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Case Study – Methods, Examples and Guide

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A case study is a research method that involves an in-depth examination and analysis of a particular phenomenon or case, such as an individual, organization, community, event, or situation.

It is a qualitative research approach that aims to provide a detailed and comprehensive understanding of the case being studied. Case studies typically involve multiple sources of data, including interviews, observations, documents, and artifacts, which are analyzed using various techniques, such as content analysis, thematic analysis, and grounded theory. The findings of a case study are often used to develop theories, inform policy or practice, or generate new research questions.

Types of Case Study

Types and Methods of Case Study are as follows:

Single-Case Study

A single-case study is an in-depth analysis of a single case. This type of case study is useful when the researcher wants to understand a specific phenomenon in detail.

For Example , A researcher might conduct a single-case study on a particular individual to understand their experiences with a particular health condition or a specific organization to explore their management practices. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of a single-case study are often used to generate new research questions, develop theories, or inform policy or practice.

Multiple-Case Study

A multiple-case study involves the analysis of several cases that are similar in nature. This type of case study is useful when the researcher wants to identify similarities and differences between the cases.

For Example, a researcher might conduct a multiple-case study on several companies to explore the factors that contribute to their success or failure. The researcher collects data from each case, compares and contrasts the findings, and uses various techniques to analyze the data, such as comparative analysis or pattern-matching. The findings of a multiple-case study can be used to develop theories, inform policy or practice, or generate new research questions.

Exploratory Case Study

An exploratory case study is used to explore a new or understudied phenomenon. This type of case study is useful when the researcher wants to generate hypotheses or theories about the phenomenon.

For Example, a researcher might conduct an exploratory case study on a new technology to understand its potential impact on society. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as grounded theory or content analysis. The findings of an exploratory case study can be used to generate new research questions, develop theories, or inform policy or practice.

Descriptive Case Study

A descriptive case study is used to describe a particular phenomenon in detail. This type of case study is useful when the researcher wants to provide a comprehensive account of the phenomenon.

For Example, a researcher might conduct a descriptive case study on a particular community to understand its social and economic characteristics. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of a descriptive case study can be used to inform policy or practice or generate new research questions.

Instrumental Case Study

An instrumental case study is used to understand a particular phenomenon that is instrumental in achieving a particular goal. This type of case study is useful when the researcher wants to understand the role of the phenomenon in achieving the goal.

For Example, a researcher might conduct an instrumental case study on a particular policy to understand its impact on achieving a particular goal, such as reducing poverty. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of an instrumental case study can be used to inform policy or practice or generate new research questions.

Case Study Data Collection Methods

Here are some common data collection methods for case studies:

Interviews involve asking questions to individuals who have knowledge or experience relevant to the case study. Interviews can be structured (where the same questions are asked to all participants) or unstructured (where the interviewer follows up on the responses with further questions). Interviews can be conducted in person, over the phone, or through video conferencing.

Observations

Observations involve watching and recording the behavior and activities of individuals or groups relevant to the case study. Observations can be participant (where the researcher actively participates in the activities) or non-participant (where the researcher observes from a distance). Observations can be recorded using notes, audio or video recordings, or photographs.

Documents can be used as a source of information for case studies. Documents can include reports, memos, emails, letters, and other written materials related to the case study. Documents can be collected from the case study participants or from public sources.

Surveys involve asking a set of questions to a sample of individuals relevant to the case study. Surveys can be administered in person, over the phone, through mail or email, or online. Surveys can be used to gather information on attitudes, opinions, or behaviors related to the case study.

Artifacts are physical objects relevant to the case study. Artifacts can include tools, equipment, products, or other objects that provide insights into the case study phenomenon.

How to conduct Case Study Research

Conducting a case study research involves several steps that need to be followed to ensure the quality and rigor of the study. Here are the steps to conduct case study research:

Define the research questions: The first step in conducting a case study research is to define the research questions. The research questions should be specific, measurable, and relevant to the case study phenomenon under investigation.
Select the case: The next step is to select the case or cases to be studied. The case should be relevant to the research questions and should provide rich and diverse data that can be used to answer the research questions.
Collect data: Data can be collected using various methods, such as interviews, observations, documents, surveys, and artifacts. The data collection method should be selected based on the research questions and the nature of the case study phenomenon.
Analyze the data: The data collected from the case study should be analyzed using various techniques, such as content analysis, thematic analysis, or grounded theory. The analysis should be guided by the research questions and should aim to provide insights and conclusions relevant to the research questions.
Draw conclusions: The conclusions drawn from the case study should be based on the data analysis and should be relevant to the research questions. The conclusions should be supported by evidence and should be clearly stated.
Validate the findings: The findings of the case study should be validated by reviewing the data and the analysis with participants or other experts in the field. This helps to ensure the validity and reliability of the findings.
Write the report: The final step is to write the report of the case study research. The report should provide a clear description of the case study phenomenon, the research questions, the data collection methods, the data analysis, the findings, and the conclusions. The report should be written in a clear and concise manner and should follow the guidelines for academic writing.

Examples of Case Study

Here are some examples of case study research:

The Hawthorne Studies : Conducted between 1924 and 1932, the Hawthorne Studies were a series of case studies conducted by Elton Mayo and his colleagues to examine the impact of work environment on employee productivity. The studies were conducted at the Hawthorne Works plant of the Western Electric Company in Chicago and included interviews, observations, and experiments.
The Stanford Prison Experiment: Conducted in 1971, the Stanford Prison Experiment was a case study conducted by Philip Zimbardo to examine the psychological effects of power and authority. The study involved simulating a prison environment and assigning participants to the role of guards or prisoners. The study was controversial due to the ethical issues it raised.
The Challenger Disaster: The Challenger Disaster was a case study conducted to examine the causes of the Space Shuttle Challenger explosion in 1986. The study included interviews, observations, and analysis of data to identify the technical, organizational, and cultural factors that contributed to the disaster.
The Enron Scandal: The Enron Scandal was a case study conducted to examine the causes of the Enron Corporation’s bankruptcy in 2001. The study included interviews, analysis of financial data, and review of documents to identify the accounting practices, corporate culture, and ethical issues that led to the company’s downfall.
The Fukushima Nuclear Disaster : The Fukushima Nuclear Disaster was a case study conducted to examine the causes of the nuclear accident that occurred at the Fukushima Daiichi Nuclear Power Plant in Japan in 2011. The study included interviews, analysis of data, and review of documents to identify the technical, organizational, and cultural factors that contributed to the disaster.

Application of Case Study

Case studies have a wide range of applications across various fields and industries. Here are some examples:

Business and Management

Case studies are widely used in business and management to examine real-life situations and develop problem-solving skills. Case studies can help students and professionals to develop a deep understanding of business concepts, theories, and best practices.

Case studies are used in healthcare to examine patient care, treatment options, and outcomes. Case studies can help healthcare professionals to develop critical thinking skills, diagnose complex medical conditions, and develop effective treatment plans.

Case studies are used in education to examine teaching and learning practices. Case studies can help educators to develop effective teaching strategies, evaluate student progress, and identify areas for improvement.

Social Sciences

Case studies are widely used in social sciences to examine human behavior, social phenomena, and cultural practices. Case studies can help researchers to develop theories, test hypotheses, and gain insights into complex social issues.

Law and Ethics

Case studies are used in law and ethics to examine legal and ethical dilemmas. Case studies can help lawyers, policymakers, and ethical professionals to develop critical thinking skills, analyze complex cases, and make informed decisions.

Purpose of Case Study

The purpose of a case study is to provide a detailed analysis of a specific phenomenon, issue, or problem in its real-life context. A case study is a qualitative research method that involves the in-depth exploration and analysis of a particular case, which can be an individual, group, organization, event, or community.

The primary purpose of a case study is to generate a comprehensive and nuanced understanding of the case, including its history, context, and dynamics. Case studies can help researchers to identify and examine the underlying factors, processes, and mechanisms that contribute to the case and its outcomes. This can help to develop a more accurate and detailed understanding of the case, which can inform future research, practice, or policy.

Case studies can also serve other purposes, including:

Illustrating a theory or concept: Case studies can be used to illustrate and explain theoretical concepts and frameworks, providing concrete examples of how they can be applied in real-life situations.
Developing hypotheses: Case studies can help to generate hypotheses about the causal relationships between different factors and outcomes, which can be tested through further research.
Providing insight into complex issues: Case studies can provide insights into complex and multifaceted issues, which may be difficult to understand through other research methods.
Informing practice or policy: Case studies can be used to inform practice or policy by identifying best practices, lessons learned, or areas for improvement.

Advantages of Case Study Research

There are several advantages of case study research, including:

In-depth exploration: Case study research allows for a detailed exploration and analysis of a specific phenomenon, issue, or problem in its real-life context. This can provide a comprehensive understanding of the case and its dynamics, which may not be possible through other research methods.
Rich data: Case study research can generate rich and detailed data, including qualitative data such as interviews, observations, and documents. This can provide a nuanced understanding of the case and its complexity.
Holistic perspective: Case study research allows for a holistic perspective of the case, taking into account the various factors, processes, and mechanisms that contribute to the case and its outcomes. This can help to develop a more accurate and comprehensive understanding of the case.
Theory development: Case study research can help to develop and refine theories and concepts by providing empirical evidence and concrete examples of how they can be applied in real-life situations.
Practical application: Case study research can inform practice or policy by identifying best practices, lessons learned, or areas for improvement.
Contextualization: Case study research takes into account the specific context in which the case is situated, which can help to understand how the case is influenced by the social, cultural, and historical factors of its environment.

Limitations of Case Study Research

There are several limitations of case study research, including:

Limited generalizability : Case studies are typically focused on a single case or a small number of cases, which limits the generalizability of the findings. The unique characteristics of the case may not be applicable to other contexts or populations, which may limit the external validity of the research.
Biased sampling: Case studies may rely on purposive or convenience sampling, which can introduce bias into the sample selection process. This may limit the representativeness of the sample and the generalizability of the findings.
Subjectivity: Case studies rely on the interpretation of the researcher, which can introduce subjectivity into the analysis. The researcher’s own biases, assumptions, and perspectives may influence the findings, which may limit the objectivity of the research.
Limited control: Case studies are typically conducted in naturalistic settings, which limits the control that the researcher has over the environment and the variables being studied. This may limit the ability to establish causal relationships between variables.
Time-consuming: Case studies can be time-consuming to conduct, as they typically involve a detailed exploration and analysis of a specific case. This may limit the feasibility of conducting multiple case studies or conducting case studies in a timely manner.
Resource-intensive: Case studies may require significant resources, including time, funding, and expertise. This may limit the ability of researchers to conduct case studies in resource-constrained settings.

About the author

Muhammad Hassan

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The Ultimate Guide to Qualitative Research - Part 1: The Basics

Introduction and overview
What is qualitative research?
What is qualitative data?
Examples of qualitative data
Qualitative vs. quantitative research
Mixed methods
Qualitative research preparation
Theoretical perspective
Theoretical framework
Literature reviews

Research question

Conceptual framework
Conceptual vs. theoretical framework

Data collection

Qualitative research methods
Focus groups
Observational research

What is a case study?

Applications for case study research, what is a good case study, process of case study design, benefits and limitations of case studies.

Ethnographical research
Ethical considerations
Confidentiality and privacy
Power dynamics
Reflexivity

Case studies

Case studies are essential to qualitative research , offering a lens through which researchers can investigate complex phenomena within their real-life contexts. This chapter explores the concept, purpose, applications, examples, and types of case studies and provides guidance on how to conduct case study research effectively.

Whereas quantitative methods look at phenomena at scale, case study research looks at a concept or phenomenon in considerable detail. While analyzing a single case can help understand one perspective regarding the object of research inquiry, analyzing multiple cases can help obtain a more holistic sense of the topic or issue. Let's provide a basic definition of a case study, then explore its characteristics and role in the qualitative research process.

Definition of a case study

A case study in qualitative research is a strategy of inquiry that involves an in-depth investigation of a phenomenon within its real-world context. It provides researchers with the opportunity to acquire an in-depth understanding of intricate details that might not be as apparent or accessible through other methods of research. The specific case or cases being studied can be a single person, group, or organization – demarcating what constitutes a relevant case worth studying depends on the researcher and their research question .

Among qualitative research methods , a case study relies on multiple sources of evidence, such as documents, artifacts, interviews , or observations , to present a complete and nuanced understanding of the phenomenon under investigation. The objective is to illuminate the readers' understanding of the phenomenon beyond its abstract statistical or theoretical explanations.

Characteristics of case studies

Case studies typically possess a number of distinct characteristics that set them apart from other research methods. These characteristics include a focus on holistic description and explanation, flexibility in the design and data collection methods, reliance on multiple sources of evidence, and emphasis on the context in which the phenomenon occurs.

Furthermore, case studies can often involve a longitudinal examination of the case, meaning they study the case over a period of time. These characteristics allow case studies to yield comprehensive, in-depth, and richly contextualized insights about the phenomenon of interest.

The role of case studies in research

Case studies hold a unique position in the broader landscape of research methods aimed at theory development. They are instrumental when the primary research interest is to gain an intensive, detailed understanding of a phenomenon in its real-life context.

In addition, case studies can serve different purposes within research - they can be used for exploratory, descriptive, or explanatory purposes, depending on the research question and objectives. This flexibility and depth make case studies a valuable tool in the toolkit of qualitative researchers.

Remember, a well-conducted case study can offer a rich, insightful contribution to both academic and practical knowledge through theory development or theory verification, thus enhancing our understanding of complex phenomena in their real-world contexts.

What is the purpose of a case study?

Case study research aims for a more comprehensive understanding of phenomena, requiring various research methods to gather information for qualitative analysis . Ultimately, a case study can allow the researcher to gain insight into a particular object of inquiry and develop a theoretical framework relevant to the research inquiry.

Why use case studies in qualitative research?

Using case studies as a research strategy depends mainly on the nature of the research question and the researcher's access to the data.

Conducting case study research provides a level of detail and contextual richness that other research methods might not offer. They are beneficial when there's a need to understand complex social phenomena within their natural contexts.

The explanatory, exploratory, and descriptive roles of case studies

Case studies can take on various roles depending on the research objectives. They can be exploratory when the research aims to discover new phenomena or define new research questions; they are descriptive when the objective is to depict a phenomenon within its context in a detailed manner; and they can be explanatory if the goal is to understand specific relationships within the studied context. Thus, the versatility of case studies allows researchers to approach their topic from different angles, offering multiple ways to uncover and interpret the data .

The impact of case studies on knowledge development

Case studies play a significant role in knowledge development across various disciplines. Analysis of cases provides an avenue for researchers to explore phenomena within their context based on the collected data.

This can result in the production of rich, practical insights that can be instrumental in both theory-building and practice. Case studies allow researchers to delve into the intricacies and complexities of real-life situations, uncovering insights that might otherwise remain hidden.

Types of case studies

In qualitative research , a case study is not a one-size-fits-all approach. Depending on the nature of the research question and the specific objectives of the study, researchers might choose to use different types of case studies. These types differ in their focus, methodology, and the level of detail they provide about the phenomenon under investigation.

Understanding these types is crucial for selecting the most appropriate approach for your research project and effectively achieving your research goals. Let's briefly look at the main types of case studies.

Exploratory case studies

Exploratory case studies are typically conducted to develop a theory or framework around an understudied phenomenon. They can also serve as a precursor to a larger-scale research project. Exploratory case studies are useful when a researcher wants to identify the key issues or questions which can spur more extensive study or be used to develop propositions for further research. These case studies are characterized by flexibility, allowing researchers to explore various aspects of a phenomenon as they emerge, which can also form the foundation for subsequent studies.

Descriptive case studies

Descriptive case studies aim to provide a complete and accurate representation of a phenomenon or event within its context. These case studies are often based on an established theoretical framework, which guides how data is collected and analyzed. The researcher is concerned with describing the phenomenon in detail, as it occurs naturally, without trying to influence or manipulate it.

Explanatory case studies

Explanatory case studies are focused on explanation - they seek to clarify how or why certain phenomena occur. Often used in complex, real-life situations, they can be particularly valuable in clarifying causal relationships among concepts and understanding the interplay between different factors within a specific context.

Intrinsic, instrumental, and collective case studies

These three categories of case studies focus on the nature and purpose of the study. An intrinsic case study is conducted when a researcher has an inherent interest in the case itself. Instrumental case studies are employed when the case is used to provide insight into a particular issue or phenomenon. A collective case study, on the other hand, involves studying multiple cases simultaneously to investigate some general phenomena.

Each type of case study serves a different purpose and has its own strengths and challenges. The selection of the type should be guided by the research question and objectives, as well as the context and constraints of the research.

The flexibility, depth, and contextual richness offered by case studies make this approach an excellent research method for various fields of study. They enable researchers to investigate real-world phenomena within their specific contexts, capturing nuances that other research methods might miss. Across numerous fields, case studies provide valuable insights into complex issues.

Critical information systems research

Case studies provide a detailed understanding of the role and impact of information systems in different contexts. They offer a platform to explore how information systems are designed, implemented, and used and how they interact with various social, economic, and political factors. Case studies in this field often focus on examining the intricate relationship between technology, organizational processes, and user behavior, helping to uncover insights that can inform better system design and implementation.

Health research

Health research is another field where case studies are highly valuable. They offer a way to explore patient experiences, healthcare delivery processes, and the impact of various interventions in a real-world context.

Case studies can provide a deep understanding of a patient's journey, giving insights into the intricacies of disease progression, treatment effects, and the psychosocial aspects of health and illness.

Asthma research studies

Specifically within medical research, studies on asthma often employ case studies to explore the individual and environmental factors that influence asthma development, management, and outcomes. A case study can provide rich, detailed data about individual patients' experiences, from the triggers and symptoms they experience to the effectiveness of various management strategies. This can be crucial for developing patient-centered asthma care approaches.

Other fields

Apart from the fields mentioned, case studies are also extensively used in business and management research, education research, and political sciences, among many others. They provide an opportunity to delve into the intricacies of real-world situations, allowing for a comprehensive understanding of various phenomena.

Case studies, with their depth and contextual focus, offer unique insights across these varied fields. They allow researchers to illuminate the complexities of real-life situations, contributing to both theory and practice.

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Understanding the key elements of case study design is crucial for conducting rigorous and impactful case study research. A well-structured design guides the researcher through the process, ensuring that the study is methodologically sound and its findings are reliable and valid. The main elements of case study design include the research question , propositions, units of analysis, and the logic linking the data to the propositions.

The research question is the foundation of any research study. A good research question guides the direction of the study and informs the selection of the case, the methods of collecting data, and the analysis techniques. A well-formulated research question in case study research is typically clear, focused, and complex enough to merit further detailed examination of the relevant case(s).

Propositions

Propositions, though not necessary in every case study, provide a direction by stating what we might expect to find in the data collected. They guide how data is collected and analyzed by helping researchers focus on specific aspects of the case. They are particularly important in explanatory case studies, which seek to understand the relationships among concepts within the studied phenomenon.

Units of analysis

The unit of analysis refers to the case, or the main entity or entities that are being analyzed in the study. In case study research, the unit of analysis can be an individual, a group, an organization, a decision, an event, or even a time period. It's crucial to clearly define the unit of analysis, as it shapes the qualitative data analysis process by allowing the researcher to analyze a particular case and synthesize analysis across multiple case studies to draw conclusions.

Argumentation

This refers to the inferential model that allows researchers to draw conclusions from the data. The researcher needs to ensure that there is a clear link between the data, the propositions (if any), and the conclusions drawn. This argumentation is what enables the researcher to make valid and credible inferences about the phenomenon under study.

Understanding and carefully considering these elements in the design phase of a case study can significantly enhance the quality of the research. It can help ensure that the study is methodologically sound and its findings contribute meaningful insights about the case.

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Conducting a case study involves several steps, from defining the research question and selecting the case to collecting and analyzing data . This section outlines these key stages, providing a practical guide on how to conduct case study research.

Defining the research question

The first step in case study research is defining a clear, focused research question. This question should guide the entire research process, from case selection to analysis. It's crucial to ensure that the research question is suitable for a case study approach. Typically, such questions are exploratory or descriptive in nature and focus on understanding a phenomenon within its real-life context.

Selecting and defining the case

The selection of the case should be based on the research question and the objectives of the study. It involves choosing a unique example or a set of examples that provide rich, in-depth data about the phenomenon under investigation. After selecting the case, it's crucial to define it clearly, setting the boundaries of the case, including the time period and the specific context.

Previous research can help guide the case study design. When considering a case study, an example of a case could be taken from previous case study research and used to define cases in a new research inquiry. Considering recently published examples can help understand how to select and define cases effectively.

Developing a detailed case study protocol

A case study protocol outlines the procedures and general rules to be followed during the case study. This includes the data collection methods to be used, the sources of data, and the procedures for analysis. Having a detailed case study protocol ensures consistency and reliability in the study.

The protocol should also consider how to work with the people involved in the research context to grant the research team access to collecting data. As mentioned in previous sections of this guide, establishing rapport is an essential component of qualitative research as it shapes the overall potential for collecting and analyzing data.

Collecting data

Gathering data in case study research often involves multiple sources of evidence, including documents, archival records, interviews, observations, and physical artifacts. This allows for a comprehensive understanding of the case. The process for gathering data should be systematic and carefully documented to ensure the reliability and validity of the study.

Analyzing and interpreting data

The next step is analyzing the data. This involves organizing the data , categorizing it into themes or patterns , and interpreting these patterns to answer the research question. The analysis might also involve comparing the findings with prior research or theoretical propositions.

Writing the case study report

The final step is writing the case study report . This should provide a detailed description of the case, the data, the analysis process, and the findings. The report should be clear, organized, and carefully written to ensure that the reader can understand the case and the conclusions drawn from it.

Each of these steps is crucial in ensuring that the case study research is rigorous, reliable, and provides valuable insights about the case.

The type, depth, and quality of data in your study can significantly influence the validity and utility of the study. In case study research, data is usually collected from multiple sources to provide a comprehensive and nuanced understanding of the case. This section will outline the various methods of collecting data used in case study research and discuss considerations for ensuring the quality of the data.

Interviews are a common method of gathering data in case study research. They can provide rich, in-depth data about the perspectives, experiences, and interpretations of the individuals involved in the case. Interviews can be structured , semi-structured , or unstructured , depending on the research question and the degree of flexibility needed.

Observations

Observations involve the researcher observing the case in its natural setting, providing first-hand information about the case and its context. Observations can provide data that might not be revealed in interviews or documents, such as non-verbal cues or contextual information.

Documents and artifacts

Documents and archival records provide a valuable source of data in case study research. They can include reports, letters, memos, meeting minutes, email correspondence, and various public and private documents related to the case.

These records can provide historical context, corroborate evidence from other sources, and offer insights into the case that might not be apparent from interviews or observations.

Physical artifacts refer to any physical evidence related to the case, such as tools, products, or physical environments. These artifacts can provide tangible insights into the case, complementing the data gathered from other sources.

Ensuring the quality of data collection

Determining the quality of data in case study research requires careful planning and execution. It's crucial to ensure that the data is reliable, accurate, and relevant to the research question. This involves selecting appropriate methods of collecting data, properly training interviewers or observers, and systematically recording and storing the data. It also includes considering ethical issues related to collecting and handling data, such as obtaining informed consent and ensuring the privacy and confidentiality of the participants.

Data analysis

Analyzing case study research involves making sense of the rich, detailed data to answer the research question. This process can be challenging due to the volume and complexity of case study data. However, a systematic and rigorous approach to analysis can ensure that the findings are credible and meaningful. This section outlines the main steps and considerations in analyzing data in case study research.

Organizing the data

The first step in the analysis is organizing the data. This involves sorting the data into manageable sections, often according to the data source or the theme. This step can also involve transcribing interviews, digitizing physical artifacts, or organizing observational data.

Categorizing and coding the data

Once the data is organized, the next step is to categorize or code the data. This involves identifying common themes, patterns, or concepts in the data and assigning codes to relevant data segments. Coding can be done manually or with the help of software tools, and in either case, qualitative analysis software can greatly facilitate the entire coding process. Coding helps to reduce the data to a set of themes or categories that can be more easily analyzed.

Identifying patterns and themes

After coding the data, the researcher looks for patterns or themes in the coded data. This involves comparing and contrasting the codes and looking for relationships or patterns among them. The identified patterns and themes should help answer the research question.

Interpreting the data

Once patterns and themes have been identified, the next step is to interpret these findings. This involves explaining what the patterns or themes mean in the context of the research question and the case. This interpretation should be grounded in the data, but it can also involve drawing on theoretical concepts or prior research.

Verification of the data

The last step in the analysis is verification. This involves checking the accuracy and consistency of the analysis process and confirming that the findings are supported by the data. This can involve re-checking the original data, checking the consistency of codes, or seeking feedback from research participants or peers.

Like any research method , case study research has its strengths and limitations. Researchers must be aware of these, as they can influence the design, conduct, and interpretation of the study.

Understanding the strengths and limitations of case study research can also guide researchers in deciding whether this approach is suitable for their research question . This section outlines some of the key strengths and limitations of case study research.

Benefits include the following:

Rich, detailed data: One of the main strengths of case study research is that it can generate rich, detailed data about the case. This can provide a deep understanding of the case and its context, which can be valuable in exploring complex phenomena.
Flexibility: Case study research is flexible in terms of design , data collection , and analysis . A sufficient degree of flexibility allows the researcher to adapt the study according to the case and the emerging findings.
Real-world context: Case study research involves studying the case in its real-world context, which can provide valuable insights into the interplay between the case and its context.
Multiple sources of evidence: Case study research often involves collecting data from multiple sources , which can enhance the robustness and validity of the findings.

On the other hand, researchers should consider the following limitations:

Generalizability: A common criticism of case study research is that its findings might not be generalizable to other cases due to the specificity and uniqueness of each case.
Time and resource intensive: Case study research can be time and resource intensive due to the depth of the investigation and the amount of collected data.
Complexity of analysis: The rich, detailed data generated in case study research can make analyzing the data challenging.
Subjectivity: Given the nature of case study research, there may be a higher degree of subjectivity in interpreting the data , so researchers need to reflect on this and transparently convey to audiences how the research was conducted.

Being aware of these strengths and limitations can help researchers design and conduct case study research effectively and interpret and report the findings appropriately.

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Knowledge Base

Methodology

What Is a Case Study? | Definition, Examples & Methods

What Is a Case Study? | Definition, Examples & Methods

Published on May 8, 2019 by Shona McCombes . Revised on November 20, 2023.

A case study is a detailed study of a specific subject, such as a person, group, place, event, organization, or phenomenon. Case studies are commonly used in social, educational, clinical, and business research.

A case study research design usually involves qualitative methods , but quantitative methods are sometimes also used. Case studies are good for describing , comparing, evaluating and understanding different aspects of a research problem .

When to do a case study, step 1: select a case, step 2: build a theoretical framework, step 3: collect your data, step 4: describe and analyze the case, other interesting articles.

A case study is an appropriate research design when you want to gain concrete, contextual, in-depth knowledge about a specific real-world subject. It allows you to explore the key characteristics, meanings, and implications of the case.

Case studies are often a good choice in a thesis or dissertation . They keep your project focused and manageable when you don’t have the time or resources to do large-scale research.

You might use just one complex case study where you explore a single subject in depth, or conduct multiple case studies to compare and illuminate different aspects of your research problem.

Case study examples
Research question	Case study
What are the ecological effects of wolf reintroduction?	Case study of wolf reintroduction in Yellowstone National Park
How do populist politicians use narratives about history to gain support?	Case studies of Hungarian prime minister Viktor Orbán and US president Donald Trump
How can teachers implement active learning strategies in mixed-level classrooms?	Case study of a local school that promotes active learning
What are the main advantages and disadvantages of wind farms for rural communities?	Case studies of three rural wind farm development projects in different parts of the country
How are viral marketing strategies changing the relationship between companies and consumers?	Case study of the iPhone X marketing campaign
How do experiences of work in the gig economy differ by gender, race and age?	Case studies of Deliveroo and Uber drivers in London

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Once you have developed your problem statement and research questions , you should be ready to choose the specific case that you want to focus on. A good case study should have the potential to:

Provide new or unexpected insights into the subject
Challenge or complicate existing assumptions and theories
Propose practical courses of action to resolve a problem
Open up new directions for future research

TipIf your research is more practical in nature and aims to simultaneously investigate an issue as you solve it, consider conducting action research instead.

Unlike quantitative or experimental research , a strong case study does not require a random or representative sample. In fact, case studies often deliberately focus on unusual, neglected, or outlying cases which may shed new light on the research problem.

Example of an outlying case studyIn the 1960s the town of Roseto, Pennsylvania was discovered to have extremely low rates of heart disease compared to the US average. It became an important case study for understanding previously neglected causes of heart disease.

However, you can also choose a more common or representative case to exemplify a particular category, experience or phenomenon.

Example of a representative case studyIn the 1920s, two sociologists used Muncie, Indiana as a case study of a typical American city that supposedly exemplified the changing culture of the US at the time.

While case studies focus more on concrete details than general theories, they should usually have some connection with theory in the field. This way the case study is not just an isolated description, but is integrated into existing knowledge about the topic. It might aim to:

Exemplify a theory by showing how it explains the case under investigation
Expand on a theory by uncovering new concepts and ideas that need to be incorporated
Challenge a theory by exploring an outlier case that doesn’t fit with established assumptions

To ensure that your analysis of the case has a solid academic grounding, you should conduct a literature review of sources related to the topic and develop a theoretical framework . This means identifying key concepts and theories to guide your analysis and interpretation.

There are many different research methods you can use to collect data on your subject. Case studies tend to focus on qualitative data using methods such as interviews , observations , and analysis of primary and secondary sources (e.g., newspaper articles, photographs, official records). Sometimes a case study will also collect quantitative data.

Example of a mixed methods case studyFor a case study of a wind farm development in a rural area, you could collect quantitative data on employment rates and business revenue, collect qualitative data on local people’s perceptions and experiences, and analyze local and national media coverage of the development.

The aim is to gain as thorough an understanding as possible of the case and its context.

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In writing up the case study, you need to bring together all the relevant aspects to give as complete a picture as possible of the subject.

How you report your findings depends on the type of research you are doing. Some case studies are structured like a standard scientific paper or thesis , with separate sections or chapters for the methods , results and discussion .

Others are written in a more narrative style, aiming to explore the case from various angles and analyze its meanings and implications (for example, by using textual analysis or discourse analysis ).

In all cases, though, make sure to give contextual details about the case, connect it back to the literature and theory, and discuss how it fits into wider patterns or debates.

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

Normal distribution
Degrees of freedom
Null hypothesis
Discourse analysis
Control groups
Mixed methods research
Non-probability sampling
Quantitative research
Ecological validity

Research bias

Rosenthal effect
Implicit bias
Cognitive bias
Selection bias
Negativity bias
Status quo bias

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Qualitative study design: Case Studies

Qualitative study design
Phenomenology
Grounded theory
Ethnography
Narrative inquiry
Action research

Case Studies

Field research
Focus groups
Observation
Surveys & questionnaires
Study Designs Home

In depth description of the experience of a single person, a family, a group, a community or an organisation.

An example of a qualitative case study is a life history which is the story of one specific person. A case study may be done to highlight a specific issue by telling a story of one person or one group.

Oral recording

Ability to explore and describe, in depth, an issue or event.

Develop an understanding of health, illness and health care in context.

Single case can be used to develop or disprove a theory.

Can be used as a model or prototype .

Limitations

Labour intensive and generates large diverse data sets which can be hard to manage.

Case studies are seen by many as a weak methodology because they only look at one person or one specific group and aren’t as broad in their participant selection as other methodologies.

Example questions

This methodology can be used to ask questions about a specific drug or treatment and its effects on an individual.

Does thalidomide cause birth defects?
Does exposure to a pesticide lead to cancer?

Example studies

Choi, T. S. T., Walker, K. Z., & Palermo, C. (2018). Diabetes management in a foreign land: A case study on Chinese Australians. Health & Social Care in the Community, 26(2), e225-e232.
Reade, I., Rodgers, W., & Spriggs, K. (2008). New Ideas for High Performance Coaches: A Case Study of Knowledge Transfer in Sport Science. International Journal of Sports Science & Coaching , 3(3), 335-354.
Wingrove, K., Barbour, L., & Palermo, C. (2017). Exploring nutrition capacity in Australia's charitable food sector. Nutrition & Dietetics , 74(5), 495-501.
Green, J., & Thorogood, N. (2018). Qualitative methods for health research (4th ed.). London: SAGE.
University of Missouri-St. Louis. Qualitative Research Designs. Retrieved from http://www.umsl.edu/~lindquists/qualdsgn.html
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Qualitative case study data analysis: an example from practice

Affiliation.

1 School of Nursing and Midwifery, National University of Ireland, Galway, Republic of Ireland.
PMID: 25976531
DOI: 10.7748/nr.22.5.8.e1307

Aim: To illustrate an approach to data analysis in qualitative case study methodology.

Background: There is often little detail in case study research about how data were analysed. However, it is important that comprehensive analysis procedures are used because there are often large sets of data from multiple sources of evidence. Furthermore, the ability to describe in detail how the analysis was conducted ensures rigour in reporting qualitative research.

Data sources: The research example used is a multiple case study that explored the role of the clinical skills laboratory in preparing students for the real world of practice. Data analysis was conducted using a framework guided by the four stages of analysis outlined by Morse ( 1994 ): comprehending, synthesising, theorising and recontextualising. The specific strategies for analysis in these stages centred on the work of Miles and Huberman ( 1994 ), which has been successfully used in case study research. The data were managed using NVivo software.

Review methods: Literature examining qualitative data analysis was reviewed and strategies illustrated by the case study example provided. Discussion Each stage of the analysis framework is described with illustration from the research example for the purpose of highlighting the benefits of a systematic approach to handling large data sets from multiple sources.

Conclusion: By providing an example of how each stage of the analysis was conducted, it is hoped that researchers will be able to consider the benefits of such an approach to their own case study analysis.

Implications for research/practice: This paper illustrates specific strategies that can be employed when conducting data analysis in case study research and other qualitative research designs.

Keywords: Case study data analysis; case study research methodology; clinical skills research; qualitative case study methodology; qualitative data analysis; qualitative research.

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Qualitative Case Study Methodology: Study Design and Implementation for Novice Researchers

Pamela Baxter , S. Jack
Published 1 December 2008
Education, Medicine
The Qualitative Report

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Definition of case study in qualitative research.

Home » Definition of Case Study in Qualitative Research

In the realm of qualitative research, understanding the definition of a case study is crucial. Through contextual in-depth analysis, researchers can explore complex phenomena within real-life contexts. This approach enables them to gather rich, detailed data that reveals the intricacies of participants' experiences and behaviors.

Case studies stand out for their ability to provide comprehensive insights into specific instances, allowing for a nuanced exploration of subjects. By employing contextual in-depth analysis, researchers can uncover patterns and themes that inform broader theoretical or practical implications. This method not only enhances understanding but also enriches the overall qualitative research experience.

What is a Case Study? A Contextual In-Depth Analysis

A case study is a detailed examination of a particular instance or event, providing valuable insights into its context and circumstances. It serves as a powerful method of qualitative research, allowing researchers to gather in-depth perspectives that quantitative data cannot offer. Through a contextual in-depth analysis, case studies explore the nuances of specific situations, revealing underlying patterns, motivations, and outcomes. This framework encourages a thorough understanding of the complexities involved, facilitating actionable conclusions that drive future decision-making.

In qualitative research, case studies are particularly effective in various fields, including healthcare, business, and education. They often encompass an array of data sources, such as interviews, observations, and document analysis. The key elements in conducting a contextual in-depth analysis include identifying the subject focus, collecting diverse data, and interpreting findings to highlight their significance. This comprehensive approach not only enhances knowledge about the specific case but also contributes to broader theories and practices within the discipline.

Historical Background of Case Studies

The evolution of case studies in qualitative research is marked by a progression toward a more contextual in-depth analysis. Originally rooted in disciplines like sociology and psychology, these studies emerged as a way to understand complex social phenomena through detailed examination. Researchers began to appreciate the intricate dynamics at play within specific cases, revealing layers of meaning often missed by quantitative approaches.

As case studies gained prominence, their methodology evolved, incorporating diverse perspectives from various fields. This approach allowed for the exploration of human behavior, cultural contexts, and real-world implications, thereby enriching the dataset produced by traditional research. Consequently, the historical background of case studies emphasizes their role in providing profound insights into human experiences, ultimately better equipping researchers to address contemporary issues in a more nuanced manner. Understanding this historical context is essential for grasping how case studies have become indispensable tools in qualitative research.

Key Characteristics of a Qualitative Case Study

A qualitative case study is characterized by its emphasis on contextual in-depth analysis, which allows researchers to explore complex phenomena within real-life contexts. This approach involves gathering rich, detailed information through various data collection methods, such as interviews, observations, and document analysis. The goal is to gain insights into participants' experiences and perspectives, offering a multifaceted view of the subject under investigation.

Key characteristics of qualitative case studies include their focus on a specific case, the use of diverse data sources, and an iterative analysis process. Researchers often engage deeply with their subjects, fostering a relationship that grants access to nuanced insights. Additionally, qualitative case studies are inherently flexible, allowing researchers to adapt their methods as new information emerges. This adaptability is crucial for preserving the depth and complexity inherent in real-world situations, which quantitative methods may overlook.

Conducting a Case Study: Steps for a Contextual In-Depth Analysis

When conducting a case study, the steps involved ensure a contextual in-depth analysis of the subject matter. The first step is to clearly define the research objectives to guide the entire investigation. Having a solid foundation allows researchers to focus on the essential questions that will uncover rich insights. Following that, selecting suitable data collection methods is crucial for gathering relevant information. This includes interviews, observations, and document reviews.

Next, organizing and analyzing the collected data requires careful attention. Researchers should look for patterns and themes while maintaining a contextual understanding of the subject. Additionally, documenting the findings can enhance the clarity of the analysis. Lastly, drawing conclusions and implications from the case study closes the loop, allowing for relevant recommendations. By systematically following these steps, a contextual in-depth analysis can be effectively achieved and contribute valuable insights.

Selecting a Case: Factors to Consider

Selecting an appropriate case for study requires careful consideration of several key factors. First, the context of the case is crucial. Understanding the setting, background, and conditions surrounding the case allows for a contextual in-depth analysis. A rich context not only enhances the quality of the insights gleaned but also adds depth to the research findings.

Additionally, it is essential to consider the significance of the case to the field of study. Selecting a case that addresses a pertinent issue or gap in the literature will contribute meaningfully to the discipline. Furthermore, the availability of data and accessibility of participants can significantly influence the feasibility of conducting an in-depth study. Selecting a case that aligns with these practical considerations will facilitate a more thorough exploration of the research questions. Ultimately, careful selection enhances the robustness and relevance of the findings.

Data Collection Methods in Qualitative Research

In qualitative research, data collection methods play a crucial role in gathering rich, contextual insights. Researchers often rely on techniques such as interviews, focus groups, and observations. Through these methods, data can be collected in ways that reveal deeper meaning, allowing for contextual in-depth analysis of participant experiences and perspectives. Gathering qualitative data emphasizes understanding the nuances within contexts, which can unveil complex relationships or themes relevant to the research focus.

For effective data collection, researchers should consider several key methods. First, semi-structured interviews provide flexibility, allowing for probing questions that yield detailed responses. Second, focus groups foster discussion among participants, generating diverse viewpoints that enrich the data set. Lastly, observational methods capture real-world behaviors and contexts, offering insight into participants' actions. By implementing these methods thoughtfully, researchers can enhance their data collection process, ultimately contributing to a robust understanding of the case study context.

Conclusion: The Importance of Contextual In-Depth Analysis in Defining Case Studies

In qualitative research, the significance of contextual in-depth analysis cannot be overstated. This approach transforms mere data collection into rich, nuanced insights. By examining circumstances surrounding each case, researchers gain a deeper understanding of the complexities involved. Effectively contextualized case studies not only highlight unique patterns but also help avoid oversimplification, enabling more robust conclusions.

Moreover, incorporating contextual in-depth analysis fosters a more comprehensive exploration of various factors influencing outcomes. This method equips researchers to interpret the emotional, social, and environmental dynamics at play. Ultimately, the careful consideration of context leads to a more accurate and holistic definition of case studies, enriching the overall qualitative research process.

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How can health systems approach reducing health inequalities? An in-depth qualitative case study in the UK

Charlotte Parbery-Clark 1 ,
Lorraine McSweeney 2 ,
Joanne Lally 3 &
Sarah Sowden 4

BMC Public Health volume 24 , Article number: 2168 ( 2024 ) Cite this article

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Addressing socioeconomic inequalities in health and healthcare, and reducing avoidable hospital admissions requires integrated strategy and complex intervention across health systems. However, the understanding of how to create effective systems to reduce socio-economic inequalities in health and healthcare is limited. The aim was to explore and develop a system’s level understanding of how local areas address health inequalities with a focus on avoidable emergency admissions.

In-depth case study using qualitative investigation (documentary analysis and key informant interviews) in an urban UK local authority. Interviewees were identified using snowball sampling. Documents were retrieved via key informants and web searches of relevant organisations. Interviews and documents were analysed independently based on a thematic analysis approach.

Interviews ( n = 14) with wide representation from local authority ( n = 8), NHS ( n = 5) and voluntary, community and social enterprise (VCSE) sector ( n = 1) with 75 documents (including from NHS, local authority, VCSE) were included. Cross-referenced themes were understanding the local context, facilitators of how to tackle health inequalities: the assets, and emerging risks and concerns. Addressing health inequalities in avoidable admissions per se was not often explicitly linked by either the interviews or documents and is not yet embedded into practice. However, a strong coherent strategic integrated population health management plan with a system’s approach to reducing health inequalities was evident as was collective action and involving people, with links to a “strong third sector”. Challenges reported include structural barriers and threats, the analysis and accessibility of data as well as ongoing pressures on the health and care system.

We provide an in-depth exploration of how a local area is working to address health and care inequalities. Key elements of this system’s working include fostering strategic coherence, cross-agency working, and community-asset based approaches. Areas requiring action included data sharing challenges across organisations and analytical capacity to assist endeavours to reduce health and care inequalities. Other areas were around the resilience of the system including the recruitment and retention of the workforce. More action is required to embed reducing health inequalities in avoidable admissions explicitly in local areas with inaction risking widening the health gap.

Highlights:

• Reducing health inequalities in avoidable hospital admissions is yet to be explicitly linked in practice and is an important area to address.

• Understanding the local context helps to identify existing assets and threats including the leverage points for action.

• Requiring action includes building the resilience of our complex systems by addressing structural barriers and threats as well as supporting the workforce (training and wellbeing with improved retention and recruitment) in addition to the analysis and accessibility of data across the system.

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Introduction

The health of our population is determined by the complex interaction of several factors which are either non-modifiable (such as age, genetics) or modifiable (such as the environment, social, economic conditions in which we live, our behaviours as well as our access to healthcare and its quality) [ 1 ]. Health inequalities are the avoidable and unfair systematic differences in health and healthcare across different population groups explained by the differences in distribution of power, wealth and resources which drive the conditions of daily life [ 2 , 3 ]. Essentially, health inequalities arise due to the systematic differences of the factors that influence our health. To effectively deal with most public health challenges, including reducing health inequalities and improving population health, broader integrated approaches [ 4 ] and an emphasis on systems is required [ 5 , 6 ] . A system is defined as ‘the set of actors, activities, and settings that are directly or indirectly perceived to have influence in or be affected by a given problem situation’ (p.198) [ 7 ]. In this case, the ‘given problem situation' is reducing health inequalities with a focus on avoidable admissions. Therefore, we must consider health systems, which are the organisations, resources and people aiming to improve or maintain health [ 8 , 9 ] of which health services provision is an aspect. In this study, the system considers NHS bodies, Integrated Care Systems, Local Authority departments, and the voluntary and community sector in a UK region.

A plethora of theories [ 10 ], recommended policies [ 3 , 11 , 12 , 13 ], frameworks [ 1 , 14 , 15 ], and tools [ 16 ] exist to help understand the existence of health inequalities as well as provide suggestions for improvement. However, it is reported that healthcare leaders feel under-skilled to reduce health inequalities [ 17 ]. A lack of clarity exists on how to achieve a system’s multi-agency coherence to reduce health inequalities systematically [ 17 , 18 ]. This is despite some countries having legal obligations to have a regard to the need to attend to health and healthcare inequalities. For example, the Health and Social Care Act 2012 [ 19 ], in England, mandated Clinical Commissioning Groups (CCGs), now transferred to Integrated Care Boards (ICBs) [ 20 ], to ‘have a regard to the need to reduce inequalities between patients with respect to their ability to access health services, and reduce inequalities between patients with respect to the outcomes achieved for them by the provision of health services’. The wider determinants of health must also be considered. For example, local areas have a mandatory requirement to have a joint strategic needs assessment (JSNA) and joint health and wellbeing strategy (JHWS) whose purpose is to ‘improve the health and wellbeing of the local community and reduce inequalities for all ages' [ 21 ] This includes addressing the wider determinants of health [ 21 ]. Furthermore, the hospital care costs to the NHS associated with socioeconomic inequalities has been previously reported at £4.8 billion a year due to excess hospitalisations [ 22 ]. Avoidable emergency admissions are admissions into hospital that are considered to be preventable with high-quality ambulatory care [ 23 ]. Both ambulatory care sensitive conditions (where effective personalised care based in the community can aid the prevention of needing an admission) and urgent care sensitive conditions (where a system on the whole should be able to treat and manage without an admission) are considered within this definition [ 24 ] (encompassing more than 100 International Classification of Diseases (ICD) codes). The disease burden sits disproportionately with our most disadvantaged communities, therefore highlighting the importance of addressing inequalities in hospital pressures in a concerted manner [ 25 , 26 ].

Research examining one component of an intervention, or even one part of the system, [ 27 ] or which uses specific research techniques to control for the system’s context [ 28 ] are considered as having limited use for identifying the key ingredients to achieve better population health and wellbeing [ 5 , 28 ]. Instead, systems thinking considers how the system’s components and sub-components interconnect and interrelate within and between each other (and indeed other systems) to gain an understanding of the mechanisms by which things work [ 29 , 30 ]. Complex interventions or work programmes may perform differently in varying contexts and through different mechanisms, and therefore cannot simply be replicated from one context to another to automatically achieve the same outcomes. Ensuring that research into systems and systems thinking considers real-world context, such as where individuals live, where policies are created and interventions are delivered, is vital [ 5 ]. How the context and implementation of complex or even simple interventions interact is viewed as becoming increasingly important [ 31 , 32 ]. Case study research methodology is founded on the ‘in-depth exploration of complex phenomena in their natural, or ‘real-life’, settings’ (p.2) [ 33 ]. Case study approaches can deepen the understanding of complexity addressing the ‘how’, ‘what’ and ‘why’ questions in a real-life context [ 34 ]. Researchers have highlighted the importance of engaging more deeply with case-based study methodology [ 31 , 33 ]. Previous case study research has shown promise [ 35 ] which we build on by exploring a systems lens to consider the local area’s context [ 16 ] within which the work is implemented. By using case-study methodology, our study aimed to explore and develop an in-depth understanding of how a local area addresses health inequalities, with a focus on avoidable hospital admissions. As part of this, systems processes were included.

Study design

This in-depth case study is part of an ongoing larger multiple (collective [ 36 ]) case study approach. An instrumental approach [ 34 ] was taken allowing an in-depth investigation of an issue, event or phenomenon, in its natural real-life context; referred to as a ‘naturalistic’ design [ 34 ]. Ethics approval was obtained by Newcastle University’s Ethics Committee (ref 13633/2020).

Study selection

This case study, alongside the other three cases, was purposively [ 36 ] chosen considering overall deprivation level of the area (Indices of Multiple Deprivation (IMD) [ 37 ]), their urban/rural location, differing geographical spread across the UK (highlighted in patient and public feedback and important for considering the North/South health divide [ 38 ]), and a pragmatic judgement of likely ability to achieve the depth of insight required [ 39 ]. In this paper, we report the findings from one of the case studies, an urban local authority in the Northern region of the UK with high levels of socioeconomic disadvantage. This area was chosen for this in-depth case analysis due to high-level of need, and prior to the COVID-19 pandemic (2009-2018) had experienced a trend towards reducing socioeconomic inequalities in avoidable hospital admission rates between neighbourhoods within the local area [ 40 ]. Thereby this case study represents an ‘unusual’ case [ 41 ] to facilitate learning regarding what is reported and considered to be the key elements required to reduce health inequalities, including inequalities in avoidable admissions, in a local area.

Semi-structured interviews

The key informants were identified iteratively through the documentary analysis and in consultation with the research advisory group. Initially board level committee members (including lay, managerial, and clinical members) within relevant local organisations were purposively identified. These individuals were systems leaders charged with the remit of tackling health inequalities and therefore well placed to identify both key personnel and documents. Snowball sampling [ 42 ] was undertaken thereafter whereby interviewees helped to identify additional key informants within the local system who were working on health inequalities, including avoidable emergency admissions, at a systems level. Interview questions were based on an iteratively developed topic guide (supplementary data 1), informed from previous work’s findings [ 43 ] and the research advisory network’s input. A study information sheet was emailed to perspective interviewees, and participants were asked to complete an e-consent form using Microsoft Forms [ 42 ]. Each interviewee was interviewed by either L.M. or C.P.-C. using the online platforms Zoom or Teams, and lasted up to one hour. Participants were informed of interviewers’ role, workplace as well as purpose of the study. Interviewees were asked a range of questions including any work relating to reducing health inequalities, particularly avoidable emergency admissions, within the last 5 years. Brief notes were taken, and the interviews were recorded, transcribed verbatim and anonymised.

Documentary analysis

The documentary analysis followed the READ approach [ 44 ]. Any documents from the relevant local/regional area with sections addressing health inequalities and/or avoidable emergency admissions, either explicitly stated or implicitly inferred, were included. A list of core documents was chosen, including the local Health and Wellbeing Strategy (Table 1 ). Subsequently, other documents were identified by snowballing from these core documents and identification by the interviewees. All document types were within scope if produced/covered a period within 5 years (2017-2022), including documents in the public domain or not as well as documents pertaining to either a regional, local and neighbourhood level. This 5-year period was a pragmatic decision in line with the interviews and considered to be a balance of legacy and relevance. Attempts were made to include the final version of each document, where possible/applicable, otherwise the most up-to-date version or version available was used.

An Excel spreadsheet data extraction tool was adapted with a priori criteria [ 44 ] to extract the data. This tool included contextual information (such as authors, target area and document’s purpose). Also, information based on previous research on addressing socioeconomic inequalities in avoidable emergency admissions, such as who stands to benefit, was extracted [ 43 ]. Additionally, all documents were summarised according to a template designed according to the research’s aims. Data extraction and summaries were undertaken by L.M. and C.P.-C. A selection was doubled coded to enhance validity and any discrepancies were resolved by discussion.

Interviews and documents were coded and analysed independently based on a thematic analysis approach [ 45 ], managed by NVivo software. A combination of ‘interpretive’ and ‘positivist’ stance [ 34 , 46 ] was taken which involved understanding meanings/contexts and processes as perceived from different perspectives (interviewees and documents). This allowed for an understanding of individual and shared social meanings/reasonings [ 34 , 36 ]. For the documentary analysis, a combination of both content and thematic analysis as described by Bowen [ 47 ] informed by Braun and Clarke’s approach to thematic analysis [ 45 ] was used. This type of content analysis does not include the typical quantification but rather a review of the document for pertinent and meaningful passages of text/other data [ 47 ]. Both an inductive and deductive approach for the documentary analysis’ coding [ 46 , 47 ] was chosen. The inductive approach was developed a posteriori; the deductive codes being informed by the interviews and previous findings from research addressing socioeconomic inequalities in avoidable emergency admissions [ 43 ]. In line with qualitative epistemological approach to enquiry, the interview and documentary findings were viewed as ‘truths’ in themselves with the acceptance that multiple realities can co-exist [ 48 ]. The analysis of each set of themes (with subthemes) from the documentary analysis and interviews were cross-referenced and integrated with each other to provide a cohesive in-depth analysis [ 49 ] by generating thematic maps to explore the relationships between the themes. The codes, themes and thematic maps were peer-reviewed continually with regular meetings between L.M., C.P.-C., J.L. and S.S. Direct quotes are provided from the interviews and documentary analysis. Some quotes from the documents are paraphrased to protect anonymity of the case study after following a set process considering a range of options. This involved searching each quote from the documentary analysis in Google and if the quote was found in the first page of the result, we shortened extracts and repeated the process. Where the shortened extracts were still identifiable, we were required to paraphrase that quote. Each paraphrased quote and original was shared and agreed with all the authors reducing the likelihood of inadvertently misinterpreting or misquoting. Where multiple components over large bodies of text were present in the documents, models were used to evidence the broadness, for example, using Dahlgren’s and Whitehead’s model of health determinants [ 1 ]. Due to the nature of the study, transcripts and findings were not shared with participants for checking but will be shared in a dissemination workshop in 2024.

Patient and public involvement and engagement

Four public contributors from the National Institute for Health and Care Research (NIHR) Research Design Service (RDS) North East and North Cumbria (NENC) Public and Patient Involvement (PPI) panel have been actively engaged in this research from its inception. They have been part of the research advisory group along with professional stakeholders and were involved in the identification of the sampling frame’s key criteria. Furthermore, a diverse group of public contributors has been actively involved in other parts of the project including developing the moral argument around action by producing a public facing resource exploring what health inequalities mean to people and public views of possible solutions [ 50 ].

Semi-structured interviews: description

Sixteen participants working in health or social care, identified through the documentary analysis or snowballing, were contacted for interview; fourteen consented to participate. No further interviews were sought as data sufficiency was reached whereby no new information or themes were being identified. Participant roles were broken down by NHS ( n = 5), local authority/council ( n = 8), and voluntary, community and social enterprise (VSCE) ( n = 1). To protect the participants’ anonymity, their employment titles/status are not disclosed. However, a broad spectrum of interviewees with varying roles from senior health system leadership (including strategic and commissioner roles) to roles within provider organisations and the VSCE sector were included.

Documentary analysis: description

75 documents were reviewed with documents considering regional ( n = 20), local ( n = 64) or neighbourhood ( n = 2) area with some documents covering two or more areas. Table 2 summarises the respective number of each document type which included statutory documents to websites from across the system (NHS, local government and VSCE). 45 documents were named by interviewees and 42 documents were identified as either a core document or through snowballing from other documents. Of these, 12 documents were identified from both. The timescales of the documents varied and where possible to identify, was from 2014 to 2031.

Integrative analysis of the documentary analysis and interviews

The overarching themes encompass:

Understanding the local context

Facilitators to tacking health inequalities: the assets

Emerging risks and concerns

Figure 1 demonstrates the relationships between the main themes identified from the analysis for tackling health inequalities and improving health in this case study.

Diagram of the relationship between the key themes identified regarding tackling health inequalities and improving health in a local area informed by 2 previous work [ 14 , 51 ]. NCDs = non-communicable diseases; HI = health inequalities

Understanding the local context was discussed extensively in both the documents and the interviews. This was informed by local intelligence and data that was routinely collected, monitored, and analysed to help understand the local context and where inequalities lie. More bespoke, in-depth collection and analysis were also described to get a better understanding of the situation. This not only took the form of quantitative but also considered qualitative data with lived experience:

‛So, our data comes from going out to talk to people. I mean, yes, especially the voice of inequalities, those traditional mechanisms, like surveys, don't really work. And it's about going out to communities, linking in with third sector organisations, going out to communities, and just going out to listen…I think the more we can bring out those real stories. I mean, we find quotes really, really powerful in terms of helping people understand what it is that matters.’ (LP16).

However, there were limitations to the available data including the quality as well as having enough time to do the analysis justice. This resulted in difficulties in being able to fully understand the context to help identify and act on the required improvements.

‘A lack of available data means we cannot quantify the total number of vulnerable migrants in [region]’ (Document V).

‛So there’s lots of data. The issue is joining that data up and analysing it, and making sense of it. That’s where we don’t have the capacity.’ (LP15).

Despite the caveats, understanding the context and its data limitations were important to inform local priorities and approaches on tackling health inequalities. This understanding was underpinned by three subthemes which were understanding:

the population’s needs including identification of people at higher risk of worse health and health inequalities

the driving forces of those needs with acknowledgement of the impact of the wider determinants of health

the threats and barriers to physical and mental health, as well as wellbeing

Firstly, the population’s needs, including identification of people at higher risk of worse health and health inequalities, was important. This included considering risk factors, such as smoking, specific groups of people and who was presenting with which conditions. Between the interviews and documents, variation was seen between groups deemed at-risk or high-risk with the documents identifying a wider range. The groups identified across both included marginalised communities, such as ethnic minority groups, gypsy and travellers, refugees and asylum seekers as well as people/children living in disadvantaged area.

‘There are significant health inequalities in children with asthma between deprived and more affluent areas, and this is reflected in A&E admissions.' (Document J).

Secondly, the driving forces of those needs with acknowledgement of the impact of the wider determinants of health were described. These forces mapped onto Dahlgren’s and Whitehead’s model of health determinants [ 1 ] consisting of individual lifestyle factors, social and community networks, living and working conditions (which include access to health care services) as well as general socio-economic, cultural and environmental conditions across the life course.

…. at the centre of our approach considering the requirements to improve the health and wellbeing of our area are the wider determinants of health and wellbeing, acknowledging how factors, such as housing, education, the environment and economy, impact on health outcomes and wellbeing over people’s lifetime and are therefore pivotal to our ambition to ameliorate the health of the poorest the quickest. (Paraphrased Document P).

Thirdly, the threats and barriers to health included environmental risks, communicable diseases and associated challenges, non-communicable conditions and diseases, mental health as well as structural barriers. In terms of communicable diseases, COVID-19 predominated. The environmental risks included climate change and air pollution. Non-communicable diseases were considered as a substantial and increasing threat and encompassed a wide range of chronic conditions such as diabetes, and obesity.

‛Long term conditions are the leading causes of death and disability in [case study] and account for most of our health and care spending. Cases of cancer, diabetes, respiratory disease, dementia and cardiovascular disease will increase as the population of [case study] grows and ages.’ (Document A).

Structural barriers to accessing and using support and/or services for health and wellbeing were identified. These barriers included how the services are set up, such as some GP practices asking for proof of a fixed address or form of identification to register. For example:

Complicated systems (such as having to make multiple calls, the need to speak to many people/gatekeepers or to call at specific time) can be a massive barrier to accessing healthcare and appointments. This is the case particularly for people who have complex mental health needs or chaotic/destabilized circumstances. People who do not have stable housing face difficulties in registering for GP and other services that require an address or rely on post to communicate appointments. (Paraphrased Document R).

A structural threat regarding support and/or services for health and wellbeing was the sustainability of current funding with future uncertainty posing potential threats to the delivery of current services. This also affected the ability to adapt and develop the services, or indeed build new ones.

‛I would say the other thing is I have a beef [sic] [disagreement] with pilot studies or new innovations. Often soft funded, temporary funded, charity funded, partnership work run by enthusiasts. Me, I've done them, or supported people doing many of these. And they're great. They can make a huge impact on the individuals involved on that local area. You can see fantastic work. You get inspired and you want to stand up in a crowd and go, “Wahey, isn't this fantastic?” But actually the sad part of it is on these things, I've seen so many where we then see some good, positive work being done, but we can't make it permanent or we can't spread it because there's no funding behind it.’ (LP8).

Facilitators to tackling health inequalities: the assets

The facilitators for improving health and wellbeing and tackling health inequalities are considered as assets which were underpinned by values and principles.

Values driven supported by four key principles

Being values driven was an important concept and considered as the underpinning attitudes or beliefs that guide decision making [ 52 ]. Particularly, the system’s approach was underpinned by a culture and a system's commitment to tackle health inequalities across the documents and interviews. This was also demonstrated by how passionately and emotively some interviewees spoke about their work.

‛There's a really strong desire and ethos around understanding that we will only ever solve these problems as a system, not by individual organisations or even just part of the system working together. And that feels great.’ (LP3).

Other values driving the approach included accountability, justice, and equity. Reducing health inequalities and improving health were considered to be the right things to do. For example:

We feel strongly about social justice and being inclusive, wishing to reflect the diversity of [case study]. We campaign on subjects that are important to people who are older with respect and kindness. (Paraphrased Document O).

Four key principles were identified that crosscut the assets which were:

Shared vision

Strong partnership

Asset-based approaches

Willingness and ability to act on learning

The mandated strategy, identifying priorities for health and wellbeing for the local population with the required actions, provided the shared vision across each part of the system, and provided the foundations for the work. This shared vision was repeated consistently in the documents and interviews from across the system.

[Case study] will be a place where individuals who have the lowest socioeconomic status will ameliorate their health the quickest. [Case study] will be a place for good health and compassion for all people, regardless of their age. (Paraphrased Document A).

‛One thing that is obviously becoming stronger and stronger is the focus on health inequalities within all of that, and making sure that we are helping people and provide support to people with the poorest health as fast as possible, so that agenda hasn’t shifted.’ (LP7).

This drive to embed the reduction of health inequalities was supported by clear new national guidance encapsulated by the NHS Core20PLUS5 priorities. Core20PLUS5 is the UK's approach to support a system to improve their healthcare inequalities [ 53 ]. Additionally, the system's restructuring from Clinical Commissioning Groups (CCGs) to Integrated Care Boards (ICBs) and formalisation of the now statutory Integrated Care Systems (ICS) in England was also reported to facilitate the driving of further improvement in health inequalities. These changes at a regional and local level helped bring key partners across the system (NHS and local government among others) to build upon their collective responsibility for improving health and reducing health inequalities for their area [ 54 ].

‛I don’t remember the last time we’ve had that so clear, or the last time that health inequalities has had such a prominent place, both in the NHS planning guidance or in the NHS contract. ’ (LP15). ‛The Health and Care Act has now got a, kind of, pillar around health inequalities, the new establishment of ICPs and ICBs, and also the planning guidance this year had a very clear element on health inequalities.’ (LP12)

A strong partnership and collaborative team approach across the system underpinned the work from the documents and included the reoccurrence of the concept that this case study acted as one team: ‘Team [case study]'.

Supporting one another to ensure [case study] is the best it can be: Team [case study]. It involves learning, sharing ideas as well as organisations sharing assets and resources, authentic partnerships, and striving for collective impact (environmental and social) to work towards shared goals . (Paraphrased Document B).

This was corroborated in the interviews as working in partnership to tackle health inequalities was considered by the interviewees as moving in the right direction. There were reports that the relationship between local government, health care and the third sector had improved in recent years which was still an ongoing priority:

‘I think the only improvement I would cite, which is not an improvement in terms of health outcomes, but in terms of how we work across [case study] together has moved on quite a lot, in terms of teams leads and talking across us, and how we join up on things, rather than see ourselves all as separate bodies' (LP15).

‘I think the relationship between local authorities and health and the third sector, actually, has much more parity and esteem than it had before.' (LP11)

The approaches described above were supported by all health and care partners signing up to principles around partnership; it is likely this has helped foster the case study's approach. This also builds on the asset-based approaches that were another key principle building on co-production and co-creation which is described below.

We begin with people : instead of doing things to people or for them, we work with them, augmenting the skills, assets and strength of [case study]’s people, workforce and carers. We achieve : actions are focused on over words and by using intelligence, every action hones in on the actual difference that we will make to ameliorate outcomes, quality and spend [case study]’s money wisely; We are Team [case study ]: having kindness, working as one organisation, taking responsibility collectively and delivering on what we agreed. Problems are discussed with a high challenge and high support attitude. (Paraphrased Document D).

At times, the degree to which the asset-based approaches were embedded differed from the documents compared to the interviews, even when from the same part of the system. For example, the documents often referred to the asset-based approach as having occurred whilst interviewees viewed it more as a work in progress.

‘We have re-designed many of our services to focus on needs-led, asset-based early intervention and prevention, and have given citizens more control over decisions that directly affect them .’ (Document M).

‘But we’re trying to take an asset-based approach, which is looking at the good stuff in communities as well. So the buildings, the green space, the services, but then also the social capital stuff that happens under the radar.’ (LP11).

A willingness to learn and put in action plans to address the learning were present. This enables future proofing by building on what is already in place to build the capacity, capability and flexibility of the system. This was particularly important for developing the workforce as described below.

‘So we’ve got a task and finish group set up, […] So this group shows good practice and is a space for people to discuss some of the challenges or to share what interventions they are doing around the table, and also look at what other opportunities that they have within a region or that we could build upon and share and scale.’ (LP12).

These assets that are considered as facilitators are divided into four key levels which are the system, services and support, communities and individuals, and workforce which are discussed in turn below.

Firstly, the system within this case study was made up of many organisations and partnerships within the NHS, local government, VSCE sector and communities. The interviewees reported the presence of a strong VCSE sector which had been facilitated by the local council's commitment to funding this sector:

‘Within [case study], we have a brilliant third sector, the council has been longstanding funders of infrastructure in [case study], third sector infrastructure, to enable those links [of community engagement] to be made' (LP16).

In both the documents and interviews, a strong coherent strategic integrated population health management plan with a system’s approach to embed the reduction of health inequalities was evident. For example, on a system level regionally:

‘To contribute towards a reduction in health inequalities we will: take a system wide approach for improving outcomes for specific groups known to be affected by health inequalities, starting with those living in our most deprived communities….’ (Document H).

This case study’s approach within the system included using creative solutions and harnessing technology. This included making bold and inventive changes to improve how the city and the system linked up and worked together to improve health. For example, regeneration work within the city to ameliorate and transform healthcare facilities as well as certain neighbourhoods by having new green spaces, better transport links in order to improve city-wide innovation and collaboration (paraphrased Document F) were described. The changes were not only related to physical aspects of the city but also aimed at how the city digitally linked up. Being a leader in digital innovation to optimise the health benefits from technology and information was identified in several documents.

‘ Having the best connected city using digital technology to improve health and wellbeing in innovative ways.’ (Document G).

The digital approaches included ongoing development of a digitalised personalised care record facilitating access to the most up-to-date information to developing as well as having the ‘ latest, cutting edge technologies’ ( Document F) in hospital care. However, the importance of not leaving people behind by embedding digital alternatives was recognised in both the documents and interviews.

‘ We are trying to just embed the culture of doing an equity health impact assessment whenever you are bringing in a digital solution or a digital pathway, and that there is always an alternative there for people who don’t have the capability or capacity to use it. ’ (LP1).

The successful one hundred percent [redacted] programme is targeting some of our most digitally excluded citizens in [case study]. For our city to continue to thrive, we all need the appropriate skills, technology and support to get the most out of being online. (Paraphrased Document Q)

This all links in with the system that functions in a ‘place' which includes the importance of where people are born, grow, work and live. Working towards this place being welcoming and appealing was described both regionally and locally. This included aiming to make the case study the place of choice for people.

‘Making [case study] a centre for good growth becoming the place of choice in the UK to live, to study, for businesses to invest in, for people to come and work.’ (Document G).

Services and support

Secondly, a variety of available services and support were described from the local authority, NHS, and voluntary community sectors. Specific areas of work, such as local initiatives (including targeted work or campaigns for specific groups or specific health conditions) as well as parts of the system working together with communities collaboratively, were identified. This included a wide range of work being done such as avoiding delayed discharges or re-admissions, providing high quality affordable housing as well as services offering peer support.

‘We have a community health development programme called [redacted], that works with particular groups in deprived communities and ethnically diverse communities to work in a very trusted and culturally appropriate way on the things that they want to get involved with to support their health.’ (LP3 ).

It is worth noting that reducing health inequalities in avoidable admissions was not often explicitly specified in the documents or interviews. However, either specified or otherwise inferred, preventing ill health and improving access, experience, and outcomes were vital components to addressing inequalities. This was approached by working with communities to deliver services in communities that worked for all people. Having co-designed, accessible, equitable integrated services and support appeared to be key.

‘Reducing inequalities in unplanned admissions for conditions that could be cared for in the community and access to planned hospital care is key.’ (Document H)

Creating plans with people: understanding the needs of local population and designing joined-up services around these needs. (Paraphrased Document A).

‘ So I think a core element is engagement with your population, so that ownership and that co-production, if you're going to make an intervention, don't do it without because you might miss the mark. ’ (LP8).

Clear, consistent and appropriate communication that was trusted was considered important to improve health and wellbeing as well as to tackle health inequalities. For example, trusted community members being engaged to speak on the behalf of the service providers:

‘The messenger is more important than the message, sometimes.’ (LP11).

This included making sure the processes are in place so that the information is accessible for all, including people who have additional communication needs. This was considered as a work in progress in this case study.

‘I think for me, things do come down to those core things, of health, literacy, that digital exclusion and understanding the wider complexities of people.’ (LP12)

‘ But even more confusing if you've got an additional communication need. And we've done quite a lot of work around the accessible information standard which sounds quite dry, and doesn't sound very- but actually, it's fundamental in accessing health and care. And that is, that all health and care organisations should record your communication preferences. So, if I've got a learning disability, people should know. If I've got a hearing impairment, people should know. But the systems don’t record it, so blind people are getting sent letters for appointments, or if I've got hearing loss, the right provisions are not made for appointments. So, actually, we're putting up barriers before people even come in, or can even get access to services.’ (LP16).

Flexible, empowering, holistic care and support that was person-centric was more apparent in the documents than the interviews.

At the centre of our vision is having more people benefiting from the life chances currently enjoyed by the few to make [case study] a more equal place. Therefore, we accentuate the importance of good health, the requirement to boost resilience, and focus on prevention as a way of enabling higher quality service provision that is person-centred. [Paraphrased Document N).

Through this [work], we will give all children and young people in [case study], particularly if they are vulnerable and/or disadvantaged, a start in life that is empowering and enable them to flourish in a compassionate and lively city. [Paraphrased Document M].

Communities and individuals

Thirdly, having communities and individuals at the heart of the work appeared essential and viewed as crucial to nurture in this case study. The interconnectedness of the place, communities and individuals were considered a key part of the foundations for good health and wellbeing.

In [case study], our belief is that our people are our greatest strength and our most important asset. Wellbeing starts with people: our connections with our friends, family, and colleagues, our behaviour, understanding, and support for one another, as well as the environment we build to live in together . (Paraphrased Document A).

A recognition of the power of communities and individuals with the requirement to support that key principle of a strength-based approach was found. This involved close working with communities to help identify what was important, what was needed and what interventions would work. This could then lead to improved resilience and cohesion.

‛You can't make effective health and care decisions without having the voice of people at the centre of that. It just won't work. You won't make the right decisions.’ (LP16).

‘Build on the strengths in ourselves, our families, carers and our community; working with people, actively listening to what matters most to people, with a focus on what’s strong rather than what’s wrong’ (Document G).

Meaningful engagement with communities as well as strengths and asset-based approaches to ensure self-sufficiency and sustainability of communities can help communities flourish. This includes promoting friendships, building community resilience and capacity, and inspiring residents to find solutions to change the things they feel needs altering in their community . (Paraphrased Document B).

This close community engagement had been reported to foster trust and to lead to improvements in health.

‘But where a system or an area has done a lot of community engagement, worked really closely with the community, gained their trust and built a programme around them rather than just said, “Here it is. You need to come and use it now,” you can tell that has had the impact. ' (LP1).

Finally, workforce was another key asset; the documents raised the concept of one workforce across health and care. The key principles of having a shared vision, asset-based approaches and strong partnership were also present in this example:

By working together, the Health and Care sector makes [case study] the best area to not only work but also train for people of all ages. Opportunities for skills and jobs are provided with recruitment and engagement from our most disadvantaged communities, galvanizing the future’s health and care workforce. By doing this, we have a very skilled and diverse workforce we need to work with our people now as well as in the future. (Paraphrased Document E).

An action identified for the health and care system to address health inequalities in case study 1 was ‘ the importance of having an inclusive workforce trained in person-centred working practices ’ (Document R). Several ways were found to improve and support workforce skills development and embed awareness of health inequalities in practice and training. Various initiatives were available such as an interactive health inequalities toolkit, theme-related fellowships, platforms and networks to share learning and develop skills.

‛We've recently launched a [redacted] Fellowship across [case study’s region], and we've got a number of clinicians and managers on that………. We've got training modules that we've put on across [case study’s region], as well for health inequalities…we've got learning and web resources where we share good practice from across the system, so that is our [redacted] Academy.’ (LP2).

This case study also recognised the importance of considering the welfare of the workforce; being skilled was not enough. This had been recognised pre-pandemic but was seen as even more important post COVID-19 due to the impact that COVID-19 had on staff, particularly in health and social care.

‛The impacts of the pandemic cannot be underestimated; our colleagues and services are fatigued and still dealing with the pressures. This context makes it even more essential that we share the responsibility, learn from each other at least and collaborate with each other at best, and hold each other up to be the best we can.’ (Document U).

Concerns were raised such as the widening of health inequalities since the pandemic and cost of living crisis. Post-pandemic and Brexit, recruiting health, social care and third sector staff was compounding the capacity throughout this already heavily pressurised system.

In [case study], we have seen the stalling of life expectancy and worsening of the health inequality gap, which is expected to be compounded by the effects of the pandemic. (Paraphrased Document T)

‘I think key barriers, just the immense pressure on the system still really […] under a significant workload, catching up on activity, catching up on NHS Health Checks, catching up on long-term condition reviews. There is a significant strain on the system still in terms of catching up. It has been really difficult because of the impact of COVID.’ (LP7).

‘Workforce is a challenge, because the pipelines that we’ve got, we’ve got fewer people coming through many of them. And that’s not just particular to, I don't know, nursing, which is often talking talked [sic] about as a challenged area, isn't it? And of course, it is. But we’ve got similar challenges in social care, in third sector.’ (LP5).

The pandemic was reported to have increased pressures on the NHS and services not only in relation to staff capacity but also regarding increases in referrals to services, such as mental health. Access to healthcare changed during the pandemic increasing barriers for some:

‘I think people are just confused about where they're supposed to go, in terms of accessing health and care at the moment. It's really complex to understand where you're supposed to go, especially, at the moment, coming out of COVID, and the fact that GPs are not the accessible front door. You can't just walk into your GP anymore.’ (LP16).

‘Meeting this increased demand [for work related to reducing ethnic inequalities in mental health] is starting to prove a challenge and necessitates some discussion about future resourcing.’ (Document S)

Several ways were identified to aid effective adaptation and/or mitigation. This included building resilience such as developing the existing capacity, capability and flexibility of the system by learning from previous work, adapting structures and strengthening workforce development. Considerations, such as a commitment to Marmot Principles and how funding could/would contribute, were also discussed.

The funding’s [linked to Core20PLUS5] purpose is to help systems to ensure that health inequalities are not made worse when cost-savings or efficiencies are sought…The available data and insight are clear and [health inequalities are] likely to worsen in the short term, the delays generated by pandemic, the disproportionate effect of that on the most deprived and the worsening food and fuel poverty in all our places. (Paraphrased Document L).

Learning from the pandemic was thought to be useful as some working practices had altered during COVID-19 for the better, such as needing to continue to embed how the system had collaborated and resist old patterns of working:

‘So I think that emphasis between collaboration – extreme collaboration – which is what we did during COVID is great. I suppose the problem is, as we go back into trying to save money, we go back into our old ways of working, about working in silos. And I think we’ve got to be very mindful of that, and continue to work in a different way.’ (LP11).

Another area identified as requiring action, was the collection, analysis, sharing and use of data accessible by the whole system.

‘So I think there is a lot of data out there. It’s just how do we present that in such a way that it’s accessible to everyone as well, because I think sometimes, what happens is that we have one group looking at data in one format, but then how do we cascade that out?’ (LP12)

We aimed to explore a system’s level understanding of how a local area addresses health inequalities with a focus on avoidable emergency admissions using a case study approach. Therefore, the focus of our research was strategic and systematic approaches to inequalities reduction. Gaining an overview of what was occurring within a system is pertinent because local areas are required to have a regard to address health inequalities in their local areas [ 20 , 21 ]. Through this exploration, we also developed an understanding of the system's processes reported to be required. For example, an area requiring action was viewed as the accessibility and analysis of data. The case study described having health inequalities ‘at the heart of its health and wellbeing strategy ’ which was echoed across the documents from multiple sectors across the system. Evidence of a values driven partnership with whole systems working was centred on the importance of place and involving people, with links to a ‘strong third sector ’ . Working together to support and strengthen local assets (the system, services/support, communities/individuals, and the workforce) were vital components. This suggested a system’s committed and integrated approach to improve population health and reduce health inequalities as well as concerted effort to increase system resilience. However, there was juxtaposition at times with what the documents contained versus what interviewees spoke about, for example, the degree to which asset-based approaches were embedded.

Furthermore, despite having a priori codes for the documentary analysis and including specific questions around work being undertaken to reduce health inequalities in avoidable admissions in the interviews with key systems leaders, this explicit link was still very much under-developed for this case study. For example, how to reduce health inequalities in avoidable emergency admissions was not often specified in the documents but could be inferred from existing work. This included work around improving COVID-19 vaccine uptake in groups who were identified as being at high-risk (such as older people and socially excluded populations) by using local intelligence to inform where to offer local outreach targeted pop-up clinics. This limited explicit action linking reduction of health inequalities in avoidable emergency admissions was echoed in the interviews and it became clear as we progressed through the research that a focus on reduction of health inequalities in avoidable hospital admissions at a systems level was not a dominant aspect of people’s work. Health inequalities were viewed as a key part of the work but not necessarily examined together with avoidable admissions. A strengthened will to take action is reported, particularly around reducing health inequalities, but there were limited examples of action to explicitly reduce health inequalities in avoidable admissions. This gap in the systems thinking is important to highlight. When it was explicitly linked, upstream strategies and thinking were acknowledged as requirements to reduce health inequalities in avoidable emergency admissions.

Similar to our findings, other research have also found networks to be considered as the system’s backbone [ 30 ] as well as the recognition that communities need to be central to public health approaches [ 51 , 55 , 56 ]. Furthermore, this study highlighted the importance of understanding the local context by using local routine and bespoke intelligence. It demonstrated that population-based approaches to reduce health inequalities are complex, multi-dimensional and interconnected. It is not about one part of the system but how the whole system interlinks. The interconnectedness and interdependence of the system (and the relevant players/stakeholders) have been reported by other research [ 30 , 57 ], for example without effective exchange of knowledge and information, social networks and systems do not function optimally [ 30 ]. Previous research found that for systems to work effectively, management and transfer of knowledge needs to be collaborative [ 30 ], which was recognised in this case study as requiring action. By understanding the context, including the strengths and challenges, the support or action needed to overcome the barriers can be identified.

There are very limited number of case studies that explore health inequalities with a focus on hospital admissions. Of the existing research, only one part of the health system was considered with interviews looking at data trends [ 35 ]. To our knowledge, this research is the first to build on this evidence by encompassing the wider health system using wider-ranging interviews and documentary analysis. Ford et al. [ 35 ] found that geographical areas typically had plans to reduce total avoidable emergency admissions but not comprehensive plans to reduce health inequalities in avoidable emergency admissions. This approach may indeed widen health inequalities. Health inequalities have considerable health and costs impacts. Pertinently, the hospital care costs associated with socioeconomic inequalities being reported as £4.8 billion a year, mainly due to excess hospitalisations such as avoidable admissions [ 58 ] and the burden of disease lies disproportionately with our most disadvantaged communities, addressing inequalities in hospital pressures is required [ 25 , 26 ].

Implications for research and policy

Improvements to life expectancy have stalled in the UK with a widening of health inequalities [ 12 ]. Health inequalities are not inevitable; it is imperative that the health gap between the deprived and affluent areas is narrowed [ 12 ]. This research demonstrates the complexity and intertwining factors that are perceived to address health inequalities in an area. Despite the evidence of the cost (societal and individual) of avoidable admissions, explicit tackling of inequality in avoidable emergency admissions is not yet embedded into the system, therefore highlights an area for policy and action. This in-depth account and exploration of the characteristics of ‘whole systems’ working to address health inequalities, including where challenges remain, generated in this research will be instrumental for decision makers tasked with addressing health and care inequalities.

This research informs the next step of exploring each identified theme in more detail and moving beyond description to develop tools, using a suite of multidimensional and multidisciplinary methods, to investigate the effects of interventions on systems as previously highlighted by Rutter et al. [ 5 ].

Strengths and limitations

Documentary analysis is often used in health policy research but poorly described [ 44 ]. Furthermore, Yin reports that case study research is often criticised for not adhering to ‘systematic procedures’ p. 18 [ 41 ]. A clear strength of this study was the clearly defined boundary (in time and space) case as well as following a defined systematic approach, with critical thought and rationale provided at each stage [ 34 , 41 ]. A wide range and large number of documents were included as well as interviewees from across the system thereby resulting in a comprehensive case study. Integrating the analysis from two separate methodologies (interviews and documentary analysis), analysed separately before being combined, is also a strength to provide a coherent rich account [ 49 ]. We did not limit the reasons for hospital admission to enable a broad as possible perspective; this is likely to be a strength in this case study as this connection between health inequalities and avoidable hospital admissions was still infrequently made. However, for example, if a specific care pathway for a health condition had been highlighted by key informants this would have been explored.

Due to concerns about identifiability, we took several steps. These included providing a summary of the sectors that the interviewees and document were from but we were not able to specify which sectors each quote pertained. Additionally, some of the document quotes required paraphrasing. However, we followed a set process to ensure this was as rigorous as possible as described in the methods section. For example, where we were required to paraphrase, each paraphrased quote and original was shared and agreed with all the authors to reduce the likelihood to inadvertently misinterpreting or misquoting.

The themes are unlikely to represent an exhaustive list of the key elements requiring attention, but they represent the key themes that were identified using a robust methodological process. The results are from a single urban local authority with high levels of socioeconomic disadvantage in the North of England which may limit generalisability to different contexts. However, the findings are still generalisable to theoretical considerations [ 41 ]. Attempts to integrate a case study with a known framework can result in ‘force-fit’ [ 34 ] which we avoided by developing our own framework (Fig. 1 ) considering other existing models [ 14 , 59 ]. The results are unable to establish causation, strength of association, or direction of influence [ 60 ] and disentangling conclusively what works versus what is thought to work is difficult. The documents’ contents may not represent exactly what occurs in reality, the degree to which plans are implemented or why variation may occur or how variation may affect what is found [ 43 , 61 ]. Further research, such as participatory or non-participatory observation, could address this gap.

Conclusions

This case study provides an in-depth exploration of how local areas are working to address health and care inequalities, with a focus on avoidable hospital admissions. Key elements of this system’s reported approach included fostering strategic coherence, cross-agency working, and community-asset based working. An area requiring action was viewed as the accessibility and analysis of data. Therefore, local areas could consider the challenges of data sharing across organisations as well as the organisational capacity and capability required to generate useful analysis in order to create meaningful insights to assist work to reduce health and care inequalities. This would lead to improved understanding of the context including where the key barriers lie for a local area. Addressing structural barriers and threats as well as supporting the training and wellbeing of the workforce are viewed as key to building resilience within a system to reduce health inequalities. Furthermore, more action is required to embed reducing health inequalities in avoidable admissions explicitly in local areas with inaction risking widening the health gap.

Availability of data and materials

Individual participants’ data that underlie the results reported in this article and a data dictionary defining each field in the set are available to investigators whose proposed use of the data has been approved by an independent review committee for work. Proposals should be directed to [email protected] to gain access, data requestors will need to sign a data access agreement. Such requests are decided on a case by case basis.

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Acknowledgements

Thanks to our Understanding Factors that explain Avoidable hospital admission Inequalities - Research study (UNFAIR) PPI contributors, for their involvement in the project particularly in the identification of the key criteria for the sampling frame. Thanks to the research advisory team as well.

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The manuscript is not currently under consideration or published in another journal. All authors have read and approved the final manuscript.

This research was funded by the National Institute for Health and Care Research (NIHR), grant number (ref CA-CL-2018-04-ST2-010). The funding body was not involved in the study design, collection of data, inter-pretation, write-up, or submission for publication. The views expressed are those of the authors and not necessarily those of the NIHR, the Department of Health and Social Care or Newcastle University.

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Charlotte Parbery-Clark

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Lorraine McSweeney

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Conceptualization - J.L. and S.S.; methodology - C.P.-C., J.L. & S.S.; formal analysis - C. P.-C. & L.M.; investigation- C. P.-C. & L.M., resources, writing of draft manuscript - C.P.-C.; review and editing manuscript L.M., J.L., & S.S.; visualization including figures and tables - C.P.-C.; supervision - J.L. & S.S.; project administration - L.M. & S.S.; funding acquisition - S.S. All authors have read and agreed to the published version of the manuscript.

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Parbery-Clark, C., McSweeney, L., Lally, J. et al. How can health systems approach reducing health inequalities? An in-depth qualitative case study in the UK. BMC Public Health 24 , 2168 (2024). https://doi.org/10.1186/s12889-024-19531-5

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Distinguishing case study as a research method from case reports as a publication type

The purpose of this editorial is to distinguish between case reports and case studies. In health, case reports are familiar ways of sharing events or efforts of intervening with single patients with previously unreported features. As a qualitative methodology, case study research encompasses a great deal more complexity than a typical case report and often incorporates multiple streams of data combined in creative ways. The depth and richness of case study description helps readers understand the case and whether findings might be applicable beyond that setting.

Single-institution descriptive reports of library activities are often labeled by their authors as “case studies.” By contrast, in health care, single patient retrospective descriptions are published as “case reports.” Both case reports and case studies are valuable to readers and provide a publication opportunity for authors. A previous editorial by Akers and Amos about improving case studies addresses issues that are more common to case reports; for example, not having a review of the literature or being anecdotal, not generalizable, and prone to various types of bias such as positive outcome bias [ 1 ]. However, case study research as a qualitative methodology is pursued for different purposes than generalizability. The authors’ purpose in this editorial is to clearly distinguish between case reports and case studies. We believe that this will assist authors in describing and designating the methodological approach of their publications and help readers appreciate the rigor of well-executed case study research.

Case reports often provide a first exploration of a phenomenon or an opportunity for a first publication by a trainee in the health professions. In health care, case reports are familiar ways of sharing events or efforts of intervening with single patients with previously unreported features. Another type of study categorized as a case report is an “N of 1” study or single-subject clinical trial, which considers an individual patient as the sole unit of observation in a study investigating the efficacy or side effect profiles of different interventions. Entire journals have evolved to publish case reports, which often rely on template structures with limited contextualization or discussion of previous cases. Examples that are indexed in MEDLINE include the American Journal of Case Reports , BMJ Case Reports, Journal of Medical Case Reports, and Journal of Radiology Case Reports . Similar publications appear in veterinary medicine and are indexed in CAB Abstracts, such as Case Reports in Veterinary Medicine and Veterinary Record Case Reports .

As a qualitative methodology, however, case study research encompasses a great deal more complexity than a typical case report and often incorporates multiple streams of data combined in creative ways. Distinctions include the investigator’s definitions and delimitations of the case being studied, the clarity of the role of the investigator, the rigor of gathering and combining evidence about the case, and the contextualization of the findings. Delimitation is a term from qualitative research about setting boundaries to scope the research in a useful way rather than describing the narrow scope as a limitation, as often appears in a discussion section. The depth and richness of description helps readers understand the situation and whether findings from the case are applicable to their settings.

CASE STUDY AS A RESEARCH METHODOLOGY

Case study as a qualitative methodology is an exploration of a time- and space-bound phenomenon. As qualitative research, case studies require much more from their authors who are acting as instruments within the inquiry process. In the case study methodology, a variety of methodological approaches may be employed to explain the complexity of the problem being studied [ 2 , 3 ].

Leading authors diverge in their definitions of case study, but a qualitative research text introduces case study as follows:

Case study research is defined as a qualitative approach in which the investigator explores a real-life, contemporary bounded system (a case) or multiple bound systems (cases) over time, through detailed, in-depth data collection involving multiple sources of information, and reports a case description and case themes. The unit of analysis in the case study might be multiple cases (a multisite study) or a single case (a within-site case study). [ 4 ]

Methodologists writing core texts on case study research include Yin [ 5 ], Stake [ 6 ], and Merriam [ 7 ]. The approaches of these three methodologists have been compared by Yazan, who focused on six areas of methodology: epistemology (beliefs about ways of knowing), definition of cases, design of case studies, and gathering, analysis, and validation of data [ 8 ]. For Yin, case study is a method of empirical inquiry appropriate to determining the “how and why” of phenomena and contributes to understanding phenomena in a holistic and real-life context [ 5 ]. Stake defines a case study as a “well-bounded, specific, complex, and functioning thing” [ 6 ], while Merriam views “the case as a thing, a single entity, a unit around which there are boundaries” [ 7 ].

Case studies are ways to explain, describe, or explore phenomena. Comments from a quantitative perspective about case studies lacking rigor and generalizability fail to consider the purpose of the case study and how what is learned from a case study is put into practice. Rigor in case studies comes from the research design and its components, which Yin outlines as (a) the study’s questions, (b) the study’s propositions, (c) the unit of analysis, (d) the logic linking the data to propositions, and (e) the criteria for interpreting the findings [ 5 ]. Case studies should also provide multiple sources of data, a case study database, and a clear chain of evidence among the questions asked, the data collected, and the conclusions drawn [ 5 ].

Sources of evidence for case studies include interviews, documentation, archival records, direct observations, participant-observation, and physical artifacts. One of the most important sources for data in qualitative case study research is the interview [ 2 , 3 ]. In addition to interviews, documents and archival records can be gathered to corroborate and enhance the findings of the study. To understand the phenomenon or the conditions that created it, direct observations can serve as another source of evidence and can be conducted throughout the study. These can include the use of formal and informal protocols as a participant inside the case or an external or passive observer outside of the case [ 5 ]. Lastly, physical artifacts can be observed and collected as a form of evidence. With these multiple potential sources of evidence, the study methodology includes gathering data, sense-making, and triangulating multiple streams of data. Figure 1 shows an example in which data used for the case started with a pilot study to provide additional context to guide more in-depth data collection and analysis with participants.

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Object name is jmla-107-1-f001.jpg

Key sources of data for a sample case study

VARIATIONS ON CASE STUDY METHODOLOGY

Case study methodology is evolving and regularly reinterpreted. Comparative or multiple case studies are used as a tool for synthesizing information across time and space to research the impact of policy and practice in various fields of social research [ 9 ]. Because case study research is in-depth and intensive, there have been efforts to simplify the method or select useful components of cases for focused analysis. Micro-case study is a term that is occasionally used to describe research on micro-level cases [ 10 ]. These are cases that occur in a brief time frame, occur in a confined setting, and are simple and straightforward in nature. A micro-level case describes a clear problem of interest. Reporting is very brief and about specific points. The lack of complexity in the case description makes obvious the “lesson” that is inherent in the case; although no definitive “solution” is necessarily forthcoming, making the case useful for discussion. A micro-case write-up can be distinguished from a case report by its focus on briefly reporting specific features of a case or cases to analyze or learn from those features.

DATABASE INDEXING OF CASE REPORTS AND CASE STUDIES

Disciplines such as education, psychology, sociology, political science, and social work regularly publish rich case studies that are relevant to particular areas of health librarianship. Case reports and case studies have been defined as publication types or subject terms by several databases that are relevant to librarian authors: MEDLINE, PsycINFO, CINAHL, and ERIC. Library, Information Science & Technology Abstracts (LISTA) does not have a subject term or publication type related to cases, despite many being included in the database. Whereas “Case Reports” are the main term used by MEDLINE’s Medical Subject Headings (MeSH) and PsycINFO’s thesaurus, CINAHL and ERIC use “Case Studies.”

Case reports in MEDLINE and PsycINFO focus on clinical case documentation. In MeSH, “Case Reports” as a publication type is specific to “clinical presentations that may be followed by evaluative studies that eventually lead to a diagnosis” [ 11 ]. “Case Histories,” “Case Studies,” and “Case Study” are all entry terms mapping to “Case Reports”; however, guidance to indexers suggests that “Case Reports” should not be applied to institutional case reports and refers to the heading “Organizational Case Studies,” which is defined as “descriptions and evaluations of specific health care organizations” [ 12 ].

PsycINFO’s subject term “Case Report” is “used in records discussing issues involved in the process of conducting exploratory studies of single or multiple clinical cases.” The Methodology index offers clinical and non-clinical entries. “Clinical Case Study” is defined as “case reports that include disorder, diagnosis, and clinical treatment for individuals with mental or medical illnesses,” whereas “Non-clinical Case Study” is a “document consisting of non-clinical or organizational case examples of the concepts being researched or studied. The setting is always non-clinical and does not include treatment-related environments” [ 13 ].

Both CINAHL and ERIC acknowledge the depth of analysis in case study methodology. The CINAHL scope note for the thesaurus term “Case Studies” distinguishes between the document and the methodology, though both use the same term: “a review of a particular condition, disease, or administrative problem. Also, a research method that involves an in-depth analysis of an individual, group, institution, or other social unit. For material that contains a case study, search for document type: case study.” The ERIC scope note for the thesaurus term “Case Studies” is simple: “detailed analyses, usually focusing on a particular problem of an individual, group, or organization” [ 14 ].

PUBLICATION OF CASE STUDY RESEARCH IN LIBRARIANSHIP

We call your attention to a few examples published as case studies in health sciences librarianship to consider how their characteristics fit with the preceding definitions of case reports or case study research. All present some characteristics of case study research, but their treatment of the research questions, richness of description, and analytic strategies vary in depth and, therefore, diverge at some level from the qualitative case study research approach. This divergence, particularly in richness of description and analysis, may have been constrained by the publication requirements.

As one example, a case study by Janke and Rush documented a time- and context-bound collaboration involving a librarian and a nursing faculty member [ 15 ]. Three objectives were stated: (1) describing their experience of working together on an interprofessional research team, (2) evaluating the value of the librarian role from librarian and faculty member perspectives, and (3) relating findings to existing literature. Elements that signal the qualitative nature of this case study are that the authors were the research participants and their use of the term “evaluation” is reflection on their experience. This reads like a case study that could have been enriched by including other types of data gathered from others engaging with this team to broaden the understanding of the collaboration.

As another example, the description of the academic context is one of the most salient components of the case study written by Clairoux et al., which had the objectives of (1) describing the library instruction offered and learning assessments used at a single health sciences library and (2) discussing the positive outcomes of instruction in that setting [ 16 ]. The authors focus on sharing what the institution has done more than explaining why this institution is an exemplar to explore a focused question or understand the phenomenon of library instruction. However, like a case study, the analysis brings together several streams of data including course attendance, online material page views, and some discussion of results from surveys. This paper reads somewhat in between an institutional case report and a case study.

The final example is a single author reporting on a personal experience of creating and executing the role of research informationist for a National Institutes of Health (NIH)–funded research team [ 17 ]. There is a thoughtful review of the informationist literature and detailed descriptions of the institutional context and the process of gaining access to and participating in the new role. However, the motivating question in the abstract does not seem to be fully addressed through analysis from either the reflective perspective of the author as the research participant or consideration of other streams of data from those involved in the informationist experience. The publication reads more like a case report about this informationist’s experience than a case study that explores the research informationist experience through the selection of this case.

All of these publications are well written and useful for their intended audiences, but in general, they are much shorter and much less rich in depth than case studies published in social sciences research. It may be that the authors have been constrained by word counts or page limits. For example, the submission category for Case Studies in the Journal of the Medical Library Association (JMLA) limited them to 3,000 words and defined them as “articles describing the process of developing, implementing, and evaluating a new service, program, or initiative, typically in a single institution or through a single collaborative effort” [ 18 ]. This definition’s focus on novelty and description sounds much more like the definition of case report than the in-depth, detailed investigation of a time- and space-bound problem that is often examined through case study research.

Problem-focused or question-driven case study research would benefit from the space provided for Original Investigations that employ any type of quantitative or qualitative method of analysis. One of the best examples in the JMLA of an in-depth multiple case study that was authored by a librarian who published the findings from her doctoral dissertation represented all the elements of a case study. In eight pages, she provided a theoretical basis for the research question, a pilot study, and a multiple case design, including integrated data from interviews and focus groups [ 19 ].

We have distinguished between case reports and case studies primarily to assist librarians who are new to research and critical appraisal of case study methodology to recognize the features that authors use to describe and designate the methodological approaches of their publications. For researchers who are new to case research methodology and are interested in learning more, Hancock and Algozzine provide a guide [ 20 ].

We hope that JMLA readers appreciate the rigor of well-executed case study research. We believe that distinguishing between descriptive case reports and analytic case studies in the journal’s submission categories will allow the depth of case study methodology to increase. We also hope that authors feel encouraged to pursue submitting relevant case studies or case reports for future publication.

Editor’s note: In response to this invited editorial, the Journal of the Medical Library Association will consider manuscripts employing rigorous qualitative case study methodology to be Original Investigations (fewer than 5,000 words), whereas manuscripts describing the process of developing, implementing, and assessing a new service, program, or initiative—typically in a single institution or through a single collaborative effort—will be considered to be Case Reports (formerly known as Case Studies; fewer than 3,000 words).

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1. Introduction

2. research methods and data, 2.1. research methods, 2.2. data sources and screening, 2.3. data processing, 3. subject categories and publication trends, 3.1. subject evolution, 3.2. trends in the number and cited times of published papers, 4. the intellectual structure, 4.1. quantitative analysis, 4.2. qualitative analysis, 4.2.1. macro-environmental research at national, regional, and city scales, 4.2.2. global industrial development and layout, 4.2.3. research on global value chains, 4.2.4. micro-information geography of tncs, 4.2.5. internationalization and commercialization of geo-information industry, 4.2.6. multiple data and interdisciplinary approaches, 5. discussions and conclusions, data availability statement, acknowledgments, conflicts of interest.

1	(accessed on 13 July 2024). One date of launch is missing from the data set, but this has a minimal impact on the overall trend.
2	, accessed on 13 July 2024) is selected as the primary quantitative analysis tool in this paper.

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Li, Z. Progress in Remote Sensing and GIS-Based FDI Research Based on Quantitative and Qualitative Analysis. Land 2024 , 13 , 1313. https://doi.org/10.3390/land13081313

Li Z. Progress in Remote Sensing and GIS-Based FDI Research Based on Quantitative and Qualitative Analysis. Land . 2024; 13(8):1313. https://doi.org/10.3390/land13081313

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Published: 19 August 2024

Collaboration for implementation of decentralisation policy of multi drug-resistant tuberculosis services in Zambia

Malizgani Paul Chavula ORCID: orcid.org/0000-0003-1189-7194 1 , 2 ,
Tulani Francis L. Matenga 3 ,
Patricia Maritim 4 , 5 ,
Margarate N. Munakampe 4 , 5 ,
Batuli Habib 3 ,
Namakando Liusha 6 ,
Jeremiah Banda 7 ,
Ntazana N. Sinyangwe 8 ,
Hikabasa Halwiindi 1 ,
Chris Mweemba 4 ,
Angel Mubanga 9 ,
Patrick Kaonga 7 ,
Mwimba Chewe 4 ,
Henry Phiri 9 &
Joseph Mumba Zulu 3 , 4

Health Research Policy and Systems volume 22 , Article number: 112 ( 2024 ) Cite this article

Metrics details

Multi-drug-resistant tuberculosis (MDR-TB) infections are a public health concern. Since 2017, the Ministry of Health (MoH) in Zambia, in collaboration with its partners, has been implementing decentralised MDR-TB services to address the limited community access to treatment. This study sought to explore the role of collaboration in the implementation of decentralised multi drug-resistant tuberculosis services in Zambia.

A qualitative case study design was conducted in selected provinces in Zambia using in-depth and key informant interviews as data collection methods. We conducted a total of 112 interviews involving 18 healthcare workers, 17 community health workers, 32 patients and 21 caregivers in healthcare facilities located in 10 selected districts. Additionally, 24 key informant interviews were conducted with healthcare workers managers at facility, district, provincial, and national-levels. Thematic analysis was employed guided by the Integrative Framework for Collaborative Governance.

The principled engagement was shaped by the global health agenda/summit meeting influence on the decentralisation of TB, engagement of stakeholders to initiate decentralisation, a supportive policy environment for the decentralisation process and guidelines and quarterly clinical expert committee meetings. The factors that influenced the shared motivation for the introduction of MDR-TB decentralisation included actors having a common understanding, limited access to health facilities and emergency transport services, a shared understanding of challenges in providing optimal patient monitoring and review and their appreciation of the value of evidence-based decision-making in the implementation of MDR- TB decentralisation. The capacity for joint action strategies included MoH initiating strategic partnerships in enhancing MDR-TB decentralisation, the role of leadership in organising training of healthcare workers and of multidisciplinary teams, inadequate coordination, supervision and monitoring of laboratory services and joint action in health infrastructural rehabilitation.

Conclusions

Principled engagement facilitated the involvement of various stakeholders, the dissemination of relevant policies and guidelines and regular quarterly meetings of clinical expert committees to ensure ongoing support and guidance. A shared motivation among actors was underpinned by a common understanding of the barriers faced while implementing decentralisation efforts. The capacity for joint action was demonstrated through several key strategies, however, challenges such as inadequate coordination, supervision and monitoring of laboratory services, as well as the need for collaborative efforts in health infrastructural rehabilitation were observed. Overall, collaboration has facilitated the creation of a more responsive and comprehensive TB care system, addressing the critical needs of patients and improving health outcomes.

Peer Review reports

Introduction

Multi-drug-resistant tuberculosis (MDR-TB) infection is a major global public health concern, with TB remaining as one of the top 10 leading causes of morbidity and mortality, especially in low- and middle-income countries (LMICs) [ 1 ]. In 2022, the global MDR-TB burden estimate was at 410 000 cases (CI 370 000–450 000) and only 176 000 (43%) were initiated on treatment [ 2 ]. The burden of MDR-TB infection and disease is unevenly distributed globally, with LMICs disproportionally affected due to high poverty levels [ 1 ]. Zambia is among 30 other countries with the highest MDR-TB burden in the world [ 1 ]. In 2022, Zambia had an estimated burden of 1900 MDR-TB cases, but only initiated treatment in 362 cases in the same year (WHO 2023 Global TB Report). The country recorded a treatment success rate for MDR-TB of 79% for the same year, which was lower than the treatment success rate for drug-susceptible TB, which was at 92%. The sub-optimal treatment success for MDR-TB cases is attributed to the complexity of the TB bacterium called Mycobacterium tuberculosis, as it undergoes mutations, rendering it resistant to first-line drugs crucial for TB treatment, hence requiring a more comprehensive and multifaceted approach during treatment and care [ 3 ].

Studies have highlighted risks and susceptibility factors, which drive MDR-TB infection. These include gender, residence, history of previous TB treatment, lack of knowledge and poor adherence to treatment, treatment failure, presence of MDR-TB in the family and low economic status [ 5 , 6 ]. Further, treatment success is hindered by adverse events that may arise during treatment, including vomiting, skin rash, anaemia and peripheral neuropathy [ 7 ]. Drivers for unsuccessful treatment outcomes include social stigma, negative experiences of physical and emotional trauma, lack of social support and non-responsiveness to healthcare services [ 8 ]. Therefore, while MDR-TB is driven by various factors such as gender and social support, its successful treatment faces challenges from both side effects and patient experiences.

Prevention of MDR-TB infection is part of the global agenda of Sustainable Development Goal (SDG) 3 (Good Health and Well-being), thus, in practical terms, the aim is to dismantle inequalities and increase universal health coverage [ 9 ]. Many countries are adopting decentralisation of MDR-TB services through health systems strengthening as a critical way of ensuring timely service delivery to all people. Global partners and international organisations are playing a critical role in strengthening the health systems through resource mobilisation, and investment into improving infrastructure, diagnostics, health information and human resources for health development, to enhance service delivery [ 10 ].

Studies have revealed that decentralisation of MDR-TB healthcare services has had significant advantages including improved accessibility, and timely delivery of care particularly for rural areas [ 11 ]. In Bangladesh, decentralisation contributed to enhanced collaboration in localising MDR-TB medical services, adapting them to local preferences and needs [ 12 ]. However, governance issues such as fragmentation and poor coordination remain significant gaps limiting equitable resource distribution for MDR-TB services, including infrastructure inadequacy. Many other challenges, however, are faced by many countries in trying to combat TB and attain the WHO global target to eliminate TB by 2030, through the End TB Strategy [ 10 ]. In South Africa, healthcare providers reported anxiety over the abrupt introduction of MDR-TB care, limited support and inadequate communication and collaboration during the service implementation [ 7 ]. These challenges are exacerbated by socio-economic and political factors including declining funding towards TB services .

In 2017, Zambia’s Ministry of Health introduced a policy to decentralise MDR-TB services through the 2017–2021 National Strategic Plan for Tuberculosis and Leprosy Prevention, Care, and Control, which was aligned to the National Health Strategic Plan and the WHO Global End TB Strategy [ 13 ]. The MDR-TB service delivery has, since 2017, been decentralised from the two national-level hospitals to about 100 sites across all 10 provinces in the country, including regional and local hospitals. The Ministry of Health has been collaborating with local and international organisations to support the delivery of decentralised TB services. Some of the funding agencies working with the Ministry of Health in supporting the decentralisation process include the Global Fund, the United States Government through the United States Agency for International Development (USAID) and Centers for Disease Control and Prevention (CDC), WHO, Japan Anti-Tuberculosis Association (JATA) and many others. Local partners such as civil society organisations (CSOs), TB survivor groups, faith-based organisations and many others have also been key in enhancing the decentralisation process in the country. In line with this strategic direction, collaboration has the potential to create an opportunity to strengthen the health system through increasing coverage, expanding access and improving the comprehensive availability of MDR-TB services across the country.

Collaboration is a participatory process of engaging key actors in addressing complex problems that cannot be handled by a single entity. Some studies have been conducted in LMICs on collaborative governance of tuberculosis control programmes (West Africa and Bangladesh) [ 14 , 15 ]. The Ministry of Health in Zambia, in collaboration with partners, is implementing the decentralisation of MDR-TB services. There is inadequate evidence on the optimal implementation of decentralised MDR services in the country with available literature only focusing on the general TB and human immunodeficiency virus (HIV) programme collaborative activities [ 16 ]. Most studies conducted have not addressed how system context issues and capacity for joint action as aspects of collaboration affect the effective or successful decentralisation of MDR-TB services. This study sought to explore the role of collaboration in the implementation of the decentralisation policy of multi-drug-resistant tuberculosis services in Zambia.

Conceptual framework: integrative collaborative governance

To address the research question, we adopted an integrated framework for collaborative governance to analyse the findings according to Emerson et al. [ 17 ]. Collaborative governance is defined as “the processes and structures of public policy decision-making, and management that engage people constructively across the boundaries of public agencies, levels of government, and/or the public, private and civic spheres to carry out a public purpose that could not otherwise be accomplished” [ 5 ]. We adopted the integrative framework for collaborative governance by Emerson et al. [ 17 ] to analyse the role of collaboration in the implementation of the decentralisation policy of multi-drug-resistant tuberculosis services in Zambia. The framework consists of key components (layers) including system context, collaborative governance regime, drivers and collaborative dynamics (principled engagement, shared motivation and capacity for joint action) [ 2 ] as shown in Fig. 1 . However, this paper focussed on exploring how collaboration dynamics namely principled engagement, shared motivation and capacity for joint action c hinder or support the implementation decentralisation policy of MDR-TB services in Zambia. The interaction and intersectionality of contextual actors including the political, social and legal environment are some of the key drivers influencing collaboration dynamics. The concept of principled engagement entails a process that unfolds over time, involving various stakeholders who may participate at different stages and in different settings, such as face-to-face or virtual meetings, cross-organisational networks or public and private gatherings. In this study, stakeholders engage through principled discussion to define the purpose, guidelines and roles necessary to govern the collaboration. The degree of shared motivation among actors influences the nature and pattern of collaboration in the delivery of MDR-TB services. Furthermore, capacity for joint action refers to the actor’s ability to collectively decentralise the delivery of MDR-TB services. The stakeholders collectively, through regular joint meetings, mobilise resources to facilitate implementation of MDR-TB services using existing networks and community structures [ 3 ].

Integrated framework for collaborative governance Emerson et al. [ 17 ]

Study context

This study was conducted in selected health facilities in Zambia, where the burden of TB, particularly MDR-TB, is high. The contributing factors to the higher prevalence include poverty, rapid urbanisation, population growth and exposure to silica in mining settlements [ 17 ]. In response to this situation, the Ministry of Health (Zambia), in collaboration with partners, implemented the decentralised treatment and management of TB from two national health facilities (in Lusaka and Ndola) to other facilities in all 10 provinces. The decentralisation of TB services was implemented in alignment with the 2022–2026 Zambia National Health Strategic Plan for Tuberculosis, which stresses the significance of adopting the primary healthcare approach in eliminating MDR-TB by 2030 [ 12 ]. The study was conducted in various selected healthcare facilities, including provincial and district hospitals, both public and private across the nation (Lusaka, eastern, southern, western, central and Copperbelt provinces). The study sites were selected on the basis of their higher volumes of MDR-TB case notifications, with decentralisation of TB services already being implemented in these sites.

Study design

A qualitative case study design was adopted to investigate the influence of collaboration on decentralising drug-resistant tuberculosis services in Zambia. The application of this approach enabled a comprehensive analysis of the collaboration in the implementation process. We used a case study approach to get a detailed understanding of the collaboration within the context of MDR-TB. Case studies are useful when conducting a detailed exploration of an issue in its real-life context, such as collaboration in the implementation of MDR-TB, and was relevant to facilitate unpacking of substantive real-life contexts, interactions and complexities [ 18 ]. The study utilised this design to understand how collaboration influenced the success and challenges of the decentralisation process.

Data collection methods and sampling strategy

In this study, we employed key informant and in-depth interviews as methods of understanding collaboration for the implementation of decentralisation policy of multi-drug-resistant tuberculosis services in Zambia. We conducted a total of 112 interviews with healthcare workers (18), community health workers (17), patients (32) and caregivers (21) in select healthcare facilities located in 10 selected districts and key informant interviews with facility, district, provincial, and nationallevel based managers (24). We engaged 10 trained research assistants who conducted various study activities under the supervision of the study team. The research assistants were divided into groups and collected data from the different facilities. Study participants were purposively sampled based on their involvement in the treatment and management of TB at different levels. Table 1 summarises the qualitative interviews per category of respondents.

Data management and analysis

The collected interviews were transcribed word for word and managed using NVivo software plus 14. We adopted an integrative collaborative governance framework focussing on collaboration dynamics to guide the analysis. A codebook was developed in NVivo and trained research assistants then used the NVivo software and coded the transcripts on the basis of the pre-determined coding framework. Subsequently, the coded projects were integrated into a unified project. The coding process enabled us to identify codes, which were later grouped into substantive themes. These substantive themes were later aligned with the respective domains under collaboration dynamics including principled engagement, shared motivation and capacity for joint action [ 19 ]. Our analysis approach was guided by the thematic data analysis method [ 19 ].

Trustworthiness of the study

To ensure the credibility and trustworthiness of the study, transcripts were coded by different coders. After coding, the authors verified the coded work to ensure that the quotes were representative of the developed codes. Additionally, quality assurance of transcripts was conducted through the sharing of transcripts with study team members and audio recordings. Furthermore, we held meetings with stakeholders who participated in the study to discuss the findings. However, this did not affect the interpretation of the themes as participants confirmed or could relate to these findings.

This section presents collaboration dynamics strategies shaping the implementation of the decentralisation policy of MDR-TB services. The results have been presented around the integrative collaborative governance domains, including principled engagement, shared motivation and capacity joint action, as highlighted in Table 2 below.

Domain 1: Principled engagement

Principled engagement was shaped by the global health agenda/summit meeting influence on decentralisation of TB, political will to support the introduction of decentilisation, engagement of stakeholders to initiate decentralisation, and a supportive policy environment for decentralisation of MDR-TB services.

Global health agenda/summit meeting influence on decentralisation of TB

The local government leadership interaction with the global community on health reignited the desire to create systems that increase access to health. Participants narrated that the global meeting on health for all heads of state on sustainable development was held. Goal number three was appreciated by heads of state, including the available leadership at the time. The notion of decentralising health governance, including the delivery of services, was adopted as part of the government’s agenda. The Zambian Government also committed itself to urgently address gaps in access to TB services. The Ministry of Health was tasked with finding mechanisms to address TB access-related challenges.

[In] 2015 there was a high-level meeting where heads of state were called at the UN summit and subscribed to the sustainable development goal number three and malaria, TB and HIV were picked globally for contributing as causes of mortalities, so the summit recognised the need to do something about it… (KII, government official 1).

Political will to support the introduction of decentralisation

The documented challenges on centralisation received government support, and this was a catalyst for decentralisation of TB services in Zambia. Some participants noted that there was a great push from the Ministry of Health that played a crucial role in preparing for decentralisation. Furthermore, the political will and ownership of appreciation of the value of decentralisation was also enhanced by the global agenda on health where the fight against TB was one of the priorities.

The government, through the Ministry of Health, emphasises zero cost on the part of the patient who has come to access TB services. There's caution to make sure that patient incur zero (or minimal) cost. So, when we look at these things and certainly say, how can we stop someone from travelling from [the provincial capital] all the way to UTH to seek treatment? (KII, TB government official 2).

Engagement of stakeholders to initiate decentralisation

The Ministry conducted capacity building to secure stakeholder buy-in for decentralisation, fostering community support and promoting integration, organisational capacity building, staff recruitment maintenance and ensuring a fertile climate for community support. Respondents indicated that obtaining explicit buy-in from critical stakeholders was necessary to foster a supportive environment through community sensitisation and capacity-building. Partnerships between the Ministry of Health and some implementing partners including local NGOs were essential to enhancing the provision of resources such as funding, equipment and training.

We built capacities, then we also conducted a lot of sensitisations, in promoting decentralisation, amongst other healthcare workers as well as amongst the patients, we assured the patients that service flow would continue smoothly, they shouldn’t be worried about those people who would be attending to them. They are capable (KII, government official 3).

Furthermore, organisational capacity was conducted to enhance institutional and structural health systems governance, and overall abilities to deliver quality services effectively and efficiently. Organisational capacity was conducted through recruiting and training new staff, equipping staff, improving infrastructure and increasing access to resources. As one interviewee stated:

So, now we actually started ah… are equipping, doing capacity-building to health workers in these other facilities which highlights the importance of investing in the development of human resources to improve the overall capacity of the healthcare system (KII, government official 4).

Supportive policy environment for the decentralisation process

The government, through the Ministry of Health, introduced policies including the 2017–2021 Zambia National Strategic Plan (NSP) on TB and Leprosy Management and Control in Zambia. To this effect, the Ministry of Health introduced the MDR decentralisation across the provinces in a phased approach. The services were decentralised first in Lusaka and the Copperbelt, and subsequently to other provinces including the Eastern, Western, North-western and Central provinces. However, little was mentioned about the impact that these policies had on operations at various levels.

There is a strategic document that we have called national strategic document for TB so that once again gives the overall guidance, and it runs for a period of 5 years so that is the mother document. The implementation part is the guideline, where everything is well documented and even algorithms are an extract from the guideline. Even when you go to the lab it will tell you an algorithm to use (KII, government official 5).

However, interviewees were of the view that the lack of stakeholder involvement during the decentralisation process may have contributed to the removal of critical policy and program features required for the successful implementation of the MDR-TB programme. They felt that engaging stakeholders, particularly healthcare practitioners, would assist them grasp the programme’s importance, build appreciation and allow for talks about how to incorporate the program into their daily activities. The absence of stakeholder participation in these talks may have resulted in missed opportunities.

I observed the relaxed support to decentralisation program by the district leadership, when you go to the district to do mentorship, our expectation was that the district leadership in most cases were supposed to be with us and just maybe even just participate for 10 minutes, even see what’s happening and have a word with a local team, but in most districts we did not see that, so this resulted in health workers not taking the program to be serious because health workers take the program to be serious when they see the top leadership is also involved (KII, government official 6).

Quarterly clinical expert committee meetings

Strengthened healthcare providers’ collaboration was recognised as a strategic approach to improving MDR-TB healthcare reform that could lead to improved patient outcomes. Expert committees were present at national, provincial and district levels. Peer-to-peer data reviews in the districts were felt to be effective. However, the capacity of provincial expert committees to go around districts providing technical assistance and facilitation for the implementation of decentralised services was reliant on the available services such as diagnosis and screening. This has led to a reduced number of visits in the last few years. The TB experts gave midweekly reviews of the performance of the decentralised MDR-TB services and identified strategies to improve them. Clinical expert committee meetings at national and provincial levels were held quarterly to review difficult cases and technical support provided on the best patient management strategies.

We also hold the quarterly clinical expert committee meetings where we review difficult TB cases pertaining to patients. Each district was given a chance to make a presentation on difficult cases that they have had in that quarter both for MDR and drug susceptibility so in that platform we build capacity, and we have a team of experts that now advise on how that patient can be managed and we have really improved in the treatment outcome for DR patients (KII, government official 7).

Domain 2: Shared motivation

Several factors influenced shared motivation in the decentralisation of MDR-TB, including actors having a common understanding, limited access to health facilities and emergency transport services, shared understanding of challenges in providing optimal patient monitoring and review, and their appreciation of the value of evidence-based decision-making in adopting the MDR-TB decentralisation.

A common understanding of the challenges faced by MDR-TB: limited access to health facilities and emergency transport services

The centralisation of TB services brought about patient discontentment regarding poor service delivery due to the poor accessibility of TB services. The patients were required to travel long distances to selected health facilities for treatment. Some patients with inadequate financial resources could not afford transportation fees to health facilities, accommodation and food while seeking care at the health facilities. The challenges contributed to socio-economic inequalities concerning access to health services. The respondents narrated that there was a great need for the government to adequately deliver these services, especially in provinces such as Eastern and North-western provinces where the decentralisation process was happening at a slow pace and had patients that still experienced difficulties travelling to health facilities.

I stayed in Lusaka for treatment for 5 months, the sixth month they said the remaining 1 month you should go and finish from home. So, when I came back home the medicine I got from Lusaka was not here the whole week and in the second week I found the medicine, and it happened that the cough came back again. When I thought of coming back to the clinic, I had no transport because where I live........ there is a distance (Patient with TB).

Centralisation also affected the emergency transport services as more patients were required to be taken to only two facilities in the country. Hence, before decentralisation, health facilities experienced challenges in referring patients. Sometimes, the unavailability of ambulances or transport limited the capacity of health facilities to deliver services to patients in time. During the decentralisation phase, more patients were attended to promptly because several health facilities across districts were offering services to patients with MDR-TB.

Before decentralisation, so, first a case could be identified by facility, and the facility would communicate to the district, then the district needed to find transport to take that patient to the central treatment centre, yet the district does not have any capacity to transport that patient (KII, government official 8).

The adoption of decentralisation facilitates opportunities for local health systems to collaborate with existing partners to provide emergency services to the nearest hospital. Compared with taking the patients to the two national treatment centres, the decentralised model reduces costs such as travel costs which were associated with TB management/services before decentralisation.

I can mention here that for us, we can’t afford a vehicle to go and pick up a client from a facility to the general hospital so our partners will provide the vehicle to move the patient and even if we want to go and visit a patient, our partners will provide transport/logistics (KII, government official 9).

Shared understanding of challenges in providing optimal patient monitoring and review

The centralisation of MDR-TB services was perceived to be affecting the monitoring and care of patients. Healthcare workers in the centralised system experienced heavy workloads due to huge numbers of patients, thus making the monitoring of patients challenging and sometimes impossible. Furthermore, seeing many patients and managing patient health information was problematic, furthering the gap in ensuring that patients are effectively monitored. The government and implementing actors recognised the multifaceted challenges and supported the decentralisation process to contribute to a reduction of the problem.

Patient overload, distance to the facility, poor record keeping and follow-ups were not being done and maybe even monitoring of these patients was difficult, so they figured out that if we decentralise maybe things will be done more orderly. So even patient care was compromised, so when they decentralised care and treatment improved because services were brought closer to home (KII, government official 10).

Appreciation of the value of evidence-based decision-making in adopting MDR-TB decentralisation

The capacity readiness assessment included evaluating the size and composition of health facilities, the availability of human resources, diagnostic and laboratory capabilities and the availability of data collection tools. These facilitated an understanding of facilities’ readiness to implement and manage MDR-TB treatment at the facility level. Key informants narrated that human resource for health were identified as a crucial factor, and facilities needed to have at least one medical doctor and a dedicated clinician or nurse trained in DR-TB management to handle the patients. Diagnostic services also had to be available to make an accurate diagnosis of MDR-TB. The decentralisation process was gradual, starting with larger hospitals in 2014 and fully decentralising to districts in 2018. There was also an imperative need for adequate drug stocks, which were crucial in ensuring that facilities could continue providing treatment and care for patients with MDR-TB. The success of the decentralisation process of TB services depended heavily on these preparatory measures, with manpower development being a key factor as one interviewee stated:

So, we did have a tool that was assessing certain things that should be in place for a site to be set to be related to start treating patients. It has to be a diagnostic site, it must have a preferred medical officer who’s also trained in drug-resistant TB (KII, government official 11).

Domain 3: Capacity for joint action

The capacity for joint action strategies included leadership roles in communicating the implementation plan, MoH initiating strategic partnerships in enhancing MDR-TB decentraliation, leadership capacity role in organiing training for healthcare workers, training of multidisciplinary teams, inadequate coordination, supervision and monitoring of laboratory services and joint action in health infrastructural rehabilitation.

Leadership capacity in communicating the implementation plan

The selected sites were assessed using a tool to ensure that each region had the necessary resources to treat patients with MDR-TB. This strategy allowed for a targeted and context-specific approach to implementing decentralised MDR-TB treatment in Zambia, rather than a one-size-fits-all plan. The communicating of the plan to all relevant implementing partners was crucial to ensuring that they were all informed and guided. Another KII participant stated:

We have to have different strategies for different provinces because the capacity of one province is not the same as the capacity of another province (KII, government official 12) I think one last important area where we are involved is to make sure that the community TB program is also supported and coordinated so that as a province, we do make sure that drug-resistant TB at the community level is implemented, where volunteers are supported. …. provide services on DRTB by for instance supporting DRTB patients at the community level. (…) even giving education at the community level for people who are coughing or people who may be on treatment but they are not getting any better so communities are involved, so in a nutshell that’s what I can say the degree to which am involved in DRTB program (KII, government official 17).

MoH initiating strategic partnerships in enhancing MDR-TB decentralisation

Strategic partner identification was critical to the successful execution of the MDR-TB decentralisation strategy. As a result, several partners were identified to assist with staffing specific facilities, sourcing equipment and providing assistance at the district or facility levels. It has been stated that increased collaboration in healthcare is a strategic approach to reform that can improve patient outcomes, such as reducing preventable adverse drug reactions, lowering morbidity and mortality rates and optimising pharmaceutical dosages.

The Ministry of Health alone cannot manage to sufficiently do a lot of things [on its own] but when you collaborate with other organisations, it helps because for example, the training which we have been having, they were supported by CIDRZ. So, then they will support those activities. In addition, when we are doing some of the community activities, they also support the communities (KII, government official 13).

Creating health partnerships extends to supporting the implementation of community-based activities. It was also important to assess which institutions were capable of offering preparatory services to assist with the decentralisation process. For instance, the [general hospital] was identified in the [province] as a training site to train health workers in MDR-TB diagnosis and treatment. For some areas, collaboration with external partners helped them not only train staff members but also led to the rehabilitation of structural facilities that would lead to a smooth decentralisation process of MDR-TB management.

The [general hospital] is a training and internship site… so we train a lot of interns in MDR TB, of course, our understanding is that as we build capacity, wherever they’ll go, they’ll carry that capacity… we trained pharmacy, trained lab, nurse, clinical people ahh we trained them and trained environmental health for public health purposes (KII, government official 14).

Leadership in organising and implementing the training for healthcare workers

The availability of trained human resources for health contributes to their increased knowledge and skills to improve the delivery of TB services. Some healthcare workers reported that after receiving the training, they were now more actively involved in the planning, implementation and monitoring of the delivery of TB services compared with the pre-decentralisation period. However, due to limited funding, several healthcare providers were not trained in the management of MDR-TB.

So, now we actually started…are equipping, doing capacity building to health workers in these other facilities, which highlights the importance of investing in the development of human resources to improve the overall capacity of the healthcare system (KII, government official).

Formation of multidisciplinary teams

The interviewees underscored that creating MDR-TB implementation teams was a crucial step in the decentralisation efforts, at the national, provincial, district, and health facility levels. In this regard, committees and expert teams were formed to spearhead the process. The National Clinical Expert Committee is composed of specialists in internal medicine, and infectious diseases including MDR TB, pharmacy, paediatrics, gynaecology, nutrition, social work and other supporting partners. Collaboration and teamwork were essential for ensuring successful decentralisation efforts, but it was not the same across regions and sites. As one interviewee stated:

You feel (the patient) is not responding well to treatment, there is a committee that the client is subjected to. They analyse the patient, analyse the drugs, should we switch, should we change maybe from second line treatment…third line treatment. That committee has been there maybe I don’t see any change I don’t think there is something that has changed if there are changes maybe it’s the number of times that probably this committee should sit…the number of times that this committee should look at the patients, discuss the patients… (KII, government official 14).

Collaborating with external partners in support decentralisation

For some areas, collaboration with external partners not only helped train health workers but also led to the rehabilitation of existing health facilities’ infrastructure, facilitating the smooth decentralisation process of MDR-TB services and management.

In 2017, we first started having visitations with NTLP to see what was on the ground… I think the major partner was FHI-360 under the challenge TB program. So, FHI-360 through the challenge TB program conducted the prevention and control training for the entire institution targeting all the workers in all the major departments… and providing infectious control guidelines and activities in each working space in the clinical area as well as in the non-clinical. They brought in partners under USAID and lobbied for us to have an MDR ward rehabilitated. That was done at UTH, here [Kabwe], Ndola and Kitwe, not sure about other provinces if something was done to that effect (KII, health facility staff 1).

Joint action in health infrastructural rehabilitation

Furthermore, the collaboration between the Ministry of Health and partners also contributed to improving infrastructure. For some areas, collaboration with external partners helped not only train staff members, but also led to the rehabilitation of structural facilities that would lead to a smooth decentralisation process of MDR-TB management. In some cases, new structures were built for MDR TB management. However, the support was limited as many health facilities required adequate health infrastructure development that remains unmet.

They brought in partners under USAID and World Bank lobbied for us to have an MDR ward rehabilitated (KII, health facility staff 2).

This study explored how collaboration influences the effective decentraliation implementation of MDR-TB in Zambia to enhance access and care quality. The principled engagement was shaped by the global health agenda/summit meeting’s influence on the decentralisation of TB, engagement of stakeholders to initiate decentralisation, supportive policy environment and quarterly clinical expert committee meetings. The study underscores the value of collaboration among stakeholders in policy development and implementation, shaping their joint capacity and shared motivation to train healthcare providers and engage communities, ultimately influencing successful treatment outcomes.

The study has revealed that the lack of TB service decentralisation in Zambia led to limited access, hindering eligible patients and clients from conveniently accessing care. However, a Pakistani study showed that expanding the centralised TB healthcare services contributed to increased adverse effects for rural and peri-urban populations [ 20 ]. The limited access to TB services in rural and peri-urban areas was attributed to limited or lack of healthcare infrastructure where patients could easily get tested. This highlights the major constraining factors that contributed to limited access to health facilities. They included emergency services transport for referring patients for MDR-TB services, constraining access to health facilities owing to long distances and challenges in providing optimal patient monitoring and review, as motivating factors.

The study suggests that a supportive decentralisation policy and governance environment plays a crucial role in health systems strengthening in MDR-TB in Zambia. The political leadership appreciated the pressing challenges, particularly poor access to MDR-TB services. Therefore, they advocated with political will for a policy shift from centralisation to decentralisation. Similarly, a South African study also showed that the health reform pertaining decentralisation of MDR-TB services was done to enhance access to care by placing TB care closer to communities, and improving TB-care success rates [ 21 ]. In addition, studies conducted on health policy and systems reforms also show how critical leadership and power are in driving collective decision-making on health system and policy development and reform [ 22 , 23 , 24 ]. The Ministry of Health realised that creating an enabling policy environment would contribute to addressing the limited access to MDR-TB services in Zambia. Therefore, taking services closer to the people promotes equity and contributes to dismantling health inequalities.

The supportive policy health environment spelt out the government’s agenda, direction and commitment to scaling up the decentralisation of MDR-TB services. This roadmap was essential not only in helping health managers, providers and partners understand the policy, but also in giving authority to key stakeholders to hold the government accountable for the status of the delivery of services. An Indian-based study showed that social accountability mechanisms empowered the community to collective negotiations resulting in demands for changes from the health leadership [ 25 ]. However, top leadership, in some cases, limited sustained momentum in the decentralisation process. This creates an impression whereby local health actors may fail to appreciate the health reform, contributing to a lack of ownership as they will only be waiting for the superiors to direct the implementation of the process. This study highlights that shared motivation is critical in making the stakeholders understand the programme, facilitate their buy-in and support the creation of the MDR-TB decentralisation structure and plan. Therefore, collaboration is key in facilitating stakeholder engagement through decentralised delivery of TB services to improve accessibility by clients to health facilities and the provision of quality services for a broader population.

Furthermore, this study has highlighted the importance of collaboration in the decentralisation of multi-drug-resistant tuberculosis services. Collaboration plays a crucial role in capacity-building and training among healthcare providers. In South Africa, trained human resources for healthcare are limited, thereby impacting optimal service delivery. Stakeholders, including NGOs’ collaboration and collective action, improved healthcare workers’ delivery of TB services through the provision of specialised healthcare and psychological social support [ 21 , 26 , 27 ]. Furthermore, through joint efforts, healthcare providers can receive specialised training to stay updated with the latest treatment options and management techniques, thus enhancing their proficiency in handling MDR-TB cases.

This study also highlighted that strategic partnerships are essential through capacity-building and training of healthcare providers by contributing to more effective patient care and enhanced treatment outcomes. This finding is in line with other studies, which suggest that collaborative efforts in delivering patient-centred decentralised approaches enable healthcare providers to navigate therapeutic options and provide effective care, ultimately contributing to improved treatment outcomes [ 4 ]. Collaboration helps healthcare workers to continue providing services through community structures [ 28 , 29 , 30 ]. However, inadequate human resources for health in Zambia is contributing to limiting healthcare provider’s involvement in the treatment of patients. Many healthcare facilities are not fully equipped to handle TB. In addition, they have a limited number of healthcare providers who have heavy workloads with marginal involvement of others in the management of patients.

Some studies have, however, shown that collaboration in delivering a patient-centred decentralised approach where healthcare providers collaborate in delivering TB services helps in navigating therapeutic options and enhances effective care [ 5 ]. Furthermore, this study shows that training healthcare providers is key to the decentralisation of TB services. The training equips the officers with specialisation on the latest treatment options in the operations and management of TB. Similarly, evidence from an African study found that equipping healthcare providers in the management of TB and adopting locally appropriate strategies enhances the implementation of the decentralisation policy [ 31 ].

Supportive collective community-based MDR-TB interventions were found to be crucial in creating awareness and improving patient treatment outcomes. It was apparent that community health actors, with the involvement of community health workers, contributed to improved awareness, enhanced case detection and strengthened referral systems and monitoring of patients [ 32 ]. The findings of the study show that there was inadequate involvement of community-based actors in the delivery of TB services, which might be contributing to low levels of knowledge and inadequate support from the community.

Limitations and strengths of the study

One of the limitations is the absence of stakeholders from supporting partners, including international organisations. This leaves a gap in understanding engagements during the decentralisation process. This could potentially limit the scope of the insights shaping decentralisation. Another limitation of this study is that we only focussed on collaborative dynamics to understand the key factors shaping the decentralisation policy of MDR-TB services, as it is crucial to provide in-depth knowledge of the key lessons influencing the implementation of these services. Despite this limitation, our study strength includes conducting inclusive interviews with stakeholders at the national, provincial, district and community levels, such as healthcare providers and managers at different levels, patients and caregivers, which facilitated an in-depth understanding of collaboration for implementation of decentralisation policy of multi-drug-resistant tuberculosis services in Zambia. The collaboration of researchers with backgrounds in health, social science and TB programs enhanced the analysis and quality interpretation of the findings.

The decentralisation of multi-drug-resistant tuberculosis services in Zambia was propelled by collaborative efforts aimed at addressing access to multifaceted challenges arising from the centralised management of TB health services. Collaboration dynamics, including principled engagement, shared motivation and the capacity for joint action, played a crucial role in involving stakeholders to tackle issues such as limited access, transportation barriers and patient monitoring challenges. The shift in policy was grounded in evidence-based decision-making, influenced by political determination and facilitated by supportive policies. However, more capacity-building trainings are needed to increase the number of healthcare workers involved in the delivery of MDR-TB services. The study also identified associated healthcare challenges, including infrastructure and service delivery limitations. Therefore, enhancing stakeholders’ collaboration will create opportunities to expand the current infrastructure and support the optimal decentralised delivery of MDR-TB services.

Data availability

The study data can be requested from the authors. The articles for this review can be made available upon request.

Abbreviations

Non-governmental organisations

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World Health Organisation

United States Government via United States Agency for International Development

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Japan Anti-Tuberculosis Association

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Acknowledgements

We would like to thank the Ministry of Health managers for facilitating easy data collection process. We also appreciate the participants for sacrificing the time in providing information on this study.

Open access funding provided by Umea University. We would like to thank the Ministry of Health through Global Fund of Zambia for providing financial support to implement this study.

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M.P.C., T.F.L.M., P.M., M.N.M., B.H. and J.M.Z. contributed towards the development of study design, review of data, analysis and synthesis. M.P.C. drafted the manuscript and all authors contributed towards its revision. All authors (M.P.C., T.F.L.M., P.M., M.N.M., B.H., N.L., J.B., N.N.S., H.H., C.M., A.M., P.K., M.C., H.P. and J.M.Z.) reviewed and approved the final manuscript.

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This study followed comprehensive ethical considerations. Ethics approval was sought from the University of Zambia Biomedical Research—UNZABREC (ref. no. 3003-2022) and protocol was further registered and approved by the Zambia National Health Research Authority. Informed consent was obtained from all participants to ensure confidentiality and clear information about the study’s purpose, risks and benefits. To protect research assistants and participants, health safety protocols, including provision of N95 masks, hand sensitising and ensuring that they maintain a safe distance during interviews, were followed.

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Chavula, M.P., Matenga, T.F.L., Maritim, P. et al. Collaboration for implementation of decentralisation policy of multi drug-resistant tuberculosis services in Zambia. Health Res Policy Sys 22 , 112 (2024). https://doi.org/10.1186/s12961-024-01194-8

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In 1993, WHO declared tuberculosis (TB) as a global health emergency considering 10 million people are battling TB, of which 30% are undiagnosed annually. In 2020 the COVID-19 pandemic took an unprecedented toll on health systems in every country. Public health staff already engaged in TB control and numerous other departments were additionally tasked with managing COVID-19, stretching human resource (HR) capacity beyond its limits. As part of an assessment of HR involved in TB control in India, The World Bank Group and partners conducted an analysis of the impact of COVID-19 on TB human resources for health (HRH) workloads, with the objective of describing the extent to which TB-related activities could be fulfilled and hypothesizing on future HR requirements to meet those needs.

The study team conducted a Workload Indicators and Staffing Needs (WISN) analysis according to standard WHO methodology to classify the workloads of priority cadres directly or indirectly involved in TB control activities as over-, adequately or under-worked, in 18 districts across seven states in India. Data collection was done via telephone interviews, and questions were added regarding the proportion of time dedicated to COVID-19 related tasks. We carried out quantitative analysis to describe the time allocated to COVID-19 which otherwise would have been spent on TB activities. We also conducted key informant interviews (KII) with key TB program staff about HRH planning and task-shifting from TB to COVID-19.

Workload data were collected from 377 respondents working in or together with India’s Central TB Division (CTD). 73% of all respondents ( n = 270) reported carrying out COVID-19 tasks. The average time spent on COVID-19 tasks was 4 h / day ( n = 72 respondents). Multiple cadres highly instrumental in TB screening and diagnosis, in particular community outreach (ASHA) workers and CBNAAT/TrueNAAT laboratory technicians working at peripheral, block and district levels, were overworked, and spending more than 50% of their time on COVID-19 tasks, reducing time for TB case-finding. Qualitative interviews with laboratory technicians revealed that PCR machines previously used for TB testing were repurposed for COVID-19 testing.

Conclusions

The devastating impact of COVID-19 on HR capacity to conduct TB case-finding in India, as in other settings, cannot be overstated. Our findings provide clear evidence that NTEP human resources did not have time or essential material resources to carry out TB tasks during the COVID pandemic without doing substantial overtime and/or compromising on TB service delivery. To minimize disruptions to routine health services such as TB amidst future emerging infectious diseases, we would do well, during periods of relative calm and stability, to strategically map out how HRH lab staff, public health resources, such as India’s Health and Wellness Centers and public health cadre, and public-private sector collaboration can most optimally absorb shocks to the health system.

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Introduction

In the past three centuries, tuberculosis (TB) has been declared a pandemic more than once [ 1 , 2 ]. It is the leading cause of mortality from chronic infectious diseases and is estimated to cause around 4000 mortalities per day globally [ 1 , 3 , 4 , 5 , 6 ]. Individuals infected with TB could transmit the disease to 10–15 people annually [ 7 , 8 ]. In 1993, WHO declared TB a global health emergency considering 10 million people are battling TB annually, of which 30% were undiagnosed, but it was only in 2018 that TB was labeled as a global priority and achieving a TB-free world was highlighted as a realistic target [ 2 , 9 , 10 ]. A global commitment was made to improve active case finding, implement prevention strategies and strengthen the research agenda, after which TB incidence and mortality declined substantially [ 10 ]). However since the start of the COVID-19 pandemic, TB case notifications dropped by 25% globally and TB related mortality increased by an estimated 0.2 to 0.4 million ( [ 11 ]. In one year, the COVID-19 pandemic reversed the global progress achieved in the reduction of TB [ 4 , 11 ].

India has the largest burden of TB globally, with one quarter of the total and one-third of the drug resistant TB burden [ 6 , 12 , 13 , 14 , 15 , 16 ]. India has fought to ensure access to appropriate and improved diagnostics and quality of care particularly in the private sector which, among other factors, contributes to an extremely high case fatality rate (an estimated two deaths every three minutes) [ 7 , 16 , 17 ]. When the COVID-19 pandemic hit India, efforts toward TB reduction and control were seriously disrupted and resources were redirected toward the pandemic.

This was a global problem: a survey done in more than 100 countries demonstrated that 78% of TB control programs were disrupted due to COVID-19 pandemic [ 18 , 19 , 20 ]. Lockdown, cancellation of essential health services, shifting of human and diagnostic resources from TB to COVID-19 management, and disruption in TB treatment availability impacted TB services at all levels and in the public and private sector [ 1 , 6 , 17 , 18 , 20 , 21 , 22 , 23 ]. The World Health Organization (WHO) estimated a decrease of 18% in reported TB cases in 2020 compared to 2019 with India being a large contributor to that decrease [ 24 ]. In India, TB notifications in April 2020 were 78% lower than April 2019, with a larger decline in the private sector [ 16 , 18 ].

While preventive measures for both diseases are similar (cough etiquette, social distancing and wearing masks), the COVID-19 measures of lockdown, quarantine and redirection of health services delayed TB patient access to diagnosis and treatment [ 4 , 10 , 13 , 16 , 25 ]. Fear of COVID-19 and imposed pandemic control restrictions led to migration, loss of employment (estimated at 140 million Indians) and increased malnutrition, thus leaving a large number of individuals at risk of both diseases [ 3 , 13 , 14 ]. A study of co-infection of TB and COVID-19 found a 12.3% mortality rate, which is much higher than for only COVID-19 [ 12 ].

The health care workforce was and continues to be the main player in the fight against COVID-19. In India as elsewhere, staff and diagnostic equipment (CBNAAT, TrueNaat and GeneXpert) were repurposed to support COVID-19 activities, while research and funds were deprioritized from their initial mandate [ 1 , 2 , 3 , 6 , 12 , 16 , 17 , 21 , 22 , 23 , 26 ]. Digital tools and technologies initially created for TB were diverted to the COVID-19 response [ 20 ].

Prior to the onset of the COVID-19 pandemic in India in early 2020, India’s National TB Elimination Program (NTEP) finalized its 2021–2025 National Strategic Plan (NSP), which set ambitious TB notification targets. Achievement of these targets cannot be met without proportionately larger gains in numbers of individuals screened, tested and diagnosed with TB, all of which require substantial health workforce investments. India’s Central Tuberculosis Division (CTD), National Health System Resource Center (NHSRC) and the World Bank carried out a Workload Indicators and Staffing Needs (WISN) assessment amongst human resources for health (HRH) involved in public sector TB service delivery, with the objective of projecting future staffing needs to support the NTEP’s NSP and Sustainable Development Goal (SDG) targets for TB notifications by 2025 and 2030. At the onset of the COVID-19 pandemic, when the WISN analysis was conducted, the burden of COVID-19 management fell squarely on the shoulders of the NTEP. Therefore, the aims of this study were to:

quantify and qualitatively describe the additional workload imparted by the COVID-19 pandemic on NTEP staff, and;

investigate whether there are sufficient hours in a standard workday and work week for cadres heavily involved in TB case-finding to fulfill all TB, non-TB, and COVID-19 requirements.

In this paper we describe the double burden of TB and COVID-19 service delivery amongst HRH working from community to state level in the NTEP and implications of these findings for realistic staffing plans to support achievement of strategic TB control targets.

Study design and population

The study team implemented a convergent parallel mixed methods study design, in which quantitative and qualitative data collection were conducted simultaneously to accommodate project timelines [ 27 ]. To accommodate interviewing during the COVID-19 pandemic, the study team conducted an adapted WISN analysis according to standard WHO methodology, as well as the qualitative interviews, by phone. Interviews were designed to quantify the workloads of 28 priority cadres directly or indirectly involved in public sector TB control activities for the year of 2019 (to quantify non-pandemic period workloads), and to project future staffing requirements based on NTEP TB notification targets [ 28 ]. In consultation with CTD, NHSRC, and World Bank stakeholders, 18 cadres were selected among the 28 priority cadres for in-depth key informant interviews (KIIs) which were assessed as having relatively greater involvement in managing or providing TB services. State, district, TB unit and peripheral health institute (PHI) level cadres were interviewed for both the quantitative (WISN) analysis and qualitative data collection [ 29 ] (Fig. 1 ).

The study was carried out in 18 districts across seven states of India. These states were purposively sampled to achieve a representative geographic country selection, a representative sample of India’s TB epidemiological transition, as well as representative levels of staff shortage. No additional inclusion or exclusion criteria were applied beyond these three criteria at the state level. Among the selected seven states, districts were stratified based on the NTEP’s TB Index Rank [ 30 ] into high, medium and low performance districts [ 31 ]. On this basis one district was randomly sampled from each of the high and medium strata for the three smaller states Assam, Himachal Pradesh, Mizoram for a total of six districts. For the four larger states Karnataka, Maharashtra, Tamil Nadu, and Uttar Pradesh, one district was randomly selected from each of the high, medium and low performance districts for a total of 12 districts. This totaled to 18 districts for all seven states. For block and PHI-level cadres, one block per district and one PHI per block were then randomly selected for all cadre interviews. There were a total of 455 NTEP staff working in all 28 priority cadres of the 18 districts for the quantitative study, and 96 among the 18 cadres for the qualitative study. These final sample sizes of 455 individuals for the WISN analysis and 96 individuals for the KII’s were not powered for statistical testing as this was not required for our research aims.

Organogram of peripheral health institutes and TB units reporting to a District TB Center

Tool development

Structured interview tools were prepared to extract necessary data to complete WISN analyses for TB and non-TB activities conducted in 2019, for each of the 28 priority cadres, and then were refined through iterative reviews by HRH and TB experts in India. Additionally, the tools included a module to capture a rough estimate of hours worked on COVID-19 tasks in 2020, along with a description of the tasks. Semi-structured interview guides were developed to steer interviews with key program staff to understand HRH planning and priority shifting before and during the COVID-19 pandemic. WISN tools were piloted amongst 10 staff working in 4 of the 28 priority cadres, and qualitative guides were piloted amongst four staff, each from a different cadre.

Data collection

All quantitative and qualitative data collection was done in September and October 2020. 393 of 455 eligible TB staff for the WISN (quantitative) analysis were reached by telephone, of which 377 agreed to participate by responding to the WISN questionnaire over the phone, and of which 372 complete questionnaires were obtained. Of the 96 eligible staff for the qualitative KII’s, 60 individuals were reached and participated. Responses were audio recorded and then digitally captured daily in a Microsoft Excel database. Qualitative data collected were captured by recording interviews, transcribing and thematically coding them in Hindi in Microsoft Excel. They were then translated into English. Transcriptions were performed independently by two researchers, then compared and adjusted.

Data analysis

We carried out quantitative analysis of WISN interview data according to standard WHO methodology [ 28 ]. All analysis of WISN data was conducted in Stata Version 16 MP. Workload was calculated at both the individual level and cadre level. A WISN ratio below 0.9 was classified as reflecting low pressure (‘underwork’), between 0.9 and 1.1 as adequate pressure, and above 1.1 as high workload pressure (‘overwork’). The WISN workload analysis and ratios did not factor in COVID-related tasks; therefore, hours reported for COVID-19 are additional and should be considered separately from the number of hours required to fulfill tasks, and staffing projections.

For ten cadres (translating to 225 of 372 respondents) directly involved in TB case-finding activities through either screening or diagnosis, we carried out quantitative analysis in Microsoft Excel to calculate time spent on COVID-19 related tasks on a weekly basis. Average weekly hours spent on TB and non-TB tasks for 2019, and COVID-19 related tasks in 2020 were summed to quantify average weekly workload per cadre required to offer uninterrupted TB services and to additionally manage COVID-19 responsibilities. We applied a framework analysis approach informed by Sousa’s Health Labor Market Framework which served as the conceptual model for our study, to classify, deductively code and interpret the qualitative data from interviews [ 32 ]. The methods applied did not account for external factors, including the impact of COVID-19 tasks on workload.

Ethical considerations

Verbal informed consent was obtained from all participants responding to the WISN questionnaire and participating in key informant interviews, and all participants confirmed that they were in a legal, safe, and convenient environment while conducting the telephonic interview. Ethical approval for all methods including the informed consent process was obtained from Sigma IRB, a division of Sigma Research and Consulting Private Ltd with approval code 10,032/IRB/20–21.

Workload pressure and staff shortage

Among 377 interviewed NTEP respondents, a complete WISN workload assessment, not factoring in time spent on COVID-19 tasks, was conducted for 372 respondents. Four out of five cadres in the peripheral health institute (PHI) level were on average overworked, as more than 50% of these cadres’ respondents had a high workload pressure (Fig. 2 ). All five PHI-level cadres however had an overall staff shortage of 36% (Table 1 ). At the block level, about one-third of medical officers and senior treatment supervisors (STS) were considered underworked, while most senior TB laboratory supervisors (84%) and approximately half of TB health visitors (56%) were considered underworked. 44% of STS and 33% of medical officers were overworked (Fig. 3 ).

WISN workload pressure by cadre level. PHI level cadres. Data in Figs. 2 – 5 do not account for time spent on COVID-19 task

WISN workload pressure by cadre level. TB unit/ block level cadres. Data in Figs. 2 – 5 do not account for time spent on COVID-19 task

At the district level, five of eight cadres were on average overworked (ranging between 70 and 80% per cadre), with only senior medical officers, NTEP accountants and data entry operators on average being underworked (Fig. 4 ). Workload showed the widest range at the state level, with pharmacists showing the lowest levels of overwork (15%) and 100% of STDC directors and senior lab technicians reporting overwork (Fig. 5 ).

WISN workload pressure by cadre level. District level cadres. Data in Figs. 2 – 5 do not account for time spent on COVID-19 task

WISN workload pressure by cadre level. State level cadres. Data in Figs. 2 – 5 do not account for time spent on COVID-19 task

District and state level cadres both had an overall shortage of staff (18% each), with only three of eight district level cadres reporting a majority low or adequate workload pressure and surplus of staff, and five of 11 state level cadres reporting the same (Table 1 ).

Double workload burden: COVID-19 and Tuberculosis

Respondents from all 28 cadres carried out COVID-19 tasks daily, approximately 73% of 372 total respondents ( n = 270) [ 33 ]. The average time spent on COVID-19 tasks was 4.4 h per day, with PHI and block level cadres reporting the highest average of 5.4 and 5.0 h per day respectively, followed by state at 4.2 h and district at 3.9 h per day [ 33 ]. This also holds true for multiple cadres which are both highly instrumental in TB screening and diagnosis and already overworked according to the WISN analysis who did not factor in the time required for their additional COVID-19 tasks.

Table 2 presents an overview of the time spent on reported COVID-19 (2020), TB (2019), and non-TB related activities (2019) on a weekly basis for ten cadres which have key roles in either screening or testing for TB. This means that each of these cadres is directly involved in identification of people with presumptive TB in the community or facility, or testing specimens for TB in the laboratory (column C). Relative to a 40-hour workweek, all 10 cadres reported that they spent more than 50% of their daily hours (extrapolated to the week) on COVID-19-related tasks (column L). Seven of the ten cadres are already overworked (columns E, F) without factoring in COVID-19 responsibilities. Summing the COVID-19, TB, and non-TB hours required, these cadres would need to work an average of 1.7 (range: 1.5 to 1.8) 40-hour work week equivalents per week, for an average of 66.8 h per week (range: 60.0–72.0). The hours spent on TB activities (column I) which are spent specifically on case-finding activities (column J) are also presented to provide a perspective on the number of hours available for work directly related to identifying, screening and testing people for TB. On average these cadres spend 32.9% of their week (26.9 h) on case-finding activities, if they have no additional COVID-19 responsibilities.

Qualitative findings

Interviews with NTEP staff revealed that cadres at all levels were responsible for setting up COVID-19 testing labs; ensuring that proper equipment for health care workers and frontline staff were provided and distributed; organizing COVID-19 specimen collection, transportation, testing and results provision. These COVID-related tasks increased workload primarily of community and PHI level cadres, in effect compromising NTEP service delivery in screening and diagnostic activities, supervision, and monitoring. Many lab technicians were diverted from TB to prioritize COVID-19 testing as the same testing platforms (CBNAAT) were shared to process both. TB testing also decreased during the national lockdown, in which all transportation was banned and most businesses were closed. One respondent expanded on this:

“Of course, yes, being involved in work related to COVID management in the district has hampered our work. We’ve had to divert staff for testing and sampling. People were assigned for identifying and following up cases etc., tracking the home isolation cases, so work still continues to suffer. We still don’t have enough to manage, how to handle all the samples? At one time, some 1,500 samples came. So, to get samples diagnosed at the field level, we had to mobilise the lab technicians’.” (CMOH)

Supervisory staff also prioritized COVID-19 related tasks:

“Supervisory staffs have also been given COVID duty and their work also got affected. That is why we have 23% decrease in notification.’ (State TB Officer).”

Respondents observed a large reduction in healthcare seeking behavior due to COVID-19 and hypothesized that this was related to fear of being tested for COVID-19, becoming infected in a facility, or being stigmatized due to ambiguous symptoms. Stakeholders reported that apprehensions around COVID-19 also added to TB stigma- that patients did not want to report symptoms including cough or cold, because they were apprehensive of having to test for COVID-19 and of possible institutional quarantine, as shown in this quote:

“There is stigma among the patient for COVID…they are not willing to come to the health facility, doctors are not willing to see the patients because of fear of contracting of the disease. Probably from October private institutions will start opening and probably things will settle gradually, but it all depends on availability of a remedy for COVID’. (DHS)”

However, responses suggest that the NTEP tried to cope with the additional COVID-19 workload by screening for COVID-19 during routine TB active case finding activities, and reduce interruptions to routine service delivery as much as possible. For instance, PHI and block level cadres conducting COVID-19 awareness campaigns, case-finding, and supporting patients at home and institutional quarantine often tried to integrate these tasks into their routine community-based TB tasks. The following quote provides an example of NTEP staff creating efficiency gains:

“My attempt has been to take advantage of the situation to combine other aspects. There haven’t been problems in getting people medicines. ASHA’s have to do per day surveys on COVID. We suggested that since they have to visit these many houses a day, they should continue their other work including Ante-Natal Care, healthcare for kids, general health, and TB. If you only ask about COVID — do you have fever, a cough and so on — it leads to the public getting scared of testing. So, the ASHA’s have been sensitized to talk about all aspects of their work.’ (District Nodal Officer CP)” “But we are committed to the goal of TB elimination. We have to do some active case finding activities after this and treat the patients. The STSs are delivering TB drug to the patients at their doorstep who are not able to come to the centers; sputum cups are provided to the ACSM coordinator during community [COVID-19] survey to collect [COVID-19 and TB] sputum samples from the patients .(District TB Officer).”

Providing drugs to TB patients was initially challenging during COVID-19 lockdowns; however, service providers quickly responded by providing extra drugs to patients during their facility visits and by conducting home deliveries:

“When we came into lockdown the policy was made that drugs should be brought to the patient instead of patient approaching us for drugs that is one thing. We also took on the decision that no dropout (of TB patients) should happen for want of drugs or want of medical aid’. (DHS)”

The WISN analysis shows that cadres working in all levels of the NTEP were overworked and suffered from staff shortages, which were substantial for both cadres (PHI and block) working closest with the community. Managing COVID-19 has seriously increased the workloads of many of these cadres, and COVID-19 tasks were reportedly prioritized above many others. Qualitative interviews suggest that the workloads calculated may be based on fewer facility attendees than expected due to reduced healthcare seeking behavior and provider hesitance to interact with patients. The WISN analysis and COVID-19 workload calculations suggest that reaching the NTEP’s 2025 notification targets may be challenging if a similar diversion of key TB screening and diagnosis staff towards COVID-19 management were to continue. To accommodate the double burden of TB and COVID-19, NTEP staff implemented workarounds, including simultaneously conducting TB and COVID screening, and delivering medicines in bulk quantity to patients’ homes during community COVID-19 surveillance.

WISN ratios underrepresent workloads

Due to the omission of COVID-19 tasks from the WISN ratio and the expectation for key cadres to carry out COVID-19 and TB services simultaneously, it can be reasoned that the actual workload pressure experienced in 2020 was likely much higher than presented. As most key screening and diagnostic cadres would have normally spent more than 50% of their weekly hours on TB tasks prior to COVID-19, they were working far beyond 40 h per week, and cutting back on delivery of routine TB services to accommodate the COVID-19 workload [ 3 , 4 , 6 , 12 , 16 , 24 ]. Although lockdowns limited healthcare seeking behavior and reduced TB workload for many, demand for TB services was still present as evidenced by continued high notifications: overall 2.4 million and 1.8 million cases were notified in 2019 and 2020 respectively [ 34 ]. Our analysis suggests that for uninterrupted TB service delivery to have co-existed with the volume of COVID-19 activities conducted in 2020, almost twice the number of HRH would have been required just among cadres involved in key TB screening and diagnostic activities (mean: 1.7; range: 1.5–1.8). Thus, in a COVID-19 endemic setting, the cadres who are most heavily involved in presumptive TB case-finding have minimal time to pull presumptive TB cases into the care cascade, upon which all NTEP TB notification targets depend. Passive case-finding of presumptive TB cases in facilities has returned to pre-pandemic levels in many settings, due to health system resilience and international funding mechanisms. However our study shows that cadres responsible for TB active case-finding (ASHAs, TB health visitors and senior treatment supervisors), which is also an essential activity to reach the NTEP’s notification targets, are overworked without COVID-19 tasks, and required at least 1.5–1.6 times their current working hours to provide uninterrupted routine TB and COVID services in 2020. While NTEP cadres can be recruited and retained to address this gap during future health emergencies, this is a particularly problematic finding for ASHAs, who are not employed staff, but volunteers who are paid for performance for a range of community-based services. In fact, ASHAs had the highest WISN ratio (2.15) of all 28 priority cadres interviewed. It is not a sustainable solution to, in emergency situations, rely more heavily on an overworked group of individuals who are not compensated equitably relative to employed NTEP cadres.

Solutions identified

Our results highlight a number of strategies implemented by NTEP staff to mitigate the impact of COVID-19 responsibilities on routine service delivery, namely adding COVID-19 to existing community outreach services, or bringing TB medications to patient homes during lockdowns. In facility settings, the CTD has implemented bi-directional TB and COVID-19 screening among higher risk groups [ 35 ]. Other opportunities to create efficiencies have been well-documented elsewhere [ 4 , 7 , 11 , 17 , 21 , 24 , 36 ].

These solutions have and likely will continue to support NTEP cadres, at all levels, in managing both routine TB and COVID-19 responsibilities. However, there are still several obstacles that need to be addressed if these solutions can provide sustained relief to overworked staff. ASHAs have demanded improved compensation and recognition for the important role they have played in carrying out community health outreach, including both TB and COVID-19 case-finding [ 37 ].

Furthermore, although the influx of COVID-dedicated PCR machines may have been hugely beneficial, for the foreseeable future India will need to test a high volume of specimens for COVID-19, and a backlog of undiagnosed prevalent TB cases which may have accrued during COVID-19 peaks [ 4 ]. This will require both additional PCR machines and laboratory staff. Finally, ensuring that people who test positive for TB or are clinically diagnosed are started on TB treatment will require additional senior treatment supervisors and medical officers.

To make gains toward TB notification targets, supporting the capacity of cadres involved in screening and diagnosis of TB is essential. In addition to providing more appropriate incentives to ASHAs, India’s private sector has a proven track record of conducting TB case-finding and can play a larger role in diagnosis & referral [ 38 ]. Within facilities, identifying more TB presumptives will be key, and can be achieved by conducting systematic screening in outpatient departments [ 39 ], although this will also require additional capacity for facility-based cadres.

Others have written about the necessity of strategies to reach populations who avoided health services during lockdowns and infection waves [ 4 , 10 ]. Strengthening this linkage between communities and facilities to increase presumptives to funnel into the TB screening cascade is essential, and may require increased HRH during future public health emergencies [ 40 , 41 ]. The more recently established Health and Wellness Centers can play an important role in providing both TB and COVID-19 screening services to communities, although this will add supervision responsibilities [ 42 ].

Given the mix of differently burdened staff in similar roles working in near proximity, the study identified task-sharing and shifting as a potential solution [ 33 , 43 ]. This could be explored between NTEP cadres or with India’s recently emerging public health cadres. In 2022 India’s Ministry of Health and Family Welfare (MoHFW) published implementation guidance for public health management cadres with the specific mandate to manage infectious disease outbreaks in health facilities, disease control offices, and educational settings [ 44 , 45 ]. Tamil Nadu, Maharashtra, Chhattisgarh, West Bengal and Odisha states have already trained and stationed public health management cadres, while other states are yet to do so [ 46 ]. The permanent availability of such a cadre could provide needed support for management of newly emerging diseases, such as COVID-19, and minimizing disruption to routine health services in the early stages of future emergencies.

Study limitations

WISN analyses are intended to be conducted through in-person observation, but due to lockdown restrictions our analysis was conducted on the telephone. Therefore, our findings were based on reported as opposed to observed activity duration, introducing potential recall bias. Furthermore, the study design did not allow for tests of statistical significance to be conducted, nor for comparisons between urban and rural or sector strata.

The devastating impact of COVID-19 on HRH capacity to conduct TB screening and diagnosis in India in 2020 and 2021, as in other settings, cannot be overstated. Our findings provide clear evidence that NTEP HRH did not have time or essential material resources to carry out TB tasks during the COVID-19 pandemic without doing substantial overtime and/or compromising on TB service delivery. To minimize disruptions to routine health services such as TB amidst future emerging infectious diseases, we would do well, during periods of relative calm and stability, to strategically map out how HRH lab staff, public health resources, such as India’s Health and Wellness Centers and public health cadre, and public-private sector collaboration can most optimally absorb shocks to the health system.

Data availability

All data generated or analyzed during this study are available from India’s Central Tuberculosis Division, and may be provided upon reasonable request to one of the co-authors.

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Acknowledgements

We gratefully acknowledge Dr. Garima Gupta, Dr. Mona Gupta and Dr. Ved Rajani of India’s National Health Systems Resource Centre for their leadership and technical contributions to this study. From India’s Central Tuberculosis Division we are grateful to Dr. Sanjay Kumar Mattoo, Dr. Ravinder Kumar, and Dr. Neha Vats for their leadership and support. We also appreciate the translation of key findings into policy recommendations of Mr. Vikas Sheel and Ms. Aarti Ahuja.

Funding for this study was provided by the World Bank Group.

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Christina Mergenthaler, Chantale Lakis & Marjolein Dieleman

The World Bank Group, Washington D.C, USA

Aarushi Bhatnagar, Di Dong, Ronald Mutasa, Sapna Surendran & Gyorgy Fritsche

Oxford Policy Management, New Delhi, India

Vimal Kumar, Shankar Dapkekar & Agrima Sahore

The International Union Against Tuberculosis and Lung Disease (South East Asia), New Delhi, India

Kuldeep Singh Sachdeva

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Contributions

CM, CL, MD, AB, and DD made substantial contributions to manuscript development. VK, AS and CM analyzed data, and all authors including RM, SD, SS, GF, and KSS contributed to interpretation of results and manuscript revisions.

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Correspondence to Christina Mergenthaler .

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Ethical approval was obtained from Sigma institutional review board, a division of Sigma Research and Consulting Private Ltd with approval code 10032/IRB/20–21. Verbal informed consent was obtained from all participants responding to the WISN questionnaire and participating in key informant interviews. all participants confirmed that they were in a legal, safe, and convenient environment while conducting the telephonic interview. The procedure to take informed consent verbally was approved by Sigma institutional review board, a division of Sigma Research and Consulting Private Ltd, all methods were carried out in accordance with declaration of Helsinki.

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Mergenthaler, C., Bhatnagar, A., Dong, D. et al. Assessing the impact of COVID-19 management on the workload of human resources working in India’s National Tuberculosis Elimination Program. BMC Health Serv Res 24 , 907 (2024). https://doi.org/10.1186/s12913-024-11131-8

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Received : 27 March 2023

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DOI : https://doi.org/10.1186/s12913-024-11131-8

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Case Study – Methods, Examples and Guide

Types of Case Study

Single-Case Study

Multiple-Case Study

Descriptive Case Study

Instrumental Case Study

Case Study Data Collection Methods

Observations

How to conduct Case Study Research

Examples of Case Study

Application of Case Study

Business and Management

Social Sciences

Law and Ethics

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Limitations of Case Study Research

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Muhammad Hassan

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What is a case study?

Case studies

Definition of a case study

Characteristics of case studies

The role of case studies in research

What is the purpose of a case study?

Why use case studies in qualitative research?

The explanatory, exploratory, and descriptive roles of case studies

The impact of case studies on knowledge development

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