Finding the unseen, listening to the unheard: using primary sources for research in the New Zealand health sector.

• Author: Thomson, George

Abstract

The purpose of this paper is to describe and discuss a research project on policy and structural change in the New Zealand health sector (ca. 1986-). The project compiled primary and secondary documents, and interviews of key informants. The methods used to locate and access material, and the extent of the material found and recorded is described. The usefulness of the sources, the efficient use of project resources and the prioritising of research methods are discussed. Examples of the matching of documentary and interview information are given. The paper concludes that qualitative scoping in the initial stages of policy research is crucial. The extent of accessible material in this research area means that selective focus is essential. The role of the interviewer in uncovering oral information can be a major element in the success of a project. There is a tension between selecting interviewees for insider information and for their view of policy effects.

INTRODUCTION

Since the mid-1980s, the New Zealand health sector has been in a state of continual transition. The transition began with the passage of the Area Health Boards Act 1983. In the late-1980s, changes in organisation and financial management were required as part of the fourth Labour government's state sector reforms. The health system was then completely reconfigured under the National government's "health reforms", the implementation of which commenced in 1991. The Health and Disability Services Act 1993 enabled the new market-oriented purchasing and delivery structures, although modifications to the system and the way in which services were configured and delivered continued beyond this point. Following the 1996 election, the health reforms were "re-reformed" with the combining of the four purchasing regional health authorities into one centralised purchaser, the Health Funding Authority. The system is again undergoing fundamental restructuring under the Labour-Alliance coalition government formed at the 1999 election.

As numerous aspects of this transition remained under-researched, the New Zealand Health Sector Transition Project (HSTP) was initiated in 1998 by the authors of this paper. (2) In particular, there had been only limited research into:

* the processes and origins of change;

* policy choices, the changing shape of the sector, and the effects of this on constituent agencies and stakeholder groups;

* perceptions of change and change processes; and

* the impact on relationships within the health sector.

The central purpose of the HSTP was, therefore, to research policy and structural change in the health sector both historically, covering prior restructurings, and as developments emerged. Of primary interest were the processes of change and the events leading up to and from crucial changes. The project explored a spectrum of policy areas: central agencies and local service provision arrangements, urban and rural provision, primary and secondary care, personal and public health, and so forth.

The HSTP sought to collect a wide range of paper documentation for subsequent analysis, and emphasis was given to material from primary sources. Primary sources were defined as those where an editorial process or mediation had not modified the author or speaker's voice. While the primary documents sought were generally unpublished, some published material such as the "Stent Report" (Health and Disability Commissioner 1998) and other official and unofficial papers were also regarded as primary documents in themselves. The document search was followed by interviews with a number of participants and close observers of policy formation and implementation processes, generally at the central government level.

Several researchers in the area of New Zealand health sector change have used similar combinations of documentary and oral sources (e.g. Malcolm and Barnett 1996, Ashton 1998, Jacobs and Barnett 2000). Others have used statistics (Brown 1999), and survey methods (Perkins et al. 1995, Donelan et al. 1999). However, it is difficult to establish the extent to which primary sources have been used in other studies. Of the over 200 journal articles and book chapters relating to aspects of the New Zealand health sector changes in the transition period, most are largely descriptive, or appear only to use published and secondary sources. Many of the articles do not describe their methodology, and are commentaries rather than research reports.

This article reports on the experience of gathering primary sources for research on health policy and health sector changes in New Zealand. It describes some of the work of the HSTP, including the process of locating and obtaining documents and the ways in which interviews were organised. Some examples of the sorts of material gathered are given. With the benefit of hindsight, we offer comments on the approach taken by the HSTP, the various sources of information elicited, and the implications for researchers and policy makers.

GETTING GOING WITH SECONDARY SOURCES

Prior to searching for primary documents and finding suitable interviewees, the HSTP explored secondary material for issues, context and the names of potential interviewees. A literature search was conducted using several electronic databases, including Medline, Index New Zealand (serials), the New Zealand National Library catalogue, and the New Zealand Bibliographic Index (generally non-serials). The most productive search words were "health reform(s)" and "restructuring". Over 200 relevant articles, and a number of books and book chapters were found. Among the problems health policy researchers must confront is the fact that many occasional and annual reports by government agencies and other health sector groups are not listed in any of the common referencing services. In recognition of this, efforts were also made to locate "gray" literature -- material produced by government departments and other organisations that is available to the public but not deposited with the National Library. Approaches to relevant agencies for the catalogues of their publications went some way toward filling this gap.

The Ministry of Health operates a computer database that enables searches for New Zealand newspaper articles of relevance to the health sector printed since 1990. However, the Ministry's own newspaper clipping collection only dates back to 1993, meaning that pre-1993 articles need to be retrieved from alternative sources such as newspaper publishers' archives. The Ministry's clippings are an excellent source of information on health sector change and of quotations from health sector figures, the search for which would otherwise be more labour intensive. Moreover, the clippings can be used to build a nationwide picture derived from the perspectives and experiences of different regions. This national picture often receives only limited attention in major metropolitan newspapers. The clipping collection proved valuable to the HSTP as a starting point for searching in government files, giving relevant dates, names and places for particular developments. Literature Sources for Health Services Research, by Nelson and Norris (1997) was also useful.

PRIMARY DOCUMENTARY SOURCES

In New Zealand, since 1982, access to the documentation of most public bodies has (in theory at least) been open through the existence of the Official Information Act 1982. The official constraints upon open access are those of cost ("reasonable" costs for items such as search time and photocopying can be charged to requestors), commercial sensitivity, personal privacy and "the effective conduct of public affairs". The unofficial constraints include finding the specific documents that will answer the questions posed. As described below, this can be an exhaustive process. In some cases, obtaining the active cooperation of the agencies concerned can also be a constraint.

Agency File Catalogues

The HSTP's efforts in accessing official information were made much easier by the work of two independent policy researchers who had previously negotiated access to Ministry of Health archives. The precedent they created and their advice on which files might provide the most relevant information simplified processes. In short, consulting other researchers or those with a knowledge of records and policy developments is often crucial.

The HSTP targeted nearly all agencies with an interest in health policy and sector change operating at a national level, including, for example, the Department of the Prime Minister and Cabinet, the Ministry of Health, Treasury, the State Services Commission, the New Zealand Nurses Organisation, and the New Zealand Public Service Association. It soon became apparent that the extent of the documentation obtainable meant that, within the resources available for the 1998 phase of the HSTP, the scoping of the documentary material became a priority. So that we could establish the priorities...