Conducting Qualitative Research in/on Health Systems: Ethical Tensions, Confounders, and Silences

  • Surekha Garimella
  • Lakshmi K. Josyula


This chapter focuses on the authors’ experiences of doing qualitative research in and on health systems and complexities. The relationship between researchers and research participants, set in a widely prevalent positivist mind set, with researchers often having to struggle to get across the message that there is not one correct answer or “complete” information that is being sought, but often subjective perspectives, are elaborated. Tensions in the design and conduct of research in health systems in India, including the difficulty in maintaining the rigour of in-depth interviews and focus group discussions sometimes, and dissonances encountered at times between certain accepted (Western) tenets of ethics, e.g. individual autonomy and privacy, in certain research and practice situations in the field are not uncommon and go to the heart of researching ethically and in a rigorous manner. In view of the fact that research is conducted into problems, and most data are of problems, dysfunction, and inequity, the researcher may often feel the disparity in the conditions of the researcher and the researched, and may frequently have to consciously disengage and recharge. We will elucidate the dynamic nature of the researcher’s experience, and highlight the importance of reflexivity when using qualitative research approaches in doing health policy and systems work.


Health policy and systems research, ethics committees Research relationships Perceptions of roles of researchers Informed consent Power differentials 



The chapter draws on data collected as part of the project based in the Public Health Foundation of India between 2014 and 2016 when we were working there as members of the research team on “Accountability at the Frontlines: Posting and Transfer Practices in the Health System, Strategic Health Partnership for Universal Health Coverage (Governance and Regulation)”. We are grateful to the research participants, who stimulated many of these perspectives, as well as to the field assistants with whom we had several conversations that led to the insights that we have presented here. We would like to acknowledge Gupteswar Patel, Bhaskar Purohit, and Kabir Sheikh from the research team conducting this study. We appreciate the collegiality in the Health Governance Hub, which nurtured our meditations on ethics in the conduct of HPSR. The reflections shared in this chapter are personal and our own.


  1. Ahlin, T., Nichter, M., & Pillai, G. (2016). Health insurance in India: What do we know and why is ethnographic research needed. Anthropology & Medicine, 23(1), 102–124.CrossRefGoogle Scholar
  2. Baez, B. (2002). Confidentiality in qualitative research: Reflections on secrets, power and agency. Qualitative Research, 2(1), 35–58.CrossRefGoogle Scholar
  3. De Vries, J., & Henly, L. (2015). Staying silent when we should speak up: Informed consent and the interface between ethics as regulation and ethics in practice. In D. Posel & F. Ross (Eds.), Ethical quandaries in social research. Cape Town, RSA: HSRC Press.Google Scholar
  4. Denzin, N. K., & Lincoln, Y. S. (2000). Handbook of qualitative research.Google Scholar
  5. Dingwall, R. (2008). The ethical case against ethical regulation in humanities and social science research. Twenty-First Century Society, 3(1), 1–12.CrossRefGoogle Scholar
  6. Ghaffar, A., Langlois, E. V., Rasanathan, K., Peterson, S., Adedokun, L., & Tran, N. T. (2017). Strengthening health systems through embedded research. Bulletin of the World Health Organization, 95(2), 87.CrossRefGoogle Scholar
  7. Green, J., & Thorogood, N. (2004). Qualitative methods for health research. London: Sage.Google Scholar
  8. Guillemin, M., & Gillam, L. (2004). Ethics, reflexivity, and “ethically important moments” in research. Qualitative Inquiry, 10(2), 261–280.CrossRefGoogle Scholar
  9. Hammersley, M. (2009). Against the ethicists: On the evils of ethical regulation. International Journal of Social Research Methodology, 12(3), 211–225.CrossRefGoogle Scholar
  10. Hammersley, M., & Traianou, A. (2012). Ethics in qualitative research: Controversies and contexts. London: Sage.CrossRefGoogle Scholar
  11. Harper, I. (2007). Translating ethics: Researching public health and medical practices in Nepal. Social Science & Medicine, 65(11), 2235–2247.CrossRefGoogle Scholar
  12. Hedgecoe, A. M. (2012). Trust and regulatory organisations: The role of local knowledge and facework in research ethics review. Social Studies of Science, 42(5), 662–683.CrossRefGoogle Scholar
  13. Hennink, M., Hutter, I., & Bailey, A. (2011). Qualitative research methods. London: Sage.Google Scholar
  14. Hyder, A. A., Rattani, A., Krubiner, C., Bachani, A. M., & Tran, N. T. (2014a). Ethical review of health systems research in low-and middle-income countries: A conceptual exploration. The American Journal of Bioethics, 14(2), 28–37.CrossRefGoogle Scholar
  15. Hyder, A. A., Pratt, B., Ali, J., Kass, N., & Sewankambo, N. (2014b). The ethics of health systems research in low-and middle-income countries: A call to action. Global Public Health, 9(9), 1008–1022.CrossRefGoogle Scholar
  16. Iphofen, R. (2011). Ethical decision making in qualitative research. Qualitative Research, 11(4), 443–446.CrossRefGoogle Scholar
  17. Israel, M., & Hay, I. (2006). Research ethics for social scientists. London: Sage.CrossRefGoogle Scholar
  18. Karnieli-Miller, O., Strier, R., & Pessach, L. (2009). Power relations in qualitative research. Qualitative Health Research, 19(2), 279–289.CrossRefGoogle Scholar
  19. Mishra, A. (2014). ‘Trust and teamwork matter’: Community health workers’ experiences in integrated service delivery in India. Global Public Health, 9(8), 960–974.CrossRefGoogle Scholar
  20. Molyneux, S., Tsofa, B., Barasa, E., Nyikuri, M. M., Waweru, E. W., Goodman, C., & Gilson, L. (2016). Research involving health providers and managers: Ethical issues faced by researchers conducting diverse health policy and systems research in Kenya. Developing World Bioethics, 16(3), 168–177.CrossRefGoogle Scholar
  21. Nader, L. (1972/1969). Up the anthropologist: Perspectives gained from “studying up”. In D. Hymes (Ed.), Reinventing anthropology (p. 284311). New York: Pantheon Books.Google Scholar
  22. Pfeiffer, J., & Nichter, M. (2008). What can critical medical anthropology contribute to global health? Medical Anthropology Quarterly, 22(4), 410–415.CrossRefGoogle Scholar
  23. Posel, D., & Ross, F. (Eds.). (2015). Ethical quandaries in social research. Cape Town, RSA: HSRC Press.Google Scholar
  24. Richards, H. M., & Schwartz, L. J. (2002). Ethics of qualitative research: Are there special issues for health services research? Family Practice, 19(2), 135–139.CrossRefGoogle Scholar
  25. Sheikh, K., Gilson, L., Agyepong, I. A., Hanson, K., Ssengooba, F., & Bennett, S. (2011). Building the field of health policy and systems research: Framing the questions. PLoS Medicine, 8(8), e1001073.CrossRefGoogle Scholar
  26. Sheikh, K., Ranson, M. K., & Gilson, L. (2014). Explorations on people centredness in health systems. Health Policy and Planning, 29(Suppl 2), ii1.CrossRefGoogle Scholar
  27. Smith, K. E. (2006). Problematising power relations in ‘elite’ interviews. Geoforum, 37(4), 643–653.CrossRefGoogle Scholar
  28. Speziale, H. S., Streubert, H. J., & Carpenter, D. R. (2011). Qualitative research in nursing: Advancing the humanistic imperative. London: Lippincott Williams & Wilkins.Google Scholar
  29. Storeng, K. T., & Mishra, A. (2014). Politics and practices of global health: Critical ethnographies of health systems. Global Public Health, 9(8), 858.CrossRefGoogle Scholar
  30. Wiles, R., & Boddy, J. (2013). Introduction to the special issue: Research ethics in challenging contexts. Methodological Innovations Online, 8(2), 1.CrossRefGoogle Scholar
  31. Wiles, R., Clark, A., & Prosser, J. (2011). Visual research ethics at the crossroads. Sage visual methods, 1.Google Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2018

Authors and Affiliations

  • Surekha Garimella
    • 1
  • Lakshmi K. Josyula
    • 2
  1. 1.Adjunct FacultyInstitute of Public HealthBengaluruIndia
  2. 2.The George Institute for Global HealthHyderabadIndia

Personalised recommendations