Studying complex interventions: reflections from the FEMHealth project on evaluating fee exemption policies in West Africa and Morocco
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Date
2013-11-08Author
Marchal, Bruno
Van Belle, Sara
De Brouwere, Vincent
Witter, Sophie
Metadata
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Marchal, B., Van Belle, S., De Brouwere, V. & Witter, S. (3913) Studying complex interventions: reflections from the FEMHealth project on
evaluating fee exemption policies in West Africa and Morocco, BMC Health Services Research, vol. 13.
Abstract
Background
The importance of complexity in health care policy-making and interventions, as well as
research and evaluation is now widely acknowledged, but conceptual confusion reigns and
few applications of complexity concepts in research design have been published. Taking user
fee exemption policies as an entry point, we explore the methodological consequences of
'complexity' for health policy research and evaluation. We first discuss the difference
between simple, complicated and complex and introduce key concepts of complex adaptive
systems theory. We then apply these to fee exemption policies.
Design
We describe how the FEMHealth research project attempts to address the challenges of
complexity in its evaluation of fee exemption policies for maternal care. We present how the
development of a programme theory for fee exemption policies was used to structure the
overall design. This allowed for structured discussions on the hypotheses held by theresearchers and helped to structure, integrate and monitor the sub-studies. We then show how
the choice of data collection methods and tools for each sub-study was informed by the
overall design.
Discussion
Applying key concepts from complexity theory proved useful in broadening our view on fee
exemption policies and in developing the overall research design. However, we encountered a
number of challenges, including maintaining adaptiveness of the design during the
evaluation, and ensuring cohesion in the disciplinary diversity of the research teams. Whether
the programme theory can fulfil its claimed potential to help making sense of the findings is
yet to be tested. Experience from other studies allows for some moderate optimism. However,
the biggest challenge complexity throws at health system researchers may be to deal with the
unknown unknowns and the consequence that complex issues can only be understood in
retrospect. From a complexity theory point of view, only plausible explanations can be
developed, not predictive theories. Yet here, theory-driven approaches may help.