HPSR Teaching Blogs

In January 2015, CHEPSAA published two open access, master’s-level courses: Introduction to Complex Health Systems and Introduction to Health Policy and Systems Research. Since then, these courses have been downloaded from more than 50 countries around the world. Recently, materials from Introduction to Health Policy and Systems Research were used in teaching in China. This blog reflects on how the course was structured, how materials were used and adapted and students’ experiences of the course.

[Above: Explaining the Chinese health system to a Martian]

In December 2015, faculty from the West China Research Centre for Rural Health Development at Sichuan University and the Department of Global Health and Development at the London School of Hygiene and Tropical Medicine ran a five-day short course on health systems research methods in Chengdu, China.  A group of 35 postgraduate students and faculty participated in lectures, small group discussions, journal clubs and group work on projects. The course was taught in English, with the group discussions mainly taking place in Chinese.

The course adapted materials from Introduction to Health Policy and Systems Research (IHPSR) and developed some entirely new materials.  Mindful of the students’ academic background (largely public health, with little social science training or exposure) we tried to provide a mix of material that would provide a common understanding of the Chinese health system, a structure for thinking about the types of health policy and systems research (HPSR) questions, and be more challenging and entirely new.

We drew heavily on the “Martian Game”, “What is HPSR”, and “Developing a Research Strategy” materials from IHPSR. The Martian game involves grouping together participants with similar work experiences or backgrounds and asking them to draw a picture that explains to a visitor from Mars what a health system is. We adapted the sessions on cross-sectional and longitudinal methods, asking health systems research questions, case studies, and ethics and rigour in HPSR.  Entirely new sessions were developed on theory of change, impact and process evaluation, action research and using findings to influence policy.  CHEPSAA’s “Introduction to Health Systems” presentation was supplemented with an overview of the Chinese health system, drawing from the newly published China Health System in Transition Review.   

For the first day of the course, a new health system case study was developed, based on the challenges of increasing institutional deliveries among ethnic minority populations in Western China.  To manage the language issues (and not assign too much English reading) we chose to present the case study as a short lecture with the PowerPoint presentation as a handout. However, we used basically the same questions as in the CHEPSAA TB case to guide the group discussions. Journal club discussion sessions encouraged critical reflection on papers about the Chinese health system published in peer-reviewed English language journals.

Another innovation was to add a group project.  Small groups were tasked with developing and presenting a short research proposal to a “selection panel” on the last day. Many of the exercises associated with lectures such as those on ethics and policy transfer required students to apply the material presented to their group project, developing for example a knowledge transfer strategy for their research proposal.  By the end of the week, participants had developed proposals for an action research project on community-based self-management of diabetes, a number of mixed methods evaluations of recent changes in the hospital payment system, and an evaluation of an approach to improving mental health services.  Many of these proposals included a theory of change, which most students had encountered for the first time during the course.

To allow reflection on the experience of learning and teaching, we provided a modified version of the IHPSR evaluation form for students to complete on the last day, and also held a small group discussion with a mixed group of students and faculty, asking what they found most challenging and what they enjoyed most from the week’s activities. 

Participants enjoyed the teaching format, which involved lots of small group discussion and student presentation.   The small groups had been constructed so that each group had researchers with more experience in health systems research, and had colleagues who were more confident with English language – this allowed for more difficult concepts to be explained and discussed by all. 

Students found it challenging to understand the role of theory in HPSR – probably because of their academic background, with many students having a primarily biomedical training. The concept of a “flexible” research approach was also difficult to grasp – many had limited exposure to qualitative research methods and struggled to link the type of question (how, why questions) with a research design and approach that would allow for a structured and reflective process of analysing data as it was gathered and using this to inform further data collection.  Participants were more comfortable with the steps involved in traditional quantitative, epidemiological study designs and this was reflected in some of the group proposals.  However, by the end of the week it was apparent that these ideas were consolidating, and many of the research proposals presented on the final day included research approaches that students had first been exposed to during the course.  The week was also very intensive, with a tight schedule running from 9 to 5 every day; many participants asked for an earlier start and longer lunch breaks next time!

Those of us teaching the course were impressed by the students’ enthusiasm and motivation for learning this material.  When assigned to small groups for discussions, participants settled down quickly to their task, with everyone contributing to the output.  The task of reporting back to the larger groups was rotated among the group members, including those who were less confident with speaking in English, and although the groups contained a mix of faculty and students, there was little evidence of hierarchy – knowledge and learning were very much co-produced by all the members.  When dealing with a group of mixed English language confidence, allowing the group discussions to take place in Chinese seemed to work well by allowing opportunities for concepts to be translated, aided by a glossary of key terms and ideas that had been developed beforehand.

Part of the motivation for the course was to provide staff from the Centre with materials and skills to run such a course in the future as part of the School of Public Health teaching programme.  Our group evaluation came up with lots of ideas for this – more use of AV technology (especially for lectures, so that class time can be devoted to small group learning and student presentations), more case studies, more integration of real research projects into the learning material, and more critical analysis of published papers.

Authors: Kara Hanson, Ben Hawkins, Melisa Martinez Alvarez, David Shallcross, Carine Ronsmans (LSHTM); Li Qian, Ziao Yuan, Li Zhao, Pei Yuan, Min Yang (West China Research Centre for Rural Health Development)