Abstract
There is a growing interest in the ethics of Health Policy and Systems Research (HPSR), and especially in areas that have particular ethical salience across HPSR. Hyder et al (2014) provide an initial framework to consider this, and call for more conceptual and empirical work. In this paper, we respond by examining the ethical issues that arose for researchers over the course of conducting three HPSR studies in Kenya in which health managers and providers were key participants. All three studies involved qualitative work including observations and individual and group interviews. Many of the ethical dilemmas researchers faced only emerged over the course of the fieldwork, or on completion, and were related to interactions and relationships between individuals operating at different levels or positions in health/research systems. The dilemmas reveal significant ethical challenges for these forms of HPSR, and show that potential ‘solutions’ to dilemmas often lead to new issues and complications. Our experiences support the value of research ethics frameworks, and suggest that these can be enriched by incorporating careful consideration of context embedded social relations into research planning and conduct. Many of these essential relational elements of ethical practice, and of producing quality data, are given stronger emphasis in social science research ethics than in epidemiological, clinical or biomedical research ethics, and are particularly relevant where health systems are understood as social and political constructs. We conclude with practical and research implications.
Highlights
There is increasing recognition in low-and-middle income countries (LMICs) of the importance of health systems in achieving health-related development goals, and of the constraints related to health system short-falls and weaknesses.[1]
We loosely defined an ethical problem as ‘a problem or situation that requires a person or organization to choose between alternatives requiring ethical analysis’, as opposed to a problem where it is clear what should be done, but a practical solution is needed. We considered how these ethical issues faced on the ground mapped on to clusters of research ethics principles outlined by Emanuel et al.,[24] given the widespread awareness of this framework in LMICs, our use of it in our previous related paper,[25] and this framework being easy to apply for the types of Health Policy and Systems Research (HPSR) we were conducting relative to others
The range of ethical issues we faced are illustrated in Boxes 1–3, grouped broadly into difficult information and observations (Box 1 and Box 2), and strengths and challenges of conducting research embedded in health systems (Box 3)
Summary
There is increasing recognition in low-and-middle income countries (LMICs) of the importance of health systems in achieving health-related development goals, and of the constraints related to health system short-falls and weaknesses.[1]. In this paper we use the extended term Health Policy and Systems Research (HPSR) in recognition of the interconnections between health policy and systems, and the social and political nature of the field.[4] HPSR is a broad field, there is emerging consensus on key areas of focus including: the performance of health systems and their subcomponents (resources, organizations, and services); how links among the subcomponents shape performance, and what forces influence those links; and how to strengthen health system performance over time.[5] Importantly, HPSR is recognized as a hybrid, or ‘trans-disciplinary’ field, drawing on different disciplinary traditions and methodological approaches. It is recognised as applied research that is undertaken with an orientation towards influencing policy and wider action to improve the performance of health systems.[6]
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