In the learning phase, the preliminary analysis step lays the foundation for fieldwork. In this step, further analysis is made possible by additional information gathered during fieldwork. New information contributes to and validates—and in some cases challenges—what is known about the role of the private health sector. Triangulation, or examining data from various sources and viewpoints, underpins the process, and ensures the validity of the findings. This step culminates in analyzing available qualitative and quantitative data, and merging the results to derive key findings.
The first task is to synthesize the extensive data collected during fieldwork, combining and comparing it with the results of the desk review and analysis of secondary data produced during the Learn phase. Sources of data include the following.
- The field guide is the product of the initial desk review and secondary analysis, and serves as a foundation for the assessment effort. The field guide can be a document, spreadsheet, or PowerPoint presentation.
- Gray literature and printed documents obtained in country, such as national health laws and regulations, training manuals, or provider registries are essential for ensuring an accurate understanding of the role of the private health sector.
- Field notes from stakeholder interviews, site visits, and observations conducted during fieldwork are the core output of the learning phase—the only record of what can be as many as 100 or more interviews.
- If available, the results from primary data collection (surveys or focus groups) will factor into the assessment analyses.
Organizing the data should begin while data collection continues. This process helps the team categorize and interpret what can be copious amounts of information, and begin piecing together an accurate understanding of private sector actors, activities, contributions, and constraints. Data can be organized by the core elements (i.e., policy environment, financing, service delivery, supply chain, and demand), or by themes emerging over the course of the assessment, or in another way agreed upon by the team. Ideally, the organization aligns with the working outline for the report.
A key feature of the assessment approach is triangulation, or the process of combining different research methods and sources to study one issue. In the context of a private sector assessment, a triangulated approach means you can combine informant interview notes and observational data to arrive at a balanced understanding. For example, does the information on clientele provided by a private doctor sync with what you observed in the waiting area? Or is information offered by a pharmacist validated by what products and drugs are available in the pharmacy? Another way to triangulate information is to compare available quantitative data on service utilization, such as Demographic and Health Surveys (DHS) data, with qualitative information gathered at private health facilities. A further example is comparing interview notes on the same topic from different sources (e.g., a public health official, as compared to a private-practice physician). Having more than one team member participate in a stakeholder interview is another way to ensure the accuracy of information. Triangulation is a very useful means of capturing more detail, and also of minimizing the effects of bias and ensuring a balanced assessment.
In practice, triangulation occurs throughout the assessment process. Daily (often in the evening) team debriefings present an opportunity to compare and contrast new information that can be further validated or refuted in subsequent interviews with key informants or by site visits. The mid-assessment team meeting, usually held on the weekend between the two weeks of data collection, serves as a further opportunity for the team to triangulate and verify information.
1.3 Describe (the private sector)
Assessments help create a basic understanding of the private sector and its role in the health system by examining fundamental questions about this sector. Documenting the private sector and its contributions to health is a cornerstone to any private sector assessment. This task is accomplished by reviewing available gray literature and secondary data, as well as key informant responses to five core questions as follows:
|Who is the private sector?||► Types and range of private sector actors engaged in health activities|
|What is the private sector doing?||► Types and range of private sector activities|
|For whom?||► Clientele, socioeconomic groups|
|Where do they render these services and activities?||► Geographic areas or concentrations|
|And at what price?||► Prices charged, cost to deliver, access to finance|
Private health sector assessments seek to identify facilitating, as well as limiting, factors affecting the private health sector. Ultimately, a private sector assessment seeks to answer the question: “How can the private health sector contribute to improved health status?” of a given population/in a given country.
As introduced in the Learn phase, teams typically analyze available data on health care provision and use of services, such as the data provided by DHS surveys. Teams may also acquire additional datasets while in country, such as provider or facility registries. These can be analyzed with software such as Stata, SPSS or SAS. Detailed guidance on analyzing DHS data using Stata is available here.
However, the majority of information collected as part of an assessment is qualitative in nature. While there are various methods for analyzing qualitative data, assessment teams typically use strengths, weaknesses, opportunities, and threats (SWOT) or root cause analyses, or sometimes both. The chosen method should align with the specific objectives of the assessment, but ultimately is at the discretion of the team leader.
Strengths, Weaknesses, Opportunities, and Threats Analysis Teams often employ a SWOT analysis to identify key issues related to the private health sector, as this method flows easily from the organization and triangulation tasks. Identifying strengths and weaknesses is the first step of a SWOT analysis. When applied to a PSA, a SWOT analysis identifies strengths and weaknesses that are internal to the private health sector, and opportunities and threats from the external environment. This approach could be implemented for each specific aspect of the private health sector, such as service delivery, or applied more broadly to the overall findings on the private health sector. Teams have had success applying the methodology both ways.
Root Cause Analysis Teams may use a root cause analytical approach to understand the causes of key findings. A root cause analysis helps generate hypotheses about the underlying causes of problems and how they relate to one another; it also helps to broaden one’s thinking to look beyond a single “cause.” Root causes are best defined as manageable problems that can be addressed through specific interventions. For example, high import taxes on medical products and drugs may be a root cause, whereas unemployment is not. There are many techniques for performing root cause analysis, including a “cause and effect” or “fishbone” diagram. The objective of this exercise is to fully explore all the possible causes impeding or facilitating the private health sector in playing a role to address key health priorities, and prioritizing them to derive actionable recommendations. Root cause analysis can be conducted on its own, or following a SWOT exercise. In the latter scenario, team members are instructed to think through the underlying causes of the SWOT findings (i.e., using the SWOT findings as the issue or problem). The assessment team in Malawi developed this useful table, which incorporates SWOT and root cause elements, to guide their analysis.