Health Administration

Definitions:
 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.

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  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

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  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.

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  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:
1. Prevalence of the problem

2. Seriousness of the problem

3. Availability of effective measures to solve the problem

4. Community concern

 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.

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  Norm–Standard: 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, protective, curative
and rehabilitative).

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  Medical care: A term used to emphasize the
organization and delivery 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
population).

 Planning: Planning is a teamwork involving an

organized, intelligent, and efficient to select the best
alternative to achieve specific objectives

 The purpose of planning

1. 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.

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 Healthcare Administration
 Definition
Healthcare administration is the process by which
knowledge, energies and social structures are
systematically utilized to achieve specific objectives.
 Functions

1. Planning function: What do we need to do to improve

health? Anticipated 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.

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  Failures in administrative functions may be
due to:
- Unqualified administrators
- The complexity of health and healthcare
- Administration itself is a developing discipline

The planning function

 Definition: planning is a teamwork involving
an organized, intelligent attempt to select the
best alternative(s) to achieve specific
objectives in efficient manner.

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 The purpose of planning
1. 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
2. Implementation
3. Evaluation

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 And a plan is a document
containing:
1. Objectives
2. Policies
3. Programmes
4. Schedules and
5. Budget

Stages of planning process:

 A. Plan formulation
1. Environmental examination and situational analysis
2. Decision on priorities: What to do first?
3. Formulation of objectives: Where to be at the end?
4. Exploration of various means to achieve objectives
5. Budgeting

 B. Plan execution
6. Choice of best programme (solution)
7. Implementation of programme

 C. Plan evaluation
8. Monitoring and Evaluation.

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 General principles in
planning:
 Planning must be:
1. Realistic
2. Comprehensive
3. Balanced with respect to central and
peripheral partners
4. Coordinated with other sectors
5. Continuous
6. Able to ensure commitment and flexibility

Factors that may disturb

healthcare planning:
 Political instability
 Economic crises
 Administrative inefficiency
 Complexity of healthcares determinants
 Conflicts between (among) different pressure
groups
 Natural disasters
 Haphazard population distribution

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  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)

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 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.

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  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.

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 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?

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  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 planning
 This 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.

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 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.

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 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.

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 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.

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 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

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 THANK YOU

THE CONTROL FUNCTION

(EVALUATION AND MONITORING)
 Perhaps, the evaluation function is the least
practiced function of administration within the
healthcare system.

Definition
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.

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 EVALUATION MAY BE PERFORMED:

1. 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?

THE PROC E SS OF E VALUATIO N I NVOLVE S A N UM BER OF QUE STION S

AN D STE PS, WHIC H MUST BE CLE AR IN THE MI ND OF THE P E RSON /
TE AM WHO IS E XP E CTE D TO CARRY OUT THE E VALUATION PROC E SS:

1 . What to evaluate? - Structure or preconditions of the care

process

- Process to be carried out to deliver care

- Outcome - Intermediate indicators

- Ultimate indicators

- Impact on the specific target and adjacent

targets or areas

- Opinion of consumers and providers

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 TAKE INTO ACCOUNT THE FOLLOWING
ELEMENTS OF EVALUATION ALSO:
 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)

2. Why to evaluate?
Three areas of interest may be identified and
related to the purpose of evaluation:
Research
Diagnosis
Administrative control

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 3. At what level?
International,
national,
or local,

single programme or multiple programmes

4. Who does the evaluation?

 Evaluation may be carried out by any of the following:
A. External experts. These may have the technical and scientific capabilities
but usually, they are ignorant in local situations.
B. University academics. They are competent in carr ying out such tasks
but they tend to be slow and meticulous and therefore, may take longer
time than health authorities can wait.
C. Health policy maker s. They are the people who can make changes in the
light of evaluation results, but they are in a threatening position and distor t
the spirit of evaluation by punishing or rewarding people.
D. Programme administration and staf f. 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).
E. The community or consumers. The opinion of consumers is of vital
impor tance 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 ser vices.

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 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

THUS THE PROCESS OF EVALUATION

INVOLVE BASIC STEPS:
1. Determining what to evaluate
2. 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
7. Re-evaluate

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 MAIN APPROACHES TO EVALUATION
A. Structure approach (structure analysis)
Structure refers to the conditions that surround process of care
including:
o Number and qualification of staff
o Characteristics of resource inputs (buildings, equipment, drugs…
etc.
o 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 (CONT.)

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.

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  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.

MAIN APPROACHES TO EVALUATION (CONT.)

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.

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 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
 Discomfort
 Dependency on family and on the healthcare system
 Disruption
 Dissatisfaction
 Disability

EXAMPLES ON EVALUATION WORK

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?

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 Item of structure Adequacy (as % of expected structure)

Building 89 %

Furniture 92 %

Doctors 50 %

Investigation facilities 76 %

Drugs 77 %

Vaccines 100 %

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.

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 Activity or procedure % of executed out of
expected processes
Physical examination 59 %

Investigations 24 %

Risk detection or exclusion 89 %

Blood pressure measurement 100 %

General urine examination 17 %

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).

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 No. of prenatal care visits % of pregnant women
1–2 53 %
3–4 32 %
5+ 15 %
Total users 66 %
None users 34 %
Doses of Tetanus Toxoid received
0 11 %
1–2 44 %
3–4 40 %
5 5%

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?

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 FURTHER EXAMPLES ON EVALUATION

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 or

solved the problem failure

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 the
is? preparation is? coverage rate? efficacy

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 THE SAME ISSUES IN THE DIAGRAM CAN BE
SUMMARIZED IN THE FOLLOWING STEPS:
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:
a. birth certificates.
b. population censuses.
c. special surveys.

2. Determination of the number of individuals in the

target population who actually received
immunization. This can be obtained from the
following sources:
a. records of health centres assuming that the
centre keeps information on the target
population and on those who receive
immunization.
b. sample household surveys looking for evidence
of immunization (cards, mother interviews,
scars).

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 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
Target population

4. Determination of the effectiveness of the immunization. This may

be achieved by the following:
a. Testing the potency of the vaccine.
b. Serology to estimate antibody titre in response to mmunization.
c. Epidemiological studies (case-control or cohor t 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 vaccine

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 EVALUATION OF OUTCOME OF INPATIENT CARE

Patients 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

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

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 QUESTIONS

1. 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.

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 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.

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 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?

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 10. What intermediate and ultimate
indicators will you use to evaluate the
outcome of:
A. Control programme of tuberculosis?
B. Effectiveness of prenatal care in a
district?
C. Outcome of curative care in a big referral
hospital.

11. Suggest a list covering process and

outcome to evaluate the quality of
nursing work.

12. Can you prepare a questionnaire form to

collect data on aspects related to structure,
process and outcome of care in primary health
centres.? Try to make this form very
exhaustive.

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 THANK YOU

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