these organizations together so that contrasting positions can be debated and broad-based solutions can be developed. Project Planning Meetings. We set up project planning meetings or reference groups on which all stakeholders are represented. The purpose of these structures is to provide technical input on how the research process should proceed. Reporting to Estuhlished Negotiating Fora. In the years leading up to the democratic elections in South Africa, numerous negotiating ford were established to guide the transition process. Members of the outgoing regime, and of the liberation movement or progressive civic groupings, were typically represented on these fora. Where a representative forum exists in our research areas we subject our research project to its political guidance. This is important to achieve a degree of political commitment to the outcome of the research process. Workshops to Generate Recommendations. Once the research project has gained political credibility and individual stakeholders have formed a trusting relationship with the researchers, it becomes possible to bring stakeholders together for the formulation of final recommendations. It is important to advance the process to this stage for several reasons. Firstly, joint planning completes the process of familiarising stakeholders with the constraints and possibilities facing one another. Secondly, it enables the identification of common ground and generally weakens old animosities. Thirdly, it allows the ratification of recommendations which have
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broad-based support. Lastly, it brings together those who have authority to implement recommendations. This process remains important despite the advent of a democratically elected government in South Africa. Very successful workshops were held in one study which involved the services in a ‘homeland’ and the surrounding areas. In another study the relationships between the different stakeholders were not far enough advanced for the researchers to convene a workshop. Instead, the researchers helped to facilitate a workshop which developed out of independent political negotiations between the stakeholders. This workshop constructed a framework within which future planning affecting the stakeholders would occur. A permanent committee was set up by the stakeholders. Amongst other things this committee will respond to recommendations put forward by the research report.
Circulation of the Final Report to all Stakeholders Lastly, a final report is circulated by the researchers to the senior representatives of the major stakeholders. The report ultimately represents the views of the researchers rather than a consensus opinion of the stakeholders, although the participatory research process guarantees a high degree of concordance of views between all the parties. For a period of 2-3 months the final report is available only to the major stakeholders. This gives the stakeholders an opportunity to develop a position on the various recommendations. Thereafter the report becomes a public document.
Diagrammatic Summary Figure 1 summarizes the participatory research process we have described. In order to make the process seem less abstract the figure makes use of an example from one of our research projects. For the sake of simplicity we focus in the example only on the process followed with the major public health service providers, of which there are four. In practice, we also followed the cycle of consultation with other structures, such as the civic association, vertical programmes within the health authorities, other government departments, and the private sector.
ADVANTAGES
OF PARTICIPATORY RESEARCH
The obligation of health authorities to involve communities in the planning of their health services is widely recognised as a matter of principle. However. participatory research and planning may also be recommended on practical grounds.
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Figure 1. The participatory
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Quality of Information The participatory research approach which we have described is a comprehensive technique for gathering accurate information. The combined experience and perspectives of individuals who provide or use the health services provide considerable guidance for planning purposes, especially where quantitative data is unavailable and cannot be gathered. Also, research which is genuinely open and consultative helps to build trust in the researchers and enthusiasm for the research process. This makes the information which is provided to the researchers that much more accurate, complete and constructive. Extensive consultation enables researchers to understand health service issues in a more complex way than their position as ‘outsiders’ would normally allow. Consensus Building A participatory research approach makes the process of planning public and accessible. Opinions are debated, alternatives are considered and constraints on planning are made clear. This process helps to redress the ignorance and distrust created by the practices of apartheid,
From Conflict to Cohesion including the fragmentation of health services. As the process unfolds within a research context it becomes easier to discover common interests and to avoid the adversarial relationships which are common in more political environments. In addition, researchers have relatively more time and resources to dedicate towards formulating issues and developing consensus than do service providers who are submerged by all kinds of other organizational demands. Commitment to the Recommendations It is much more likely that health authorities and community groups will be willing to accept the final recommendations of a research project in which they have participated actively. Importantly. it is more likely that there will be a sense of commitment towards implementation of the recommendations. Development of Capacity Through active participation in research, health workers and community members develop their understanding of research and planning techniques. We feel that participants are empowered to some degree by being encouraged to formulate and express their opinions, especially when they are not normally part of the decision-making hierarchy. The skills that are learned help to extend the contribution of the participants beyond the lifespan of the research project. For example, in the course of one study, certain members of civic associations became familiarized with many of the research issues, thereby increasing their competency in general negotiations. In another study, we arranged for a health worker to be seconded to the research project to develop his skills. In the same study, the process of general consultation stimulated mid-level managers to re-evaluate their own managerial styles. Advocacy Many research findings reflect what is common knowledge within the health services and the community. A research report is able to present this body of experience in an ordered and academic manner. From this perspective the consultative process represents an opportunity for the views of participants to be taken seriously by higher authorities.
CHALLENGES TO PARTlCIPATORY RESEARCH We have argued above for the usefulness of participatory research. We acknowledge, however, that achieving participation is a lengthy and difficult process. It is not always possible to follow the process as methodically as we desire. Below we list the challenges we face as researchers applying the participatory approach.
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Our point is not that the approach should be abandoned on account of its difficulty, but that researchers need to strategize carefully to make the approach effective. Resource Constraints Time. A participatory approach is time-consuming, not only for the researcher but for the other participants in the process. Some participants, especially managers who have busy services to run, may feel that the process of in-depth group discussions is unnecessary. Sometimes these discussions do not in fact yield new information, although they help to develop a sense of joint ownership of the research process. As policies develop organically out of the research process it is difficult to predict a definable outcome. Often new initiatives evolve out of the process which expand the scope of research and create an added workload for the researchers. As researchers are dependent on participants for the progress of the project it is difficult to keep to strict deadlines for the client who originally commissioned the research. In terms of the policy needs of the country the tension is between developing rapid results that can be used in the transitional process and ensuring that these results are sound and widely supported. Cost. The time spent by researchers employing participatory techniques costs money. In a comprehensive review of primary health care services in the former south-eastern Transvaal we calculated that the financial cost of these techniques was 6.5% of the overall research costs (Doherty, Price & Harris, 1991). When the costs to the services of allowing health workers to participate in the study were added the economic costs rose to 14%. Economic costs will be even higher in studies which rely heavily on participatory techniques, but we doubt that there are cheaper, effective alternatives. It may be difficult to convince clients or funders who are used to consultancies that employ different approaches that their money is being well-spent in this manner. Researcher Fatigue. The stress experienced by researchers in such a research process should not be underestimated. The process involves extensive interaction with numerous individuals and involvement in repetitive meetings, not all of which are exclusively devoted to the purpose of the research. As meetings are held at the convenience of participants considerable evening and weekend work has to be tolerated. Researchers are sometimes confronted with suspicion, at least initially, and throughout the research process have to deal in a diplomatic way with difficult individuals and sensitive situations. The responsibility for fostering good relationships between adversaries weighs heavily on the shoulders of people whose primary function is research and not reconciliation.
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The Social Conte.ut. In South Africa, community members and health workers often operate under conditions of severe stress. They experience’ poverty, social upheaval, uncertainty about the future, and violence. For example, a clinic in one study experienced 6 burglaries in an 8 week period (Centre for Health Policy, Chris Steel Architects and Rosmarin and Associates, 1994). This affected the morale of staff, with the result that issues of future planning received secondary importance. At times of heightened violence it is often unwise for researchers to pursue their research activities. Health Worker Relutionships. The morale of health workers in the public sector has been low over the past 2 years. Staff are uncertain about which authority will be responsible for primary health care services in the future and fear for their job security. Issues of salaries, promotion, pensions and other benefits generate a lot of concern. There are thus often tensions between different levels of management within the health service and sometimes instances of ‘go slow’ action. The public health sector is also subject to strikes by non-professional staff. Strikes disrupt normal service delivery, and create tensions between professional and non-professional staff. At such times it is often inappropriate for researchers to continue with their programme of research. Researcher Credibility. Part of the rationale for employing participatory research techniques is to deal with the dynamics that exist between and within different power groups. In an environment of confrontation it is important yet difficult for researchers to maintain their credibility with all parties. Individual parties may try to use researchers to further their own political agenda. Alternatively, certain groups may feel that the participatory research process is subversive as it allows the expression of ideas which undermine their power. Researchers even find themselves in difficult positions when they are well-trusted by all parties. For example, we were sometimes requested to give ‘technical inputs’ to community organizations prior to their meetings with health authorities. This created a dilemma for the research team as we were in fact contracted by the health authorities to conduct the research. To prevent ourselves becoming ‘political footballs’ we observe the following procedure. We maintain strict confidentiality as to the source of opinions, but remain completely open and equitable in terms of the process we follow and the information we make available to participants. When very sensitive issues are raised with us and these issues fall outside our project brief we highlight these issues as needing to be addressed but do not intervene further. We also reserve the right to formulate our own final recommendations. In other
and LAETITIA C. RISPEL words, we see the researcher as someone who facilitates consensus but who is not obliged to put forward a consensus opinion. This may cause tension if a recommendation conflicts with the position of one of the participants. Credibilit), qj’ the Reseurch St?,le. The participatory research process generally proves popular with participants. However, in some cases clients may not feel that researchers are in fact experts because, at least initially, they simply gather opinions rather than provide answers. In addition, the participatory process gives the researchers a high profile. Participants begin to trust the researchers and believe that the researchers are ‘on their side.’ However, the researchers have no authority to implement their recommendations, and thus run the risk of discrediting their own research process if implementation does not take place. It is very important to emphasize to all stakeholders that researchers cannot guarantee the implementation of research recommendations. At the same time, it is necessary to provide concrete and achievable recommendations, and to foster the creation of structures that are committed to these recommendations. Methodological The issues listed by researchers approach. But tations.
Problems previously deal with the problems faced employing the participatory research the approach itself has certain limi-
F&e Impressions qf’ Priorities. By insisting on participation the researcher may exaggerate the relative priority accorded to health service issues. The phrasing and emphasis of research questions is particularly important. For example, asking the community to identify their health care needs does not provide a sense of whether there are other more pressing needs. Biased or /nuccurutr Itzftirmution. The opinions expressed by participants in group discussions may not necessarily reflect real situations. In some discussions certain individuals may not feel free to express their opinions. This is particularly the case when more senior or powerful people are present in the discussion. For this reason we try to meet separately with senior and junior personnel. However, in community meetings it is often difficult to extract the opinion of underrepresented groups, such as women or inhabitants of informal settlements. To minimize inaccuracy and bias we try to consult as widely as possible [and in one study met with women from a community-based women’s organization on their own (Marais, Schneider, Price & Doherty, 199 I )], and balance recommendations generated through discussion groups with more objective
From Conflict to Cohesion research measures, such as record reviews or structured interviews in household surveys. Whereas a participatory style of research tries to create a feeling of openness it also precludes the researcher from wielding the authority sometimes available to outside consultants. The researcher has to rely on the goodwill and co-operation of the participants: if the participants are not co-operative the researchers have no mandate to enforce access to information. Accessing Communit>- Members. The cycle of extensive consultation works relatively well within health authorities. This is partly because the research is commissioned by the authorities or directly relevant to their planning process, and partly because the hierarchical nature of these authorities makes it easy to organize meetings with health workers. As many researchers realize it is much more difficult to achieve proper community participation. Once the political hurdle of involving community groups in the research process has been passed, numerous practical problems remain. Community organizations have less access to resources (such as transport and telephones) and usually consist of volunteers who have other occupations: for these reasons it is difficult even to set up meetings. Resource constraints also mean that community organizations have to prioritize issues which they wish to address. Often health issues receive less emphasis than other issues (for example, political representation). We often put great effort into arranging meetings which are eventually poorly attended. Given the disproportionate amount of time that goes into arranging community meetings, and the poor attendance at such meetings, we tend to settle in the end for meetings with community representatives rather than with the membership at large. Another problem we experience with some community meetings is that participants do not always have adequate knowledge or confidence to contribute usefully to the process. On some occasions participants make recommendations which we think are ill-conceived or unrealistic (participants often request narrowly-defined curative and hospital-based services, for example). We thus have to make a judgement as to the success of the consultative exercise before incorporating recommendations. In some cases we offer workshop sessions which outline and explain the issues more fully. This is obviously a problematic approach as it could lead to manipulation of the participatory process by the researchers. Whilst we generally conduct patient exit interviews as part of our research process, we usually find focus group discussions with community members are more productive. Not only do patients represent a biased sample but they seldom provide useful information about the service.
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CONCLUSION We have argued for a participatory approach to certain kinds of health policy research. We emphasize that this approach should include community members as well as the health services, and should involve all the levels within these organizations. We feel that in transitional periods, such as that currently experienced by South Africa, such an approach is necessary on principle as well as for practical reasons. We feel that policies arising from such a process are more likely to be rational, implementable and enjoy wide political support. The participatory research approach may thus be more efficient in the long run than research which avoids the arduous process of extensive consultation, and is likely to be relevant to sectors other than health.
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