The pursuit of qualitative social research can be generally viewed as a continuous communication process between the researcher and the field of study. Observations and interactions need to be systematically written down as field notes and be reflected by the researcher in order to refine hypotheses and questions towards the field (Przyborski and Wohlrab-Sahr 2008). This also informed the sampling process to conduct the expert interviews. In this sense, participant observation in the actual
60 working context of Malawian public health professionals constitutes the backbone of this study.
During the field research phase I had the opportunity to participate in a range of meetings and events concerning the subject of HRH and development assistance in Malawi. All of these meetings involved Malawian as well as international participants, which allowed me to make observations on the immediate interactions between those parties and on the roles that individual participants fulfilled. In these settings I was usually introduced - or I introduced myself - as a German PhD-student working on HRH and hosted by the GDC. Moreover, I had individual appointments or informal conversations with key informants working in this field. Due to the above mentioned network, many of those informants were deployed as technical assistants and were either German or of European or US-American origin. Some of the authors who conducted studies commissioned by the GDC also agreed to give me an interview, and I had the opportunity to participate in a ‘peer review’ meeting on these studies.
Furthermore, I talked to some Malawian authors of articles on HRH which have been published in international journals. There were also a number of informal contacts with Malawian health professionals and students, for example as I was staying in a nursing school dormitory during my time in Zomba. These meetings and encounters I have noted down and reflected in my field notes. For an outline of the field research, see Annex 7.3.
The study in its present form, including the six months’ field research phase in Malawi, was only possible through the financial support of Hans-Böckler-Foundation, flexible work arrangements of the researcher, and the specific institutional background and linkages at Bielefeld University. Along with these enabling resources, however, come certain constraints such as being a singular researcher in an unfamiliar geographical and cultural setting, having a time-limited field access, and communicating and analysing data in a foreign language. I have aimed to reflect the effects of both the opportunities and constraints on the scope and depth of the research, and to integrate this into the analysis.
61 3.2.3 EXPERT INTERVIEWS
The method of open, theory-generating expert interviews (Meuser and Nagel 2005) was applied to capture the special role of health professionals who are holding a leading position within their organisation. The interviews were aimed at finding out about the transnational contacts and collaborations and the mobility of these professionals. Furthermore, their idea of Public Health and their personal involvement with human resource management, capacity development and policy making were of interest.
The group of Public Health practitioners has received little attention in the international research on Human Resources for Health (HRH) so far, the focus usually being put on medical doctors and nurses. The assessment of the Public Health workforce is often hampered by problems of definition. Beaglehole and Dal Poz (2003) highlight that even the term ‘Public Health’ is used with a variety of meanings, e.g.
referring to a condition, a discipline, an infrastructure or a philosophy. They refer to Public Health professionals in a very broad manner as those who are mainly carrying out non-personal health services, irrespective of their organisational base. The AfriHealth project differentiates between field level Public Health staff (e.g. laboratory personnel and staff offering immunisation and screening services) and Public Health professionals. The latter are defined as “those responsible for providing leadership and expert knowledge to health systems at district, provincial, national and international level to manage the health of the public” (Ijsselmuiden et al. 2007, p.914). Such professionals are not only working in the governmental service, but international aid agencies and non-governmental or private actors involved in the health sector of developing countries require similarly qualified staff for planning, implementing and evaluating projects and programmes.
Health workers might be primarily qualified for personal health service provision, but can be deployed to carry out non-personal health services. Similarly, they may have qualified in neighbouring disciplines, but specialise in health-specific activities and even acquire a Master of Public Health (MPH). For the purpose of this study, particularly the sampling, the term health workers is therefore used in the larger
62 sense. It includes qualified clinical, nursing and environmental health personnel as well as social scientists, managers and administrators working in the health field.
Sampling
Due to my limited period of stay in Malawi, it was not possible to synchronise the collection of primary data with the unfolding analysis. Instead, my approach was to develop a sampling matrix and determine the requirements for study participants ‘ex ante’. This is aimed at covering the major dimensions supposedly shaping the field of study. At the same time, it is giving leeway to enlarge the sample if new theoretical aspects occur during the data collection phase (Merkens 2005; Przyborski and Wohlrab-Sahr 2008).
The following general inclusion criteria were used to define local professional experts in the health sector:
• Malawian origin
• academic qualification in health and/or related sciences (public health, medicine, nursing, management/economics)
• currently holding a leading position in the health sector or a consultancy contract, working at least at district level or comparable position
• working in a development aid context (contractual relations or collaboration, remuneration (co-)financed by international development aid)
For reasons of anonymity, the composition of the sample can only be presented at an aggregate level in the form of cross-tabulations, see tables 1 and 2.
qualification/employer MoH NGO/CHAM University self-employed Total
Medical doctor 4 1 1 6
Clinical Officer 1 1
Nurse 1 3 4
Env. Health Officer 3 1 4
Administrator 3 1 4
Social Scientist 1 2 2 1 6
total 13 6 3 3 25
Table 1: Distribution of initial qualification and current employer among the interview partners (n=25)
63 In total, 25 expert interviews were carried out. Interview partners were identified through staff of the GDC or the COM, through the NGO register and through snowball sampling. For the research not to interfere or to be confused with evaluation and supervision activities, I preferably contacted potential participants personally or by phone call, rather than being introduced by third parties. Having acquired ethical approval by COMREC, I could approach participants working in the public sector directly. As the sample of interview partners consisted of health personnel in leading positions, it was not necessary to approach superior levels of management as a first step to gain approval.
Age group / sex male female total
≤34 years 4 7 11
35-49 years 6 2 8
≥50 years 5 1 6
total 15 10 25
Table 2: Distribution of age and sex among the interview partners (n=25)
I aimed at including participants working in various geographic regions of Malawi and at different hierarchical levels within their respective organisation, at reaching a relatively even distribution of age groups and sexes, and at covering the spectrum of relevant professions as differentially as possible.
Developing the interview guideline
As leaders and decision makers, Public Health professionals would be in a position to influence the political process by their professional engagement and interpretative authority. Regarding the field of HRH, they have a potential double function as policy makers (or policy translators at least) and policy targets. They often have considerable experience as interviewees and informants in the context of health sector development. Due to this specific position of the interview partners within the research field and in relation to the researcher (having the same professional background), I decided to change the method from biographic to expert interviews upon my arrival in Malawi. The theory-generating expert interview, based on Meuser and Nagel (2005) and further differentiated by Bogner and Menz (2005), proved to be
64 a more suitable approach to data collection. According to these authors, expert interviews mainly fulfil the purpose of reconstructing expert knowledge in the sense of operational knowledge about their specific field of action. Operational knowlegde can be distinguished into exclusive technical or institutional know-how on the one hand, and into interpretations or appraisals of circumstances and situations on the other hand. The latter is of relevance precisely because the experts are attributed or take over a prominent role in a field of action, which comes along with interpretative authority and often with the authority to make decisions. Both forms of knowledge can be covered within the same interview, but require different interview strategies (Przyborski and Wohlrab-Sahr 2008).
Usually a semi-structured interview guideline is applied to focus the expert interview to the area of interest. This also gives credit to the often limited amount of time that experts can make available, and to the status constellation of interviewer and interviewee in the interview situation. Przyborski & Wohlrab-Sahr (2008) highlight that, as any guideline interview, expert interviews should only be considered a qualitative method if the interview partner is given sufficient leeway to explicate and amplify those aspects that he or she considers relevant. The interview guideline should therefore stimulate narrations and detailed descriptions and be handled in a very flexible way, in order to not force the accounts of the interview partner into a direction preconceived by the researcher. Interview material produced in this way can then be submitted to interpretative and reconstructive analysis.
The interview guideline was slightly amended throughout the 6 months of field research, especially to include some more questions on the issue of personal leadership experience. Annex 7.5 shows the last version of the guideline. The interviews were started with an initial stimulus for the participants to tell about their own career and professional development – a tribute to the originally pursued biographic approach. Probing questions were inserted particularly on episodes that involved international contacts and exchange. The interview guideline then included questions about future career aspirations, leadership and human resource management, personal understanding of public health, involvement in policy making and consultancy activities. Interfaces with international agencies or partners were
65 covered, as well as their view of the Malawian health system and its human resource problems. The order of the questions was adapted to the individual course of the interview and the topics that the interview partners raised.
Conducting the interviews
The interviews were mostly carried out at the interviewees’ workplace; two interviews took place at the GDC office and five were conducted in restaurants. The duration of the interviews ranged from 40 minutes to 3 hours, with the majority taking approximately 1 hour. Upon first contact, I informed the potential study participants about my research intent. I then asked them whether they would be willing to give an open interview and whether they would accept me visiting their workplace. The consent form included a short description of the research project and issues of data handling (see Annex 7.4).
I considered the consent form mainly as a commitment on behalf of the researcher, which is why I handed it over to the participant to read and to remain with him or her.
Consent was generally asked verbally, before the start of the interview. In 23 out of 25 cases the interview partner accepted the use of a digital recorder, while the other two were documented in writing after the interview. I generally wrote down field notes on the interview situation and other observations on the same day of the interviews.
66 3.3 DATA PREPARATION AND ANALYSIS
The Institutional Analysis and Development (IAD) framework is applied for the analysis as well as the synthesis of the different types of data gathered on HRH in Malawi. The framework is rooted in games theory on the one hand, and large numbers of case studies of resource systems on the other hand. It therefore provides for the conduct of rational-choice oriented games in the lab as well as for empirical field research.
Ostrom (2005) explains that using the framework in field research means to make summaries of legal, written or oral statements which are or relevance to the action arena under study: “the researcher’s task is to discover the linguistic statements that form the institutional basis for shared expectations and potentially for the observed regularity in behaviour” (p. 171).
Within the overall IAD framework, two practical analytical methods are pursued, namely structural data analysis according to Lueger (2010) for documents and secondary statistics, and thematic analysis according to Froschauer and Lueger (2003) for the interview data. These will be outlined in the following (chapter 3.3.1 and 3.3.2).
Some relevant components from the IAD framework and their application to the subject of this study are then described in the final part (chapter 3.3.3).