18415 - Pan American Health Organizationhist.library.paho.org/English/ACHR/ACHR23_2_2.pdf · 2004-02-24 · 18415 Pan American Health Organization PAHO/ACHR/23/2.2 Original: Spanish

18415

Pan American Health Organization PAHO/ACHR/23/2.2Original: Spanish

TWENTY THIRD MEETING OF THEADVISORY COMMITTEE ON HEALTH RESEARCH

Washington, D.C.4-7 September 1984

RESEARCH PRIORITIES

HEALTH SERVICES DELIVERY PROGRAM

The issue of this document does not constitute formal publication. Itshould not be reviewed, abstracted or quoted without the agreement of thePan American Health Organization. Authors alone are responsible for viewsexpressed in signed papers.

INDEX

Page

I. THE PROBLEM 1

II. PRESENT SITUATION 3

1. Purposes of the Survey 4

2. Design of the Survey

3. Results 6

4. Difficulties in Conduct of Research 21

5. Setting Priorities for Research Areas 22

III. BASIS FOR THE DEVELOPMENT OF HSR 26

1. Introduction 26

2. Criteria and Basic Elements 27

3. Strategies and Lines of Action 34

IV. FINAL CONSIDERATIONS 36

PAHO/ACHR/23/2.2

HEALTH SERVICES RESEARCH

I. THE PROBLEM

Research in health services is extremely important for itscontribution to an objective understanding of the problems faced byhealth services. It is, therefore, a fundamental constituent of thesystem's response in its planning of services.

Health services research has itself become an object of studybecause of the need for information as an input to the planning ofscientific development in this field of knowledge.

In the United States, HSR and its development as a distinctactivity began in 1969 as part of the program of the National Center forResearch in Health Services and Development.(l) This research wasdirected toward improving the organization, delivery of services andfinancing of the health system. Although the conceptual framework hasbeen evolving over the last 50 years, the greatest development took placein the sixties with a surge in the number of research projects in allareas of this field.

Those initial studies were extremely valuable in identifyingcritical problems. They opened new sources for research and discussionand lald the foundations for a second level of research: the formulationof tests of hypotheses and, most importantly, of those concerning causalrelationships.

This second level of research drew on methods and skills of thesocial science.

Examining changes in the content and method of HSR over the years,two parallel developments are clearly distinguishable as the basis forwhat seems to be an emerging concept of HSR. The first development iscommon to all areas of scientific research and might be called the growthof empirical or descriptive studies at the level of explicative oranalytical research. The area of HSR that includes studies of groups orindividuals has begun to make use of comparative methods and controlledstudies based on random distributions of research topics. The use ofprogressively more sophisticated methods for collecting and analyzingdata as well as "quasi-experimental" designs is one aspect of the presentconcept of HSR.

(1) Flook, Evelyn E. and Sanazaro, Paul J. (Editors). "HealthServices Research and R & D in Perspective", p. 2. Health Adm.Press.

-2-

This combination is itself a good basis for advancing the general

framework of theoretical knowledge in the parent disciplines such as

sociology, epidemiology, economics, social psychology, etc. However, thegoal of HSR is to improve health services through greater knowledge andunderstanding of them as they are today.

The second development defining the present concept of HSR is thisdeliberate establishment of relationships between some areas of theprovision of health services. This approach can best be described asintegrated analytical, and it refers to:

the use of sophisticated methods of description and analysis.

the establishment of relationships between the differentcomponents of health services (patients, providers of healthservices or institutions), functions (services, utilization,financing) and attributes (individuals and institutionalcharacteristics, incidence or prevalence of disease, qualityof care, costs, etc.).

The importance of HSR becomes clear when we observe the extent towhich services fail to meet needs. The availability of services must beincreased substantially and a solid foundation laid for the organization

and development of facilities capable of meeting the steadily growing

demands of the population. These demands are increasingly diversifiedand complex because of "'developmental" and "modern" pathologies requiringgreater technological utilization of highly specialized human resources.Added to this problem is a general downtrend in the quality of services.The combination of these two factors has led in the countries not only tosituations of insufficient coverage, but also to inequalities andinequities in the distribution and delivery of services, and to misuse ofresources and technologies, and has encouraged the persistence ofanachronJstic organizational and administrative systems, all of which isaggravated by funding problems. The inevitable outcome is inefficientoperations, low productivity and measures of highly doubtful

effectiveness in preserving and improving the community's state of health./

Most Latin American and Caribbean countries are presently .experiencing their worst socioeconomic recession in 50 years. Thehistorical and structural causes of this recession have been aggravatedby causes deriving frotm the present situation. In 1980, the growth ofthe gross national product began to decline for the region as a whole andthe situation was even more serious in some individual countries. In1980, the growth rate relative to the preceding year was 5.1%, and a mere

1.5% in 1982. It sank to a negative 1% in 1982 and was a negative 3.3%

in 1983.(2)

(2) PAHO/WHO. Fourth Session of the Subcommittee on Long TermPlanning. Executive Committee. "Repercusiones Financieras yPresupuesto a Nivel Nacional e Internacional de las Estrategias

Regionales y del Plan de Acci6n de Salud para Todos en el Af!o2000". p.l. Washington, D.C./84

-3-

The crisis has produced a decline in GNP per capita and aworsening of living conditions especially for the intermediate and lowermiddle classes and for the least favored strata of society; the resulthas been the marginalization of a greater number of citizens anddiminished access to indispensable goods and services such as education,food, health and housing.

This situation is aggravated further by the restrictions whichinternational financial institutions impose upon their member countriesby recommending a decrease of government investment in services.

Hence, as has been suggested in numerous international forums anddocuments, these countries will have to make over their political, socialand economic structures. Noteworthy among those documents is the Plan ofAction for Health for All by the Year 2000, according to which thenumerous questions the countries face in this area can only be answeredby a systematic effort using multiple approaches to health servicesresearch that will yield better and more extensive knowledge of thepopulation groups for which services are designed and of the diversefactors that contribute to the community's use and acceptance ofservices; open up new ways of thinking about health problems andinnovative ways and approaches to resolve them, and help improve theconcepts and procedures used in the organization of services and in theforms and concepts and procedures used in the organization of servicesand in the forms and contents of the information available for theirplanning and evaluation.(3)

II. PRESENT SITUATION

In its 22nd meeting the PAHO Advisory Committee on MedicalResearch recommended "that PAHO collect and organize the availableinformation on health services research so that a concise andcomprehensive document may be written which introduces the concept of thediscipline as such and produces general guidelines on how the researchshould be conducted and, where appropriate, defines and suggests uniformcriteria for such matters as coverage, unit costs, the demarcation oflevels of care, etc.".

In compliance with this recommendation, a Study of Trends inHealth Services Research in 15 Latin American and Caribbean countries wascarried out with the following purposes, methodology and results.

(3) PAHO/ACMR. "Bases Generales para un Programa Regional de ISS".p.4 XVIII Session ACMR, Washington, D.C., 1979.

-4-

1. Purposes of the Survey

1.1 To learn more about the status of health services research incountries of the Region in relation to present national andinstitutional policies, the priorities as to research areas,difficulties in pursuing research in them, and the generalavailability of funds for these purposes in the countries.

1.2 To facilitate exchanges of experience in health services researchamong countries of the Region.

1.3 To contribute to the definition of PAHO's policies on prioritiesin health services research.

1.4 To establish a basis for the conformation and development ofnetworks of country offices for Regional and intercountrycooperation in matters of health services research.

2. Design of the Survey

In October 1983, PAHO brought together a group of consultants toprepare a basic document on the trends of health services research in 17Latin American and Caribbean countries.

This preparatory meeting accomplished the following purposes:

2.1 Definition and discussion of the basic documents for compliancewith the ACMR's recommendation on HSR.

2.2 A working definition of HSR was worked out on the basis of the oneframed in the 18th Session of the Subcommittee of WHO on HealthServices Research, of HRS as the systematic study of the means bywhich basic medical and other useful knowledge is applied to thehealth of individuals and communities in a given set of existingconditions.(4) In addition, it was resolved that an HSR projectis any that:

2.2.1 Has a preestablished plan stating the purposes of theresearch and the procedures to be followed.

2.2.2 Calls for the preparation of periodic research reports and afinal report describing the findings of the research.

2.2.3 Has a purpose wholly related to health services.

2.3 A system for the classification of health services research wasadopted (Annex 1) and the parameters of the survey were defined.(5)

(4) WHO. Subcommittee on Health Services Research, November, 1978.(5) WHO. "Research for the Reorientatlon of National Health Systems:

Report of the WHO Study Group." Feb. 83.

- 5 -

2.4 A data-collection system and data processing and analysis methodswere designed. A questionnaire and instructions for its use wereprepared (Annex 2) and a basic bibliography for each researcherwas selected.

2.5 Guides were prepared for the conduct of interviews with localresearchers and with directors of health services (Annexes 3 and4) so that the local researcher could inquire into the country'sHSR policies, difficulties in developing HSR, priority areas ofresearch, and strategies and actions for the development of HSR.

At the end of 1983, visits were made to each of the 17 countriesoriginally included in the survey in order to work with the localresearcher, who produced a document on HSR trends in his or her countryand sent in the information requested on the questionnaire.

During the period from January to March 1984, the researchers inthe different countries administered the questionnaires and forwardedthem filled in to Headquarters in Washington. In April, they drew upreports on HSR in their countries. Following is a list of theindividuals who participated in the survey:

1. Argentina Dr. Carlos Bloch2. Barbados Dr. Frank Ramsey3. Bolivia Dr. Carmen Rosa Serrano de Taboada4. Brazil Dr. Eurivaldo Sampaio de Almeida5. Chile Dr. Juan Giaconi6. Colombia Dr. Ricardo Galán7. Costa Rica Dr. Herman Vargas8. Cuba Dr. Raúl Díaz Padrón9. Ecuador Dr. Mario Paredes10. Guyana Ms. Greeta R. Walcott11. Jamaica Ms. Elsie Le Franc12. Mexico Dr. Guillermo Díaz Mejía13. Peru Dr. Pedro Brito14. Uruguay Dr. Efraín Margolis15. Venezuela Dr. David G6mez Cova

The country reports cover health services research policies,trends, priorities, problems and general recommendations. Thisinformation was the basis for the analysis of national HSR policies to bepresented in this document. The information collected in thequestionnaires was processed in the computer system at the Central Officeof PAHO/WHO.

2.6 A seminar-workshop was held from 16 to 21 July in collaborationwith the Secretariat for Public Health and Welfare and the Schoolof Public Health of Mexico to examine the results of the study ontrends in health research and consolidate its conclusions. Thisseminar was attended by the local researchers charged withcompiling the information in their respective countries, guest

-6-

speakers, officers of different health institutions anduniversities in Mexico, and officers of PAHO. The opinionsexpressed by the participants were used in the preparation of thepresent document. The Proceedings of the seminar-workshop will bepresented in a separate document.

The information obtained in this survey has been worked into adocument on Trends in Health Services Research, which will bepublished by the Pan American Health Organization and circulatedwidely in the countries. In addition, a Directory of Researchers,Institutions and Studies of Health Services Research has beencompiled and, it is hoped, will serve as a basis for thepreparation of similar catalogs in the individual countries as ameans to promote the circulation and exchange of information inthis field.

3. Results

3.1 National and Institutional Policies

An analysis of the policies on health services research in thedifferent countries is essentially an inquiry into the part played bygovernment in defining the objectives, and the organization andfunctioning of the resources available for the development, of scienceand technology.

In the sixties, as part of the Latin American developmentalistmovement and with the impetus of the Alliance for Progress, the charterof Punta del Este and the promotional efforts of UNESCO and PAHO, centralagencies for science and technology were established and developed inLatin America. Before the sixties, Argentina, Brazil and Mexico had setup advisory centers for the promotion of scientific research. 4-

Virtually all the countries participating in this study haveorganized science and technology bureaus as agencies of their governmentsto promote and coordinate developments in this field.

The level of organization and implementation of these systems willdepend directly on the economic and social development of the countries,and any action priorities they identify on the development processes inthem. Thus, areas will be brought into the planning of scientific andtechnological development as they are perceived to be useful or necessaryfor the maintenance or development of the existing social structure.

The circumstances that gave rise to these entities also promptedthe governments to promote not a harmonious development of science as awhole, but rather, in most countries, projects in the production sector -to the detriment of the development of the social sector, of which healthis a part.

-w

-7-

As pointed out in a document of the working group on the study ofscientific work in the health field in Latin America and the Caribbean,in the underdeveloped countries there is a manifest contradiction betweenthe explicit scientific policy as expressed in their declarations on andplans and agencies for the coordination of scientific work and the policyimplicit in the country's demands in science and techonology. Thiscontradiction accounts for the little effectiveness of a country'sscientific activity in redirecting its economic and social development,and reduces the explicit policy to merely symbolic status."(6)

Health research, especially that which, like HRS, is concernedwith the orientation of health care in the aggregate, is not necessarilyengaged in when those coordinating entities are being set up anddeveloping, and is only taken up when the realization dawns that healthis important, when a social awareness and social-mindedness emerge in thedevelopment process, or when the contradictions and interests of limitedsocial development necessitate government action commensurate with theproblems they can cause; and this requires that alternatives for theorganization of the services be found which are responsive to the growingdemands and needs of the population.

Health research in Latin America has developed on its own and hasconcentrated on areas closely associated with the dominant model ofmedical practice, which takes a biologistic view of the health-diseaseprocess and prefers the provision of medical care by individualpractitioners. The few cases of collective approaches were to meet needsfor the control of major endemias, and have resulted in the inception ofmany research institutes.

There is great concern about deficiencies in medical care. Healthservices are not responsive to demands. In addition, the rising costs ofmedical care and the severe financial constraints faced by the LatinAmerican governments in their efforts to attain their set goals makes HSRan acceptable way to improve the planning of their health services andthereby to arrive at more balanced approaches to current problems,.However, a difficulty is encountered at the very outset in the lack ofagreement even among researchers as to what constitutes HSR. A majormethodological problem arises when it is seen that Latin America is not ahomogenous group of countries with similar sets of problems. Acomparative study loses value as such if all we want from the analysis issimple comparisons between countries. As Arouca points out, trendanalysis carries with it the possibility of grossly erroneousgeneralizations, which give rise to extremely serious problems.(7)

(6) PAHO/WHO "Estudio de la Actividad Científica en América Latina y el.A ̂ Caribe", Work Group Report. January 17-21, 1983. p. 15. Washington, D.C.

(7) Arouca, Sergio. "Tendencias de la Atención Médica en AméricaLatina." Cuadernos Médico-Sociales No. 27. Rosario, Argentina. 1983

-8-

We must stress that the presentation in this paper of the HSR _policies of the various countries is an orderly account of the salientdevelopments over time without offering any analysis of the political andsocial settings in which they occurred, which is not the purpose of thisstudy. However, the aspects already noted should be of use to theindividual countries in pondering the dynamics of past events, withoutwhich their understanding of this process would remain incomplete.

The foregoing reservations notwithstanding, these results remainvaluable to the extent that they shed light on the present status of HSRpolicies and contribute to the formulation of proposals for theirimprovement both at the organizational level and in identification of 4

research priorities, which is undoubtedly of value in the orientation oftechnical cooperation for their development.

Analysis of the data provided by the researchers reveals a widerange of variation in the degree of consolidation of HRS policies both inthe countries and internationally. ,.

In Cuba the changes in the economic, political and socialstructure since 1959 have permitted a rapid development of public healthand therewith the conduct in the country of a real revolution in scienceand technology and, by extension, in research in the health field. In1975 this orientation t:ook form in a national scientific and technicalpolicy that was reaffirmed in 1980. -

Science and technology in Cuba are guided, directed and supervised Wby the Cuban Academy of Sciences, which is the highest authority in thosetwo areas. Work in the health sector itself is guided and supervised bythe Ministry of Health, which sets priorities, concentrates resources andefforts, and promotes the articulation and integration of results inkeeping with approved directives and guidelines.

In Brazil, HSR policies have not as yet emerged in the state andmunicipal health secretariats or in the National Institute for MedicalCare and Social Welfare (INAMS), the country's principal medical careagency, though studies have been done and proposals made for theirimplementation. In the Ministry of Health, it was not until theestablishment of the Secretariat for Science and Technology in 1981 thatguidelines were provided for the systematization of health research; thispolicy is thus in the initial stages of implementation. The firstexpression of these policies at the national level was the establishmentof research programs in the Brazilian Scientific and TechnologicalDevelopment System. These programs include an integrated endemicdiseases program (1973-74), followed by programs for socioeconomicstudies in health, and population and epidemiological studies (1976-77).The Integrated Health Program began in 1978 and was followed by theCollective Health Program (1982) as part of the Third Brazilian Plan forScientific and Technological Development (1980-85). This Plan explicitlyrecognizes the need for ItSR and makes the areas of Health Determinants,

,,

-9-

Health and Organization Policies, and Health Services Technology thefocus of its programmed action in the health field. Educationalinstitutions, particularly the Institutes of Preventive Medicine andSocial Medicine and the Schools of Public Health, are actually doing workfor the development of HSR. Other agencies, including the Institute ofEconomic and Social Planning (IPEA) and the President's Secretariat forPlanning, are becoming increasingly involved.

Health research in Colombia can be divided into two periods:

a) The "Estudio de Recursos Humanos para la Salud y Educaci6n Médica"(Study of Health Manpower and Medical Education) (1964-1968).This study established the first benchmark for the identificationof the country's leading problems and of the ways in whichservices were utilized.

b) In 1974 the national government took the very important step ofsetting up a Research Department in the Ministry of Health,thereby creating the means for the framing of policies, objectivesand strategies in health research and the promotion of mechanismsfor its coordination and evaluation and the dissemination of itsresults. In 1983 the Research Department was transferred to theNational Institute of Health.

Since 1977 Mexico has had a Health Services Research Unit in theUnder-Secretariat for Planning of the Secretariat of Health, and anotherunit has been recently set up in the Mexican Social Security Institute.In 1978 a seminar on HSR held by CONACYT, with the participation of theSecretariat for Public Health and Welfare and the National AutonomousUniversity of Mexico (UNAM), indicated priority areas for HSR. In 1982PAHO established a special HSR program in Mexico.

In Venezuela HSR is cited as important in the VI National Plan,which went into effect in 1980. Up to that year there were explicitpolicies only in the universities (the Medical School and School ofPublic Health).

Costa Rica gave institutional expression to HSR in 1982 with thecreation in the Social Security agency of an office with HSR as its soleobject, although isolated efforts in this direction had been made in theMinistry of health, the universities and other divisions of the SocialSecurity agency.

In Chile, HSR was part of a document on health policies preparedby the Ministry of Health. In addition, a law has created a jointMinistry of Health-Universities body called the National Commission onHealth Training and Services, (CONDAS) for the coordination oftraining-service and research programs in the health field.

- 10 -

Although, as will be seen further on, health service providers anduniversity groups in the other countries surveyed do participate in HSR,the country reports say nothing about any systematization of HSRactivities under a national coordinating agency.

Analysis of the information shows that in some countries thehealth institutions and universities do not clearly perceive theimportance of HSR.

3.2 General Situation in Health Services Research

3.2.1 Subject Areas of HSR and Trends

A series of criteria were established for selection of theresearch, projects to be considered in this survey. Fifteenof the countries surveyed sent in their questionnaires foranalysis and processing. However, some projects wereeliminated because:

· The subject area was not related to health services.. They were methodologically unclassifiable as HSR.

Country researchers were consulted on some of the researchprojects; they responded by confirming that the projects didqualify or indicated that they should be eliminated.

This weeding out left a sample totaling 2,899 questionnaires. In _some cross tabulations, the total number is smaller because somequestionnaires contain incomplete information and so count as lost data.

As noted before, even in the most developed countries this kind ofresearch began only in the sixties. In Latin America, as we have seen inthe discussion of research policies, it began to emerge during the sameperiod. At present, there are some countries where the importance of HSRis minimized or not perceived at all.

Tle classification adopted was proposed by the Study Group onHealth Research for the Reorientation of Health Systems (WHO) in 1982 andmodified for purposes of this study. The nine major subject areas forHSR under this classification are presented below with their numbers ofprojects and percentages of the total number:

Relationship between health services and society as awhole: 289 (9.97%)Determinants of the health needs of the population: 906(31.27%)Production and distribution of health resources: 345(11.89%)Organizational structure and components of the healthsystem: 199 (6.86%)

- 11 -

^ - Delivery of health services: 512 (17.66%)_ - Health systems management: 241 (8.32%)-- Economic support: 74 (2.55%)+ - Program evaluation: 292 (10.07%)- Community participation: 41 (1.41%)

In analyzing the HSR pursued by the countries, we find that tensubdivisions of the nine above-mentioned areas account for 71.1% of thetotal number of research project starts as followed:

Morbidity 16.8%Risk 5.9%Need/Demand 5.5%Secondary and tertiary care 9.1%Primary care 6.3%Economic structure 8.1%Production of resources 5.5%Evaluation of the process 5.6%Evaluation of results 4.4%Organized medicine 4.2%

Percentages for the remaining subdivisions decrease from 3.9%.

The distribution of HSR by years shows a general trend toward

sustained growth, with figures rising from 188 (6.5%) in 1974 to 392(13.5%) in 1983. The largest number of research projects started in any

one of the years in this period was 443 (15.3%) in 1982.

The number of such projects remained stable in the first years ofthis period, and began a sharp upturn in 1978.

It is worth noting that the number of studies started in Cuba rosesteadlly from year to year from 21 (3.8%) in 1974 to 86 (15.7%) in 1981,and then dropped to 11% in 1983.

In 1983, when the number of research starts decreased slightly

from the previous year in the other countries, in Brazil it doubled from74 in 1982 to 115 in 1983.

Jamaica reported wide variations in the number of studies startedfrom year to year.

The number of research studies done in Peru trended downward overthe period 1976-1980. Thereafter, research starts jumped from 1 study to38 in 1982, but then fell back to 14 in 1983.

Although the general trend of HSR projects from year to year canbe described as upward, except for a short drop in 1983 for which thereis no clear explanation, analysis by area of research shows significantvarlations in the magnitude of the increase.

- 12 -

The number of research starts in 1983 was twice as high as in1974. Breaking down these variations by area, as can be seen in Table 1and Annex 6, in the areas of program structure and evaluation three timesas many projects were started in 1983 as in 1974, and in the remainingareas they doubled over the same period. The exception was the area of

community participation, in which their number increased 1.5 times, witha relatively small number of research studies, which is surprisingparticularly because of the emphasis placed on this field since theAlma-Ata meeting and the Plan of Action for implementation of thestrategies toward Health for All by the Year 2000.

Before considering the priority given to the different areas ofresearch in the individual countries, it is important to remember howhard to classify some of the studies are. This difficulty was remarkedon by the researchers and mentioned in the section on methodology, andwas also noted in analyzing the studies sent in.

We feel that the areas in which classification andsubclassification were most difficult were Needs and Demand, andResources. In the first area, Needs and Demand, we looked for studies ofmnrbidity, mortality, disability and risks which contributed to adetermination of the needs of the population and of how the healthservices could meet them. The method that contributed the most to thistype of research is the epidemiological one, which has served as a meansto the understanding, evaluation and control of health problems. Aspointed out in the Seminar on the Uses and Prospects of Epidemiology,held in Buenos Aires in November 1983, this method is extremely importantin research on services. However, although there were more projects onNeeds and Demand than in any other area, not all the studies turned up inthe epidemiological study were concerned with health services, and thismay have distorted some of the results.

4-

A possible distortion of classification was found in the area ofResources owing to the inclusion of clinical and laboratory tests underthe heading of evaluation of technology. Although, strictly speakingthese studies are indeed assignable to evaluation of technology, many ofthem were not directly associated with health services. The as yetrudimentary development of these two areas could contribute to confusion,and it can be foreseen that they will become increasingly distinct andindependent objects of study.

In considering the importance given in each country to thedifferent areas, we find that there is a general trend to concentrate HSRefforts on Needs and Demand. Exceptions are Costa Rica, which placesmore importance on Resources; Ecuador, which stresses the Social Setting;

and Jamaica, which emphasizes Utilization.

Emphasis on research in the area of Needs and Demand is heaviestin Cuba (55.4%) and Brazil (30.3%).

_1

- 13 -

In the first four subject areas we find that Costa Rica, Chile,Uruguay and Peru show a balance in the numbers of studies conducted.

3.2.2 Institutional Characteristics of HSR

i. Source of Initiative

The leading source of initiative for the performanceof the health services research projects identifiedin the survey was the institution in which theresearcher was employed, which accounted for 1,492(49.3%) of the total number, followed by theindividual researcher, who initiated 1,195 (41.2%).The other sources considered in the survey were"another institution in the country," "foreignagencies," and "others", which initiated relativelyfew of the projects: 4.5%, 3.6%, and 1.3%,respectively.

This distribution is constant for the subject areas,although it is slightly reversed in the area ofOrganizational Structure of the Health System and thedifference is greater in the area of CommunityParticipation.

This pattern obtains in seven countries, andinstitutional initiative is most pronounced inVenezuela, Cuba and Uruguay. In Barbados, Mexico,Colombia, Brazil and Argentina, however, the largernumber of studies were initiated by the individualresearcher.

ii. Conduct of the Research

The leading category of entities responsible forresearch projects was the educational institution,with 42.5% of the total, followed by the ministry orsecretariat of health and the research institute,each of them responsible for about 22% of theprojects. "Others" accounted for 8.3% and SocialSecurity for a mere 4.8%.

This predominance of educational institutions occursin seven countries, particularly Brazil (71.8%),Colombia (66.9%), Venezuela (63.2%), and Peru (55.3%).

In only three countries - Barbados (70%), Guyana(50%) and Ecuador (44.1%) - was the ministry orsecretariat of health clearly predominant.

- 14 -

The research institute was unusually predominant inCuba, where it was responsible for 72.2% of allresearch projects.

The proportion of projects conducted under theresponsibility of the social security authority waslargest in Costa Rica, where it was 48.0% of thetotal number of projects. It is also worth notingthat Costa Rica accounted for 61.4% of all theprojects carried out under the aegis of socialsecurity agencies in the countries surveyed, followedby Mexico with 13%.

iii. Sources of Initiative Relative to ResponsibleInstitutions

The research projects undertaken on institutionalinitiative were evenly divided among the three mostrepresentative classes of institutions responsiblefor them, with 33.8% under the responsibility ofeducational institutions, 28.1% under that ofministries and secretariats of health, and 25.6% ofthe research done on institutional initiative, andthe remaining 12.4% was divided between the other twogroups.

Research originating in the initiative of individualsresponsible for projects was carried on mostly ineducational institutions, which hosted 55.9% of theprojects, followed by health ministries and researchinstitutes, with 16% each.

Of the 131 research studies identified as initiatedby other local institutions (not the researcher's),81.6% were divided among the three leading projectexecution classes, with research institutes andeducational institutions predominating.

As for the 104 research studies initiated by foreignorganizations, the pattern of distribution among thedifferent categories is similar to that of thepreceding group.

Analysis of the relationship between sources ofinitiative for and execution of research projects inthe individual country yielded the following findings:

For research initiated by institutions,educational institutions predominated in only fourcountries (Brazil, Peru, Uruguay and Venezuela),and ministries and secretariats of health in seven(Bolivia, Chile, Colombia, Ecuador, Guyana,Jamaica and Mexico).

- 15 -

The Social Security agency was predominant inCosta Rica, and research institutes in Cuba.

s fP . For research conducted on the initiative ofindividual researchers, educational institutionswere predominantly responsible in seven countries(Colombia, Jamaica, Brazil, Costa Rica, Peru,Venezuela and Chile); in the first five of thesecountries the percentages varied from 88.6% to63.2%. The predominance of these institutions wasless in Venezuela and Chile, where the proportionswere 48.2% and 45.8% respectively.

The ministry or secretariat of health waspredominant in two countries, particularly inBarbados with 73.7%.

In Cuba, the research institutes group wasresponsible for most research, with a preponderant85.1% of the total.

In two countries, Uruguay and Mexico, thedistribution among the three groups was roughlyeven. In Bolivia and Ecuador "Other Institutions"predominated. In Argentina the institutionresponsible could not be identified for 55% of theresearch projects initiated by individuals.

Execution of the 272 projects (9.4% of the total)initiated by other groups was distributedproportionately among the groups cited as most

representative in the first two.

iv. Type of Institution Responsible for the Research

The data show a significant predominance of publicinstitutions in the conduct of research (89.5%).This predominance, though variable, obtained in allthe countries, being above 90% in six (Cuba, CostaRica, Venezuela, Colombia, Guyana and Brazil), 80% orgreater in another six (Mexico, Jamaica, Chile,Bolivia, Barbados and Peru), and lower--78% and65.1%--in Ecuador and Uruguay respectively. InArgentina, when unidentified studies were excluded,the research projects were almost evenly dividedbetween public and private institutions.

-41

- 16 -

v. Types of Institution and Subject Areas of Research

Table 3 shows that Institutions were predominant in

all subject areas, accounting for more than 90% of tthe projects in five of them (Needs and Demand,Utilization, Systems Management, Program Evaluationand Community Participation), more than 80% in onlyone area (Social Setting). This predominance isconstant for all countries and parallels theproportions cited above for types of institutions andconduct of research projects.

Private institutions were most heavily involved withprojects in the areas of social setting (21.1%),structure of the health system (19.1%), economic 'analysis (17.6%) and Analysis of Resources (12.8%).

3.2.3 Scope of Health Services Research and Methodology of Analysis

1. Subject Areas and Scope of Research

Some of the variables we examined in this study _related to the scope of the research projects and themethodology used in them.

In regard to the scope of the projects, a sizablepercentage (30.9%) of them was of nationwide scope,followed by local projects with 19.6% and regionalprojects with 18.1%.

The percentage of research projects at the level ofthe hospital or outpatient clinic is remarkably low.Projects at these two levels account for only 25% ofthe total number considered.

In Brazil the pattern is of a preponderance ofresearch at the local level followed by that of theregional and nationwide scope.

In Cuba the largest number of research projects werecarried out at the hospital level, followed by thoseat the regional and national levels.

As i[n Cuba, most studies in Venezuela were done atthe hospital level.

In Costa Rica 75% of the research was divided evenlybetween the national and hospital levels.

eOi, _

- 17 -

In Uruguay the proportion of the research projectscarried out at the national level is strikingly high(61.3%). The remaining countries follow the generaltrends already described.

In regard to the scope of the research projects inthe different areas, we found that most of those onneeds and demand, utilization and program evaluationwere done at the level of the hospital and outpatient

'4ž -" care unit, and in the other areas at the nationallevel.

No significant differences were found between thescope of the research and the institutions initiatingit.

ii. Methodology of Analysis

Of the total number of research projects analyzed,41.7% were classed as analytical, 33.3% asdescriptive and 24.9% as evaluative. This- > distribution is noteworthy in that the recentdevelopment of HSR would lead one to expect mostresearch to be descriptive, while analytical andevaluative studies would await greater experience anddevelopment in the field because of their inherentmethodological complexity. One factor that couldexplain the actual situation is the reluctance ofresearchers to admit that their research wasdescriptive because of the low value wrongly placedsometimes on such work. It was thought that thelarge number of studies conducted by universitiescould be influencing this distribution, but we foundno significant differences in the methods used by thedifferent institutions.

In our analysis of the different countries weobserved that most of them followed this generaltrend. In Colombia and Uruguay the larger number ofprojects were done by descriptive methods, followedby those of analytical and evaluative nature. InCosta Rica, evaluative projects were preponderant,followed by those analytical and descriptive.Finally, in Venezuela the order of frequency of themethods was analytical first, followed by evaluativeand descriptive.

The analysis of subject areas and types ofmethodology shows that the analytical methodpredominated in research on social settings, economicanalysis and community participation.

- 18 -

As expected, program evaluation studies were donechiefly by the evaluative method. .

Of all the research projects examined, 16.1% had beencompleted and 13.9% were in progress. In Brazil theproportion of projects in progress was found to be .,higher (27.7%) owing to the larger number of studiesin :1983, which at the time of this survey weightedthe proportions in favor of studies in progress.

No significant differences were found in the durationof research projects in the different areas. ,

In Brazil, Colombia and Cuba the trend was forresearch projects to be of longer duration.

iii. Presentation of Results

Most HSR studies are published as documents, followedby theses and articles.

It is important to note that a high percentage of theresearch projects (55%) are presented as publicdocuments, theses, and in other forms that make them ihard to find and circulate.

A small percentage of the studies, mostly in theeconomic area, were of a confidential nature.

3.2.4 The Participant Personnel

In this analysis we were unable to determine the totalnumber of scientific and technical personnel involved inhealth services research because our frame of reference andanalysis required us to characterize that personnel. Forfurther details on the size of the researcher population,see the publication: "La investigacion en el campo de lasalud en América Latina" by Dr. Juan C. García.

The numbers of scientific and technical workers whoparticipated in the research projects considered were asfollows:

No. of personnel % of studies Cumulative %

1 24.1 24.12 14.5 38.63 16.5 55.14 12.5 68.05 8.7 76.6

6 -10 15.5 92.211 or more 7.3 99.5data missing 0.5 100.0

- 19 -

In 68% of the research projects the number of researchersand technicians combined was four or fewer, which conveysthe relative smallness of the staff employed in thisresearch work.

From one subject area to another there was no greatvariation in either the numbers or percentages of staffemployed in these research projects.

The wide range of HSR subjects made for the participation ofprofessionals of different fields in both isolated andmultiprofessional projects, and it is through the subjectthat the different disciplines were able to contribute theirmethods to the research without necessarily coming intoconflict or striving for dominance over one another.

This analysis seeks to determine the extent to which thedifferent professionals participated in the researchprojects. However, the tallies made for this study did notbring out how many members of each profession participatedin the research, but only whether the profession was or wasnot represented.

The following table shows the percentages by which thedifferent professions were represented in all the researchprojects:

Physicians, Specialist 42.5%lY, Physicians, Public Health 40.5%

General Practitioners 23.7%Social Scientists 18.8%Nurses 18.0%Engineers 7.7%Administrators 6.8%

* Dentists 6.5%Educators 5.3%Economists 5.0%Others 43.7%

An analysis of the number of professionals participating inthe projects considered shows that 42.4% of them were thework of single professionals, and 27.4% involved twoprofessionals, 15% three, and 7% four.

In regard to the most common combinations of professionalsengaged in these research projects, it was found thatphysicians alone, as a single profession embracing generalpractitioners and medical and public health specialists,accounted for 25.8% of the total number.

-a Á1- 20 -

Combinations of general practitioners and specialists, andcombinations with other professionals includingdemographers, statisticians, architects, computerscientists, etc. were responsible for 13.6% of the projects.

Only 3.8% of the projects were conducted by nurses.

There is some correlation between the profession of the'researcher and the subject area chosen.

All the professionals except the administrators, economistsand educators focused on the area of needs and demand.

The area of management was preferred by 22.2% of theeconomists and 10.2% of the administrators.

Educators, nurses and social scientists made the greatestcontribution to the study of community participation.

3.2.5 Financing of the Research..

One of the elements singled out by health servicesresearchers as fundamental for the pursuit of HSR wasadequate financing.

They also cited the need for external funding for thepromotion of specific research teams and projects.

Information on the patterns of research financing conveys aclearer picture of the financial agencies that contributedthe most to the funding of this activity.

The principal source was the national public sector, whichput up over 76% of the funding for 1,882 research projects(65% of the total). Public financing was most important ofall in Cuba and Venezuela, where it funded almost allresearch.

The national private sector contributed 75% or more of thefinancing in 144 (5.0%) of all projects. It financed 22% ofthe research in Ecuador and 31.2% of it in Uruguay.

Foreign funds from international organizations contributedin some measure to the financing of 234 research projects(8%). The countries in which this financing was relativelygreatest were Jamaica, Ecuador and Uruguay.

Funds from foreign governments were some part of the totalfinancing of only 2.3% of the studies. The countries thatbenefited the most from this type of financing were Jamaicaand Bolivia.

t'

-.

- 21 -

Foreign funds from private agencies financed all or part of74 research projects (2.6%). The leading beneficiaries ofthis financing were, again Jamaica and Bolivia.

Funding from public sources was spread evenly among all

areas of HSR, and there was no significant concentration onany one of them.

Foreign funds went chiefly to the areas of structure and

utilization.

It was found that in a high proportion (61.5%) of the cases

in which international agencies funded research projects,

they also provided the initiative. The trend is less

pronounced in funding from local public and private sourcesand from foreign governments and private agencies. This is

striking in view of the conviction of many researchers thatthey need external funds in order to be free to choose their

own research subjects.

4. Difficulties in Conduct of Research

Most researchers agreed that the greatest difficulty encountered

in the conduct of HSR was a lack of clear statements of HSR policy, bywhich is meant not just the legal expression embodied in the existence of

one or several scientific or service establishments or institutions of

higher learning, but the presence of a research structure with a clear

order of priorities and endowed with human and financial resources that

enable it to engage in research. This situation is complicated in most

countries by the existence of health systems with many participating

institutions, which make these policies enormously more difficult to

apply. Other results of this situation are low regard for HSR,

inadequate political-administrative coordination, a lack of machinery for

inter- and intrainstitutional coordination and of government interest and

support, and a view of research as a mere expense rather than as an

investment.

Thus, programs lack continuity and consistency and can be

interrupted and delayed by changes of management in agencies,

particularly in those that provide financing.

Other difficulties were cited in the areas of human and financial

resources and methodology; they were almost a natural outcome of thepreviously described situation.

On top of the existing qualitative and quantitative difficulties

in the human resources area, further constraints are imposed by tihe small

number of the identified firmly established centers, a lack of

communication among researchers, inadequate reporting and circulation of

k-.6

- 22 -

findings, and poor working conditions and low remunerations. Inaddition, in these countries the structure for interinstitutionalcollaboration in continuing education and scientific exchanges is weak.All the countries reported a shortage of funding for HSR, whether fromdomestic or foreign soiurces, and this shortage is aggravated by thegradual erosion by currency devaluations of what little funding isprovided from year to year, which gets in the way of any advance lplanning. Besides, in some countries much of these already insufficientresources have to be spent on the insufficient human and materialresources allowed to service and research units by the low budgets towhich the financial crisis in the health sector confines them.

Also, as a consequence of the failure to establish concrete,coherent policies, the flow of funds for programs and projects alreadyapproved or in progress is at times delayed or cut off, which impedes not ' +

only the proper conduct of the research, but also the consolidation ofresearch units, which prompts these teams of people already experiencedin specific lines of research to lose interest and disperse.

Other problems cited were grouped together by the countryresearchers under the head of "methodological difficulties," notably the .very difficulty of framing conceptual and operational definitions of HSR,which was even encountered in the conduct of this study.

Another difficulty was described as insufficient knowledge ofmethodology for the pursuit of research in some subject areas because ofeither the complexity of the subject or shortcomings in the methods ofanalysis used.

Methodological problems were also reported in harmonizing theinterests and perspectlves of funding agencies, research units, andservices during the design and execution of research projects. A relatedproblem was difficulty in assigning priorities to the problems of concernto HSR.

It is worth noting that many researchers found it extremelydifficult to obtain from official agencies and even from professionalsthe information needed to examine and characterize the subject of studyin some HSR areas. This difficulty of access was due as much toshortcomings in records and processing systems as to restrictions onaccess to existing information imposed by individuals, regulations andpolicies.

5. Setting Priorities for Research Areas

5.1 Methodology

The difficulty of establishing priorities for research is wellknown. This difficulty is brought out in practically every reportgenerated by specialized meetings on research policies. For example, in .4

the Pan American Conference on Health Research Policies, held in Caracas

- 23 -

in 1982, the problem was depicted in all its magnitude in the reportspresented by the countries and by work groups. In the introduction tothe report of working group 4, the chairman stressed

...the difficult responsibility involved in planning scientificprograms. Problems are made worse when it becomes difficult toobtain accurate basic data, when tight resources make it necessaryto give one purpose priority over another equally important one,

*- and when changes in the funding situation interfere with thelong-term planning of objectives. The choice of priority areasfor applied research depends on the assessment of the physical,emotional, social and financial burdens imposed by the differentdiseases; the readiness of information for application to theprevention of treatment of diseases; and the extent to whichdifferent research strategies may be expected to alleviate thosedifferent burdens. The process is complex because of thepreponderance of research studies initiated by researchers as

against research directed at objectives determined elsewhere; theprevention of diseases as against their treatment; and basic asagainst applied research. The programmer faces an extremelyarduous task, and the numerous factors involved in this decisionmust be pondered in relation to the availability of resources andwith a view to their equitable utilization."(8)

Nor is there enough epidemiological information, for the existingdata on morbidity and mortality do not convey the full measure of theproblems and needs in the health field.

These methodological difficulties in setting priorities in thearea of HSR are aggravated, as previously noted, by the lack of anorganization to coordinate and implement policies and articulate the

interests of the different agencies involved in the process.

The methodologies reported by the countries participating in thisstudy for setting priorities varied enormously. They ranged from usingmorbidity and mortality levels to establish priorities to more complex

-M F procedures combining those indices with others such as risk, operatingcosts, efficiency and effectiveness, and the organization of services.

These aspects could be generalized into a methodology for settingpriorities grounded in the epidemiological, social and operationalfields. In addition, all the countries recognize the need to organizethe priority-setting process, which involves examining the needs with theroutine participation of all organizations concerned; it is absolutelynecessary that the services be involved in that process, whose ultimateeffects are felt in the formulation of the national research policiesthemselves.

(8) PAHO/WHO Pan American Conference on Health Research Policies.Caracas, Venezuela. April, 1982. p. 314.

- 24 -

One of the essential requirements for improving thepriority-setting process is information systems that will provide readyaccess to needed information.

The countries recognize that HSR priorities are not set in theabstract, and that the process of setting them is directly linked to theexisting level of organization and delivery of services in the givencountry and to the strategies adopted for their development. Hence thatprocess is intimately bound up with the existence of health policies andsystems.

These aspects in connection with the methodology for setting thepriorities of research areas are reflected in the diversity of both thesubjects of research and the approaches taken to them as reported by thecountries.

5.2 Research Area Priorities

Following is a condensed, representative list of the subject areasmost frequently mentioned in the information sent in by the countries,arrayed for orderly presentation, but without any suggestion of an orderof priority, under the main categories used for classification of theresearch projects considered by the study.

5.2.1 Health Systems and Society

Analysis of the crisis in society as a whole and itseffects on the country's health system.

. Health policies and social policies.

. Determinants of health conditions.

. Economics and health in relation to the social setting.· Studies on welfare: literacy, housing, electricity and

water.. Social anthropology studies. ,. The environment and health.

5.2.2 Determination of the Population's Health Needs/Demand

· Mental health.. Chronic diseases.• Nutritional studies.. Maternal and child care.. Control of communicable diseases.

Demand studies.. Worker's protection.

,

- 25 -

5.2.3 Production and Distribution of Resources

. Analysis of medical technology· Production and utilization of appropriate technologies,

including diagnostic, therapeutic, prophylactic, clinicaland surgical procedures.

· Human resources in the health field.· Production, distribution and consumption of medicaments.

5.2.4 Organizational Structure and Components of the Health System

. Organization of health systems and service modalities.· Comparative international public health studies.

5.2.5 Study of the Delivery of Health Services

· Primary care and accessibility.· Emergency medical care.· Extension of health services.. Analysis of policies on levels of care.. Study of medical care.

5.2.6 Administration of Health Services

Parameters for integrated health systems.. Planning methodology.

Improvement of management in the health field.. Study of the functioning of auxiliary diagnostic and

treatment services.· Records and methods for data collection and processing.. Organizational analysis.· Study of administrative procedures.

5.2.7 Economical Analysis

* Study of costs.* Economic impact of hospital stays.* Health economics, including studies on the financing and

costs, operating costs, cost-benefit ratios, andeconomic-financial studies of the various ways oforganizing service providers.

5.2.8 Program Evaluation

. Evaluation of services to the elderly.

. Evaluation of services, including analyses of efficiency,effectiveness and actuality.

5.2.9 Comminity Participation in its Relationship to HealthServices

Community participation.

a,

- 26 -

III. BASIS FOR THE DEVELOPMENT OF HSR

1. Introduction

The basis for the development of HSR starts with the assumptionthat the definition proposed by the WHO Advisory Committee is valid andapplicable. It is advisable, however to work out a consensus on thescope of health services and the significance of HSR.

Health services are understood as all means and procedures thatcan be applied, used or expended for diagnosis and treatment, bothcurative and preventive, in the process of promoting, preserving andrestoring health. Hence, it embraces both the organization of services,their management and guiding policies, and their actual production ofservices for the popu:lation.

In their simplest form, the components of the service system are _determined by how the health needs of the population are interpreted andtranslated into demamnds for care; the state of development of thescientific and technological apparatus; and how the human and materialresources are organized for the application of knowledge and techniquesto the solution of tlhe health problems made manifest as demands on thesystem.

As a relatively new field, HSR is still seeking recognition in theformulation of explicit policies. It is clear from the foregoing thatmere formulation is not enough, and that progressive development isrequired to achieve coherence between explicit and implicit policies,between direct and indirect instruments for planning in the area with aview to fostering a broadening of the fleld, along with the establishmentof arrangements for articulation between the production, distribution andutilization of knowledge, and of mechanisms to ensure the participationof organized sectors of society, and especially of researchers, in theformulation and monitoring of those policies.

While HSR shares some features with health research In general,and hence may benefit from the existing body of experience, there areaspects specific to HSR that must be considered in the formulation ofpolicies for it. HSR clearly has scientific and technological dimensionswhich, though intimately linked, have quite different characteristicsthat require equally different policy-making, priority-setting andplanning machinery. In these two dimensions knowledge is produced fordifferent purposes, by different researchers using different researchinstruments and even in different places, in addition to which thefindings are different as are the means by which they are published andapplied to the operation of services.

In its technological dimension HSR is concerned with the study ofthe processes and procedures applied by health services, with a view to e -making them more effective and efficient. The researchers who usuallyuse the methodologies of operations research are largely the healthprofessionals themselves, who pursue their research in the services,where they are aided by the production process to hand, the introduction

- 27 -

and evaluation of knowledge of the forms of organization of health care,their characteristics and determinants. The multiplicity of the aspectsof articulation between health care and the socioeconomic setting inwhich it is provided requires a complex technical and methodologicalarmamentarium, which is necessarily multidisciplinary. In this case, howthe knowledge generated is used depends essentially on the rationality ofthe sectoral organization. Although the two dimensions of HSR arearticulated and mutually complementary, each chooses policy and planninginstruments that are consistent with its specific features and ensure itsbalanced expansion and development. Economic crisis hinders this courseby promoting development of the purely technological dimension of HSRwith a view to making care more efficient and thereby reducing costs. Inthis setting HSR is the application of the scientific method to answerquestions we ask about the performance of health operations and theorganization of health institutions, and about the characteristics o" thesocial setting in which they are designed and implemented.

2. Criteria and Basic Elements

2.1 In policy formulation

Health services research policy is the body of general andspecific guidelines for the proper conduct of activities in this field.

The criteria regarded as important and to which policies shouldconform, include the following:

· Policies must be explicit and be sanctioned by the competentgovernment agencies.

· They must be consistent with the policies on scientific andtechnological research.

· They must be consistent with the country's development plans.

· They must be consistent with the country's health policies.

· They must be applicable everywhere and continuously.

· They must contribute to coordination in the sector and withother sectors.

· They must establish criteria for the assignment of prioritiesto identified needs.

· They must allow evaluation of the results and dimensions of theimpact.

· They must enable service delivery units to participate in thepolicy-formulation process.

- 28 -

In the setting of the given country, the breadth and depth towhich policies are formulated for health services research depends on theextent to which the situation is understood and the receptivity of thedecision-making levels. Similarly, whether policies are to beindicative, normative, programmatic or coordinative will be determined ineach particular case. However, it is felt that health research policiesshould include the following elements:

· Determination of the location, structure and function of the

agencies responsible for the promotion, guidance,encouragement, coordination, evaluation and counseling of HSR.

· Formalization of the infrastructure of human, technical and -'material resources that constitute the apparatus for health

services research, and determination of the functions and

responsibiliLties of the institutions and levels of the system.

· The establishment of HSR as an integral function of services atthe different levels of complexity.

· The formulation of purposes and setting of priorities for HSR

in relation to the country's health and socioeconomicdevelopment policies and in response to the actual problems tobe investigated.

The design of mechanisms and procedures for the formulation,

evaluation and approval of proposals for research in priorityareas in keeping with the essential characteristics ofscientific research, including its interdisciplinarity, andwith the observance of ethical considerations.

. The establishment of provisions for meeting needs in advisory

services and in technical and material support for thecompletion of studies.

· The implementation of an effective system for reporting on

scientific and technical capabilities, including the registry, -

classification and dissemination of information on researchersand their researches both in progress and in prospect, the

methodologies applied, the resources used, and the principalresults obtained.

· Definition of the contribution of HSR to the planning and -

decision-making processes, including mechanisms for

communication among researchers, planners and decision-makinggroups in the design and performance of studies, to ensure thatthe results thereof are used to improve the organization and

functioning of services.

4 ._

- 29 -

Provisions for meeting needs in manpower training anddevelopment for the conduct of research at the undergraduate,graduate and continuing education levels in keeping with theinterdisciplinary requirements of research and with thecomplexity of the given problem in its national or regionalsetting.

The establishment of appropriate systems for planning andfinancing research that will ensure a reliable and coordinatedflow of domestic and foreign funding for priority areas inhealth services research.

2.2 The determination of areas of research

2.2.1 Classification

It has been shown that there must be a proper way to classify HSRthat will help in the identification of gaps, the framing ofcriteria for setting the priority areas for study, and theevaluation of the HSR process itself.

Inaccuracies can be present in any scheme of classification atthe outset, and can only be corrected with progress in theunderstanding of the problems to be studied.

Difficulties in the identification and classification of subjectareas would arise chiefly in cases involving two or moresubjects. Recognition of the connections between fields andphases of research that are interconnected and interdependentmust be a basic premise in the construction of any possibleclassification scheme. To distinguish between components andtypes of activity is not to separate them, but, to the contrary,suggests and establishes the need to ensure a continuous flowamong the various areas of study.

From a practical standpoint, the classification into nine areasproposed by the WHO expert group is an initial guideline that canbe progressively improved as the definition of HSR, its scope,and the interactions among the different disciplines involved areincreasingly refined.

2.2.2 Methodologies

Description of the methodological approaches in use in healthservices research was not a purpose of this study of HSR trends.However, the difficulties met in classifying research projectsfrom this standpoint make it necessary to encourage the designand adoption of methodologies for the description, interpretationand evaluation of the development of health services.

- 30 -

Since the state of the art does not include a methodology properto HSR, which uses theoretical frames of reference and methodsdrawn from diverse disciplines such as the social sciences,epidemiology, economics, demography and operations research,among others, it is essential to systematize what is known aboutthe possibilities of and experiences in the application of thosemethods to HSR. r

2.2.3 Setting Priorities

Setting priorities for HSR is an important area in thedevelopment of this research. In view of the difficultiesencountered in the study of trends in this area, it is felt thatit should be approached from two different directions:

Analysis of HSR trends as a means of measuring progress in thegeneration of knowledge in the health services field both inthe individual country and in the region. It is importantthat these studies of trends not confine themselves to adescription of the production in the various possiblesubjects, but that they seek to analyze and interpretfindings. For example, the relative scarcity of researchfound in the areas of economic analysis and communityparticipation may be connected with a lack of the informationneeded for researchers to make headway in the formulation ofhypotheses and research methodologies. This lack may also beconnected with the ideological framework that guides HSR.

· The contribution of studies to satisfying the basic postulatesof health policies in relation to the principles of equity,efficiency and effectiveness. -

· In regard to equity, HSR must contribute to the generation ofknowledge for improvement of the coverage, accessibility,availability and continuity of services.

· As to the improvement of efficiency, a research project mustbe directed at generating information and formulas for actionthat will maximize the output obtainable from the existinginfrastructure, and at raising the quality of the servicesprovided, reducing needless costs, and regulating theintroduction of technology and critical inputs for theperformance of health services.

. On the score of effectiveness, a research project must guideproposals for the financing and organization of deliveryschemes in keeping with the real needs of the population.

4 't

- 31 -

2.2.4 In the strengthening of administration

The findings of the survey bring out the inadequate developmentof the structual and functional aspects of HSR administration.

There can be no doubt that HSR policies must find expression inthe establishment of effective administrative strategiesaccompanied by clearly defined structures and resources andhaving the flexibility needed in the actual situation of thegiven country and for the level at which the research systemfunctions.

· Levels of administration

The administration of HSR is perceived as consisting of fourlevels corresponding roughly to:

i. The national management level, which in most of thecountries is embodied in the national science andtechnology system (or the equivalent thereof).

ii. The intersectoral level, associated with planning oificesor departments that are usually part of the executivebranch.

iii. The institutional level, situated in ministries,decentralized agencies, universities anl researchestablishments.

iv. The operational level of health work, made up of thehealth service delivery establishments.

· HSR administration functions

The general functions in HSR administration are distributedamong the different levels, though at different strata ofresponsibillty and with clearly defined degrees of authority.

The most important of these functions are as follows:

i. Guidance and Decislon-Making in general policy onpurposes and priorities in keeping with the country'shealth and development policies.

ii. Structural and Functional Organization of all levels ofthe system for the proper use of resources, including theformulation and application of standards and procedures.

- 32 -

iii. Coordination chiefly to articulate the efforts of thevarious institutional levels involved in the researchprocess (research centers, teaching establishments,health services, and others) in order to optimizetheir contribution to the development of HSR policies.

Coordination must also facilitate the identificationof priorities, the orientation of research subjects toavoid duplications, and communication amongresearchers for exchanges of experience and knowledge.

iv. Personnel Management and Development. Theavailability and organization of human resources is acritical area in HSR development, not only because ofthe interdisciplinary requirement for the training ofresearchers, but also because of the chiefly economicdifficulties involved in associating them withpermanent research projects.

In the training area, existing programs must bereviewed and new programs guided with a view to:

- Ensuring an adequate selection of students inkeeping with the interdisciplinary approach of HSR;

- Improving the provision of appropriate subjectmatter, chiefly of a methodological nature, and

- Linking research training programs to the

realities of service. This applies both to basictraining programs and to those for the furthertraining of personnel in a continuing educationsystem.

In regard to the use of human resources for HSR, theproblem has two aspects:

- The placement of researchers in health services at

the different administrative levels described byincreasing the staff of existing facilities andsupporting the establishment of new facilities asnecessary. It must be emphasized thatprofessionals in nontraditional fields such associal scientists, engineers and economists, must

be added to the tables of health personnel.

- The establishment of HSR as a standing function of

services by providing the objective conditionsrequired for it.

The inclusion of HSR activities in the localprogramming of health services must be promoted, andmust provide for allocation of the requisiteresources.

- 33 -

_v. Advisory services and logistic support to the designand performance of the studies are seen as a need forthe development of HSR.

.i They are particularly necessary for the developmentand application of research methodologies, for whichthe staff of national and international centers ofexcellence must be augmented and mechanisms developed

to assist in interaction between research facilitiesand service units. Moreover, provision must be madefor the availability of and access to data processingfacilities, and for instruction in the handling and

r·' applications of the software needed for research ofthis kind.

vi. Information. As in other fields of knowledge, acontinuous flow of appropriate information is

essential for the development of HSR. The principalneeds in this regard are as follows:

- The body of information on the particular subjectof HSR, such as the social setting, health

conditions, and the organization and functioningof the services on which the formulation ofstudies is based. The quality, relevance anddelivery of health information must continue to be

improved, and the information itself made easilyaccessibile to researchers.

- Information on past research and theidentification of researchers and researchestablishments in each country.

- Information on the state of knowledge on HSRcontained in periodicals, books, graduate theses,

author's communications, and other sources.

- Information on national and international agencies

and institutions interested in supporting thedevelopment of HSR and endowed with technical andfinancial resources for doing so.

vii. Planning and Financing. Awareness of the important

part played by HSR in the development of healthservices must be based on proper planning which leadsto the establishment of a program that givescoherence to the strategies for dealing with thepriorities identified and at the same time places the

- 34 -

research facilities on a firm footing. Theconventional practice of allocating resources for thefinancing of disconnected projects and on the solebasis of protocols presented on the initiative of theresearchers themselves must be complemented byapproaches that make it

possible to strengthen a country's overall researchcapabilities. When the financing problem is viewedin this light as a component of the planning process,it becomes easier to demonstrate needs and articulatepossible courses of action for the training and useof personnel, equipment and logistic support forresearch.

In this context the financing problem cannot beviewed as just the need to allocate budgetary fundsspecifically for HSR development; mechanisms mustalso be implemented to ensure proper utilization offunds so allocated and their availability for as longas may be needed to bring such studies to their finalstage, which is the implementation of their results.

When the basis for HSR development has beenestablished in the aspects of policy, research areasand administrative strengthening, it is absolutely

necessary to emphasize that this whole effort ofdesign and development of HSR wil] make no sense ifits results have not been put to any real use inimproving the delivery of health services to thepopulation. A natural corollary to this is the needto establish mechanisms for determining the extent towhich this is happening.

Ultimately, the point about the use of HSR is reallyto assess the extent to which HSR policies areactually articulated with the health and socialdevelopment policies of the countries.

3. Strategies and Lines of Action

3.1 Promotion of and support to the development of national HSR policies

· Encouragement and support to meetings among the country's scienceand technology agencies, institutions and services having HSRresponsibilities, for the purpose of evaluating HSR and placing iton a firm basis.

· Placement of HSR on the agendas of international health meetingssuch as those of schools of public health, schools and faculties ofmedicine, health ministries, social security agencies, and others.

t ¿

- 35 -

· Introduction of the subject of HSR in meetings of the GoverningBodies of PAHO.

· Exchanges of experience in the establishment and functioning of HSRregulating bodies in the countries of the Region.

· Development of appropriate mechanisms for obtaining thecontributions of experts of international standing in the field forthe review of HSR subjects and methodology.

· Further pursuit, and insuring the continuity, of the study of HSRtrends in the countries of the Region.

3.2 General and specialized personnel training and development for HealthServices Research

· Use of fellowships of PAHO and other cooperation agencies for

general and specialized personnel training in the HSR field.

· Organization of courses, workshops and seminars for continuing

personnel training and education in specific aspects of HSR withemphasis on methodology.

• Promotion of and support to exchanges of experience and informationbetween research establishments in the same and different countries.

· The identification and classification of existing researchestablishments, and documentation on their personnel, lines ofresearch and areas of instruction.

· Compilation of a directory of HSR training programs at the graduatelevel.

3.3 Development of cooperation at the national, intercountry and regionallevels for the performance of health services research projects

· Promotion of intercountry collaborative studies on subjects ofcommon interest and critical importance for the development ofservices, capable of producing results in the short term. Importantpossible subjects are the analysis of costs and investments, theintroduction and evaluation of health technology, essential inputs,

emergency care, and the study of integrated health care systems.

· Framing of proposals for the consolidation of national facilities

and intercountry collaboration networks for HSR development forpresentation to institutions and agencies interested in providingtechnical and financial support to intercountry cooperation in thisfield.

- 36 -

Inclusion of HSR aspects, together with the related budgets, inprojects for the strengthening of health services, with specialreference to investment projects.

Facilitating contributions by experts to the design and execution of

projects in priority areas of HSR under PAHO's regular cooperationprograms, and financial support subject to the availability of fundsand in accordance with national technical cooperation priorities.

3.4 Collection, selection, documentation and dissemination of informationon substantive HSR matters A

· Maintenance and periodic updating of catalogs of HSR research andresearchers,

Identificati:on of reports on the state of knowledge on HSRmethodology and administration, and use of existing facilities(Medlars, Medline, Index Medicus Latinoamericano) for theircirculation among research facilities and service establishments inthe countries of the Region.

· Production of serial publications on selected subjects.

· Exchanges of protocols and reports on studies in progress or

completed in research facilities.

Support to the organization and operation of national HSR reporting

methodologies and resources used.

Support to the generation and exchange of information on the use ofHSR findings in the practice of health services.

IV. FINAL CONSIDERATIONS

It has to be emphasized that the data obtained in the study of trendsin health services research do not necessarily reflect every one of theresearch projects carried out in each of the countries on this subject duringthe period considered. The methodological difficulties of this kind of study,the variety of approaches to and definitions of the scope and characterization

of health services research, the little time available for compilation of dataand the limitations of the available data advise the consideration of thisstudy as a first approximation to an understanding of the situation. Despitethese limitations, it is worth nothing that it has met with a very favorableresponse from the countries and researchers that participated in it and withremarkable interest in the futher pursuit of the subject.

*

1

- 37 -

In the view of the local researchers who participated in thecompilation and analysis of the information, the classification scheme used asa conceptual and methodological base for the conduct of the study is valid andmust be used in further work on the subject. Any difficulties encountered inidentifying and classifying research projects are encountered chiefly in casesin which two or more research areas overlap.

However, this difficulty stems from the breadth and diversity of thesubjects that can be studied in health services research regardless of theclassification employed. The point is to have a scheme that aids in thedetection of gaps and the framing of criteria for assigning priorities tostudies, and which at the same time lends itself to refinement as the researchproceeds.

Lastly, we must emphasize the unanimous view of the participants in thestudy of and seminar-workshop on Trends of Health Services Research thatmechanisms must be provided to ensure that the findings of research projectsare actually used as guides to the changes needed to make the delivery ofhealth services more equitable, efficient and effective.

Doc. 0390t