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IDS Impact Innovation and Learning Workshop March 2013: Day 1, Paper session 1 John Grove
1. I M P A C T , L E A R N I N G A N D I N N O V A T I O N : T O W A R D S A
R E S E A R C H A N D P R A C T I C E A G E N D A F O R T H E F U T U R E
I N S T I T U T E F O R D E V E L O P M E N T S T U D I E S , B R I G H T O N ( U K )
M A R C H 2 6 , 2 0 1 3
JOHN T. GROVE, M.A., PH.D .
B I L L A N D M E L I N D A G A T E S F D N . *
* C U R R E N T A F F I L I A T I O N . T H I S W O R K W A S C O N D U C T E D B E T W E E N 2 0 0 6 A N D 2 0 1 1 W H E N J G W A S
P A R T O F T H E C E N T E R S F O R D I S E A S E C O N T R O L & P R E V E N T I O N A N D A S A N I N D E P E N D E N T
R E S E A R C H D E G R E E
M O D E L I N G W A S C O N D U C T E D B Y D R . J A C K H O M E R
Aiming for utility in ‘systems-based
evaluation’:
A research-based framework for practitioners
2. Outline
Defining SBE
Research Objectives, Methods, Stance
Key Features and Utility of SBE
The Zambia Case: Strategic Evaluation with SD
Preparatory (Pre-Model) Phase Findings
SD Model Highlights & Reflections
Post-Model Findings
Recommendations for Practice
3. What Is Systems-Based Evaluation?
Systems-Based Evaluation (SBE) is the application
of specific methods that are influenced by systems
concepts and methodologies to the task of
evaluation.
These methods articulate and analyze the
interrelationships and interdependencies
of real-life factors, including perspectives and
boundaries, in a process of intervention toward
action.
4. Research Scope & Objectives
The broad objectives of the research were:
1. To investigate the utility of system dynamics
(SD) in terms of how it does or does not add
value for evaluation of the ART strategy in
Zambia.
2. To identify useful principles and methods for
the broader application of SBE to other health-
services research.
5. Methods & Philosophical Stance
The research questions and utility framework were
informed by relevant literature, in-depth interviews,
extensive field notes, and a 6-year personal research
journal.
Data collection and analysis for the research was
guided by narrative-based inquiry and critical-
hermeneutics philosophy:
Gadamer’s (1998) role of language;
Habermas’s (1976) communicative action;
and Ricoeur’s (1985) threefold mimesis.
6. Literature: Key Features of SBE Approaches
Three unique core concepts in application together
are essential for an SBE:
Interrelationships
Perspectives
Boundaries
• (MIDGLEY 2000: 45; WILLIAMS & HUMMELBRUNNER 2010: 3).
7. Utility Framework: Transformative vs Representative
Tensions of SBE utility:
‘Now that I understand that the problem is a system, I can see
or consider (evaluate) what’s needed to possibly change it. I
may be the one to make the change or I can help advocate for
someone else to do so.’ (Representative)
‘I was part of describing the problem and the system, I am part
of the system, I care about the system, and I value certain
factors and connections. I will now go create and be part of the
new system.’ (Transformative)
9. Utility Framework: Spectrum of Utility—
From Alignment to Action
For Utility, we mediate Representative and Transformative
on a spectrum:
aligning pre-understandings
developing a shared comprehension of the dynamic
situation and components
providing space for argument on the validity of opinions and
data and reinterpretation of inter-relationships,
perspectives, and boundaries.
Move to action
Trigger, Comprehend, Validate, Re-Interpret, Act
10. Case Study: Zambian ART Scale-Up Strategy & Context
2005–2009 :
Zambian Ministry of Health’s ART scale-up strategy aimed
to rapidly expand HIV/AIDS services
Overarching goal to achieve dramatic change in the
epidemiological profile of HIV/AIDS in the country.
Complexity of the Zambian ART scale-up plan
raises need for dynamic and systems-oriented view
in the midst of linear target-setting.
Opportunities:
1) Apply a systems lens, and 2) Study the process
11. Preparatory Research Data and Findings
Data revealed three common themes:
1. Critique of current M&E practice for ART
2. Necessity for boundary-setting for the system of
interest
3. Interest in systems-oriented approaches but
cautious about new methods.
12. Preparatory Research Data and Findings
So we’re good at getting the clinical stuff, and we’re good
at counting things and following patients, but we’re bad at
the more psycho/social stuff … ‘Psycho/social’ is a term of
art, which, I don’t really know what it means exactly.
When I say it I’m talking about taking care of the patient’s
non-medical needs, so: counselling and making sure that
the systems and structures are in place in the family, in
order to take care of the family unit. In the point of view of
things we measure, we’d like to know how well those other
services are doing, because they affect the clinical
outcomes that we’re trying to deliver.
- Rep from lead NGO partner
14. Case Study: Strategic Evaluation
Objectives:
to assess the typical point at which the ART patient load in any given
clinic has reached beyond its capacity to provide sustainable, long-
term care
to determine how increasing the number and/or type of supportive
services networked with an ART clinic reduces the patient load of the
clinical site
to ascertain what level of access to and participation in supportive
services is necessary to sustain ART for clients into the future
Strategic evaluation is for: ‘evaluating relationships among elements of
strategy’, including ‘coherence of different strategy elements, complexity of
interrelationships, understanding of interdependence and interrelationships,
and evidence of systems thinking and complexity understandings’
(Patrizi: 2010: 99)
17. Strategic Evaluation Conclusions
1. Zambia’s strategic goal to ‘prevent, halt and begin to
reverse the spread and impact of HIV and AIDS by 2015’
might be plausible for Lusaka if the huge need for
additional clinical staff is met.
2. Unless supportive service workers can perform
particular tasks (e.g. screening & monitoring) tasks, their
presence may actually increase patient load.
18. Post-Model Data and Findings
SD model:
1. readily triggered stakeholders to reflect on their
existing boundaries (i.e., their beliefs and values)
2. stimulated reinterpretation of interrelationships
3. generated new possible boundaries of the ART care
system
Stakeholders:
1. had comfort with and an understanding of the model’s
structure talked about concerns with the perceived
complicatedness of the approach
2. expressed concern about the potential for false
assumptions to be reified in the model calculations
3. placed confidence/trust in investigators to be rigorous
19. Post-Model Data and Findings
Benefits
SD model triggered discussion and elaboration of
system boundaries among participants, trending
towards unified understandings.
SD model generated new and unfolding
understandings through dialogue.
Constraints
Process did not lead to transformative action
could have been more useful had stakeholders been
engaged in intensive boundary-setting dialogue
both during the development and after the
completion of the model
20. Discussion: Utility of SBE
Participants asked for more time and opportunities to
understand modeling and analysis.
Need to collect a broad variety of perspectives at very
outset of modeling process.
SBE demands planner/evaluator to emphasize
representative and/or transformative process aims.
Determining system’s boundaries is methodological
requirement/asset for/of systems-based approaches:
transformative power of this discussion in itself, where
it can be an evaluative intervention.
SBE can be facilitated with an aim to move
stakeholders to consensual coordinated action.
Sometimes things fall apart…
22. Acknowledgments
Government of the Republic of Zambia, Ministry of Health
CDC Zambia
Bill and Melinda Gates Foundation
Patricia Rogers
Bob Williams
John Barton
Jack Homer
Countless others…..
Dissertation is available at:
http://researchbank.rmit.edu.au/eserv/rmit:160050/Grove.pdf
Thank You