METODOLOGI KAJIAN, REVIEW SISTIMATIK DAN META-ANALISIS*

SOEWARTA KOSEN

DISAMPAIKAN PADA WORKSHOP PENYUSUNAN REKOMENDASI KEBIJAKAN, PUSAT TEKNOLOGI TERAPAN & EPIDEMIOLOGI KLINIK, JAKARTA 27-28 AGUSTUS 2015

Definisi Analisis Kebijakan Analisis Kebijakan Publik dapat di definisikan sebagai upaya untuk menentukan yang mana dari berbagai alternatif kebijakan publik akan menghasilkan tujuan yang ingin dicapai ( Nagel)

What is Policy Analysis? "The process through which we identify and evaluate alternative policies or programs that are intended to lessen or resolve social, economic, or physical problems." - Carl V. Patton

Elemen Analisis Kebijakan:

1. Tujuan, termasuk hambatan “normative” dan bobot relative berbagai tujuan tersebut

2. Kebijakan, program, proyek, keputusan, opsi, cara atau alternative lain yang tersedia untuk mencapai tujuan tersebut

3. Hubungan diantara kebijakan dan tujuan, termasuk hubungan berdasarkan berdasarkan intuisi, otoritas, statistik, observasi, deduksi, perkiraan atau cara lainnya

4. Mengambil kesimpulan sementara, dimana kebijakan atau kombinasi kebijakan terbaik yang dipilih, dengan memperhatikan tujuan, kebijakan dan hubungan keduanya

5. Menentukan pilihan kebijakan terbaik dan alasannya

ENAM LANGKAH DALAM ANALISIS KEBIJAKAN

1) Periksa, definisikan, dan uraikan masalah 2) Tentukan kriteria evaluasi 3) Identifikasi alternatif kebijakan 4) Analisis/Assess alternatif kebijakan tersebut 5) Tunjukkan dan bedakan berbagai alternative, pilih yang terbaik 6) Implement, monitor, and evaluasi kebijakan tersebut

JENIS ANALISIS KEBIJAKAN

Analisis Kebijakan yang sudah/sedang dilaksanakan (Analysis of Policy)

Analisis Kebijakan Baru (Analysis for Policy)

Metode Analisis Kebijakan 1. Bagaimana mengambil kesimpulan, sehingga kebijakan dapat diambil dari

informasi tentang tujuan, kebijakan saat ini dan hubungan antara keduanya

2. Bagaimana menentukan tingkat hubungan antara kebijakan dan tujuan yang akan dicapai

3. Bagaimana menetapkan alternatif kebijakan yang tersedia untuk dilakukan dan tujuan apa saja yang layak untuk dipertimbangkan

SIKLUS ANALISIS KEBIJAKAN 1.

Define the Problem

2. Assemble some

Evidence

3. Construct

the Alternatives

4. Select the

Criteria

5. Project

the Outcomes

6. Decide which

policy is best

Verifikasi, definisikan rincian masalah dan tujuan

Merupakan bagian terpenting dari proses analisis kebijakan

Masalah dan Tujuan yang ingin dicapai dengan melakukan analisis kebijakan sering kurang jelas

Merupakan dasar untuk hasil seluruh proses, agar efektif dan efisien

Harus ditanyakan berbagai pihak yang terkait menyangkut program dan hasil/outcome yang dituju

Hindarkan keraguan, agar dapat dipergunakan di masa depan

Tentukan kriteria untuk evaluasi Untuk membandingkan, mengukur dan memilih diantara alternative yang tersedia, kriteria evaluasi yang relevan harus ditentukan. Pertimbangkan cost, net benefit, effectiveness, efficiency, equity, kemudahan administrasi, aspek hokum dan penerimaan secara politis. Economic benefits juga harus dipertimbangkan. Apakah kebijakan akan membahayaakan atau memberi manfaat pada kelompok masyarakat, tergantung pada pilihan yang tersedia Pilihan kebijakan diputuskan melalui analisis kemudahan dalam pelaksanaan, dampak kebijakan yang mungkin terjadi, aspek politik dan variabel lainnya, sesuai kriteria evaluasi yang telah ditentukan Pada akhirnya, kelompok/perorangan yang mempunyai otoritas, akan menentukan arah atau kriteria evaluasi

Identifikasi Alternatif Kebijakan Langkah ini dilakukan setelah dua langkah sebelumnya telah dilakukan (incrementalist approach) Dibutuhkan pengertian yang jelas (bantuan expert) mengenai masalah dan bagaimana mengatasi masalah tersebut. Alternatif kebijakan termasuk "do nothing approach" (status quo), dan alternatif lain yang dapat memberi manfaat, seperti kombinasi alternatif yang belum pernah dilakukan Pengalaman sebelumnya (dari daerah/negara lain) dapat menjadi masukan untuk dipertimbangkan Agar optimal, keputusan dalam memilih alternative yang akan disarankan, harus dipertimbangkan masak-masak (brain-storming, concept mapping, scenarios); sebelum menentukan alternative kebijakan yang akan disarankan .

Evaluasi Alternatif Kebijakan

Alternatif kebijakan harus dilanjutkan dengan penentuan strategi dan bandingkan sesuai kriteria yang telah ditetapkan Kadang-kadang dibutuhkan tambahan data/informasi yang menyangkut aspek ekonomi, politik dan sosial dari masalah. Brbagai aspek ini dapat dianalisis secara kuantitatif atau kualitatif Patton “suggests to avoid the tool box approach: attacking options with a favorite analysis method; its important to have a heterogeneous approach in analyzing the different possible alternatives. It becomes inefficient to view each alternative under a single perspective; its clearly relevant the need to evaluate each alternative following diverse evaluating approaches singled out according to the uniqueness of each of them”.

TIPS UNTUK ANALISIS KEBIJAKAN PRAKTIS

1) Quickly identify the central decision criterion of the problem (What is the most important factor in buying a car? Taking a new job?) 2) Identify what types of public sector actions can be taken (Taxing, spending, sanctions, incentives, moral suasion, education?) 3) Avoid the "one best way" approach (Have many tools in the tool box, not just one) Learn how to deal with uncertainty (Admit it, estimate its possible effects) 5) Say it with numbers (Charts, graphs, tables, maps, etc.) 6) Make the analysis simple and transparent (Provide details in a technical appendix) 7) Check and re-check the facts (Use multiple sources of facts, triangulation) 8) Learn to anticipate the objections of opponents (Improves the ultimate product) 9) Give analysis, not decisions (Distinguish between analysis and advocacy) 10) Push the boundaries of the envelope (Expand the problem definition; introduce novel solutions) 11) Policy analysis is never 100% complete, rational, and correct (How much time, money, and personnel is available to do the job?)

REVIEW SISTIMATIK

Key Characteristics of Systematic Reviews

Clearly stated title and objectives

Comprehensive strategy to search for relevant studies (unpublished and published)

Explicit and justified criteria for the inclusion or exclusion of any study

Clear presentation of characteristics of each study included and an analysis of methodological quality

Comprehensive list of all studies excluded and justification for exclusion

Linda N. Meurer, MD, MPH Department of Family and Community Medicine. “Systematic Synthesis of the Literature: Introduction to Meta-analysis”. Power Point Presentation.

What is a systematic review?

Systematic undertaking of a review with a focused research question that tries to identify, appraise, select and synthesise all high quality research evidence relevant to that question.

Meta-analysis

Systematic reviews

Reviews (narrative/literature/ traditional)

Types of reviews

Advantages of systematic reviews Reduce bias

Replicability

Resolve controversy between conflicting studies

Identify gaps in current research

Provide reliable basis for decision making

Key elements of a systematic review

Structured, systematic process involving several steps :

1. Formulate the question 2. Plan the review 3. Comprehensive search 4. Unbiased selection and abstraction process 5. Critical appraisal of data 6. Synthesis of data (may include meta-analysis) 7. Interpretation of results All steps described explicitly in the review

Systematic vs. Narrative reviews Scientific approach to a review article

Criteria determined at outset

Comprehensive search for relevant articles

Explicit methods of appraisal and synthesis

Meta-analysis may be used to combine data

Depend on authors’ inclination (bias)

Author gets to pick any criteria

Search any databases

Methods not usually specified

Vote count or narrative summary

Can’t replicate review

How to do systematic reviews? Formulate clear clinical questions from our knowledge needs

Search the literature to identify relevant articles

Critically appraise the evidence for its validity and usefulness

Synthesize evidence

The systematic review process

Formulate research /

policy conclusions

Search bibliographic databases

Identify possible papers from

titles/abstracts

Retrieve papers

Extract data

Further selection of primary studies

using inclusion criteria

Synthesis

Formulate research question

Design search strategy

Quality

appraisal

Quality Assessment Randomized Controlled Trials (RCT): ◦RCT are considered to be more rigorous than observational studies

◦A review based on well-designed RCT will likely be more valid and accurate than a review based on observational studies or case reports

Margaliot, Zvi, Kevin C. Chung. “Systematic Reviews: A Primer for Plastic Surgery Research.” PRS Journal. 120/7 (2007) p.1839

Quality Assessment

“The validity of a systematic review ultimately depends on the scientific method of the retrieved studies and the reporting of data.”

Margaliot, Zvi, Kevin C. Chung. “Systematic Reviews: A Primer for Plastic Surgery Research.” PRS Journal.

120/7 (2007) p.1839

Data Synthesis “Once the data have been extracted and their quality and validity assessed, the outcomes of individual studies within a systematic review may be pooled and presented as summary outcome or effect”

Margaliot, Zvi, Kevin C. Chung. “Systematic Reviews: A Primer for Plastic

Surgery Research.” PRS Journal. 120/7 (2007) p.1840

The systematic review process

Formulate research / policy

conclusions

Search bibliographic databases

Identify possible papers from

titles/abstracts

Retrieve papers

Extract data

Further selection of primary studies

using inclusion criteria

Synthesis

Formulate research question

Design search strategy

Quality

appraisal

Meta-Analysis “Meta-analysis is a statistical technique for combining the results of independent, but similar, studies to obtain an overall estimate of treatment effect.”

“While all meta-analyses are based on systematic review of literature, not all systematic reviews necessarily include meta-analysis.”

“If a meta-analysis is to be included in a systematic review, an experienced statistician or an epidemiologist should be consulted during all phases of the study.”

“The validity of a meta-analysis depends on the quality of the studies included, and an assessment of quality is a necessary part of the process.”

Kevin C. Chung, MD, Patricia B. Burns, MPH, H. Myra Kim, ScD. “Clinical Perspective: A Practical Guide to Meta-Analysis.” The Journal of Hand Surgery. Vol.31A No.10 December 2006. p. 1674

Midwife Screening Ultrasound For Pregnancy Complications

in Bogor District, West Java, Indonesia

ABSTRACT (POLICY RESEARCH)

Background: Demographic Health Survey (DHS) 2012 shows that the estimated Maternal Mortality Ratio (MMR) has increased from 228 per 100,000 live births to 359 per 100,000 livebirths. To anticipate and reduce maternal mortality, Indonesia needs to improve the quality of health care. At present, most maternal deaths occur as a direct obstetric complications, that include between others: hemorrhage, obstructed deliveries, sepsis, abortion complications, and eclampsia. The objective of the study is to assess ability of midwives with ultrasound in the early identification of pregnancy complications and to compare with ability of midwives without ultrasound.

Methods: The prospective (cohort) study was designed to detect an increase of the overall early identification of pregnant mothers with fetal demise (IUFD), multiple pregnancy, malpresentation, and placenta praevia. A two-week training session was conducted to provide midwives and physicians working at Intervention health centers with the education and skills needed to conduct basic obstetric Ultrasound scanning. Data gathered at ten Intervention health centers and ten Control health centers, as well as two referral district hospitals, namely Ciawi Hospital and Cibinong Hospital.

Results: The results showed that the Midwives with Ultrasound device have 2.252 higher probability to detect complications (Multiple Pregnancy, Placenta Praevia, Malpresentation, and IUFD) compared with midwives without Ultrasound device. There were high agreement between the results of Ultrasound examination performed by the trained midwives at the health centres with Ultrasound examination results performed by Obstetrician at referral Hospitals on those four obstetric complications.

Conclusions: The ability of midwives with ultrasound device were better than midwives without ultrasound device in early detection of pregnancy complications. Thus it should be further replicated in remote area of Indonesia, in order to contribute for the efforts to reduce morbidity and mortality due to pregnancy and delivery. NIHRD-MOH, Indonesia;