| 1 |
Methods development and application |
1.1 |
Before participating in the iPIER initiative, teams had no knowledge about EIR. |
1.1.1 |
The first thing [we have gained] is being familiar with this Implementation Research theme, because none of us had any knowledge about it or knew this existed or what it is about. In a way, understanding it is a competence we have gained. PI, C4, 2°, M, CI, Medicine |
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1.2 |
It is necessary to identify a research problem for which changes are feasible. |
1.2.1 |
It is important to identify a problem that can be solved, which cannot be a structural problem, because, obviously, a structural problem cannot be solved with an implementation research (…). So, to identify the problem is also very important for this kind of research. (PC, C6, 1° & 2°, F, PI, Medicine) |
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1.3 |
The use of qualitative methodology is needed to reach deep understanding. |
1.3.1 |
(…) Qualitative research strengthens research (…) In P3, health issues are presented, at least in the media, in quantitative terms, which somehow makes data presentation a bit dark (…) Those complexities of the health world that are often not only explained with the analysis framework, but also using context and qualitative elements. (PG, C4, 2°, M, CI, Anthropology) |
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1.4 |
It is necessary to consult implementers and health staff in the health policies, programs and services. |
1.4.1 |
These people (implementers and health staff), as it is quite often, are for the first time consulted in an interview (…) it is not only that someone asks them, but that they can participate and express their point of view… I mean, I find the methodology interesting (…) And if it is not done with the actors of implementation, it is quite difficult to think that you can do something… (PB, C7, 2°, F, CI, Political Sciences) |
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1.5 |
It is also important to consult the users of programs and services to inform about social and cultural factors affecting the implementation. |
1.5.1 |
Pictures and videos of the nutritional sparks [Chispitas nutricionales] used to say: “Give it in a banana to the child,” but unfortunately in El Alto people don't eat bananas, mothers don't want to give bananas to their children because they believe this will cause caries in their teeth, so they don't give them bananas. Now they ask themselves, “With what should I give (the nutritional sparks) to them?” One mother told us: “I didn't give them to my child because the doctor said I should give them with banana, so I didn't give the sparks to him”. For me, these things are important. (PC, C6, 2°, F, PI, Medicine) |
| 2 |
Timeline and human resources availability |
2.1 |
EIR sometimes involves outsourcing researchers due to the implementers” workload. |
2.1.1 |
It is very difficult to find a research team in a ministry. Usually, you find them in academia or, if you do find researchers, they are very busy working in administration activities, so it is not easy to find researchers doing qualitative research (…) basically, implementation processes need a lot of qualitative research, because of in depth interviews, focal groups or the methodology that is necessary to discover barriers and the such… Therefore, you can outsource that. (PA, C7, 1°, F, PI, Medicine) |
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2.2 |
It is also necessary to generate motivation in the health staff collaborating in the research project. |
2.2.1 |
To do the interviews, one must have time and needs to work after his or her working Schedule and sometimes the personnel is exhausted… and have many patients… (…) they have to fill in a bunch of papers for the health insurance, besides the clinical file. (…) So, we have to find the time to do the research. You need to be very motivated. You need a lot of motivation. (PC, C6, 1°, F, PI, Medicine) |
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2.3 |
A strategic element to develop EIR is the profile of who performs it as well as the implementers’ involvement. |
2.3.1 |
The decision maker's profile is essential, if (you choose) the basic personnel profile, one that has never made any research, the person will not be interested… this is the first thing… (…) A decision maker or an administrator who is not interested by academia [will complicate the research]. (PI, C3, 2°, F, CI, Medicine) |
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2.3.2 |
The participation of the [regional decision maker] was very important, this gave us access to the health services (…) If the person in charge participates and facilitates things, this is very important, because [health personnel] usually don't like to give information. This is why we consider their participation as a priority, because, besides that, the results of this research can be applied. (PK, C2, 1° & 2°, F, CI, Medicine) |
| 3 |
Financial and budgetary conditions |
3.1 |
The funding allocated to EIR constitutes a basic condition for developing it. |
3.1.1 |
To say the truth, even though budgets include research, it is very difficult to have access to these resources… (PO, C1, 2°, F, CI, Medicine) |
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3.1.2 |
I think that this kind of implementation research is very feasible, because I think that the reason why not more of it is done is the lack of financial resources, but the authorities have shown good disposition and interest in it. (PN, C1, 2°, F, CO, Sociology) |
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3.1.3 |
We currently have the financial support of PAHO, so, to do research you need a whole team, so we only have a very small amount to do research, which is not enough to hire this kind of experts, because you need experts… In some way, this would be one of our limitations. (PI, C3, 2°, F, CI, Medicine) |
| 4 |
Institutional dynamics and organization |
4.1 |
Some institutions have regulatory limitations to conduct research. |
4.1.1 |
The Health Ministry does no research, the ministry finances research, this is an important point. XYZ is essentially a research institution; an important proportion of the research that the Ministry is interested in, is contracted with us. The ministry asks XYZ to do it. However, the Ministry, itself, does no research; it contracts partners to do it. (PE, C5, 2°, F, CI, Psychology) |
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4.2 |
The instability of decision makers brings uncertainty, due to the lack of institutionalization of health policies and programs. |
4.2.1 |
Unfortunately, in our country political will is too linked to the person holding a post. So, those who are currently responsible at the Public Health Ministry do have the political will related to the execution of this kind of logic in decision making. We cannot guarantee that if the people who are responsible for the process (change) this will continue to have the same acceptability. We, as a country, have certain limitations in our institutions that is hard to admit. (PM, C1, 1°, F, CI, Medicine) |
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4.2.2 |
In (C4) we are very radical, there is no continuity in public policies… But, as I told you, if the political coalition that I think will win does win, they are going to put a lot of attention to this [medical drugs] policy according to their perspective and interests. (PG, C4, 2°, M, CI, Anthropology) |
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4.2.3 |
The discontinuity of public officials who were acquainted with a line of action can have consequences. (PB, C7, 2°, F, CI, Political Sciences) |
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4.3 |
Decision makers fear highlighting what doesn't work in their health programs or policies as well as the possibility of generating critical evidence. |
4.3.1 |
National politics (…) are very important regarding this, when we have a very limiting government, we can have problems (…) There have been times in the country when programs were personalized, the person in charge was the owner, the god, and nobody could investigate him and say that things were not working, but this is not the case now, I think we are well. (PK, C2, 1°, F, CI, Medicine) |
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4.3.2 |
[There is the need] to undo the idea that behind this they are a sanction, because if there is a sanction it must go through the right channels, it has nothing to do with any health research. (PB, C7, 2°, F, CI, Political Sciences) |
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4.3.3 |
We also work with a very critical perspective of the freedom that a studies or research center gives us… It is different from a government institution… (PG, C4, 2°, M, CI, Anthropology) |
| 5 |
Political environment |
5.1 |
Health issues are prioritized according to political agendas and how they are addressed depends on the particular ideology of the ruling political group. |
5.1.1 |
It does depend on political will (…) Nevertheless, now it is different. As I was telling you, the ministry belongs to the party holding power, but the municipality and the regional government are in the opposition… but are eager about it, because this an issue of interest, it is an issue related to the interest in the health of the population. (PC, C6, 1°, F, PI, Medicine) |
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5.1.2 |
I think that first, if one puts in the agenda that the imprisoned population has the right to access healthcare, I think this is new vision, yes? (…) What one finds here is the result of years of policies… of not putting in the agenda, maybe, not health, but the penitentiary services of the province of XYZ, and this leads to a degradation in all senses (…) In my opinion, this has to do with a previous value consideration in relation to public policy that has been there for years (…) I believe this is a policies prioritization and to put the necessary funding and to work with a true sense of rights. (PB, C7, 2°, F, CI, Political Sciences) |
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5.1.3 |
I believe that today, with the vision of the new coordinator, processes are being dismantled because she has a political mandate (…) If one of the leading lines of iPIER is the participation of health leaders, of the heads of health services, decision makers, I think that now the execution of this methodology (EIR) … I'm being sincere, may be difficult… (PD, C5, 1° & 2°, M, PI, Psychology) |
| 6 |
Perception on the use of research results |
6.1 |
Use of EIR results. |
6.1.1 |
In the municipalities they do very little on health issues, they do very little while they could be taking a more important role in prevention and search for a solution (…) This is going to be a good tool at the national level that will help the local and regional authorities to act. (PK, C2, 2°, F, CI, Medicine) |
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6.1.2 |
I believe that [with our research] the process [of the elaboration of a drug bioequivalence policy] will become visible since it worked, as little as it worked, but it did work… and I think that we will also generate inputs for more critical references for these processes so they can follow-up and monitor future policies in the domain that we have evaluated. (PG, C4, 2°, M, CI, Anthropology) |
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6.1.3 |
It is very possible that the results be applied, the health system is strengthening its steering system, so this kind of research is timely and pertinent… in fact, the Health Ministry is currently in the process of clinical practice guides and protocols development. (PO, C1, 2°, F, CI, Medicine) |
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6.2 |
Different strategies to apply EIR results. |
6.2.1 |
We are still working in the second phase of the project, which consists of the establishment of a deliberative dialogue among social actors that really are responsible of the implementation of the TB prevention, treatment and control policy in the prisons of (our)the province… (PB, C7, 2°, F, CI, Political Sciences) |
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6.2.2 |
I think that the results will help, but we have to present them in different decision-making levels, for instance, at the different health centers, this is super important (…) and to the regional authorities of the programs. (PC, C6, 2°, F, PI, Medicine) |
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6.2.3 |
I have an advantage, because I will directly apply the findings that we have and the recommendations in my institution, this is the advantage, because I am the decisions maker, so I can already implement them. To implement it in the other [institutions of the city of XYZ], well I think it is necessary to sensitize the secretary of health in order to scale-up our strategy in other centers. (PI, C3, 2°, F, CI, Medicine) |
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6.3 |
It is necessary to involve actors from different social sectors to generate changes in health programs and policies. |
6.3.1 |
I believe that there is a lot of space to generate a link with certain sector of the [national] private sector in which certain general criteria can be deepened to face the most important economic power, which is represented by the international pharmaceutical industry that functioned as important social actors in the development of this policy (…). There are people in technical instances, people in the civil society, the medical and the chemical and pharmaceutical academies who are most critical about these processes. They are going to have close information of our analysis that will help to follow-up future processes. (PG, C4, 2°, M, CI, Anthropology) |
