With the field guide in hand, the team is ready to begin in-country data collection. Fieldwork is critical to verifying information, filling in gaps, and answering key questions about the private health sector. Remember that a wide range of stakeholders, including women’s NGOs and professional associations, will yield a more representative snapshot.
This step involves:
- Key informant interviews with stakeholders from the public and private health sectors, including site visits
- Additional data collection, such as hard copy documents (gray literature) which may be available only in country
- Travel to other regions to ensure a balanced view of the private health sector
- Daily team debriefs to share notes and findings from interviews and site visits
This week at a glance overview illustrates a typical first week of fieldwork.
TAKE NOTE ► Your team only gets ONE SHOT to carry out quality fieldwork. Missing a key stakeholder interview or failing to collect important data while in the field can undermine an assessment. Be meticulous about advance research and planning: identify informants, prepare interview guides, and establish a fieldwork schedule and a process for keeping it up to date (it will change). Interview as many stakeholders as possible and to capture diverse perspectives that you can use to triangulate findings—even if this means staying in country a little longer.
3.1 Key informant Interviews
Team members typically conduct stakeholder interviews related to their particular area of expertise, or to the technical area as assigned to them. (That said, you may be asked to conduct an interview or include questions for another team member.) Interviews serve three purposes:
- Address information gaps or validate information to ensure an accurate description of private sector contributions to health.
- Gauge perceptions and attitudes about the role of the private sector in health.
- Vet ideas for potential private sector interventions or public-private partnerships generated during the discovery phase.
Identifying Key Informants
Each team member creates a list of informants for his or her assigned area and gives it to the team coordinator prior to fieldwork. As you form interview teams, consider whether the sex of the interviewer may influence results (for example, assigning a male interviewer to a female key informant in a conservative social or religious setting).
The donor and local partners can assist with identifying key informants. Draw from the range of health sector stakeholders—including public officials, not-for-profit health entities, for-profit health providers, private insurers, professional associations, distributors, medical institutions, and women’s NGOs and professional associations.
TIP ► Key informants for HIV and AIDS-focused assessments:
- National HIV/AIDS program coordinator
- Members of the national HIV/AIDS committee (if one exists)
- Business coalition on HIV/AIDS (if one exists)
- Companies with HIV workplace programs
- Chair of country coordinating mechanism (Global Fund)
TIP ► Typical key informants for family planning-focused assessments:
- Maternal and child health directorates at the Ministry of Health
- Public and private pharmaceutical wholesalers and distributors
- Retail outlets in the informal marketplace
- Local affiliates of family-planning focused international NGOs (e.g., MSI, PSI, IPPF)
The local logistics consultant, with direction from the team lead and assistance from the team coordinator, is responsible for developing and updating the consolidated interview schedule for all team members.
Begin developing the schedule two to four weeks in advance of the initiation of fieldwork. During fieldwork, the team coordinator and local logistics consultant must coordinate closely to ensure that available time is used efficiently for meetings.
Fieldwork requires flexibility. Meeting times frequently change, or ad hoc meetings may be arranged with little advance notice, so team members must be patient and adaptable. Depending on the size of the country, It is not unusual for a team to interview upwards of 100 individuals over a two-week period.
TIP ► Use a Google Calendar to organize the schedule, which shows informants by assigned team member(s), day and time, location, and informant contact information. Team members can access the calendar remotely to identify conflicts or make schedule changes to allow an additional member to attend a particular interview. The calendar can be color-coded by team member or subject matter, which can help ensure all technical areas are covered and make efficient use of each team member’s time.
Preparing for and Conducting Interviews
Team members are responsible for formulating interview questions. To facilitate this process, we have developed interview guides for key stakeholders typically involved in an assessment. These should serve as a starting point, but may need to be adapted according to the objectives of the assessment.
Begin interviews with a brief overview of the purpose of the assessment, the process, and the expected outputs, as well as an explanation as to why the informant was selected to participate. It is important to let the interviewees know how the information they provide will be used/represented in the report (e.g., will any information be attributed to an interviewee as an individual?). In all cases, be sure to document the sex of the key informant interviewed. The team should review tips for conducting key informant interviews prior to fieldwork, which include prompts about gendered power dynamics that can affect interview data..
TIP ► Convene all team members for a fieldwork kickoff meeting on the day before you begin interviews. Typically held on a Sunday, this meeting should include introductions, a review of the field guide (assignments, key issues, and information gaps), expectations, guidance on conducting stakeholder interviews, and the most current schedule, as well as the process that will be used to keep it up to date.
Private sector interviews
Interviews with a broad range of private health sector stakeholders form the basis of the assessment. These typically include:
- Private health associations
- Professional medical and pharmaceutical associations
- Owners of large private health facilities
- NGOs engaged in health
- Private health insurers
- Technology companies, such as mobile operators
- Private health providers
RESOURCE ► Increasingly, private health sector assessments are exploring mobile health (mHealth) solutions to identified problems. mHealth is the use of mobile technology to improve health outcomes. Given explosive growth of mobile technology in developing countries, mhealth is emerging as a key tool to strengthen clinical care, connect with target users, reduce isolation and fragmentation of providers, improve program management, and attract corporate partners. We include questions to inform potential mhealth recommendations, and if this area is of interest, teams may wish to interview mobile operators and mobile service providers.
Private health providers comprise a diverse group of practitioners that may vary from one country to another. If possible, the assessment should cover three types of private providers:
- For-profit — For-profit, formally trained, and licensed providers such as private doctors and nurses, midwives, and paramedical staff (clinical officers, physician assistants), and pharmacists and other medical suppliers. This group should include individual practitioners as well as professional association leaders. Practitioners may be found in facilities such as hospitals, clinics, or even small house-based practices.
- Nonprofit — Nonprofit providers and clinics, including faith-based organizations that deliver health services. The most common nonprofit entities are networks of facilities run by international NGO affiliates, such as MSI, PSI, and IPPF, or by faith-based institutions such as churches or mosques.
- Informal — Traditional healers, traditional birth attendants, and market drug vendors.
Public sector interviews
While understanding the roles of key private sector actors, and thus conducting interviews with these entities, is key the assessment, the team should also interview select government officials and representatives, particularly Ministry of Health personnel. Within the Ministry of Health, agencies responsible for licensing health care personnel, inspecting facilities, and ensuring the quality of drugs are typically interviewed.
Some key informant interviews will incorporate site visits. These may include visits to pharmaceutical distributors and their warehouses, and to private sector midwives, clinics, and hospitals. Visits to health facilities are essential in order to verify data collected at the national level, and to solicit private sector perspectives on pressing health issues. Include facilities in both rural and urban areas.
RESOURCE ► To improve our understanding of the pharmaceutical supply chain and systematize our approach to gathering information on family planning commodities, we developed retail pharmacy checklists. While first used in Kazakhstan and Ukraine, these checklists have been adapted and used in many subsequent assessments, including those focused on HIV/AIDS.
Site visits also allow for data collection through observation. Subject-matter experts on the assessment team use this opportunity to observe conditions, wait time and consumer information in private health facilities, retail pharmacies and other points of service delivery or distribution, informing their overall findings and recommendations. For example, teams often complete a checklist of available family planning products to gauge current inventory at retail pharmacies.
TIP ► Take photographs if possible. Photographs can be used to illustrate key points (e.g., facilities in need of repair) and otherwise bring to life the assessment findings in the report of related presentations.
3.2 Additional Data Collection
An important aspect of fieldwork is identifying and collecting documents that may not be published or publicly available. These forms of “gray literature” often contain information that is very germane to the assessment, such as statistics on the number of private health facilities in the country. Common examples of documents obtained during fieldwork include:
- Ministry of Health or Ministry of Finance strategic plans, and budgets if available
- Policies, laws, and norms that govern the provision of health services, and that may affect demand for and supply of specific health services (determine to what extent these apply to the private sector, and any accreditation procedures that may actually be in place)
- Policies and laws regulating private practice and business practices
- Conditions of participation for major private or national health insurance plans
- Statements of covered benefits, premiums, and provider payment levels for major health insurance plans
Private sector assessments typically stop short of conducting primary data collection, and instead focus on leveraging existing data and information and supplementing this with information gleaned from key informant interviews. In selective instances, teams have convened limited focus groups or conducted brief surveys, but this is the exception more than the rule. Given the limited time in country—typically two weeks—and considerable breadth of most assessments, adding on primary data collection is not generally feasible. Increasingly, such research requires approval from an in-country review board, which can be a lengthy process. Teams often find that available data and information is sufficient for informing the assessment and generating recommendations.
TIP ► While formal surveys or focus groups are not typically part of an assessment, group interviews are fairly commonplace. These are sometimes the result of a stakeholder request—for example, the Ministry of Health may prefer for several staff to be interviewed jointly. In other instances, the team may initiate group interviews, in an effort to maximize input from multiple informants and perspectives in the shortest amount of time. Group interviews work best when conducted with members of the same stakeholder group, such as private providers or labor union representatives.
3.3 Travel Outside the Capital
Based on the assessment scope, size of the country, and reach of the private health sector, teams may wish to travel to one or more regions outside the capital to conduct interviews and site visits. Such regional visits add perspective to the assessment, as the situation is often quite different outside the capital, and new issues—as well as opportunities—may emerge. If regional visits are planned, teams often take advantage of the weekend to travel, minimizing time away from data collection. The local consultant is instrumental in planning and scheduling appointments during regional visits.
3.4 Daily Digest
Teams typically meet nightly to update one another of their key impressions of the day. This gives team members the chance to revise and modify the focus of their activities based on information gathered. The meetings includes brief updates from each team member, identification of priority issues, and review of the remaining schedule of interviews and site visits.
TIP ► Based on our collective experience, we distilled our top five fieldwork tips for a successful private health sector assessment.