Need: Need can be defined as the gap between optimal health (successful adaptation to environment) and ill-health (failure of such adaptation) or equivalently, need can be taken to mean the required measures and services to bridge or at least to narrow that gap.
Need might be perceived by client, professionally defined by doctors according to scientific parameters, normative as measured against standards or comparative as indicated with reference to health indicators of another community.
Demand: The desire and actual effort involved in attempting to bridge the gap between optimal health and ill health (to meet health needs) through the utilization of health care services.
In general, demand reflects population health needs, their ability to pay for service utilization and availability of services to be used.
Utilization: It expresses what people actually “consume” of the health care services.Coverage rates or utilization rates are used to express utilization of a given item of services in quantitative terms.
For example, the coverage rate (utilization rate) of BCG immunization for a given population at a given time is calculated as according to the following formula:
Number of babies immunized
Coverage rate = ----------------------------------------- X 1000
Total number of live births
Some times, we use the number of events of utilization (e.g., number of visits to outpatient clinics, number of admissions to a hospital) instead of the number of service users (persons who use outpatient care or persons admitted to a hospital) in the numerator of utilization rates.
The level of utilization of health care services is variable and is determined by extent of illness, distance, income, socio-demographic, sociocultural and organizational factors.
Utilization is very useful indicator of interaction between services and population that assists health policy makers to rectify and improve services availability and delivery.
A high utilization rate suggests a high level of morbidity and/ or a good accessibility to available health care services.
A low utilization rate may suggest a relatively high standard of population health, inaccessible health care services (due to high cost, complicated administrative rules) or very low level of service supply.
• Goal: A general term, signifying a desired end, which may be the change required on a given state, condition or situation or maintenance of that state, condition or situation.
• Priority: A ranking of problems, needs or solutions in order of preference based on views derived from data and intelligent judgment.
• Factors that are taken into consideration when ranking problems, needs or solutions are:
Prevalence of the problem انتشار
Seriousness of the problem خطورة
Availability of effective measures to solve the problem
Community concern اهمية
Prioritization is resorted to when resources are not adequate (as the situation is in almost all countries) to deal simultaneously with problems, needs or solutions in a given community.
Norm–Standard المعيار : A desired state, acceptable level of health or qualification.
Who decides such norm?
Criterion: A characteristic or indicator by which one recognizes, measures or tests whether and to what extent a norm or a standard has been attained or deviated from.
For example we need criteria to judge whether an immunization programme was successful or not in achieving its objectives.
Resources: Trained personnel (knowledge and skills), facilities, supplies, equipment, money and time that can be used in attaining specific goals or objectives.
Health care services: All services (personal or public) performed by individuals or institutions for the purpose of promoting, maintaining or restoring health.
Health care: the product of health care services delivered through.
personal and public health services: It implies a comprehensive care (promotive تعزيز , protective حماية , curative علاج and rehabilitative تأهيل ).
Medical care: A term used to emphasize تاكيد the organizationتنظيم and delivery توصيل of curative care.
It is a subset of health care.
Health care system: The totality of organized efforts at the community, state or national level to deliver health care in order to attain predetermined health- related goals.
A health care system implies organized activities to achieve an optimal level of health for a defined population (catchment's مجمعات population).
Planning: Planning is a teamwork involving an organized, intelligent, and efficient to select the best alternative to achieve specific objectives
The purpose of planning1. To match limited recourses with unlimited problems
2. To use resources effectively and efficiently. Minimize or eliminate wasteful use of resources.
3. To develop the best course of action to accomplish pre-defined objectives.
Healthcare administration is the process by which knowledge المعارف , energies الطاقات and social structures are systematically utilized to achieve specific objectives.
1. Planning function: What do we need to do to improve health? Anticipated العمل المتوقع action for tomorrow
2. Management function: What to do and how to do it? Action for today
3. Evaluation function: Does what we plan work?
Healthcare programmes must be administrated in such away that:- Users must accept them.
- They must achieve their objectives.
- They are linked to socioeconomic development
- They work efficiently.
Failures in administrative functions may be due to:- Unqualified غير مؤهل administrators
- The complexity of health and healthcare
- Administration itself is a developing discipline
The planning functionDefinition: planning is a teamwork involving an organized, intelligent attempt to select the best alternative(s) to achieve specific objectives in efficient manner.
The purpose of planning1. To match limited recourses with unlimited problems
2. To use resources effectively and efficiently: Minimize or eliminate wasteful use of resources.
3. To develop the best course of action to accomplish pre-defined objectives.
Planning in broad sense includes:1. Plan formulation تحديد
2. Implementation تنفيذ
3. Evaluation تقييم
And a plan is a document containing:1. Objectives موضوعي
2. Policies سياسات
3. Programmes جداول
4. Schedules and جداول
5. Budget ميزانية
Stages of planning process:A. Plan formulation
1. Environmental examination and situational analysis فحص
2. Decision on priorities: What to do first? اولويات
3. Formulation of objectives: Where to be at the end? تحديد
4. Exploration of various means to achieve objectives استكشاف
5. Budgeting وضع ميزانيه
B. Plan execution6. Choice of best programme (solution)
7. Implementation of programme
C. Plan evaluation8. Monitoring and Evaluation.
General principles in planning:Planning must be:
3. Balanced with respect to central and peripheral partners
4. Coordinated with other sectors
6. Able to ensure commitment and flexibility
Factors that may disturb healthcare planning:Political instability
Complexity of healthcares determinants
Conflicts between (among) different pressure groups
Haphazard population distribution
The stages of healthcare planning which were listed previously may be further elaborated under what is usually described as (Population-based planning), which will be further elaborated on Population-based planning (need oriented planning)
The following steps are carried out in population based planning of healthcare services:1. The first step in the population –based planning model is the scientific comprehensive situational analysis and environmental examination:
a. Population size, age and sex composition
b. epidemiological analysis of morbidity and mortality. Define the types of problems, extent, severity, causes and impact on the community as a whole.
c. identify financial, manpower, legal, ethical and other constraints.
d. Identify complaints and expectations of the population.
e. Available healthcare facilities (for training and services delivery)
2. The second step is to decide on priorities.To decide on which problem to deal with first, when we have limited resources and we face more than one problem.
The usual criteria used in this context are:
Extent of the problem
Severity of the problem
Manageability of the problem
Community concern about the problem
3. The third step is to state clearly the short-term and long-term objectives or goals to be achieved.
These are the desirable end results of an action.
They are the guide to action and the yardstick to measure work after it is done.
It is preferable that objectives are phrased in quantitative and measurable terms.
4. The fourth step is to explore and formulate alternative strategies to be adopted: their feasibility, operational choice and the likely outcome and cost of each alternative is carefully studied.
5. The fifth step: Once these alternative strategies are fully explored, an operational plan or programming is selected.
The allocation of resources, authority, timetabling and monitoring system is decided upon.
6. The sixth step: The selected programme or plan is then implemented and the collection of monitoring data is initiated.
At this phase, the effects of the programme on clients and on adjacent systems such as the housing and educational systems are also evaluated.
Any deviation from the planned activities is sorted out and corrective measures are undertaken.
Implementation requires effective organization and adequate resources.
7. The seventh step: The last step in the planning process is evaluation, which might be applied at three stages of the planning process:
a. Prior to plan implementation: evaluation of the plan itself. Is it going to work and achieve the stated objectives?
b. During implementation (monitoring). Day to day follow up of activities. Is the plan achieving the stated objectives?
c. At the end of the implementation: Final evaluation. Has the plan achieved the stated objectives?
Always write a draft plan on paper or any other suitable medium. The plan includes background, objectives, strategies, practical stages and inbuilt feedback and evaluation parameters.
Population-based planning is faced by two major obstacles:
a. The type of data required, which encompasses a variety of aspects, is fairly difficult to acquire adequately.
b. The social orientation of the approach. It helps to uncover underlying social and environmental causes of ill health.
Resource-based planningThis approach follows a similar systematic process but it is only palliative because it attempts to relieve crises in the healthcare system.
It never addresses the deep- rooted problems behind the unmet needs of the population.
In this approach, the following steps are undertaken:A service to be studied is selected because of under-utilization or over-utilization problems or physical deterioration of its building.
The current utilization, together with the past utilization trends, is determined to determine the forecasted demand on the service.
The current demand (utilization) is compared with the expected or forecasted demand and the last is compared with the maximum current capacity of the service.
The resources in the study service are readjusted if necessary to accommodate the projected utilization or demand.
Tow basic problems face resource-based planning:The assumption that healthcare is for curative purposes – No links with population health needs.
It is linked to market rationales or fine tuning.The management function
Definition of selected concepts:
a. Accountability: The process by which a subordinate reports the use of assigned resources to a designated superior.
b. Authority: The legitimate right to use assigned resources to accomplish a delegated task or objective. The right to give orders and to exact obedience. The legal bases for formal authority are state, private property or Supreme Being.
c. Feedback control: Techniques and methods, which analyze historical data to correct future events.
d. Group decision: A decision that is reached within the structure of a group by the membership.
e. Informal group: A group that develops apart from official management plans and operates as a subculture within the organization.
f. Informal group norms: The agreement among group members to adhere to a level of production, a group attitude or a group belief.
g. Leadership: The ability of a person to influence, in an interactive manner, the activities of followers in an organizational setting.
h. Management: It is difficult to define because it involves decision making by every one. Every one faces situations and makes decisions to deal with such situations. The difference lies in the spectrum, which is touched by the decisions. Management, however may be defined as “The process of coordinating individual and group activity toward group goals”.
In further detail, management consists of activities undertaken by one or more persons to coordinate the activities of other persons to achieve results not achievable by any one person acting alone.
i. Management by objectives: A management technique, which consists of the following major components:
1. A superior and subordinate meet to discuss goals and jointly establish attainable goals for the subordinate
2. The superior and subordinate meet again to evaluate the subordinate performance in terms of the pre- established goals
j. Management performance: The extent to which a manager achieves coordinated work through the efforts of subordinates; coordinated work results from appropriate use of planning, organization and controlling (evaluation) techniques and methods.
k. management functions: The activities which a manager must perform as a result of position in the organization or firm. From one point of view, these consist of planning, organizing and controlling the organization activities.
l. Organization: The pattern of responsibilities and accountability as defined by the terms of reference and the powers of various health agencies and of divisions and departments within these agencies
THANK YOU• Perhaps, the evaluation function is the least practiced function of administration within the healthcare system.
Evaluation is defined as the systematic attempt to determine the degree to which means (programmes) achieve intended (predefined) objectives and the factors that contribute to or hinder this achievement.
The control function (evaluation and monitoring)
• Prior to implementation of programme or action plan (preliminary evaluation). The question is “Will the programme or plan achieve intended objectives or desired results?
2. During implementation (it is called here monitoring or concurrent evaluation). Is the programme achieving its intended objectives?
3. At the end of implementation (final or feedback evaluation. Has the programme or plan achieved intended objectives or desired results?
Evaluation may be performed:
1. What to evaluate? - Structure or preconditions of the careprocess
- Process to be carried out to deliver care
- Outcome - Intermediate indicators- Ultimate indicators
- Impact on the specific target and adjacenttargets or areas
- Opinion of consumers and providersThe process of evaluation involves a number of questions and steps, which must be clear in the mind of the person/ team who is expected to carry out the evaluation process:
• Relevance: Is the healthcare needed?• Adequacy: The relation between recognized need and allocated resources
• Accessibility: The easiness with which people can use services when they are in need to do so
• Acceptability: The degree of accommodation between client and provider characteristics
• Effectiveness: The extent to which planned objectives are attained .
• Efficiency: The extent to which given resources are utilized to maximize achievable objectives (benefits). A comparison of costs and benefits.
• Impact: The overall effect of a programme on targeted and adjacent systems or components of the socioeconomic sectors. (Malaria control, health and agriculture)
Take into account the following elements of evaluation also:
2. Why to evaluate?Three areas of interest may be identified and related to the purpose of evaluation:
• Administrative control
3. At what level?International,
single programme or multiple programmes4. Who does the evaluation?
• Evaluation may be carried out by any of the following:
• External experts. These may have the technical and scientific capabilities but usually, they are ignorant in local situations.
• University academics. They are competent in carrying out such tasks but they tend to be slow and meticulous and therefore, may take longer time than health authorities can wait.
• Health policy makers. They are the people who can make changes in the light of evaluation results, but they are in a threatening position and distort the spirit of evaluation by punishing or rewarding people.
• Programme administration and staff. These are the people who are much familiar with their own situation. They may be biased however to or against the programme justifications and continuation. This depends on whether they like the programme (they may exaggerate its achievement) or dislike it (they undermine the merits of the programme).
• The community or consumers. The opinion of consumers is of vital importance but lay people generally lack the technical abilities to judge the merits and limitations of many health actions or programmes. It is useful, however to listen to their views and to know how they think about the healthcare services.
5. For whom? This depends on the purpose of the evaluation.6. Where? Place and institutions to be covered
7. When? At what stage of the programme? i.e., preliminary, monitoring or feedback
1. Determining what to evaluate2. Establish standards and criteria (The use of checklists)
3. Plan the methodology to be used
4. Gather information
5. Analyze the results
6. Take action
Thus the process of evaluation involve basic steps:
A. Structure approach (structure analysis)Structure refers to the conditions that surround process of care including:
• Number and qualification of staff
• Characteristics of resource inputs (buildings, equipment, drugs… etc.
• Organizational and environmental framework.
The question is how adequate the structure is in a given institution, town, or area?
A/ The available structure in any institution is compared to a standard checklist containing the ideal structure to be available in such institution. The assumption is that if the structure is available in adequate and functioning state, then process of care is expected to be optimal and objectives are achieved.
Main approaches to evaluation
B. Process approach (process analysis)• Process is the combination of procedures and activities that are carried out and intended to produce the desired ends/ outcomes.
• In this approach, a comparison is made between an ideal list of what is required for a given disease or situation and what is actually done.
• The deficient procedures and activities are identified and action to overcome these is undertaken.
• The method is time consuming, of doubtful accuracy, and it is difficult to prove connection between process and outcome.
Main approaches to evaluation (cont.)
• Sometimes, it might be difficult to attribute the deficiency in process of care to the individual providers or to the health setting where such providers are working.
• For example, a chest x-ray indicated for a given patient might not have been done either because the provider (doctor) did not make a request to do it or the x-ray machine was not operating at the time that patient was seen by the provider.
• Anyhow, this is a necessary process item, which was missing and represented a deficient process of care.
C. Outcome approach (outcome analysis)Outcome refers to what is expected from a programme, a therapy, an educational activity or any other measure that is intended to improve individual or population health.
In this approach the status of individuals or population after the application of “treatment” is compared to the status before the treatment. A successful treatment is expected to produce desired results (outcomes) which can be measured by:
• Either intermediate indicators like coverage rate
• Or ultimate indicators like reduction in indicators of ill health such as reduction in infant mortality rate.
Main approaches to evaluation (cont.)
In general, a good quality care is expected to lead to reduction in basic indicators of population or individual health.
The following indicators of ill-health are examples:
• Disease incidence
• Death rate
• Dependency on family and on the healthcare system
1. Structure evaluation:• How adequate are the structures in primary healthcare centers?
• The figures below represent the percentages of items of structure (resources) actually available out of planned items to be available.
• Would you comment on the figures?
Examples on evaluation work
Item of structureAdequacy (as % of expected structure)
2. Process evaluation:• Are all procedures and activities carried out?
Example:• The methodology involved examination of prenatal care cards.
• A service item was considered as being carried out if the part in the card was filled by data related to that item.
• If that part was blank, it was considered as if it was not carried out.
• The indicator used was the percentage of cards with written evidence out of total cards examined.
• The table below shows clearly that investigations including general urine examination were very deficient.
Activity or procedure% of executed out of expected processes
Risk detection or exclusion
Blood pressure measurement
General urine examination
3. Outcome evaluation:Example:
• Total visits, to ANC clinics made by women who completed their pregnancy, and tetanus toxoid doses received by them were used here as intermediate indicators of outcome of prenatal care.
• Both indicators show inadequate care.• Only 15% of pregnant women attained the minimum recommended number of prenatal visits (5 visits).
No. of prenatal care visits% of pregnant women
1 – 2
3 – 4
Doses of Tetanus Toxoid received
1 – 2
3 – 4
• Now try to examine the data displayed in the above three tables and make any conclusion out of them.
• What will you tell health providers and health administrators about the state of prenatal care in this district?
Evaluation of immunization programmes• Immunization programme represents a good example for the application of evaluation techniques.
• To simplify the process of evaluation, first we represent the whole subject in a diagram where we start with a bit system view of the situation in the form a simple flow char:
Problem to be Action to solve Results Protection orsolved the problem failure
Further Examples on Evaluation
Then let us examine the situation in some details using diagrammatic representation with the same system view of the problem.
We use a hypothetical situation which is not very different from any Iraqi community:The problem Action Results
A group of communicable Immunization of Children
diseases still form a health all children against Eligible immunized
problem in Iraq. selected diseases (protected or not)
How big the problem How good the What is the What is theis? preparation is? coverage rate? efficacy
1. Definition of the problem and the target population. The target population includes all individuals who need to be immunized against specific communicable diseases. Information about target population can be obtained from the following sources:
• birth certificates.
• population censuses.
• special surveys.
The same issues in the diagram can be summarized in the following steps:
2. Determination of the number of individuals in the target population who actually received immunization. This can be obtained from the following sources:
• records of health centres assuming that the centre keeps information on the target population and on those who receive immunization.
• sample household surveys looking for evidence of immunization (cards, mother interviews, scars).
3. Using the data from 1 and 2 above, we can calculate an intermediate outcome indicator, which is the coverage rate for each and every vaccine and for different sub- populations if desired:
People who received immunizations
Coverage rate = ------------------------------------------------------- x 100
4. Determination of the effectiveness of the immunization. This may be achieved by the following:
• Testing the potency of the vaccine.
• Serology to estimate antibody titre in response to mmunization.
• Epidemiological studies (case-control or cohort studies) to determine the reduction in the incidence rate, death rate, severity of disease…etc.). The data on incidence rate can be used to calculate the efficacy of the vaccine as follows:
IR among non-vaccinated - IR among vaccinated
Efficacy= --------------------------------------------------------------------------------- x 100
IR among non-vaccinated
The greater the value of the efficacy, the greater the protectiveness of the vaccinePatients admitted to hospital are expected to get cured or at least their illness is ameliorated.
In real life, the outcome may take one of the following alternatives:• Complete cure of the disease or condition
• Amelioration of the symptoms of the disease or condition• The patient may die
• The patient may leave the hospital on his own decision• The patient may be transferred to other hospital
Evaluation of outcome of inpatient care
• The same outline for the evaluation of the immunization programme may be used to evaluate other healthcare programmes such as prenatal care, ambulatory care ….etc
• Available data suggest that prenatal care for pregnant women in a big city is very underutilized. Make a study of the causes of such problem and suggest a working plan to improve prenatal care utilization.
Hint: the causes of underutilization may be due to problems within the healthcare services and/or the population characteristics. You need to distinguish between underutilization and inadequate providers capacity.
2. Make a resource-based plan to overcome the problem of very crowded clinic of prenatal care serving a population of 30000.
3. Signals are coming from various parts of the governorate that the healthcare provided at PHCCs is inadequate, lacks continuity and of low quality. Prepare an inventory to gather information on status of healthcare at PHCCs as a prerequisite for comprehensive reform.
4. How can you formulate a population-based plan to cover all newly born babies with basic immunizations for the next five years? Consider your plan in reference to a population of 2.5 millions.
5. In a population of 250 000, you have a limited resources to deal with the many health problems facing your population. The main health problems are neonatal tetanus, malnutrition, AIDS, cancer of cervix and tuberculosis. Suggest a plan of prioritization to deal with such problems in a reasonable sequence.
6. The three major areas of goal setting in universities are teaching, research and public service. Discuss and explain the potential conflict among these goals from the perspective of a university professor.
7. Prepare a draft plan to provide a population of 200 000 inhabiting a district of 450 seq. km. Within this district, a main population residence exists. This residential place is close to the main market in the area. A big general hospital is located 10 kms from the north border of the area in the adjacent district. (Hint: You have limited resources).
8. Use outcome approach to evaluate the quality of a training programme related to self - examination to detect early stages of breast cancer.
9. What are the likely indicators that can be used to evaluate quality of care provided in primary healthcare centres?
10. What intermediate and ultimate indicators will you use to evaluate the outcome of:• Control programme of tuberculosis?
• Effectiveness of prenatal care in a district?
• Outcome of curative care in a big referral hospital.