policy environment prior to the introduction of a series of ambulatory care innovations for acute lower respiratory disease in children (pneumonia and obstructive bronchitis), as well as prevention of stroke.

A study in the Santiago Metropolitan region of Chile used stakeholder analysis to assess the related Priority stakeholders were defined according to the knowledge of the researcher about the Chilean health sector. They included policy-makers, doctors, nurses, managers and professions allied to health care.

The study mainly involved the collection of qualitative data about the perceptions, aspirations and expectations of a range of stakeholders. It also gathered material on the perception of local power and authority, as this was seen as likely to affect implementation processes.

While this methodology did not permit statistical inference, it was seen as providing an understanding of the context and probable responses of stakeholders to the planned innovations. The research was intended to provide data on the negotiation and understanding perceptions within social interaction. It considered domains such as experience, knowledge and action.¹⁹

Background: The distinguishing features of IR includes the importance given both to the context within which a programme operates, as well as the populations that are affected by the project. It seeks to involve implementers and populations affected by an intervention in all aspects of research right from the research design, the process of research, and as users of research outcomes. The emphasis on involving ‘local’ populations and groups in research to enable a ‘bottom-up’ approach ensures that local priorities are recognized and participants have a voice. This subsequently makes research and the actions that result from it more relevant and acceptable locally. Incorporating programme implementers’ perspectives makes the research process sensitive to the complexity of the world that the programe implementers inhabit and are trying to change.

The IR approach was used to ascertain how the nature of emerging questions differed in focus when compared to those found in the literature on the evaluation of health insurance programmes in low- and middle-income countries (LMICs). The context was one of the longest serving government-funded insurance schemes in India, the Rajiv Aarogyasri Scheme (RAS) in the state of Andhra Pradesh. The RAS has been operating since 2007 and covers the cost of inpatient care for people below the poverty line. The programme has around 70 million beneficiaries. The IR approach was comprised of a series of meetings during 2012, involving various groups of stakeholders. Staff from the Aarogyasri Health Care Trust, the Public Health Foundation of India and the Indian Institute of Public Health, Hyderabad met to identify research questions that could serve as a guide for evaluation of the RAS. The derived research questions were compared with the ones identified by a literature review.

Findings: Around 60% of the research questions in the published literature pertained to programme outputs and outcomes while 40% were related to programme input/process. This was in contrast with the questions generated through IR, where 81% of questions were related to input/processes and only 19% focused on outputs and outcomes. Furthermore, the majority of the studies in published literature that sought to evaluate health insurance programmes were researcher-driven. They also had a stronger tendency to evaluate the insurance programme against a set of outcomes rather than to the process and input aspects of the programme.

Conclusions: The research questions identified through the collaborative approach established and offered a more comprehensive view of programme performance and were more closely aligned to with the implementers’ needs. Furthermore, involving implementers/stakeholders gave an insight into the programme activities. If implementers are not involved, it becomes difficult for external researchers to incorporate the implementers’ tacit knowledge (which are often more relevant into the needs of policy-makers ) in formulating the research questions and the subsequent research process

Lessons: The set of research questions resulting from IR were much broader in scope and put more emphasis on processes and inputs. The collaborative process also enabled the researchers to appreciate the heterogeneous nature of implementers, a fundamental characteristic of IR.