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Western Pacific Advisory Committee on Medical Research, Sub-Committee on Health Systems Research, Manila, Philippines, 12 - 13 April 1984 : report

December 31, 1984 World Health Organization

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Iep/HSR/OOI

ENGLIS!l ONkY

WESTERN PACIFIC ADVISORY COMMITTEE ON MEDICAL RESEARCH SUB-COMMITTEE ON HEALTH SYSTEMS RESEARCH THIRD SESSION

Convened by the

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Manila, Philippines 12-13 April 1984

Not for sale Printed and distributed by the Regional Office for the Western Pacific of the World Health Organization Manila, Philippines June 1984

NOTE

The views expressed in this report are those of the members of the Sub-Committee on Health Systems Research of the Western Pacific Advisory Committee on Medical Research and do not necessarily reflect the policies of the Organization.

" " " II

This report has been prepared by the World Health Organization Regional Office for the Western Pacific for the members and secretariat of the Sub-Committee on Health Systems Research of the Western Pacific Advisory Committee on Medical Research, held in Manila, Philippines, on 12-13 April 1984

CONTENTS

INTRODUCT ION •••••••••••••••••••••••••••••••••••••••••

1 2

OBJECTIVES OF THE THIRD SESSION •••••••••••••••••••••• REPORT OF THE MEETING •••••••••••••••••••••••••••••••• 3.1 3.2 3.3 3.4 3.5 Review of activities undertaken during April 1983 - March 1984 ....................... . Planned activities for 1984-1985 ••••••••••••••• Review of hospital utilization studies ••••••••• Links between training, service delivery and research in health services ••••.••••.•....•.••. Discussion topic for the next meeting of the Sub-Cormni t tee. • • • • . • . . . . . . • • • • • . . . . . • . • • . . . • • • •

3 3 5 5 6 6 6 6

RECOMMENDATIONS ••••••••••••••••••••••••••••••••••••••

4.1 4.2 4.3

Support to Member States in HSR development •••• Inf omat ion exchange .......................... ..

4.4 4.5 4.6

Development of guidelines for training in health systems research ••.••.•••.•.......•.•..• Hospital utilization studies ••••••••••••••••••• Links between education, service and research •• Main topic for discussion at the next session of the Sub-Cotnmittee ........................... .

7 7 8

ANNEX 1 - OPENING ADDRESS BY REGIONAL DIRECTOR....... ANNEX 2 - LIST OF MEMBERS OF THE SUB-COMMITTEE AND SECRETARIAT............................ ANNEX 3 AGENDA •••••••••••••••••••••••••••••••••••••

9 11 13/14 15/16

ANNEX 4 - LIST OF DOCUMENTS •••••••••••••••••••••••••• ANNEX 5 - ACTIVITIES UNDERTAKEN DURING APRIL 1983 MA.RCH 1984 •••••••••••••••••••••••••••••••••

17 19/20 21 53 63

ANNEX 6 - PLANNED ACTIVITIES FOR 1984 - 1985 ••••••••• ANNEX 7 - DEVELOPMENT OF HEALTH RESOURCES ALLOCATION MODEL IN REPUBLIC OF KOREA •••••••••••••••.• ANNEX 8 - STUDY OF HOSPITAL UTILIZATION IN PENINSULAR MALAySIA •••••••••••••••••••••••• ANNEX 9 - STUDY OF HOSPITAL UTILIZATION IN THE PHILIPPINES................................

INTRODUCTION

The Sub-Committee on Health Services Research was established by the Western Pacific Advisory Committee on Medical Research at its fifth session in April 1980. The first session of the Sub-Committee was held in 1981 in Manila when it reviewed the medium-term programme for health services research for the period 1981-1983. A number of significant activities have been undertaken since the 1981 meeting. No meeting of the Sub-Committee was held in 1982 but the Scientific Group on Research Needs for Health for All by the Year 2000, held from 30 March to 2 April 1982, identified priority areas for health services research and a medium-term programme for health systems research for the period 1984-1989 was drafted. The second session of the Sub-Committee was held on 17-18 April 1983 in Kuala Lumpur. It reviewed the progress of health services research during 1978-1983, endorsed the draft medium-term programme for health systems research for the period 1984-1989 and recommended general directions for the future development of research in the Region. The Sub-Committee also recommended that its name be changed to Sub-Committee on Health Systems Research starting from 1984. The WHO Regional Committee for the Western Pacific, at its thirty-fourth session held in September 1983, adopted a resolution on the development of health services research (WPR/RC34.R5), urging the Member States to apply health services research as an effective tool for introducing desirable changes, as an integral part of the process to develop and improve health systems, to develop health services research manpower and to become actively involved in the exchange of information and share their experience in health services research. It also requested the WHO Regional Director to collaborate with the Member States in developing national capability in health services research methodology related disciplines. The third session of the Sub-Committee was opened by the Regional Director, Dr H. Nakajima, who emphasized the fact that health systems research had become increasingly important since it provided a scientific basis for the formulation of health policies and plans to meet the challenge of reaching the goals of health for all by the year 2000. He also highlighted the activities being developed in accordance with the Regional Committee resolution on health services research and in response to the recommendations made at the second session of the Sub-Conunittee on Health Services Research. A full text of the Regional Director's address 1S given in Annex 1. Professor Jong Huh, as Chairman of the Sub-Committee on Health Systems Research, presided over the meeting. Professor Gu Xing-yuan served as ViceChairman and Dr G. Salmond acted as Rapporteur. A list of members of the Sub-Committee and secretariat is given in Annex 2.

- 2 -

OBJECTIVES OF THE THIRD SESSION

Considering the implications of the resolution on health services research adopted at the thirty-fourth session of the WHO Regional COlnmittee for the Western Pacific, the objectives of the third se~sion of the Sub-committee on Health Systems Research were as follows: (1) to review the health services research activities undertaken during the period 1983-1984, including achievements, problems and constraints in relation thereto; (2) to exchange experience gained in hospital utilization studies carried out recently in the Republic of Korea, Malaysia and the Philippines; (3) to consider future plans for developing health systems research in 1984-1985. The agenda of the meeting is given documents used, 1n Annex 4. 3. 3.1 ~n

Annex 3 and the list of

REPORT OF THE MEETING

Review of activities undertaken during April 1983 - March 1984

The secretariat introduced the report on the topic WPR/RPD/HSR/84.4 (Annex 5). The Sub-Committee was pleased to note the successful workshop on research in family health programmes, held in Suva, Fiji, from 27 June to 8 July 1983, and the national training course in HSR methodology and information analysis, held in Harbin City, Heilongjiang Province, People's Republic of China, 18-23 October 1983. The initiative taken by the participants at the end of the course to form a national association on health systems research was most encouraging and should be actively supported by WHO. The Sub-Committee noted the plan to provide a research training grant for a senior staff member of the Korean Institute for Population and Health and expressed strong support for the practice of providing grants for senior workers and research leaders. The support given to hospital utilization studies in Malaysia, the Philippines and to the development of a health resource allocation model 1n the Republic of Korea was noted. The Sub-Committee considered that these projects were valuable and deserving of continuing support.

- 3 -

On the topic of information exchange, the Sub-Committee noted the production of an inventory of health systems research in selected countries in the Region. A great deal of effort and time on the part of many people had been expended to produce what should be a useful document. Efforts should be made to evaluate its cost effectiveness - how much it cost to produce and by whom and how it was being used - before the inventory was updated. Of particular interest was the guide to health services research, developed by New Zealand, the content and format of which provides a model which, if suitably modified, might be useful for other countries. If countries could produce their own guides along similar lines the information coordination task of the Regional Office would be easier. It was agreed that copies of the New Zealand guide should be widely distributed within the Region and that countries be invited to follow the New Zealand lead. Where the necessary expertise and resources existed to produce such a guide, these should be shared between countries. For example, New Zealand could be invited to assist Fiji and the smaller countries in the South Pacific in the production of a guide and in other aspects of health systems research. 3.2 Planned activities for 1984-1985 (See Annex 6.) In noting the plan to hold a national meeting on health systems research methodology and information analysis in the Philippines in early 1985, it was observed that national workshops on similar topics had recently been held in the Philippines. The plan to hold this national meeting should be reconsidered. The Sub-Committee was pleased to note that the global level health systems research training package would be available in 1985. It was agreed that a regional meeting should be held to examine the package and to decide how it could best be used in the Region. 3.3 Review of hospital utilization studies The following presentations were made to the Sub-Committee: (1) Development of a health resource allocation model in the Republic of Korea - document WPR/RPD/HSR/84.7 (Annex 7) - presented by Dr Young Soo Shin. Hospital utilization in Peninsular Malaysia - document WPR/RPD/HSR/84.8 (Annex 8) - presented by Dr Indra Pathmanathan. Hospital utilization in the Philippines - document WPR/RPD/HSR/84.9 (Annex 9) - presented by Dr W. Asoy.

(2)

(3)

Not only did all three studies illustrate the benefits to be gained from well-conducted major HSR projects but also, in different ways, they highlighted many of the practical problems encountered in the conduct of such research.

- 4 All three studies showed the importance of having top management involved in and committed to projects from the outset. Although this greatly facilitated the conduct of the research, the potential sensitivity of certain issues made publication of the results difficult. While accepting the need for discretion and good timing in releasing results, the Sub-Committee agreed that countries should be encouraged to share the results of research if at all possible. The studies illustrated the organizational efforts needed to bring together the multidisciplinary teams and resources necessary to undertake major research. Administrators and health workers at all levels in the system could with benefit be involved in such projects. This could greatly facilitate the study design, data gathering, analysis and implementation of decisions based on the results. However, if this was to be done successfully, strenuous and continuing efforts would be needed to keep all involved adequately informed. If the results of health systems research were to be used to influence patterns of service delivery and resource allocation, it was essential that the research be soundly based. The conduct of such research required knowledge and skills which could only be obtained by practical experience gained over some years. There was a tendency for members of research teams to be seconded from service posts for the duration of the study and then to return to their usual work. While this was an efficient way to involve a large number of health personnel in health systems research, it was essential that there be a small core of experienced people able to provide the required leadership and support. Without such people, major studies were unlikely to achieve their full potential and might fail. Inexperienced people should not be discouraged from undertaking small projects but if at all possible they should seek skilled advice. Large projects involving major resources and political or administrative commitment at a regional or country level should not proceed without skilled and experienced leadership. This might come from a number of sources but was best provided by someone with relevant local experience. Where possible there was great advantage in having an HSR resource unit within the Ministry of Health. This could be developed within the Ministry's planning structure and make people available who would act as research brokers, facilitators, advisers or directors and others capable of assisting with technical problems such as computing and data processing. Countries should be encouraged, with WHO support, to recruit, train, deploy and employ such people. Although such people might obtain some of their training overseas, they must have experience in their own countries to be fully effective. It \~as observed that major hea 1 th sys terns research required major resources. Inexperienced research directors often seriously underestimated the size of the task and consequently underbudgeted projects. Those funding projects should be aware of this problem.

- 5 Considerable scope existed for HSR in the hospital field. Despite the emphasis appropriately placed on primary health care, most countries spent more than half their health care resources on hospitals and this was likely to continue. Continuing efforts, including research efforts, were needed to ensure that these resources were used cost-effectively. Information was required to plan, to set standards and to effectively manage hospital services and their interaction with community-based primary health care. Ways and means must be found to carry out the required research and to disseminate the results widely. At present, information about technical innovation in the clinical area spread very rapidly; unfortunately information about innovations in management science spread more slowly. In financially difficult times, there was a tendency for health decision makers to cut back on the funding of all research - including health systems research. Such policies were misguided if the result was ill-informed decision making and damaged and inefficient health services. In difficult times more, rather than less, well directed health systems research was required since countries could not afford to be without it. 3.4 Links between training, service delivery and research in health services

It was observed that stronger links must be forged between institutions responsible for the training of health workers, health serV1ce delivery interests - including ministries of health - and the HSR community. For too long these activities have existed in relative isolation. Ways and means must now be sought to bring them closer together. Joint involvement in HSR projects of common interest was one way in which this might be done. It was noted that the role of universities and other education and training institutions in the better preparation of health workers for careers in primary health care would be the subject of Technical Discussions at the 1984 World Health Assembly. The Sub-Committee believed that these discussions should take due account of the facilitating role that could be played by health systems research in bringing education and service interests closer together. Those who researched together would better come to learn together and to work together.

3.5

Discussion topic for the next meeting of the Sub-Committee

It was observed that the Sub-Committee had gained great benefit from the presentations on hospital utilization. It was only by studying projects and the practical problems they presented that knowledge of health systems research could be expanded and the necessary steps taken to promote it. With this in mind, the Sub-Committee expressed the wish that at its next meeting projects would be presented concerned with research and development at the community level. Projects concerned with the levels at which technology and manpower could be applied would be of particular interest. Projects concerned with community initiatives and self help activities with limited involvement by health professionals would also be of great interest.

.;. 6 -

4. 4.1

RECOMMENDATIONS

Support to Member States in HSR development

The Sub-Committee noted with satisfaction the progress made in the health systems research programme during the past year, particularly in the promotion of health systems research activities and in the development of national capability in carrying out HSR activities among the Member States. Recommendation The Sub-Committee recommended that efforts should be made or continued: (a) to support Member States in further strengthening manpower to develop HSR activities; however, training activities in this regard should be geared to complementing national efforts and not duplicating them. to encourage and support well designed HSR studies on priority issues in health systems development. to facilitate greater contact and understanding between researchers and the users of health systems research.

(b) (c) 4.2

Information exchange

The Sub-Committee noted the production by the WHO Regional Office of an inventory of health systems research in selected countries in the Western Pacific Region and the publication by New Zealand of a guide on health services research. Recommendation Efforts should be made to enable countries or areas in the Region to develop a guide on health systems research in order to provide information on national policies and plans for health systems research, organizational framework, funding and technical support available or capable of being mobilized, and including an inventory of research projects or studies ongoing or completed to enable them to promote the programme. Application of the TCnC approach in development of national guides should be facilitated. Until such time as the national guides are developed, efforts should continue to improve and update the regional inventory of health systems research studies in order to facilitate management of the regional HSR programme and to share among countries in the Region the information on ongoing studies.

- 7 -

4.3

Development of guidelines for training in health systems research

The Sub-Committee was pleased to note that the global level HSR training package would be available in 1985. Recommendation The Sub-Committee recommended that a meeting be held to examine the training package and to develop regional guidelines for the use of the countries in the Western Pacific Region for HSR training activities. 4.4 Hospital utilization studies

The Sub-Committee heard the excellent presentations made by the principal investigators for the hospital utilization studies conducted in the Republic of Korea, Malaysia and the Philippines and noted the problems encountered. Recommendation The Sub-Committee recommended that: (1) (2) countries should be encouraged to publish reports on studies and to share the results; countries should be encouraged, with WHO support, to recruit, train, deploy and employ a core of experienced people to take leadership in HSR studies; efforts should be continued to improve the planning and operational efficiency of hospital services since these services would continue to absorb a large proportion of health care resources.

(3)

4.5

Links between education, service and research

The Sub-Committee believed that health systems research could be used as a means of building better links between the training of health workers and the manpower requirements of health services. Recommendation The Sub-Committee recommended that WPACMR should discuss the role that research - particularly health systems research - could play in forging closer links between the education aspects and the service delivery aspects of health care and that thought be given to the framing of recommendations and supporting information which could be injected into the Technical Discussions at the WHA and otherwise used to encourage the desired development.

- 8 4.6 Main topic for discussion at the next session of the Sub-Committee.

The Sub-Committee noted that it had gained great benefit from the presentations on hospital utilization studies in the current session. It was felt that in the future Sub-Committee meetings. consideration should be given to prp.senting specific studies on health systems research. Recommendation The Sub-Committee recommended that at its next meeting projects concerned with research and development at community level should be presented.

- 9 -

ANNEX 1 OPENING ADDRESS BY DR HIROSHI NAKAJIMA REGIONAL DIRECTOR, WHO REGIONAL OFFICE FOR THE WESTERN PACIFIC Distinguished Members and Colleagues, It is a real pleasure for me to welcome you to the third session of the WPACMR Sub-Committee on Health Systems Research. Our special greetings go to the temporary advisers, Dr Asoy of the Philippines. Dr Pathmanathan of Malaysia. Dr Young Soo Shin of the Republic of Korea and Dr Sharma of Fiji. Allow me also to express my deep appreciation to those members who have participated in previous Sub-Committee meetings and have made significant contributions to the Sub-COIDIIli t tee. The WHO Western Pacific regional strategy for health for all by the year 2000 was adopted by the WHO Regional Committee at its thirtysecond session in 1981. The strategy implies that national health systems should be reviewed and modified on the basis of primary health care so that they can respond more adequately to the tasks required of them to reach the goals of health for all by the year 2000. This has posed a great challenge to all countries and it is because of this challenge that health systems research has become so increasingly important since it provides a scientific basis for the formulation of concrete plans and proposals by health administrators for health systems development based on primary health care. During the past few years, there has been a greater awareness of health systems research as an effective tool for introducing desirable changes in the health system. However, in many developing countries, the lack of adequate manpower resources to promote, develop and support health systems research activities continues to be a crucial problem. It will be recalled that, when the Sub-Committee met in April last year, you reviewed the progress of the health services research programme for 1981-1983 and endorsed the regional medium-term programme on health systems research for the period 1984-1989. You also made recommendations for the future development of the health systems research programme. One of the recommendations, which was accepted by the Western Pacific Advisory Committee on Medical Research, was to give priority to support for educational activities on various methodological and technical aspects of health systems research and to the undertaking of promotional activities to interest and involve policy workers, health service managers and other health workers in health systems research. In this connexion, a sub-regional workshop on research in family health programmes was held in Suva, in June/July 1983, with the participation of health officials from the South Pacific countries and China. A national workshop on health services research methodology and information analysis was also conducted in China in October 1983 with WHO technical support.

-10-

Annex 1

In addition, I included, as part of my report to the thirty-fourth session of the WHO Regional Committee for the Western Pacific in September 1983, a special evaluation report on the development of the health services research programme in the region. The Regional Committee, after reviewing the evaluation report, adopted a resolution urgina Member States to apply health systems research as an effective tool for introducing desirable changes and as an integral part of the process for health systems development, and to become actively involved in the exchange of information on health systems research activities. Another important recommendation made by the Sub-Committee was that Member States should be encouraged to share their experiences in carrying out health services research studies. In this connexion, I am pleased to see that the responsible officials for the hospital utilization studies carried out in Malaysia, the Philippines and the Republic of Korea, namely, Dr Pathmanathan, Dr Young Soo Shin and Dr Asoy, have accepted our invitation to participate in this session and to share with us their experiences in the health systems research studies. I expect that you will review the progress made in health systems research programme during the past year and I welcome your recommendations for the future development of the programme. I wish you all a successful meeting and a pleasant stay in Manila.

- 11-

ANNEX 2

LIST OF MEMBERS OF THE SUBCOM!-IITTEE AND SECRETARIAT

1. CHINA

MEMBERS OF THE SUBCOMMITTEE Professor Gu Xing-yuan Deputy Chief Health Statistics Department Shanghai First Medical College Shanghai

FIJI

l Dr Kesho Dutt Sharma Director, Hospital Services Mini5try of Health and Social Welfare Suva Professor T.A. Sinnathuray Head, Department of Obstetrics and Gynaecology Faculty of Medicine University of Malaya Pantai Valley, Kuala Lumpur Dr Indra Pathmanathan Medical Officer of Health Public Health Institute Ministry of Health Kuala Lumpur I

MALAYSIA

NEW ZEALAND

Dr G. Salmond Deputy Director-General of Health Department of Health Wellington Dr W. Asoy Chief, Planning and Programming Division Ministry of Health San Lazaro Compound Sta. Cruz, Manila 1

PHILIPPINES

- 12 -

Annex 2 REPUBLIC OF KOREA Professor Jong Hun Professor of Public Health Administration School of Public Health Seoul National University Seoul Dr Chong-kee Park In ha University Incheon 160, Republic of Xorea

Dr Young Soo Shin l Institute of Hospital Services Seoul National University Seoul 2.

SECRETARIAT Dr R.D. Mercado Director Health Services Development and Planning Western Pacific Regional Office Manila Dr Y.H. Paik Chief Research Promotion and Development Western Pacific Regional Office Manila Dr Y.T. Kuo (Operational Officer) Regional Adviser in Health Services Development Western Pacific Regional Office Manila Dr D. Stern Regional Adviser in Health Services Development Western Pacific Regional Office Manila

WHO/WPRO

Mr M. Subramanian Regional Adviser in Health Information Western Pacific Regional Office Manila

Coopted members

- 13/14 ANNEX 3

AGENDA 1. Opening Session 1.1 1.2 2. Address by Dr H. Nakajima, Regional Director, Western Pacific Regional Office Nomination of Chairman. Vice Chairman and Rapporteur

Review of HSR programme for 1983-1984 and planned activities for 1984-1985 2.1 2.2 2.3 Activities undertaken during April 1983-March 1984 Planned activities for 1984-i985 A Guide to Health Services Research in New Zealand. 1983

Discussion on experience gained in health systems research studies 1..1 3.2 3.3 Development of health resources allocation model in Republic of Korea Study of hospital utilization in Peninsular Malaysia Study of hospital utilization in the Philippines

4. 5.

Consideration and approval of the report of the HSR Sub-Comadttee Closing

- 15/16 -

ANNEX 4

LLST OP DOCUMENTS Title 1.

DoOUllleh t

No.

Prov1r;lonal agenda

WPR/RPD/HSR/B4.1 WPR,IRPO/J13R/84.1a WPR!RPD/HSR!B4.2 WPR/RrD/HSR/84., wrn/RPD/f1SR/84 .4

2. 3. ~.

Tentative timetable LtRt of participants

Objectives of the ThIrd Session of WPACMR Sub-Committ.ee on flSR Activities undertaken during Aptil 196' March 198/~

G. '{.

Planned actIvities for

1984 - 1965

WPR/RPD/HSR/B" •5 WPR!RPD/UsR/f.l4 .6

A GuIde to Health Servioes Researoh Ln New ZeaVmd 198}

SUlllllary of th~ study on development of health re::;011rces allooation model In Hepubl1c of Korea SUmmftry of study on hospital utIlIzation in Penln:o:ular MalaTsia

9. 10. 11.

r.ummary of study on hospital utilization in the Phllippines ~IO

Regional Committee resolut10n. wPR/RC,-.R5

12. 13.

Ilea \th Flystems research medium-term progr.....e

for 1934 - 1989 Rp.port of the second ~ub-Commlttf'!('

WPR/RPD/HSR,/84 • 11

S8SSton of the WPACfom on H(!lllth Servioes Resul'oh,

Kuala Lwnp\Jr. Malaysia.

17-18 April 1983

WPR/YU'l>/HS1V'84.12

- 17 -

ANNEX 5

ACTIVITIES UNDERTAKEN DURING APRIL 1983 - MARCH 1984 The Sub-Committee on Health Systems Research of the Western Pacific Advisory Committee on Medical Research at its second session held in Kuala Lumpur, Malaysia, 17-18 April 1983 evaluated the achievements of the regional BSa Programme for 1978-1983 and endorsed the WHO regional medium-term programme on health system research for 1984-1989. It made recommendations on the future development of the programme, laying particularly emphasis on the promotion of health systems research as an integral part of the health managerial process and to involve policy makers, health services managers and other health workers in health systems research. strengthening of national capability in health systems research; promotion of information exchange and sharing experience in health systems research. The WHO Regional Committee for the Western Pacific at its thirtyfourth session held in September 1983. after reviewing the progress made in the health services research programme, adopted a Resol~tion on the Development of Health Services Research, urging the Member States to apply health services research as an effective tool for introducing desirable changes and as an integral part of the process to develop and improve health systems, to develop HSR manpower and to become actively involved in the exchange of information and share their experience in HSR. It also requested the WHO Regional Director: (1) to continue efforts to promote health services research as part of the process of organizing and managing health systems based on primary health care; (2) to cooperate with Member States in developing national capability in health services research methodology and related disciplines in order to organize, carry out and manage health services research, through the strengthening of national intitutions and the development of manpower; (3) to develop mechanisms for the exchange of information and experience in health services research among Member States. To comply with the mandate, the following activities were developed during the period under review: For the promotion of health systems research activities and the development of national research capability, a sub-regional workshop on research in family health programmes was held in Suva, Fiji from 27 June to 8 July 1983. There were 16 participants from 7 South Pacific countries and 2 from the People's Republic of China. The

- 18 -

Annex 5

workshop arrived at the development of essential capability in health systems research methodology to formulate, initiate and conduct HSR studies in priority areas of family health programme. A number of proposals were formulated by the participants. A national training course on health services research methodology and information analysis was conducted in Harbin City of Heilongjiang Province, People fS Republic of China from 18 to 28 October 1983 with WHO technical input. The course was attended by 30 participants from 8 provinces and municipalities and 20 observers from Heilongjiang Province, including i participants each from the 4 WHO primary health care collaborating centres. The course emphasized the importance of health services research as an effective tool for improving the health system management, illustrated the principles in identifying the priority areas for health services research in China and covered the essential elements involved in health services research methodology and information analysis. At the end of the course, the participants took the initiative to organize a national association on health services research. It is expected that a follow-up national workshop will be held in the latter part of 1984 at one of the WHO collaborating centres on primary health care in China. Arrangement is being made to provide a research training grant for a senior staff member of the Korea Institute for Population and Health which has been designated as a WHO collaborating centre for research and health development. Support was given to Malaysia and the Philippines to conclude the studies on hospital utilization. The study for the development of health resource. allocation model in the Republic of Korea, which was concluded in 1982, is being updated with WHO support to solve certain basic issues in order to enhance the practical application of the model. WHO has also been supporting a study on the functions and problems of health staff and health services at the periphery in Papua New Guinea and an in-depth evaluation of the primary health care development in Fiji. . To facilitate the information exchange, an inventory of health systems research in selected countries in the Western Pacific Region has been established and published, which will be updated from time to time. New Zealand developed a Guide to Health Services Research which is being distributed to relevant persons in various Member States for possible use in developing their national guides.

- 19/20 -

ANNEX 6

PLANNED ACTIVITIES FOR 1984 - 1985 The WHO regional medium-term programme (MTP) for health systsma research covering the period from 1984 to 1989 was established in 1983. It serves as a general sad flexible guide for the development of health systems research activities. Based on the general framework of the MTP the following activities are planned for 1984-1985.

A national workshop on health systems research will be conducted in People's Republi~ of China in the fourth quarter of 1984, to follow-up the activities developed since October 1983 when the national training course on health services research methodology and information analysis was held. Participants are expected from the four WHO collaborating centres on PRC and the 6 model health counties. Contacts will be maintained with the participants of the sub-regional workshop on research in family health programmes which was held in June/july 1983. Support will be provided to some of the participants to formulated research protocols and to conduct field research. Subject to further negotiation with the Government, collaboration will be provided for holding a national workshop on health systems research methodology and information analysis in the Philippines in early 1985 to follow-up activities developed since 1982 when the national workshop on biomedical and health services 'research methodology was held in Manila. A regional working group on evaluation of health systems research for national application is planned to be held in the latter part of 1985 to develop criteria for evaluation of HSR studies and procedures to apply research findings for improving health systems management and development. Experienced workers in this field in the Region will be invited to participate in the working group. It is expected that the health systems research tra1n1ng package being developed at the global level will be finalized by the end of 1984. In the light of the global training package and based on the experience gained through the national and intercountry group education activities carried out in the Western Pacific Region, the regional guidelines for health systems research training will be formulated 1n 1985. Research grants will be awarded to the health systems research proposals which are well formulated and are aiming at solving high priority problems in health systems development. Research training grants and fellowships will be engaged in health systems research activities. The inventory of health systems research in the Western Pacific Region will be updated. Member States will be encouraged to develop national inventory or guide of health systems research studies.

- 21 ANNEX 7

DEVELOPMENT OF HEALTH RESOURCES ALLOCATION MODEL IN REPUBLIC OF KOREA

Title of study -Development of health resources allocation model in Republic of Korea

Sponsorship Ministry Health and Social Affairs of Republic of Korea

Primary reason for starting the study

Many developing countries, in spite of all their limitations in the political, economic and social conditions, have adopted, and are implementing various policies to meet the basic health needs of the people. Nevertheless, one common problem found in the operation of their health care systems is desperate shortage of health resources. Even the resources available are not finding a geographical distribution which would most effectively meet the needs for medical care of the population, and various categories of the resources are functionally in competing, rather than collaborating and compatible, relationships among themselves. It is also difficult to find balance in the quality of medical care provided,-in some cases it being of a luxuriously high class, while in other cases it failing to keep minimum standards. In other words, developing countries are confronted with two major problems: one, desperate shortages of all three constituents of medical resources, namely, medical facilities, medical manpower and medical financing, and the other lack of planning to maximize the productivity of the available resources through improvement of balance in the quali"ty of the services provided. The medical care system of the Republic of Korea is not much different in respect of the features common to all developing countries.

- 22 Annex 7

During the last decade the Republic of Korea achi 7ved a remarkable economic growth which in turn greatly ~proved the overall living standards of the population and, as a result, the social demand for health care increased quite substantially. In order to meet the rising demand, the Government introduced a medical insurance system in 1977, the first year of the 4th Five-year Economic Development Plan, and the system is now in the stage of taking roots and development. As of 1982, 41.5\ of the population received the benefit of the scheme including 32\ who were covered by the Medical Insurance and 9.5\ who were covered by the Medical Assistance for low-income groups. The Government is gradually expanding this program with a view to encompassing the entire population by early 1990's. As for the difference in the demand of medical care between

those insured and those not insured in 1981, the former group outnumbered the latter in average by 2.7 times among outpatients, by 2.1 times among in-patients, while, with those insured over the 4-year period of 1978 to 1981, in-patients increased by 1.6 times, and out-patients by 2.8 times. Considering all these phenomena, it is easily foreseeable that in the course of attaining the nationwide health care service, the overall effective national demand for medical care will increase radically, and it is beyond doubt that the requirements of medical resources including the facilities to meet the demand will be tremendous. In other words, the Republic of Korea is now at the juncture to form the framework fundamental for attainment of medical care security. Cre~tion of.m7d~cal resources, especially, construction of med1cal fac1l1t1es requires a tremendous amount of investments, and facilities· once constructed must be used as they are at least for 30 to 50 years.

Poor planning and reckless implementation in the building of medical facilities including hospitals can result in t~emendous was~e of funds, and as wrongly designed hospitals w111 ~lso requ1re excessive operation costs, the losses would be two-fold. The p:esent st~dy has developed a model using quantitative techn1que ~o analyze and solve such various problems comprehens1vely.o

- 23 -

Annex 7

Who articulated the need for the study and elaborated its scope Institute of Hospital Services (IRS) developed the initial draft of the study proposal in August 1980, and introduced it to the relevant authorities in the Government. It took approximately a year before the Government made a final decision that this project should be the official one for providing basic scheme of long term national health care system development. The study was conducted over the period of 18 month from JUly 1981 to December 1982. The opinions were collected for modication of study results through a series of public hearings and seminars with the participants of various interest parties and authorities. The second step study, revision of the first study, was conducted from JUly 1983 to December 1983 by IRS. Since the scope of the objectives extend over all aspects of the health care system development in Korea, and the technologies proposed in the study methods requires various types of expertise, i.e., public health administrators, physicians, health planners, economists, architects, medical engineers, accountants statisticians operations research specialists, computer specialists, etc., a multidisciplinary research team was organized for conducting the tasks more successfUlly. WHO/WPR showed special interest in it, assisting the study team by sending a leading expert in application of operations research technology to health fields for technical conSUltation on the study.

- 24 -

Annex 7

5. 6.

Who carried out the study. Who were the other agencies, institutions and departments involved in the Study. Coordinator Contritutors Basel.ine Study I

Young , Soo Shin, MD,DrPH

IHS, SNU

S K MS Y I YH

Ahn, Hong, Chung, Cho,

MD,PhD MPH. MPH MPH MD,PhD MD,PhD MD,PhD MD,MPH MD,MPH MA,CPA BEng,DipHFP BEng,MA MD,DrPH MD,PhD PhD MSc MSc

KIPH KIPH KIPH KIPH YO YO SNU

Health Care Delivery System. Del.ineation of Catchment Area & Estimation of Heal.th Care Demand Devel.opment of Basic Modul.es Development of KOHFAM

I S Kim, S H Ryu, D S Han,

o R Moon, B I Kim, K S Chung, UH Ryu, S H Lee, Y Y H K S S Shin, I Kim, Hwang, I Son, B Choi,

SNU SNU

IRS IRS IRS IRS, SNU

IRS, SNU KAIST KAIST KAIST

IRS SNU

Institute of Hospital Services Seoul National. University Hospital Seoul National University Korea Advanced Institute of Science and Technol.ogy Korea Institute of Population and Health Yonsei University

KAIST KIPH YU

- 25 -

Annex 7

What was the objective of the study.

The objective of this study is to provide basic data needed for establishing long-term and short-term national health plans by developing a model which can show the overall requirements for meeting the increasing health demand of the Republic of Korea, namely, new health care facilities that are going to be built,· the funds that must be raised for it, medical manpower needed to operate them, and optimum distribution of the facilities. In other words the study will develop a model called -Korea Health Facility Allocation Model" (KOHFAM) whose final outputs may be summarized as follows:' a. Forecast of the requirements of health facilities including hospitals by year and level of hierarchy b. Selection of optimum locations for the health facilities c. Computation of investments needed for building facilities and selection of optimum investment plan d. Forecast of health manpower required for the operation of facilities Before attaining the final objective, the development of KOHFAM, the present study must first accomplish the following tasks: a. Conceptualization of health care delivery system in the context of Korean tradition of society and health care b. Delineation of catchment areas by category and by hierarchy of the hospitals c. Long-term forecast of medical care utilization, 1982-1991 d. Comparison of current and planned supply of hospital beds and forecasted requi~ement of hospitals e. Design of basic types of hospitals by category and hierarchy

Give a short summary of the approach adopted and methodology used in the study. (Research Frame)

~ p ro X '-J

nH.alth 'oUel.. F.cI11t, ••• tlant Ori.ln Surv" •• U ho,pll.lo and "cU"ico" "Ith eor. th.n'20 b.d, Hanpo~r.

}'"""" M.diul UtlU •• tion .octorn. 1P81

roreca.t of Claar,cearf.tic. uC the Ar •••

1 Will-b,o., ...d.d Medical F.cUltle.

rer,,,c'flc 'orfta,t of M,di.,.1 utill .. tlon .. "" U ion of T•••• to OuteoM" I, Optl .. , Hadl •• l

Tarlet IIttlna

r IlIn.,. .r •••

l.ttMt,d Hadleol Supply

M,dlcal

Ie-aoure,. Requi . . .nt Planalnll Allou t lOA

a"Clure ••

Haapov.r. r.cliley • •ou ... t O.laln IaU eltnlu In .0.,10

Medieal Supply. 19.1

r Additional data on crllvll COlt. ItC.

....

AU oen 1"" 1) Hu .... r 01 ... dlcol I.e Hit le. and 11.01 r opt 1_1 loeaclon. 2) Medlcol .... pOWtlf

N 0\ I

Md 1.. 1 Utl, hOC I". ... Surv~y In a..pl. Are ••

rlqulr . . .n\

F ..plried Catch. .nt

Se t tlnll-uP u( "be.t tl

J) lnva"lllOnt co.t •• tl-

A..... 1981

Catchaant

Ar ....

Invantor, of . . ""co ..ory Medical '.eIUti .. Chareceorlatlce 01 Ar"" d ....... phlc. IDe: loeeono.tc. _dlcal 1Alurance etc. _ _ _ _ ___ .J State-olth.-arta oC '-0 axhtln, H.alth Cor. SYlt ••

Mod.' of H •• lth Car. Doliv.r), I,at ..

Hodul .. or He,ilcol roclliel ..

...tlon 4) Halu. "",dlul • .. ulp.nt Z. Iyatl_tl.ed H.alth C.r. Ottl h.ry 5y.t.,. ,. Me II 1""111 I.nt'""

.. r

Hedl~1I1

CAra

---------------------------

- 27 -

Annex 7

Brief summary of the significant findings.

10. What is the tangible output and overa.11 outcome from the study. Summary of findings 1) Intermediate Products

1-1)

Health Care Delivery System Basic idea of health care delivery system is. to classify the health care facilities. both of the existing and the future, by category .and hierarchy, then, to organize them into a systemic patient referral system. The basic frame work of the health care delivery system is shown as follow.

Population a. Primary medical institution 1) The primary medical institutions are where people

contact with medical services first. The institutions can provide integrated general medical care including preventlive care. 2)

The institutions are clinics of Reneral practitioners or specialists, health centers or health subcenters. CHP centers, !:lCH centers. midwifery clinic. hospital ships etc. Generally hospitalization is not permitted in the primary medical institutions with exception of those in remote areas or of emergency cases.

Secondary medical institution 1)

The secondary medical institutions serve to the patients referred from the primary medical institution of secondary level catchment area. They also have functions of primary medical services for the inhabitants of primary level catchment area.

- 28 Annex 7 2) The secondary medical institutions are divided into 4 kinds, according to the capability. The 2-1 type is a hospital that provides specialist care with 16 specialties and with more than 400 beds. The 2-2 type provides medical care witb specialties with 250 beds, while the 2-3 type is a hospital with 9 specialties with 120 beds. The model 2-4 type is with 4 specialties and with 40 beds. We adopted the classification to the existing hospitals. The hospitals OJ: 290-499 beClS are type 2-1. of 160-289 beds are type 2-2. of 60159 beds are type 2-3 and of 20-59 beds are type

2-4. c. Tertiary medical institution 1)

The tertiary medical institutions will be located at the center of the tertiary level catchment area. It will be in charge of the referred patient frca primary or secondary institutions. The half of the beds are for the referred patient from the secondary or primary institutions and the other half are for the patient of secondary level from the secondary level catchment area to which i t belongs. Although the tertiary medical institutions are that with more than 500 beds in case of the existing hospitals, the basic module is that with 700 beds. The tertiary medical institution is the center of medical research, health manpower training and patient care in tertiary catchmant area. 1 i ,,

1-2) Catchment area For primary, secondary detined in health care and tertiary catchment on the catchment areas and tertiary medical institutions, delivery system trimary, secondary areas were set up. The basic idea is shown below schematically.

- 29 Annex 7 Catchment area Medical institutions

o <=> (', \.oJ

tertiary catchment area secondary catchment area primary catchment area

m .GP •

tertiary medical institution secondary medical institution primary medical institution

Objective functions considered in setting up catchment areas were the minimization of the travel distance and the population beyond the maximum aIlowable travel distance. under the constraint of minimum feasible population size of the catchment area. Maximum allo~ble travel distances in tertiary and secondary catchment areas were respectively 80Km and 40Km. and the mimum feasible population size 1 million and 0.15 million. Cities which alrealy have medical institutions classified as tertiary were "fixed" as the "centre" of tertiary catchment area and the "candidate centres" were tested with the objective functions by computer. Six candidate centres were selected in addition to six fixed centres. Therefore. twelve tertiary catchment areas were set up but the boundaries were adjusted minutely by protessional opinion. Then the secondary catchment areas were set up by the procedure same as above. 109 secondary catchment areas were set up. (Fig 1 at appendiX) Primaty catchment area was deliberately detered to·the further project.

1-3) Long-term forecast of health care utilization To forecagt the inpatient care utilization rate. a multiple regrestion formula was developed in which the dependent variable is the standardized number of discharges per 1000 of population. and the independent variables are medical insurance rate. medical assistance rate. per capita local taxes. population density and residence of urban or rural area. Sur e

7.4649377 + 0.001482852 x DNST + 0.072342205 x ASSR + 0.030488398 x INSR + 0.00016596068 x PGRP - 1.5346802 -V41 + 2.9852895 x V42 + 2.3424787 x V43

Notations in the formula are SUR : Standardized number of discharges per 1000 per year DNST: Population density

- 30 Annex 7

ASSR: INSR: PGRP: V41 : V42 V43

Coverage rate of medical assistance program Coverage rate of medical insur~ce program Per capita local taxes per year 1 in counties not in the vicinity of cities o otherise 1 in counties in the vicinity of cities o otherwi.se 1 in cities whose population is more than 500 thousands o otherwise

Inpatient utilization rate covered by Workers' Compensation was seperately forecasted. To calculate the inpatient care utilization rate in future the independent variables were forecasted. Then, by multiplying the population to the rate, total amount of inpatient c.are was calculated. Outpatient care utili.zation was forecasted based on inpatient care. . The results of the forecast were shown in Table 1 and Table Z at-appendix.

1-4) Design of basic IICdules of hospitals by category and

hierachy. According to the functional hierachy of health care facilities designed in health ~re delivery system, four types of secondary hospital modules and one type of tertiary hospital ~odu1e were formulated. The ~odules are developed on the basis of the situation analysiS of existing hospitals in Korea, and the consideration of eC:OtID~y-of-scale. '!he contents of each hospital. modul.es were shown in Table :3 and Table 4 at appendix.

- 31 Annex 7

Final Products (Developnent of KDHFAM) Mathematical model for the allocation and planning of the tertiary and secondary beds were developed. Korea Hospital Facility Allocation Hodel (KOHFAH) is the mathematical model developed in this study. it has the characteristics as follows. 1. 2. 3. 4. The input variables can be up-dated. whenever necessary. The input variables are selected only if available in Korea. ~hey

are

Modernization and expansion of existing hospitals has priority to the new hospital establishment. Input and output variables of KOHFAH can be incorporated with the other fields of health care system.

The items determined by the KOHFAH are the kind. number. time and place of hospital bed supply. Tertiary hospital beds are allocated heuristically according to the forecasted demand of medical care by the tertiary catchment area. For the allocation of the secondary hospital beds. an objective function was developed. It is aiming at the minimization of shortage of beds and maximization of spatial accessibility under the constraints of number of expansion and investment cost. The algorithm is as follows.

min

(E A, E d;,-ESj EXj.)++ E E (ViI ,... I

·c

i~l

leOi"

'-I i-I

• •,

SjE Xj.+Mi/(d,,-r....S/ pi Nw

.... 1

EXi,)+J) 12

. Subject to

'-1

E X if 5. 1 f or all j

C E Wi·Xj,+ E '..!J EXi.I+,S;B, E Xi.t. 1 +E JRlU4 j"IUll 2 ....O "I"fLT3 I 3 .... 0 t=l. ······;10. Xif =0 or 1

W;I

Wi 2

a+=rnax {O. a}

- 32 -

Annex 7

The notations used in these formulae are as follows i j t

secondary catchment area hospital :

time small area number of secondary catchment area in a tertiary catchment area bed requirement of i secoodary catchment area at time t number of beds of hospital j average travel distance per bed in a tertiary catchment area from small areas to the centre of secondary catchment area at tilJJ! t. average travel distance per bed from small areas to the centre of secondary catchment area of 1 secondary catchment area at time t average travel distance per bed from small areas to the centre of tertiary catchment area of i secondary catchment are a at time t. investment cost of hospital j.

1 c

dit: Sj At

Vit

Kit:

LT Bt Xjt limitation of investment cost at time t. 1 i f hospital j allocated, and 0 if not at time t

The main results of allocation and planning are Table 5,6,7,8 and Figure 2,3 at appendix.

- 33 -

Annex 7

11.

How were or how will the study findings and conclusions be used The results and recommendations that have been found in the KOHFAM study completed in December 1982 were formally accepted by the Government for adopting it as the basic scheme for the future development of national health care system in Korea. The opinions were cOllected for modification of study results through a series of public hearings and seminars with the participants covering various parties of different interest and public authorities. The Government took action to modify some boundaries of catchment areas' for adjusting to the local situation. Thus, the Second step study, revision of the first study, was conducted from July 1983 to December 1983. The MOHSA is schedUled to prepare the final draft for implementation of KOHFAM that includes establish ment of a new law and revision of a series of existing law and codes. The following is a summary description of the recommendations for KOHFAM implementation a.nd the future direction of further development of KOHFAM that have been proposed in the study report.

I) Future Direction of KOHF AM Development

KOHFAM has been developed by mobilizing to a maximum extent the ~ata available in Korea today, but as there are many th~ngs which remain to be further improved ~eveloped in the future, and as changes in the m~l~eu are bound to Occur either due to shifts of ~mphasis in Gover~ent policies or factors emerging ~n the co~rse,of,~plementation of the plans, KOHFAM cannot ma~nta~n 1ts status without constant retouching and supplementation.

The future direction of KOHFAM development may be summarized as follows: a. Refinement of Method for Medical Demand Forecast The forecast of the demand for medical care which is being m~de in only two subdivisions of i~patients and outpat1ents, must be expanded and improved so that,more specia~ized forecasts such as those by spec1al~y of med1cal care, by type of dise~ses, and by 1l1ness, etc. can be made, and the accuracy of forecast can be improved.

34 -

Annex 7

b. Modernization of Existing Hospitals It has emerged as a big problem that there are too many small-size hospitals, and modernization of existing hospitals is a task no less important than adding of new hospitals is. As existing hospitals have already been engaged in medical activities in the catchment areas they belong to, modernization of their facilities and manpower with relatively small investments not only will be more effective but can eliminate factors of waste of medical resources. For this reason, from now on, KOHFAM should be fed further detailed information of various facts about existing facilities so that it can offer solutions to the problems related with allocation of manpower, facilities, equipment and other resources as well. c. Inclusion of Other Types of Health Facilities in KOHFAM Application In order to cope with the changing patterns of disease incidence and structural changes of the society, Korea will require more diversified medical facilities than before. Various types of specialized facilities such as mental hospitals, industrial accident hospitals, rehabilitation hospitals, old people's hospitals, children's hospitals, cancer centers, etc. should be made independent, and plans for allocating such facilities should also be developed. d. Development of Health Facility Allocation Methodology within the Urban Area For city planning purposes and for the sake of convenience of medical care delivery, the medical care delivery system and medical facility allocation on an independent individual urban area basis should also be considered. Especially important is allocation of first-aid facilities. e. Development of Allocation Methodology for Medical Care Facilities Pr~ary

As the allocation of primary medical care facilities must fully consider conditions peculiar to incividual localities concerned, it should be made possible to develop sound allocation methodology for th~~ by using quantitative model technique and, at the same time.

- 35 -

Annex 7

reflecting the opinion of both the local population and local administrative authorities concerned, and to develop allocation plans for each of the diversified types of primary medical care institutions. f. Incorporation of Planning and Implementation with Other Fields of Health Care System In the health care system there are, besides medical facility allocation, many other fields that require planning work. KOHFAM ought to contribute to establishment of comprehensive health planning by providing mechanism which are -linked to the planning of other fields.

Recommendations for

KOHF AM I mpiementation

a. Activation of Medical Care Delivery System We have defined problems of the medical care system of Korea and proposed a new system to overcome them. This must be followed by formation of an organizational set-up to bring it into being and various other concomitant actions such as legislation. b. Inducement of Investments in Medical Facilities Implementation of the allocation plan requires 153.2 billion won per annum in average until 1991. Especially, allocation of hospital beds to problem areas in medical care requires special arrangements for inducement and control of investments. c. Modernization of Small-Size Hospitals A tas~ no less important than construction of new hospitals is enlargement of the scale of existing small-~ize hospitals. They have problems in many respects such as achievement of financial independence, facility utilization, and quality of medical care provideq, etc., and as long as there are many small-size hospitals various factors of waste will remain, working as a fundamental impediment to raionalization of the medical care system, which must be eliminated. d. Realignment of Administrative Set-up in Charge of Medical Facility Allocation

- 36 -

Annex 7 ------

For successful implementation of this plan, it would be nessary to take various measures to depart from the past laissiz-faire policy towar~ ~spit~l bed supply, especially, to found an adm~n~strat1ve a~ency which has the authority to plan and control hosp1tal bed allocation and to follow up implementation of the plan. It appears to be inevitable for the agency to have its headquarters in the central government and its local branches in all the tertiary and secondary catchment areas, which will perform unified function of handling not only medical facility allocation, but procurement of medical care fund sources, patient referral system, and medical manpower allocation, etc. This will be the key to open the door to success of the plan. e. Health Care Information System Realignment of the health care information system will be essential and indispensable for implementation of the plan and development of KOHFAM. f. Special Assistance in Research and Development of KOHFAM As KOHFAM has its footing on various current conditions and policy variables, any changes that occur in the conditions under which it is to operate must be reflected in it ~ediately. Accordingly, KOHFAM needs continued retouching and supplementation, without which it will loose its validity within a couple of years. The Government assistance should" also be continued so that it may be developed into a computerized model with a capacity far more extensive and diversified than now. 50 far the absence of health planning has been mentioned as the largest single blind spot in the health and social affairs a~inistration. Keeing KOHFAM alive and developing it will also greatly contribute to the development of the health administration as a whole.

37 -

Annex 7

12.

Major problems encountered in the conduct of the study. 1) The limitation in acquisition of various input variables which must be fed into the model. 2) uncertainty and sometimes vertua11y non-existing long term national policy in various aspects of health care system developments. 3) Recruiting various specialty experts who well understand unique character of health care environment. 4) Coordinating activities of various background experts performing the goal of the project. The frame of the study especially requests orderly a.nd well ba.la.nced team work 5) Methodology of aculately a.s possible forecasting medical care demards in the future. 6) Methodology developing mathematica.l model which can easily accomodate many revisions and supplementation. 7) Coping with pressures from various interest parties (i.e.,local politicians for revision of catchment area boundaries, physicians association for revision of medica.l care delivery systems, university hospitals are very sentive to the selection where the future center of ca..tchment regions should be located.) 8) Incorporation of planning and implementation with other fields of health care system and national planning (Le. ,general economic development planning, long term development planning for nat ional resources, hea.l th manpower planning, health insurance development planning, public health sector planni~g population policy, national policy for local political ana administration development etc.)

13.

How the problems were solved or the study scope modified. 1) Recognizing the availability of input variables and parameters being limited, the KOHFAM should be structured by maximum utilization of available data.•

- 38 -

Annex 7

2) Model algorithm should be developed and furnished according to the input variables so tha.t KOHFAM may be able to accomodate revisions and supplementation a.s needed. 3) Input information for the mo~el opera.tion re9uests some essential long term nat~onal health pol~Cy such as those not formally documented until now. A comprehensive enquiry having been ma.de by the meetings with the project team members and the relevant government officers enabled the project report for the first time to formally document alternatives of national health policies in the future. One of the merits that mathemetical model can provide in national health policy formulation is that model can be used to show how various assumptions and input alternatives can result in future output consequences. The model can simulate all alternative situations and it can be utilized as a powerful instrument for policy makers determining the best suitable health policy for the future. 4) coping with lOcal voices and pressures from various parties especially local pOlitics, a series of reconfirming field surveys were conducted and revisions were ma.de for the modificat ion of catchment area boundaries that were requested. 14. What lessons were learnt from the study and hence, what aspects shOUld be carefully reviewed if similar studies a.re initia.ted by others or other countries. 1) The ultimate objective of the project was to develop a model which will allOW planners to make jUdgements, based on the health demand increase anticipated over the 10 years from 1982 to 1991, on medical facility requirements, especially, hospitals to be newly built and hospital beds to be newly supplied, along with capital investment requirements inVOlved, and which will furnish methodOlogy for optional allocation of these facilities. Before development of the model, however, it was necessary to fully understand the historical developments of hea.lth care system in Korea and to assume the future development of its network which shOUld be the most adequate for aChieving health care security in Korea in the future. Thus the project must consider over all aspect of national health care system development. Such a.s health care del i very system,

- 39 -

Annex 7

regionalization of health care, health care financing mechanism, population pOlicy, economic development, etc. 2) One of the most important feature the project ha.s taken into conderation is that process of achieving national health security shoUld be carefully designed of well bala.nced development of all part of health resources essentially necessia.ted for heal th care such as health manpower, health facility, and health financing mechanism. Inter-relations of each of the three type of resources should be well examined and dynamically equated. And a.lso emphasis must be placed on finding the most efficient and effective mixture of various subcomponents within one category of resources such a.s mixture of various types of heal th facilities. 3) The inherent characteristics of mathematical model construction is the process clearly finding input and output relations among numorous factors for the production, a.nd decribe each relations between two variables in quantifIable terms. Thus project team can produce acurate terms of check list, necessary for health Care system development. Heal th policy planners can utilize this check list as valuable information for their decision process. 4) KOHFAM resea.rch frame enable us to identify types of information exactly necessary for health care system planning. It is not suprising that the existing nationa.l mechanism for collecting this information lacking in systematic analysis of such type of requirement. Therefore, in view of the uncertainty, variability of such information parameters, it was decided to maximize the flexibility of the model so that if they were cha.nged or newly constructed, new solution might be obtained by inputing their up-todate information. Realignment of the health care information system will be essential and indispensable for implementation of the plan and development of KOHFAM. 5) For achieving national health care security, the nation must secure adequate level of medical care in the most effedive and efficient way within the means they can provide. One of the most difficult tasks KOHFAM project had to confront was how to achieve certain levels of standa.rdization in its quality and its economicity with existing disorderly and lassezfair style health facilities.

- 40 -

Annex 7 6) Comprehensive health care planning is cal~ing fOr

wide range of specialists in the health f~7ld. The first problem in this part is how to recru~t most adequately trained specialists, a.nd the next problem is how to gather the consensus to achieve the goal most efficiently. It certainly is a very difficult task to succefully perform. tion of medical facilities requires a tremendOUS amount of investment, a.nd facilities once constructed must be used a.s they are at least for 30 to 50 years. Poor planning and reckless implementation in the building of medical fa.cilities including hospitals can reSUlt in tremendous waste of funds, and as wrongly designed hospitals will also require excessive operation costs. It is very important to have in each developing country, well trained health facilities planners working in the government or in the private sector.

7 ) Creation of medical resources, especially, consturc-

15.

Has the study contributed to any further strengthening of HSR capability of individuals or institutions. IHS took the main responsibility to conduct the KOHFAM project from initiating, performing, revising through to implementing. Neverthless IHS could have accumulated a very broad range of technical expertise and the informa.tion necessary for such a comprehensive planning. IHS itself fUlly recognizes that resea.rch in the health service area should be a mUltidisciplinary approach and ha.s recruited full time staff researchers of various backgrounds such as medical doctor, nurse, economists, architects, medical engineers, hospita~ administrators, operation resea.rch specialists. A series of discussion is going on between the MOHSA and IHS for the future role of IHS in KOHFAM implementation. The strong possibility is that IHS is taking a role of continuously revising and up-dating the data base of KOHFAM and generating a wide range of information necessary for implementation of national health care system development.

- 41 Annex 7

APPENDIX

Fig. 1 Fig. 2 Fig. 3

Catchment Areas of Korea Number of Hospitals as of 1982 Number of Hospitals as of 1991

Ta.ble 1 Ta.ble 2 Table 3 Table 4 Table 5 Table 6 Table 7 Table 8

Forecasted Inpatient Care Utilization Forecasted Outpatient Care Utilization Outline of Ea.ch Hospital Modules Specialties of Each Hospital Module Change in the Number of Hospitals Change in the Number of Beds Investment Cost Estimated Number of Hospital Manpower by Region by Year

Annex 7

- 42 -

Fig. 1.

Catchment Areas of Korea

- 43 Annex 7

Legend

•

100 .50

•

• 1

Fig. 2.

Number of Hospitals as of 1982

- 44 Annex 7

Legend Fig. 3.

.100

•

•1

Number of Hospitals as of 1991

- 45 Annex 7

Table. 1. Forecasted Inpatient Care Utilization 1985 Tertiary Total Catchment inpatient Area days per year Seoul Wonju Kangneung Daejon Chonan Jeonju Kwangju Sunchoon Andong Daegu Busan Jinju Total 5,635,312 242,799 175,989 5~7,856

1986 Inpatient days per 1,000 persons per year 390.59 180.90 198.31 196.92 145.54 199.03 173.43 154.00 135.84 227..64 311.98 157.85 278. '!X) Total inpatient days per year 7,587,031 322,556 249,758 )

1991 Total inpatient days per year 10,621,378 472,554 380,078 1,327,130 375,278 851,154 1,088,362 376,981 376,349 1,865,352 3,483,942 362,166 21,571,724 Inpatient days per 1,000 persons per year 648.37 321.66 363.10 402.11 275.30 343.47 335.33 280.69 261. 51 384.21 512.26 290.43 480.09

Inpatient d.ays per 1,000 persons per year 490.72

231.76 262.93 275.51 198.88 264.40 234.88 212.66 179.89 285.01 291. 30 199.55 358.00

832,114 268,702 611,610 702,420 254,768 256,297 1,265,405 2,430,956 232,880 15,014,557

193,885 436,292 489,330 175,100 191,897 894,816 1,733,912 177,266 10,893,454

- 46 -

Annex 7

Table 2. 1982 Tertiary Catchment Area

Forecasted Outpatient Care Utilization 1986 No. of outpatient visits per year * 127,513 5,391 3,729 14,380 4,437 9,760 12,313 4,117 4,615 21,116 40,123 4,429 251,923 No. of visits per person per year 8.25 3.88 3.93 4.76 3.29 4.22 4.11 3.44 3.25 4.76 6.44 3.80 - - ---

1991 No. of outpatient visits per year * 176,083 8,390 6,163 24,168 7,179 15,454 19,704 6,958 7,349 39,222 56,133 7,045 366,848

No. of visits outpatient per visits per year * person per year

No. of

No. of visits per person per year 10.75 5.71 5.89 7.33 5.26 6.24 6.06 5.31 5.12 6.64 8.25 5.65 8.17

Seoul Wonju Kangneung Oaejon Chonan Jeonju Kwangju Sunchon Andong Daegu Busan Jinju Total

84,476 3,607 2,499 8,197 2,882 6,-473 7,477 2,713 3,010 12,918 25,278 2,858 162,388 *Unit: 1,000

5.86 2.69 2.82 2.93 2.16 2.96 2.65 2.39 2.13 3.21 4.54 2.55 4.16 visit~

6.00

- 47 Annex 7 Table 3. Outline of Each Hospital Modules Secondary Hospitals

2-4 No. of beds No. of mandatory

Tertiary Hospitals 2~3

2-2 250 13

2-1 400 16, 4 552 344 440 25,080 26.540 700 20 0 950 625 800 48,510 59.769

120 9 2

specialties No. of optional specialties

4 2 35 25 80 2,178 1.637

3 335 207 397 14,438 14.959

No. of personnels No. of inpatients per day No. of outpatients per day Total building area (m 2 ) Investment cost* * Unit:

125 91 232 5,940 5.496

million US Dollars

- 48 -

Annex 7

Table 4. Module

Specialties of Each Hospital Module Secondary Hospital

Dep~ . .

2-4 Internal Medecine General Surgery DB & GY Pediatrics Dentistry Orthopaedic surgery ENT 0 0 0 0

2-3 0 0 0

2-2 0 0 0 0

2-1 0

Tertiary Hospital

Basic Four

0 0 0

0 0

Other Twelve

A A

0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0

A A

Neurosurgery Neuropsychiatry Ophthalmology Urology Dermatology Chest Surgery Plastic Surgery Family Medecine Health Screening Supporting Five Anesthesia Radiology Clincal Laboratory Pathology Rehabilitation

A A A

0 0 0

A A 0 0

0 0 0

" 0 0 0 0

- 49 -

Annex 7 Table 5. Change in the Number of Hospitals

Tertiary Level Catchment Area Seoul Wonju Kangneung Daejon Chonan Jeonju Kwangju Sunchon Andong Daegu Busan Jinju Nation-Wide

No. of hospitals as of 1982

1983-1986 No. of new hospitals No. of hospitals as of 1986 203( 8) 17( 1) 15( 1) 30( 1) 14( 0) 20( 1) 41( 1) 14( 0) 20( 0) 36( 3) 7S( 3) 13 ( 1) 501(20)

1987-1991 No. of new hospitals No. of hsopitals as of 1991 245{ 8) 20( 1) 19( 1) 36( 1) 19( 1) 25( 1) 46 ( 1) 16( 1) 22 ( 1) 45( 3) 90( 4) 15( 1) 598(24)

185( 8) l5( 1) 12( 0) 26( 1) 13( 0) 15( 1) 36( 1) 9( 0) IS( 0) 31( 2) 74( 3) B( 0) 442(17)

18 2 3(1) 4 1 5 5 5 2 5(1) 4

42 3 4 6 5(1) 5 5 2 (1) 2(1) 9 12(1) 2 97 (4)

5(1) 59(3)

*Figures in parenthesis are the number of tertiary hospital.

Table 6 • Change in the Number of Beds 1983-1986 No. of Beds as of 1982 22,367 1,117 739 2,955 1,023 1,539 3,119 509 1,197 3,974 7,019 563 46,121 Additional Beds 5,748 153 330 490 40 885 360 460 130 1,337 1,873 710 12,516 No. of Beds as of lq86 28,115 1,270 1,069 3,445 1,063 2,424 3,479 969 1,327 5,311 8,892 1,273 58,637 Increment Rate 25.7 13.7 44.7 ..

s;:s ro ~

.,--.J

Tertiary Level Catchment Area Seoul l~onju

1987-1991 Additional Beds 8,560 550 400 1,488 640 821 552 592 450 1,986 3,791 240 20,070 No. of Beds as of 1991 36,675 1,820 1,469 4,933 1,703 3,245 4,031 1,561 1,777 7,297 12,683 1,513 78,707 Increment Rate 30.4 43,3 .. 37,4 43,2 60.2 33.9 15.9 61.1 33.9 37.4 42.6 18.9 34.2

Total Total Additional Increment Beds Rate 14,308 703 730 1,978 680 1,706 912 1,052 580 3,323 5,664 950 32,586 64.0 62.9 98.8 66.9 66.5 110.9 29,2 206,7 48.5 168.7 80.7 68.7 70.7 I

Kangneung Daejon Chonan Jeonju Kwangju Sunchon Andong Daegu nUR.,n Jinju NntionHide

16,6 3,9 57,S 11.5 90.4 10.9 33.6 26.7 126.1 27.1

\.ft

- 51 Annex 7 Table 7. Investment Cost (Unit: US$ in millions) Tertiary level Catchment area SeQul WOl!.ju K,angneung Daejon Chonan Jeonju Kwangju Sun chon

1983-1986 Sum 407.8 6.6 24.8 lS.3 24.5 47.0 16.3 20.9 5.6 71.5 127.3 47.9 818.4 Annual Ave~a8e

1987-1991 Sum 418.5 24.8 18.4 ~2.1

Annual Average

Total 826.3 31.4 43.2 110.4 46.6 92.5

-"-

101.9 1.6 6.2 4.6 6.1 11.8 4.1 4.3 1.4 17.9 31.8 12.0 204.6

104.6 6.2 4.6 23.0 5.5 11.4 6.3 10.7 7.5 28.6

22.1 45.4 25.3 42.8 30.0 114.6 174.S 11.1 1,019.9

49.5 63.7 35.5 186.1 302.1 59.0 1,838.2

Andong Daegu Busan Jinju Nation-Wide

43.7 2.8 255.0

§ (1)

Table

Estimated number of hospital manpower by region by year

....,

Region 1. Seoul l. Wonju J. Kangneung 4. Daejon S. Chonan 6. Jconju 7. Kwangju B. Sunchon 9. Andong 10. o.egu II, Buaan 12. Jinju

Phys.

Hur.

1982 Pharo 656 3.l

Tech. Others 1,500 77

PhY8.

Nur.

1986 Pharo Tech. Other8 825 1,882 11,805 467 37 88 416 73 32 228 1,41>7 102 413 72 30 936 68 165 238 1,363 101 27 68 352 468 35 95 149 356 2,123 265 599 3,692 34 87 472

PhY8.

Nur.

1991 Pharo Tach. Others

4,650 10,819 209 499 98 338 535 1,468 479 134 201 721 603 1,451 59 227 134 522 717 1,811 1,291 3,359 63 241

22 88

29 44

92 15 32 111 210 14

51 195 69 105 213 36 85 269 476 39

9,280 421 100 1,260 401 60S 1,235 186 429 1,573 2,901 203

5,717 13,739 224 553 184 485 611 1,707 138 493 425 1,119 643 1,607 111 430 147 567 1,012 2,523 1,716 4,296 561 2U

7,264 18,036 1,065 2,448 15,417 662 127 51 790 285 ~('6 100 42 670 no J27 1.121 145 924 2,460 661 U5 783 48 l89 no 1,247 90 558 1,493 276 1,568 115 706 1,859 58(, 107 257 44 703 632 126 48 756 245 488 2,965 206 1,418 3,503 5,372 866 379 2,561 6,242 514 103 675 40 H9

\.11

Total

8,694 22,007 1,346

3,115 18,794 11,209 28,080 1,705 3,951 23,974 14,933 37,970 2,273 5,303 32,361

- 53 ANNEX 8

STUDY OF HOSPITAL UTILIZATION IN PENINSULAR MALAYSIA This Study was commissioned by the Ministry of Health. BACKGROUND Health planning in Malaysia is an integral part of the national 5 year Development Plans. During the situational analysis that preoe4ed the formulation of the Fourth Malaysian Plan (1981 - 85), officers at national, state, and district levels highlighted a number of problems that they perceived as affecting the utilization of hospital services. These problems may be summarized briefly as 1. Under-utilization

(low bed occupancy rates) of some hospitals; bypassing of more peripheral patient care services and ineffectIveness of the referral system.

2. High demand for building more hospitals and high cost of construction and maintenance of hospitals. 3. Problems related to management of hospitals and patient oare services The Planning Division of the Ministry of Health prepared a Paper articulating these problems and requesting a study to provide information for policy makers on : 1. Why some hospitals are under-utilized. 2. How to plan for optimal utilization, efficiency and effectiveness of the inpatient care services. ~.

How to strengthen management policies and practices so as to improve hospital performance.

This Paper was accepted by the top policy making body in the Ministry of Health (the Planning Committee) which requested the Public Health Institute to conduct the study. The Public Health Institute (PHI) a training/research institute in the Ministry of Health had been identified as the focal point for development of a Health Services Research (HSR) programme, and this study was envisaged as a vehicle that would assess the potential of the PHI to establish the linkages necessary for HSR and develop skills in conducting HSR.

- 54 -

Annex 8

IMPLEMENTATION OF THE STUDY

The Publio Health Institute set up a Health Servioes Researoh Team headed by the Coordinator of the Study. This team was augmented by manpower assigned to the Team for the period of the Study by the Hospital Division and Nursing Division. It was this team that was primarily responsible for the methodological and technioal aspeots of the Study. The Planning Division and Hospital Division of the Mtnistry of Health initially identified the problems and issues that needed research and provided guidanoe on polioies and oonstraints. The study was oarried out as a partnership between the Health Services Research (HSR) team of the Publio Health Institute (PHI). the Hospital Division of the Ministry of Health (who had an advisory role). and staff at State level and in the partioipating hospitals and clinics who were known as Field Researchers. The study design as well as many of the instruments were developed after tntensive disoussions with senior Speoialists in the General Hospital. Kuala Lumpur and in the University of Malaya. The steps that were used in developing this study are summarized in Figure 1.

The organisational structure for the Study refleoted the close interaction between the Public Health Institute and the national level of the Ministry of Health as well as the State and Institutional levels that participated in the study. Figure 2 illustrates the organisational structure.

- 55 Annex 8

The Ministry of Health Identify problem

J., Request Research Conceptual/Analytical Functions

....... .....:J

Field Work

Public Health Institute Design Research Project

State/District Service Units Participate in the implementation of Research

.;t- -,

, I

Design Instruments Coordinate Data Collectio~ff----~~

I Data Collection

( Process Data

I I I I ) Develop in depth understanding of problems. Develop solutio

Analyse Findings

I I

~<-------------

Document Findings - Present Findings - Promote understanding of findings - Develop consensus solution and future plan for action

- ... -

......

--I

Figure 10

Steps in Developing the Study

- 56 -

Annex 8

Planning Division Ministry of Health

Publie Health Institute

Hospital - - - Ministry

Division of Health

Research and Development Group

1 Field Resea reh Managers North, South,East

...

• - Field Researeh , Di rectors State level

I Assistant Field Managers

-.-- •

I Supervis ors of Interview Teams

, • I

Field Research Directors Hospital level

l Interviewers

• I .. ••

Data Colleetors - Admission Rooms - Record Officers - Wards

Figure 2. The Organizational Structure for the HSR Study on Utilization of Hospitals in Peninsular Malaysia

- 57 -

Annex 8

The study included an analysis of patterns of utilization of beds and manpower, patterns of referral and bypassing, utilization in relation to the population and the perceptions and expectations of the community and the medical profession. An analYSis was also done of the management policies and practioes affecting the inpatient care services. The study was conducted in a sample of eleven (11) hospitals and in a sample of ninety-five (95) Government and private clinics in the districts where the hospitals are situated. The samples were seleoted to represent areas with different geographic and socio-economic situations, and hospitals with high and low Bed Occupancy Rates. Districts Hospitals and clinics were selected from within the same State as the seleoted General Hospitals so that referral patterns could be studied. Utilization patterns and characteristics of patients (age, sex. residence, length of stay, diagnosis, referrals etc) were analysed (a) for a I year retrospective period from data that was routinely maintained in hospital Records Officers and from case records. (b) for a 3 month study periOd from data on a 20% random sample of patients admitted during that period. Data on hospital faCilities, manpower and outpat:!ent attendances were obtained from records in hospitals. District Health Offices. and State Medical and Health Departments covering a one-year period January December, 1982. Data for population, mortality and morbidity indices were obtained from records in health offices, Department of Statistics and State and District Police records. Specially trained teams of interviewers interviewed (,846 patients (or relatives) in the wards and outpatient clinics in the hospitals as well as patients attending urban polyclinics, rural clinics and private olinics to obtain data on the perceptions and expectations of the oommunity. Four members of the research team interviewed III doctors in outpatient clinics in hospitals, urban polyclinics, rural clinics and private clinics to obtain data on the perceptions and stated practices of the medical profession in relation to referrals and admissions. The data on management policies and practices were obtained by two members of the research team through a series of interviews with 102 managerial staff in hospitals and at State and National levels and with specialists in the study hospitals.

- 58 -

Annex 8

SIGNIFICANT FINDINGS AND OUTCOME OF STUDY

The 1.

s~udy

provided:

Quantitative data on the types of hospitals and olinioal units that were underutHized and those that were very heavily utilized.

2. Data on the Clinioal groups of patients who bypassed or were referred from smaller underutl1ized hospitals as well as the faoilities that these hospitals appeared to be deficient in. " Data on distribution and appropriateness of utilization of manpower and beds.

4. Data on institutional management problems relating to patient care programmes. 5. Data on the public image of various aspects of hospital services. The findings were discussed by the Plar~ing Committee of the Ministry of Health in August 1983 and the Study Report has been offioially aocepted. The Hospital Division of the Ministry of Health was directed to study the findings and reoommendations, priorities follow-up action taking i.nto consideration the relative importance as well as the ease of implementation of eaoh set of findings and recommendations.

FOLLOW UP 1. The Hospital Division has formed a number of working groups who have further studied the problem of bypassing of smaller hospitals and made recommendations to upgrade the servioes in these hospitals so as to improve utilization. Pilot projects to implement these reoommendations have been started. Findings and recommendations related to appropriate distribution and utilization of resouroes are being further studied to decide on measures of implementation. 2. Appropriate training programmes are being developed to upgrade and strengthen clinical as well as management skills. 3. The major findings of the Study are currently being utilized in the review of the 4th Malaysia Plan and in the preparatory phase in the development of the Fifth r·laJaysia Plan.

- 59 -

Annex 8

MAJOR PROBLEMS AND THE DEVELOPMENT OF

HSR CAPABn.ITY

Since this was the first major HSR project undertkan by the Public Health Institute, it has been envisaged that the Study would stimulate the development of HSR capability in the PHI. Since an HSR Unit had not yet been officially created at the PHI, the manpower as well as the physical support for the study was made available by a number of administrative adjustments within the PHI to assign the Coordinator (to spend 80 - ~ of her time) and various other officers on full time, part time and temporary basis. Also, the Hospi~al Division and the Nursing Division of the Ministry of Health assigned &taff on a temporary basis for the duration of the study, while the planning Division contributed a statistician on a part time basfs. All of the HSR team (except the Coordinator and the Senior Nurse Tutor) had no previous research experience and the Study served as an exoellent vehicle for acquiring experience. Since most full-time members of the HSR team were only temporarily aSSigned to this activity, the experience they gained will not be of future benefit to the PHI. However, members of PHI staff who assisted on a part-time basis in specific aspects of the study have gained considerable experience and will be a va uable resource for the future. But the number and type of staff who will be needed to sustain a viable HSR programme at the PHI mve not yet been assigned to this activity. The experience of this study shows that electronic data processing is one of the most problematic areas in terms of establishing ESR capability at the PHI. Studies of this scope require a computer. Computer time is available at various Government and University centres at a fairly reasonable cost, but competent computer manpower is not available. The PHI had no access 1.0 the computer manpower available within the Ministry of Health, and therefore, had to resort to the private sector where costs are prohibitive. Therefore, for this Study a linkage had to be established on a personal ad hoc basis for programming support. An HSR programme cannot become viable until an institutional linkage is established whereby computer expertise and adequate facilities will be available to the PHI whenever the need arises. One major disadvantage of conducting HSR with a temporarily assigned and inexperienced team as in this project was that the coordinator of this Study had to devote a great deal of time and energy to training the HSR team members. Since the benefits of this training will be lost from the HSR programme, this time and energy may be viewed as wasted at the expense of productive HSR activity. Despite this disadvantage, this project has demonstrated that the PHI. if given a few additional resources, has the potential to develop and sustain a productive HSR programme.

- 60 -

Annex 8

LESSONS LEARNT FROM STUDY 1. The selection of an appropriate Team Leader for the Research Project is essential. Such a team leader should : 1) possess basic knowledge and skills in research.

ii) have credibility with the higher managerial levels of the health services and be able to establish appropriate linkages and obtain support and cooperation from staff at various levels of the bealth services. This requires an intimate understanding of administrative procedures as well as formal and informal power structures in the health services. iii) be able to train and supervise inexperienced research staff. 2. The volume and type of data to be collected should be finalised only after personal inspection of data that is routinely compiled in the Wards and Records Officers of different types of hospitals, and an on-site assessment of the skills of staff who will be collecting the data and the time available for this activity. Data collection must be closely supervised by research staff themselves at the points of collection - otherwise much data might later need to be discarded because of poor quality.

3. The major features in the management of the field work that contributed to its successful implementation were a) the prior documentation of the roles of all those involved in data collection and of all procedures and instructions in the form of a Field Work Manual which waS_distributed to everyone who was involved in the Study. b) a series of initial meetings at State and hospital levels with all levels of managerial staff during which it was established that they were partners in the health services research venture. As a result, an excellent cooperation and support in the form of manpower, physical facilities and accessibility to records was a strong feature of the study. c) intensive training sessions for data collectors which was carried out in each hospital in turn, and for interviewers which was done for the team of each region in turn. To ensure standardisation, the same officers trained each category in all regions.

- 61/62 Annex 8

ct) A strong supervisory and coordinating system whereby the

8 Field Research Staff from the PHI met at the PHI once in four weeks to report on progress and problems. These se8sions enabled the early reoognition of problems so that it was possible to rediatribute resources according to needs, retrain data collecting staff when neoessary or clarify doubts on definitions and coding, and make appropriate contacts with supervisory staff at State and hospital levels. 4. The aspect of the Study for which administrative support wa~ most deficient was data prooessing. Since most administrators who make decisions regarding manpower and financial support do not un6erstand the type of computer faoilities, manpower, money and plaaning required for data processing for large research projects this is likely to be a continuing problem.

- 63 -

ANNEX 9

STUDY OF HOSPITAL UTILIZATION - PHILIPPINES

Introduction The Ministry of Health of the Philippines has been endlessly looking for better and improved health care delivery services to the population. Among the milestone of these efforts during the last decade are:

In the past, a study was conducted with the assistance of the World Health Organization (WHO) to increase the effectiveness of the Rural Health Units. The outcome of this study was accepted by the Ministry of Health, hence the strategy to restructure the health care delivery services of the rural areas has been adopted in 1975. During the same period, the Ministry of Health has strengthened the management effectiveness of all administrative levels by intrOducing the knowledge and skills of health planning. Again with the assistance of the WHO, training of the key staff on health planning at the central level, then later at the sub-national and provincial levels has been concluded, resulting in better and realistic health plans. Management by Objective as a tool to increase productivity has been introduced to all units and institutionalized by the organizations. After a thorough analysis of the health care delivery system of the country, the Primary Health Care strategy has been adopted and efforts to institutionalize it into the government organization and to the people of the villages, started in 1980.

The resultant outcome of these activities of the Ministry of Health converged towards better health services, yet the strategies employed in each of these efforts require strong complementary support. The Restructured Health Care Delivery services at the rural areas need better hospital services for their referral. The planning for better hospital services require reliahle and nearly

- 64 -

Annex 9

accurate information. Increased productivity as a goal of the "Management by Objective" must have better information on capacity and capability requirements of units. The Primary Health Care approach is fore~een to increase utilization of health facilities, hence ~hould be improved. All of these promoted the Planning Service of the Ministry of Health to conduct the study on hospital utilization so as to improve ho~pital ~el~ice effectivene~s to support the requirement~ of the past effort~. The World Health Organization, Western Pacific Regional Office has been reque~ted by the Minister of Heal th to assist the Planning Service in all aspects of the ~tudy. II. Objectives The overall objectives of the study is to establish data-base for managerial decision-making in relation to planning, management and evaluation of hospitals; and to look for a more technically valid, operationally fea~ible, acceptable, and relatively more efficient alternative~ by which the pre~ent efficiency and effectiveness of emergency/di~trict ho~pital services can be further improved. Specifically, the 1. objective~

of the study are:

To deve lop a methodology to improve hospi tal performance using the following procedures: a. To carry out series of field studies to define the actual demand on hospital services; To determine ways by which exi~ting resources have been deployed and have met the hospital requirements of the population of a hospital catchment area; and To develop alternatives that. would increase the present. level of efficiency and effectiveness of hospital ~ervice~.

To develop capability in the Ministry of Health to carry out studies using Operational Research approach.

- 65 -

Annex 9

£II. Methodology

To carry out the study, the procedures of Operation Research has been utilized. This means that the application of scientific methods, techniques and tools to problems involving the operation of a system in order to provide those in control of the system with optimal solutions to such problems. There are four distinct phases in operation research employed, namely: (1) the development of a conceptual framework of the study; (2) an analysis of the situation; (3) the generation of alternative solutions; and (4) the conduct of a test run and evaluation. Under these phases, the following steps were used 1n the conduct of the study: 1.

Development of a framework to describe the hospital services, as a basis for the study of the efficiency and effectiveness of its operation; Identification of various factors that influence or condition the interaction between the population and hospital services; Through the field studies and analysis of data, isolated possible slackness of the hospital service system; Identification of various critical factors that maybe responsible for these weaknesses; Deve lopment and study of various technically feasible and acceptable solutions to improve the efficiency and effectiveness of these systems; A decision to which of the alternatives could be test-run; Test-running the acceptable solution/alternative for operational feasibility and to demonstrate its superiority, under field condition, to the present system; Analysis of the information gathered on the test-run to see whether it is really superior than the existing system; and Recommendation for its use/implementation, sta'ting the constraints at which it wi 11 be at odds in a given situation and control measures to overcome these constraints.

4. 5.

6. 7.

- 66 Annex. 9

VI.

Survey Desist!. The study was carried out in two Primary Hospitals and two district hospitals. Both OPD and In-Patient operations were studied. To observe whether the referral system is operating within the three service levels (primary, secondary and tertiary), the OPD of a tertiary hospital has also been studied. The study followed closely the protocol. Six. forms were designed and tested. The descriptions of each forms are as follows: Form I - Staff Information. This form was intended to gather basic information on the characteristics of the staff in terms of age, designation, education, training, duration of work experience. including their salary and non-productive days. Form 2 - Inventory of Equipment and/or Drugs. This forms was intended to provide information about the availability and usability of equipment/drug In different service points of the hospital and on action taken to remedy shortcomings, if any. Form 3 - Activity Record. This foon relates to activities performed by different hospital staff on each day of observation period. This will give information on service point where the activity is being done, the type of the activity performed and tbe duration of each activity, including the type of form used to give and to record the information. Form 4 - In-Patient Record. This form relates to information of population-hospital service interaction. Form 5 - OB Record. This form was intended to gather information on pregnant mother-hospital service interaction. Form 6 - OPD Record. This is another form that was intended to gather information on population-hospital service interaction which takes place in the out-patient department. Two Operation Research Teams were constituted, each consisted of two medical officers, one dentist, two health planners, and five nurses. All of them were trained for two weeks on the methodology.

- 67 -

Annex 9

Each primary and secondary hospitals were observed for five weeks while the OPD of the tertiary hospital for only two weeks. Data were processed through the National Computer Center of the Philippines, analyzed and synthesized by the Operation Research Core Team to identify the core problems and develop solutions. Chosen alternative has not yet been tested. This will be done during the third quarter of the 1984. Findings and recommended solution will not yet be published until discussed with the Minister of Health and his management staff.

Problems Encountered 1. Underestimation of budget requirement due to: a) b) c) 2. 3. 4. unprogrammed training for researchers the unforeseen three shifts of observers within the 24 hours per day No provision for editing and transcribing of coded information.

Difficulty of recruiting researchers especially medical staff. Accommodation of Researchers in the hospital. Unforeseen marital physiological development of a female researcher which at times affected her effectiveness as an observer. Delayed completion of the ~tudy. The members of core team responsible for the study have other principal function related to their legal positions which cannot be set aside. Drawing the salary of researchers from their unit. Running out of forms. Simultaneous use of patient chart by the observer and by staff of the hospital.

- 68 -

Annex 9

VI.

Significant Lessons Derived from the Study The study has given the Planning Service the following lessons: 1. 2. A project such as this, should be planned with sufficient time to avoid budgetary problems. Training of researchers on the methodology shall be given attention, especially on the actual entries of gathered information during test-run of the instrument (forms) Which is a part of the training. For better conduct of the research, it is not recommended to recruit female researchers who are on the family way. Equally important is adequate social preparation of the staff of study area to avoid misinterpretation of the purpose of the study and to ensure better and facilitate cooperation for a smooth conduct of the survey.

Capability building on Health Services Research (HSR) in the Ministry of Health is~a continuous process. HSR skills cannot be acquired/developed in just a short time. A trained staff on HSR must practice his skills in order to grow. The experience of the Planning Service in conducting several studies, like this, increases its capability to write research protocol, to construct study instruments/forms, to conduct researches, to analyze data gathered and to write results of research studies.

Key facts

Organisation World Health Organization (WHO)

Document type Technical Documents

Adoption date December 31, 1984

Source World Health Organization