UNIVERSITIES SELDOM PLAY AN INNOVATIVE ROLE IN PHC

In Bennett's discussion of health and development obstacles he notes that:

Instead of being involved with the interpretation of new technology into appropriate forms for peripheral use, some departments [of Universities] are often concerned with advanced and nationally inappropriate technology. The technical aspects also tend to overshadow the socio-cultural orientation needed which would lead to more useful participation by their graduates in national programmes within communities.

Universities are traditionally thought to be the experts in research. However, research using clinical trials and control groups is not what is most needed to improve PHC. This is why operations research has gained popularity as both a research and management tool.

Operations Research consists of a three-step process of problem analysis, solution development and solution validation. It places as much or more emphasis on the research process as on the research results. While OR may be carried out validly at and by any level within the health system, ideally OR is best conducted by the health personnel involved in the actual operations of the system or by the immediate supervisors of the operations. OR is as much of a learning and management tool as it is a research tool. In fact the steps in the learning/health education process, the health planning/management process and operations research are quite similar (see Table 1).

Table 1

COMPARISON OF OPERATIONS RESEARCH WITH HEALTH EDUCATION, AND HEALTH PLANNING & MANAGEMENT⁽¹⁾

HEALTH EDUCATION	OPERATIONS RESEARCH	HEALTH PLANNING & MANAGEMENT
Problem Perception	Problem Analysis	Identify Problems
Information Exchange
Information Comprehension	Solution Development	Select Alternatives
Conviction & Solutions		Prioritize
Applying Solutions	Solution Validation	Implement
		Evaluate

Operations research should not be conducted in isolation, but rather should be an integral part of health education and management at all levels in the health care system. The promotion of community empowerment to discuss, propose and implement solutions to local health problems, for example, should be seen as a valid form of operations research even though it may be organized as an IEC or community participation activity.

Unfortunately, some projects promote operations research lead to the establishment of a review and approval committee that become in itself an obstacle (see Box 7)⁽²⁾. To avoid this sort of problem it is advisable to diversify the levels, implementers and project sizes for operations research.

Box 7

STRENGTHENING HEALTH SYSTEMS RESEARCH IN MALAWI

The purpose of the Promoting Health Interventions for Child Survival (PHICS) project, which began in 1989, is to increase the institutional capacity of the MOH to deliver and sustain health and child survival services, and to increase the supply and utilization of these services at the community and family level. The project includes a specific objective to strengthen MOH capacity to coordinate health research, especially operations research, to improve the effectiveness and efficiency of primary health care and child survival, particularly in the areas of:

-priority diseases and policy-relevant service delivery issues; -increases of skills & knowledge of providers (including mothers); -primary and preventive services as opposed to curative care; -how to deliver services as opposed to what to deliver; -home and community-care as opposed to clinic-based care; and -interventions & strategies which Malawi can realistically afford to sustain.

The 1993 mid-term evaluation of PHICS found that considerable training in operations research had taken place, and that a national review committee had been established to approve projects for funding (including several university professors). However, while a total of 10 proposals had been approved by the review committee, only two, according to USAID, actually met the above criteria.

One reason PHICS has not succeeded in funding many Operations Research projects through the central Research Unit is that this level is too far from service delivery. Also the research training workshops, which was directed at individuals rather than District Health Management Teams, had established a protocol development and review process that encouraged clinical or individual research rather than research related to improving community-based service delivery. The central Research Unit agreed that they needed a way to create a project environment to encourage the development of protocols, especially at the health district level, and a mechanism to avoid or streamline the approval and funding process.

To resolve these problems, it was recommended that PHICS encourage and reward Operations Research conducted by health districts. Operations Research should be promoted as a management and IEC tool that should be part of the training of the DHMTs and integrated into the health district workplans. The national Research Unit also agreed that regions and districts could and should conduct low budget Operations Research without approval from the national level. It was also suggested that the organization of a national primary health care/child survival conference could provide a opportunity for the exchange lessons learned from operations research, and at the same time reduce the proliferation of training and dissemination workshops.

back to OBSTACLES TO SYSTEMS STRENGTHENING

1. Baer, F.C. Creative Management: Learning to Think Creatively about Management. BaerTracks, 1992.

2. Baer, F.C. et al. The Promoting Health Interventions for Child Survival Project (PHICS) Midterm Evaluation, Malawi. Research Triangle Institute, 1993.