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Indian Journal of Community Medicine

Continuing Medical Education - Operations Research in Health Care: Concepts and Methodologies

Author(s): Rajesh Kumar

Vol. 27, No. 3 (2002-07 - 2002-09)

Department of Community Medicine, PGIMER, Chandigarh-160012

Medicine can be defined as the science and art of prevention, diagnosis and treatment of diseases among individuals, whereas, Community Medicine is concerned with the total physical, mental, social and spiritual health of individuals within the home environment and it applies comprehensive care to prevention of illness and disability, promotion of health and life expectancy in the entire community. Thus, community physicians have responsibility for not only finding cause(s) of disease occurrence in the community but also for assisting the community in organization of services to meet their promotive, preventive and curative health needs. Often these services establish complex administration and functional structures so as to systematize the activities for achieving a range of health policy goals articulated by the community. Health needs and demands invariably exceed the available resources, therefore, priority setting requires a careful assessment of the available alternatives by application of epidemiological, sociological, economic, and other analytic sciences. Commonly physicians, who possess not only the basic clinical, epidemiological, statistical and managerial skills, but also have familarity with sociological methods; are in a unique position for undertaking systematic analysis of health care activities, procedures, methods and techniques so as to determine what activities must be accomplished and how the necessary operations may best be carried out. Not much attention had been given to these issues a few decades ago, but this type of research termed as Health Services Research, Health System Research, Action Research, Operational or Operations Research has become increasingly important.

Concept and Scope of Operations Research (OR):

Operations research (termed as operational research in UK) is concerned with the conduct and co-ordination of activities within complex systems, using tools like queuing theory, game theory, mathematical modelling, simulation and decision analysis, to study the consequences of alternative courses of action and to optimise performance of the system. Starting with military and industrial applications during and shortly after the Second World War, it soon spread to other areas, including hospitals and health services. Compared with many other organizations, health services have been slow in adopting operational research as a mean to improve their performance. Operational research provides rational basis for decision making by seeking to understand and structure complex situations and to use this understanding to predict system behaviour and improve system performance. OR draws upon ideas from engineering, management, mathematics and psychology to contribute to a wide variety of application domains; the field is closely related to several other fields in the "decision sciences" - applied mathematics, computer science, economics, industrial engineering and systems engineering. On the other hand health service research deals with the functions and services of health sector and the health needs of the population. It is usually concerned with relationships between need, demand, supply, use and outcome of health services i.e. evaluation - particularly in terms of structure, process, output and outcome. It is multi disciplinary field of scientific inquiry that studies how social factors, financing systems, organizational structures and processes, health technologies and personal behaviours affect access to health care, the quality and cost of health care and ultimately health and well-being of population. Its' research domains are individuals, families, organizations, institutions, communities and populations. When the research process is indissolubly linked with the process of advocating and promoting change it is referred as action research.

Public health programmes usually employ large number of employees to cover extensive geographical areas and involve huge expenditures. Successful implementation of these programmes requires close co-ordination, training, supervision and monitoring at various levels of health system. Complex service delivery problems need to be dealt so as to have desired impact of the programme. Just as epidemiologists search distribution and determinants of diseases in human population to develop disease control policies, health service managers can rely upon OR to find solutions for the service delivery problems. In other words, OR is a systematic research technique focussed on programme improvement. It aims to increase the efficiency, effectiveness and quality of health services delivered by the providers; and the accessibility, acceptability of services desired by the users.

The goal of OR is to provide information to programme managers that they can use to make decisions for improving their programme operations. OR helps managers to decide alternate courses of actions by identifying and taking advantage of opportunities and by solving the identified service delivery problems. Operations research studies have been conducted in the field of family planning since 1950s. Initially, the focus of these studies was to find out whether family planning programmes have an effect on reproductive health. Thereafter, OR was used to experiment with new service delivery strategies to improve access to and impact of programmes. In 1960s, OR was used to test community based delivery of contraceptives, mobile clinics, postpartum family planning programmes and a variety of family planning promotional strategies. OR has also been used for resource allocation and mobilization. More recently the emergence of an international womens' critique of family planning programmes has led to a focus on the reproductive health and has provided scope of OR for study of quality of care. OR components are now included in HIV, child survival, breast feeding promotion and many primary health care initiatives.

Operations Research Methodologies:

Like epidemiological research, OR also applies systematic research techniques but it differs from epidemiological research as it focuses on the factors which managers control and can modify to improve the programme. The process of operations research follows several steps that are common with other research disciplines. The essential steps are problem definition, solution generation, solution testing and result dissemination.

There is no single method that is unique to OR, both quantitative and qualitative methods can be used including service statistics, secondary data, observations, focus groups, questionnaire, in depth or structured interviews and content analysis etc. It is not a particular method or design which distinguishes OR from other forms of research. It is the focus or the objective of the research that differentiates it from others. In other words, the independent variables in operations research are factors that can be manipulated by managers, for example type of training, frequency of supervision, prices of services and dependent variables are indicators of programme success, for example programme outputs, outcomes and impact or cost effectiveness of programme operations. Research that does not fulfil both the criteria of managerial control over the independent variables and inclusion of indicators of programme success as dependent variables is not OR.

As in the epidemiological research, both experimental and non-experimental designs are employed in OR depending on the situation. Pre and post test both in the intervention and control groups is a true experimental design where intervention is assigned randomly. It helps to assure that the two groups will be equal before the programme intervention is introduced. Only post test in the intervention and control groups when no pre-test observation is measured does not allow the investigator to determine the extent of change within the experimental group because there was no baseline pre-test measurement. Quasi-experimental design compares pre-test and post-test in experimental group with a control group, which is comparable to experimental group but intervention is not assigned randomly. Time series design is similar to the quasi-experimental pre-test post-test design except that it has the advantage of repeated measurement observation before and after the programme. The pre-test post-test design not having any control group allows the researcher to examine changes over time but in the absence of a control group it is difficult to separate out the effect of intervention from changes that may have occurred due to other factors in the area. In another non-experimental design only post-test observations both in the experimental and control group are compared where random process is not used to create experimental and control groups.

A good OR design is the one which does not violate rights and dignity of people or deny the quality of services they otherwise would have received. Practical and administrative constraints do exist. Due to shortage of funds or time it is not possible to choose ideal experimental OR design. Moreover, a technically sound design may get ruined due to unavoidable circumstances such as flood, civil disturbance, transfers etc. But one should assure that if it is not possible to assign experiment randomly then a comparable control group should be selected. When even this is not possible time series design is a good one and even if this is not possible then as a minimum, before intervention starts, one should try to get baseline information to be compared with the post test. In the absence of pre-test information multivariate analytic techniques should be considered to measure the effect of intervention.

One should always consider the principle of three multiples while selecting OR design. Multiple data sources provide reliability check on the other sources for the same variable. Using qualitative information on process is particularly useful for determining how and why an intervention effect was obtained or not obtained. Multiple measurements over time provide information on trends before, during and after the intervention. Multiple replications in different settings provide information on the extent to which the intervention effects are unique to a particular area and population or can be generalized to other areas and populations.

The success criteria for OR is the amount of programme change that results from the research. It means that the OR process must include steps those maximize the potential for using the results. The OR researcher must have access to decision makers and should be able to communicate the results of OR effectively to them. It is important to involve managers and other stakeholders from the very beginning of the OR process so that the successful programme interventions are moved from OR to the routine programme.

Suggested Readings:

1. Fisher AA, Laing JE, Stoeckel JE, Townsend JW. Handbook for Family Planning Operations Research Design. Second Edition. New York: Population Council, 1991.

2. Cretin S. Operational and system studies. In, Holland WW, Detels R, Knox G, Breeze, E.ed. Oxford Textbook of Public Health. Oxford: Oxford University Press, 1985, pp 222-236.

3. Foreit JR, Frejka T. Family Planning Operations Research, A Book of Readings. New York: Population Council, 1998.

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