Training of personnel for health services operations research in Latin America

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Ed/ Pm An, Hrcrlrl, Orgon 13(4). 1979

TRAINING OF PERSONNEL FOR HEALTH SERVICES

OPERATIONS RFSFARCH IN LATIN AMERICA’

Jorge Or& Castro2

The subject of health services operations research (the quantitative and analytical study of health services) has attracted growing attention in recent yeal-s. This article describes health services operations research activities in Latin America and in- dicates some of the things that can be done to meet present and future needs.

DdhitiOIlS

There appears to be no single universally accepted definition of health services research. However, in 1976 the XVIII Meet- ing of the WHO Advisory Committee on Medical Research accepted the definition of health services research as “the systematic investigation and evaluation of a coun- try’s health services in terms of both their interrelationship with all health related factors and such measures as feasibility, needs, coverage, effectiveness, utilization, costs, and efficiency.” Health services research is multidisciplinary in nature; ideal- ly, it should improve the decision-making process and lead to the optimatization of the use of resources (I).

Health services operations research (HSOR) is the application of scientific methods, techniques, and tools to problems involving the operation of health systems so as to provide the administrators responsible for those systems with the optimal or at least adequate solutions to their problems. As used by PAHO, the term encompasses the quantitative and analyticaE approach to health services research.

*Condensed version of an article appearing in Spanish in the Boletin de la Oficina Sanitaria Pana- mericana, 1979.

ZRegional Adviser in Operations Research, Division of Human Resources and Research, Pan American Health Organization.

Academic Background of Health Services Researchers

Disciplines that can lead into health services research (HSR) include administrative management, cultural anthropolo- ZirY, economics, epidemiology, industrial engineering, mathematics, operations research, political science, sociology, statistics, and systems analysis. In general, most health services researchers agree that only those who have received proper training in their original discipline are likely to do effective research in this field. On the other hand, of course, it would be futile to try and give any researcher a thorough knowledge of all the disciplines involved (2).

As a result, although health services research should be multidisciplinary, in actual practice each investigator trained in any particular discipline constructs partial models of reality that omit variables per- taining to other disciplines. In this regard, it is worth noting that much of the health services operations research performed in Latin America has been carried out with the cooperation of industrial engineers, mathematicians, statisticians, systems engineers, and specialists in operations research.

Work Done in Latin America

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nent may be present in academic programs (health administration, public health, epidemiology, biostatistics) as well as others (industrial engineering, systems engineering, mathematics, statistics, business administration). Moreover, some health sector institutions (social security, health minis- tries) may be developing health services operations research.

In order to establish HSOR policies and develop personnel training programs, it is necessary to know what is being accom- plished in the field of personnel training and what studies have been carried out in HSOR.

Training of Administrators

The development of HSOR training programs has made health workers (partic- ularly health administrators and planners) increasingly aware of the need and useful- ness of this kind of research. In the past the Latin American Center for Medical Ad- ministration in Buenos Aires, Argentina, and the Pan American Health Planning Center in Santiago, Chile (these institutions are no longer in operation) conducted HSOR work and training activities. More recently the Pan American Zoonoses Center has incorporated an operations research component into its international program of animal health planning, and PAHO has joined with various Member Countries in

sponsoring courses and seminars on health administration that have covered some aspects of HSOR.

Recently there has been a tendency to establish advanced training programs in health care administration that are sponsored jointly by health service institutions and by academic institutions specializing in health sciences, administration, industrial engineering, and systems engineering. Within these programs health services research plays an important training and institutional research role.

To date three such programs of advanced

health care administration have been established. These are (1) a program of public health administration for the health sector at Brazil’s Getulio Vargas Foundation in Rio de Janeiro; (2) a program of hospital and health systems administration sponsored by the Getulio Vargas Foundation at the Clinical Hospital of the SHo Paulo University Medical School in Szo Paulo, Brazil; and (3) a program in health administration sponsored jointly by the departments of administration, social medicine, and systems engineering of the University of Valle in Cali, Colombia.

Training of

Health Service Researchers

Various Latin American educational institutions offer training in operations research within the context of undergraduate and graduate programs in business administration, industrial engineering, mathematics, production engineering, statistics, systems engineering, and operations research. However, there is no formal program in Latin America for training personnel specifically in health services operations research. Instead, some of the present researchers in this field have attended universities in the United States, where they received a master’s degree or doctorate in industrial engineering with emphasis on the health services field. Others received their training through active participation in health services research projects.

In recent years, faculty members and students in some Latin American programs have been performing health services operations research. This research has placed special emphasis on evaluating and improving the efficiency and effectiveness of selected health services. Besides making progress toward these goals, this work has provided an excellent learning experience for those involved.

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o&z Castro l TRAINING IN OPERATIONS RESEARCH 405

engineering departments. Nine of these located in seven countries,3 were found active to some degree in health services operations research. The degree of participation ranged from individual student projects, such as thesis research, to activities agreed upon jointly by the engineering faculties involved and the ministry of health or national social security agency. The Annex at the end of this article lists known health services operations research projects being carried out by these and other institutions and the methodologies used.

One such program was among the first experiences involving participation of an industrial engineering faculty in health services operations research. The work, carried out at Mexico’s Technological Institute of Advanced Studies of Monterrey (ITESM) through the so-called Practical School (Escuela Prdctica), has provided an ongoing means of training HSOR personnel .

The concept of Practical School training became a reality at the ITESM in 1968, but it was not applied to health services research until the summer of 1972. The fore- mentioned experimental program, begun at that time, involved 12 industrial engineering and systems engineering students. The students were divided into three sub- groups, each of which devoted six weeks of full-time study to specific problem areas defined by Mexico’s Social Security Insti- tute. Each group was advised by a member of the industrial engineering faculty and was assisted by active participation of the medical officers and administrators responsible for the areas involved.

One group studied the hospital clinic’s information systems and its subsystems for pharmacy and outpatient consultation. Another studied problems relating to the number and location of new health clinics

SBrazil, Colombia, Costa Rica, El Salvador, Mexi- co, Panama, and Peru.

and reassignment of insured workers and their families to particular clinics. The third group studied the dining room, kit- chen, and laundry operations at a general hospital with an eye to improving their efficiency.

The satisfactory results attained by these experimental projects were ascribed largely to the following circumstances: (1) The problem areas studied were defined in collaboration with the administrators involved and in accordance with their priorities; (2) the participants were technically well- qualified; and (3) at each phase of the work active collaboration was provided by the personnel involved. This was -the first HSOR endeavor financed by P’AHO’S research grant program. Since then the ITESM has been conducting this program frequently with direct funding provided by Mexico’s Social Security Institute.

Obstacles to Training

Health Administrators

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Researchers

Many academic programs, such as those in industrial engineering and operations research, have overlooked the health field as a potential activity in health service research. One possible reason is that the demand for graduate industrial engineers and operations researchers is high in other sectors, while in the health sector there are presently no opportunities for attracting or retaining such professionals. Another is that virtually no personnel trained in operations research have a firm under-

standing of medical care and the organization of the health service system. Also, there is a marked lack of communication between the administrators who must cope with health services problems and the researchers who can apply specialized knowledge to their solution. In addition, there is virtually no communication between relevant academic programs (in industrial engineering, operations research, health administration, business administration, etc.) and health service institutions. And, finally, the concepts most relevant to the health care process lack operational defini- tions amenable to quantification and use in ‘analytical studies.

Recommendations

Preparation

of

Administrators

and

Researchers

It appears that training in health services operations research would prove particular- ly useful for two groups of personnel- health administrators and health services researchers.

In the case of the health administrator concentrating in management science, training should seek to improve his ability to diagnose problems, to apply the techniques needed to solve them, and (in more complex cases) to request the collaboration of a qualified researcher. This assumes, of

course, that the administrator is primarily a user of health services research, rather than an expert specializing in this field. Clearly, training conducted for this pur- pose should contain both an operations research component and a behavioral science component, and should give due emphasis to the need for a systematic approach, multidisciplinary work, and use of the scientific method.

Regarding the training of future health services researchers, there are really two alternatives. One can train health workers in the various quantitative disciplines needed to conduct health services operations research. Or else, one can train selected operations researchers, industrial engineers, mathematicians, statisticians, and others in those subjects related to the organization and operation of health services- including health administration, health planning, demography, epidemiology, and medical sociology. Given the limited mathe- matical content of programs presently used to train health personnel, this second alter- native would appear to be the better of the two.

Actions at the National Level

To promote execution of health services operations research and preparation of qualified personnel, the countries involved need to define the health services research component of their national research policies.

Some possible actions to carry out an effective HSOR training program-relating to both administrative and research training-are as follows:

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coordination between academic and health service institutions. (4) Promote the establishment of joint programs sponsored by health service institutions, departments of health administration, and industrial engineering departments-in order to carry out training and institutional research activities. (5) Involve students of administration in ongoing health services research.

Training Researchers:

(1) Assign priori- ty to fellowships for postgraduate studies in health services operations research. (2) Encourage inclusion of an HSOR component in academic programs of industrial engineering, systems engineering, production engineering, economics, mathematics, statistics, etc. (3) Involve students in health services research programs-as part of their practical training or in connection with thesis work. (4) Conduct seminars on research methods. (5) Promote the establishment of joint programs by health service institutions and departments of industrial engineering, business administration, and the health sciences for training health services operations researchers.

Other Considerations.

Appropriate train-

ing and research programs may be funded by both health service institutions and universities. Hence, as awareness of the need for health services research increases, countries should establish appropriate structures for promoting and developing training and research programs. One example of this kind of action, taken in Mexico, was crea- tion of a special Division of Health Services Research within the Government’s Sub- Ministry of Health Planning.

Actions at the International Level

Technical agencies such as PAH 0 should

continue to encourage development of research policies-with special emphasis on the field of health services.

In addition, in keeping with its technical assistance criteria, PAHO has been promoting development of “project networks” located in various countries. These networks provide a basis for the countries’ coordi- nated development of joint programs and for exchanges of experiences and personnel. In the specific case of health services operations research and training, development of such a network would facilitate the following activities:

(1) Design of regional investigations in critical areas of interest.

(2) Exchange of staff members engaged in training and research programs.

(3) Identification of national and international sources of financingfor both training and research.

(4) Development of a system for dissemi- nating information to researchers in this field.

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Establishment of a continuing educa- tion program on specific HSOR topics for both health administrators and researchers.

(6) Holding of meetings of groups of ex- perts to define and standardize the content of those subjects deemed to be within the HSOR field.

In addition, it would be appropriate for international financial agencies to stipulate that feasibility studies for programs extending health coverage should single out health services research (including evaluative design) as a component of these programs and should call for specific funds in the budget to be earmarked for such research.

SUMMARY

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services operations research (HSOR). At the present time, with growing emphasis being placed on provision of primary care and exten- sion of health coverage, health authorities around the world are becoming increasingly aware of the need for sound health services operations research.

With regard to Latin America, although various educational institutions offer ooerations research training as part of other programs, there is no formal program for training people specifically in health services operations research. Instead, some researchers in this field got their background through direct participation in HSOR projects, while others obtained it through health-oriented industrial engineering studies conducted at universities in the United States.

In recent years, a number of Latin American instructors and students have been performing HSOR. For example, a survey of 35 industrial engineering programs in Latin America showed that nine of these programs (in seven countries) were engaged to some degree in health services operations research. One such research effort, begun in 19’72, was carried out by Mexico’s Technological Institute of Advanced Studies of

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Monterrey. The project, initially funded by PAHO, yielded satisfactory results and has been continued with Mexican Social Security funding.

Despite limited successes of this kind, however, health services research activities in many parts of Latin America are spotty or nonexistent. Therefore, the countries of the Region need to start by defining their HSOR needs, determining what relevant training and projects are currently underway, and taking the initial steps required to set up an effective HSOR training program. At the international level, PAHO could contri- bute to these efforts by continuing to encourage development of national research policies (with special emphasis on the health services field) and by working to further international coordination of HSOR activities-perhaps through establishment of a “project network” similar to ones established for other fields. In addition, it would be appropriate for international financial agencies to stipulate that feasibility studies for programs extending health coverage should single out the health services research component of these programs and should set aside specific budgetary allotments for such research.

REFERENCES

(1) Health Service Research. Working paper (2) Haggarty, J. Health Services Research in prepared for the WHO Regional Office/Head- Academia: A Personal View. In E. E. Floock and quarters Consultation on Health Services Re- P. J Sanazaro (eds.), Health Services Research search held at Geneva, Switzerland, in April and R&D in Perspective. Health Administra- 1977. Mimeographed document. World Health tion Press, 1973, p. 129.

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ANNEX

Some Health Services Research Projects in Latin America and the Caribbean

Section A. Studies Peqfonned within the Context

of

Industrial Engineting Pmgmnzs

Study title Institution Year(s)

of study

Special methodologies used

Placement of clinics in Monterrey (quantity and location)

Studies concerning emergency services

Study of number and location of day-care centers

Economic analysis of cen- tralizationvs. decentraliza- tion of laundries serving clinics and hospitals Economic impact of new

drug inventory policies Analysis and evaluation of

an emergency service

Systematization of the emergency service

Study of the dining room at a children’s hospital

Study of emergency services

Programing the operating room

Evaluation and design of an X-ray unit

Simulation of an ambulato- ry system

A model for a university hospital drug inventory control system

Evaluation of a drug inventory control system

Technological Institute of AdvancedStudiesofMonte-

rrey, Nuevo Leon, Mexico

I,

Mexican Social Security Institute, Monterrey, and Technological Institute of Advanced Studies of Mon- terrey, Nuevo Leon, Mex- ico

91

,>

San Juan de Dios Hospital, and Industrial Engineer- ing School of the Universi- ty of the Andes, Bogota, Colombia

Santo Tom&s Hospital, Pa- nama, and Industrial En- gineering School, Univer- sity of Panama

National Children’s Hospi- tal, San Jose, Costa Rica, and University of Costa Rica

,?

National University of Peru

Lima, Peru; San Juan de Dios Hospital and Univer- sity of the Andes, Bogota, Colombia

Ministry of Health and Na- tional University of Costa Rica

1972

1973

1974

1974- 1975

Industrial engineering tech- ni ques

Flow charts and work sampling

Survey and prediction techniques

Work sampling and prediction techniques

Simulation

Information not available

Work sampling, waiting lines theory, simulation, and study of time and movements

Work sampling and waiting lines theory

Work sampling, flow chart, and statistics

Work sampling and statistics

Inventories and simulation

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410 PAHO BULLETIN l

vol. 13. no. 4, 1979

Study title Institution Year(s) Special methodologies of study used

Designs of a structural model for a drug inventory control system

Projection of demand and ABC classification for a

drug inventory control system

Design of an automated drug inventory control system

Study of the pharmacy system of the Salvadorean In- stitute and design of a gen- eralized pharmacy model Study of a hospital informa-

tion-decision system

Analysis of maternity services

Programming the operating room of a hospital

Statistical analysis of the maternal-fetal risk index

Development of the information system of the Mexi- can Social Security Insti- tute, tuberculosis program in the Monterrey metropo- litan area

Analysis of infant mortali- ty

Optimization of a tuberculosis control program A system for making medi-

cal appointments; formulation of an evaluative model

I,

Salvadorian Social Security Institute and University of El Salvador

Max Peralta Hospital, Car- tago, Costa Rica, and Na- tional University of Costa Rica

Carmelita Datra Maternity Hospital, Florianbpolis, and Federal University of Santa Catarina, Brazil Workers’ Fund Hospital,

Lima, Peru, and National Engineering School, Peru University of the Andes and

the “SER” Research Insti- tute, Bogota, Colombia, Mexican Social Security In-

stitute and Technological Institute of Advanced Studies of Monterrey, Nue- vo LeBn, Mexico

Catholic University of Peru

Federal University of Rio de J aneiro, Brazil

1974- 1975

Interviews, review of re- ports, correlation analysis, and inventories

Prediction techniques

1974- Industrial engineering tech- 1975 niques and automatization

1975

Industrial engineering techniques, waiting lines theory, Monte Carlo cech- niques, and simulation Flow charts and interviews

1976 General systems theory and digital simulation

1976 Information not available

1976 Multivariate analysis and discriminatory analysis

1976 Industrial engineering techniques

1977

-

Section B. Studies Pevformed within the Context

of

Other

Pmgnwns

A birth, life, and death Costa Rica, Pan American 1970 Markov chains model for evaluation and Health Organization,

planning in health service Washington, D.C. programs

Information system of a Jamaica, Pan American 1971 Flow charts, histograms, blood bank inventory Health Organization, statistical quality control,

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l TRAINING IN OPERATIONS RESEARCH 411

Study title Institution Year(s) Special methodologies of study used

Model for analysis of health sector financing

Research on medical quality

Application of the birth, life, and death model to tumor prediction

The steady impact of birth control on health services systems

Dynamic information systems for evaluating support to patient units

Efficacy of teleradiography as a routine examination

Estimate of the population to be protected, for pur- poses of including the fam- ily of the insured in the health program of the social security system Information system for the

planning, administration, and evaluation of health programs in the Ixtlera area of Mexico

Formulation of design and expansion plans for the nu- trition and dietetics service Design of a system for con-

trol of injectable drugs Study of the use of working

time in the nursing service (hospitalization and outpatient consultation)

Mendoza, Argentina, Pan American Center for Health Planning, Santia- go, Chile

Latin American Center for Medical Administration, Buenos Aires, Argentina Costa Rica, Pan American

Health Organization, Washington, D.C.

I,

San Juan de Dios Hospital, Bogota, Colombia, Pan American Health Organi- zation, Washington, D.C. Institute of Social Medicine of the State University of Rio de J aneiro, Brazil Salvadorean Social Securi-

ty Institute, El Salvador

Ixtlera area of Mexico and Mexican Social Security Institute

Salvadorean Social Security 1976- Industrialengineering tech- Institute, El Salvador 1977 niques

1972 Numerical experiment;l tion models

1972 Markov chains

1973 Markov chains and theory matrices

1974 Hypothesis tests and statistical quality control

1975- Multiple correlation and 1976 variance analyses

1975- 1976

Decision models and industrial engineering techniques

1977

Industrial engineering techniques