Josefien van Olmen

Is realist evaluation keeping its promise? A review of published empirical studies in the field of health systems research

This overview aims to stimulate conceptual and practical discussions to help unlock the full potential of realist evaluation in health systems research. Based on a structured literature search, this review maps how the concepts of realist evaluation are applied in health systems research and which methodological problems are encountered. We found a great diversity in the depth of application of the philosophical concepts, use of terminology and scope of application in the research process. Terms of theory-driven evaluation, theories of change and realist evaluation are often used interchangeably. Diverging views exist regarding the nature of ‘mechanism’ and the difference between mechanism and essential context condition. A lack of methodological guidance was highlighted by many authors. Realist evaluation is slowly gaining traction in health systems research, but more clarity is needed concerning the definitions of mechanisms and context and how the configuration of context, mechanism and intervention can be described and assessed.

Health systems frameworks in their political context: framing divergent agendas

BackgroundDespite the mounting attention for health systems and health systems theories, there is a persisting lack of consensus on their conceptualisation and strengthening. This paper contributes to structuring the debate, presenting landmarks in the development of health systems thinking against the backdrop of the policy context and its dominant actors. We argue that frameworks on health systems are products of their time, emerging from specific discourses. They are purposive, not neutrally descriptive, and are shaped by the agendas of their authors.DiscussionThe evolution of thinking over time does not reflect a progressive accumulation of insights. Instead, theories and frameworks seem to develop in reaction to one another, partly in line with prevailing paradigms and partly as a response to the very different needs of their developers. The reform perspective considering health systems as projects to be engineered is fundamentally different from the organic view that considers a health system as a mirror of society. The co-existence of health systems and disease-focused approaches indicates that different frameworks are complementary but not synthetic.The contestation of theories and methods for health systems relates almost exclusively to low income countries. At the global level, health system strengthening is largely narrowed down to its instrumental dimension, whereby well-targeted and specific interventions are supposed to strengthen health services and systems or, more selectively, specific core functions essential to programmes. This is in contrast to a broader conceptualization of health systems as social institutions.SummaryHealth systems theories and frameworks frame health, health systems and policies in particular political and public health paradigms. While there is a clear trend to try to understand the complexity of and dynamic relationships between elements of health systems, there is also a demand to provide frameworks that distinguish between health system interventions, and that allow mapping with a view of analysing their returns. The choice for a particular health system model to guide discussions and work should fit the purpose. The understanding of the underlying rationale of a chosen model facilitates an open dialogue about purpose and strategy.

Primary Health Care in the 21st century: primary care providers and people’s empowerment

International health debates often confront enduring values with new realities. The events and publications surrounding the 30th anniversary of Alma Ata, the Primary Health Care (PHC) focus of the 2008 World Health Report and the report(s) of the Commission on Social Determinants of Health illustrate the durability of PHC values such as equity, self-determination, participation, trans-sectoral collaboration and the right to health (Gilson et al. 2007; Chan 2008; Lawn et al. 2008; Reich et al. 2008; Walley et al. 2008; World Health Organisation 2008; Hanson et al. 2009). Taking into account recent transitions that are changing the relationship between primary care providers and their patients, we examine that the role providers can play in enhancing people’s individual and collective empowerment, an important but rather neglected component of PHC (Walley et al. 2008).

Process evaluation of a mobile health intervention for people with diabetes in low income countries – the implementation of the TEXT4DSM study

Introduction Evidence about mobile health (mHealth) approaches to manage diabetes shows modest effects on outcomes, but little is known about implementation variability. This is a process evaluation of an mHealth intervention to improve diabetes self-management through Short Message Service (SMS) provision in three diabetes care programmes in the Democratic Republic of Congo (DRC), Cambodia and the Philippines. Methods The intervention involved Diabetes Self-Management Support via text messages. The content and process of the intervention is based upon the core principles of diabetes self-management and behaviour theory. In each country, messages were sent by project managers to 240 participants in each country, who were randomly assigned to the intervention group. Contracts were negotiated with national phone providers and open access software was used to send the messages. Participants received a mobile phone and SIM card. We analysed data about the implementation process over a one year period. Results The mean monthly number of messages delivered to recipients’ phones was 67.7% of the planned number in DRC, 92.3% in Cambodia and 83.9% in the Philippines. A telephone check revealed problems with one-third of the phones, including breakage, loss and cancelled subscriptions. The number of people reached at least once was 177 (70.0%) in DRC; 147 (60.7%) in Cambodia; five in the Philippines (2.0%). Those reached each time was 144 in DRC (56.9%), 28 (9.9%) in Cambodia, none in the Philippines. People used their phone more frequently than before the intervention. Discussion Implementation of the intervention meets constraints at every step in the process. Barriers relate to the technology, the context and the participants.

The effect of text message support on diabetes self-management in developing countries: a randomised trial.

Highlights • Report of a randomised trial on an mHealth intervention in 3 low income countries.• There was no additional effect of the text message self-management support.• Coverage, routine care and disease progression interfere with the potential impact.

Partnerships In Health Markets Need Regulation

written permission from the Publisher. All rights reserved. mechanical, including photocopying or by information storage or retrieval systems, without prior may be reproduced, displayed, or transmitted in any form or by any means, electronic or Affairs Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of by Project HOPE The People-to-People Health 2011 Bethesda, MD 20814-6133. Copyright