Health Services Management and Needs Identification Health Services Management requires and even presupposes a pragmatic look

at the identification of needs and problem. Health services managers must determine which services should be offered and to whom. The first steps of planning process respond to these two basic questions. The first planning step, regardless of the different meanings of concepts of need, boils down to a description of the population surrounding the organization; description of its health problems and of its utilization in health services, analyze, and the identification of resources present in the community to address such factor

Description of the population The description of the population to be served by the organization is essential to the planning and management of health care. The population should be analyzed by demographic, socioeconomic, and geographic attributes.

Description of health problems Three major approaches to needs assessment are the indicator, the survey, and the consensusreaching approaches. By using combination of approaches, the purpose of a given needs assessment is more productive and adequate than any method. The contribution of epidemiology to health services management, however, is examined here primarily as to the indicator approach, which is essentially the descriptive epidemiologic approach. The health services managers analyze the morbidity, mortality, and risk factors using the epidemiological principle, methods, and techniques. Morbidity include disease, discomfort, and disability both acute and chronic. Risk factor related to elements with each of the four dimensions of the health field concept (biology, environment, lifestyle, and health care organization). Included in this category are the health maintenance needs or needs for services presumed to benefit people who are well by improving or protecting their good health

Analysis of Etiology Once problems are identified, it is useful to try to determine their source or as Blum puts it, the prime forces [that] causally underline them. Using data and knowledge from analytic epidemiology, the health problem, expressed in terms of mortality or morbidity, can be translated into its precursory risk factor in one or all of the four dimensions of the health field. This approach is useful for three main reasons: 1) The immediate search and analysis of precursor risk factors to major causes of ill health reveal that certain precursors are common to many conditions. 2) It gives a direction for intervention: the risk factor becomes the problem that needs solving; this provides a concrete possibility of intervention. 3) It is likely to provide for a more comprehensive and global view of the problems and of the possibilities of intervention by using an extended ecologic or holistic model of health. It also indicates the possibilities of cooperation with other community agencies.

Step 1. Identification of community resources The last component of the first planning step is the identification of all other community resources that are addressing or could address the risk factor identified. These might include public health agencies, hospitals, school, or community groups. This can be done in a summary manner or by marketing techniques. Needs: gaps and market opportunities from the demographic evaluation of the population of the epidemiologic description and analysis of mortality, morbidity, and risk factors data there should emerge a clear picture of the health problems and their needs in the area. This constitutes the input into the second step of the planning process: the setting of priorities.

Step 2. Determination of Priorities One problem that the organization could address are identified, health services managers must determine which ones are the most important and therefore call for the most attention in planning and relocating resources.

Many criteria, including some highly political ones, come into play in the determination of priorities. One source lists the following factors: time horizon, scope, and range of pro blems, range of interested parties, degree of uncertainty, degree of complexity, and degree of consensus. Epidemiology plays an important role in decision making and rationalizing priorities. Anderson comments: because health needs at any time exceed the sources available, choices must be made. The community physician (epidemiologist) has the function of providing the evidence which is to guide the political and policy choices about alternatives, particularly in the second and third stages of planning. Epidemiologys contribution to the determination of priorities is based on a simple notion: the health problems that are the most important are those that cause the greatest loss and most amenable to prevention and amelioration. Two epidemiologic criteria can be used in this second planning step. Magnitude of loss, epidemiologic techniques can be used to estimate loss of life because of a given cause of mortality, or similarly time lost because of morbidity. The relative importance of risk factors can be assessed through the use of epidemiologic concepts such as attributable risk, absolute risk, excess risk, and relative risk. Amenability of loss to prevention or reduction. The second set of criteria that epidemiology can contribute to the determination of priorities is the sensitivity of the problem to a health program are the readiness with which the disease may be prevented or its adverse effect minimized. This amenability or sensitivity can determined in any of following ways. 1) Normatively, using experts judgment and consensus 2) Empirically, based on the experience of other regions, states, or countries 3) Operationally, using some type of cost benefit analysis the lower the cost of a program in achieving a predetermined objective, the more amenable or sensitive it is to prevention or reduction.

Step 3. Setting objectives

Once priorities are determined, program planning can take place for each group of problems or risk factors. Epidemiologys contribution in this step is mostly expressing the objectives in a quantified way (using incidence or prevalence test).

Step 4. Activities to attain objectives For the objectives to be met they must be translated operationally into activities or services. This also involves the prediction, identification, and allocation of resources that will be needed to produce the services required. The fourth planning step starts with the generation of ideas for possible ways of achieving the objectives. The analysis of risk factor performed in step 1, using the four dimensions or inputs to health, can and should be of much help and creative inspiration in developing alternatives. Once alternatives are generated, they should be evaluated using cost-benefit analysis, comparing the benefits obtained from each alternative with the cost and risk of adopting it.

Step 5. Mobilization, coordination of resources The activities to achieve the objectives have been chosen, and the appropriate resources have been determined and allocated. The fifth step of the planning cycle is the actual delivery of the services. The contribution of epidemiology is minimal, limited to the collection of data that can be used to monitor the program and its effects and, subsequently, to evaluate it more formally. Situation can arise in which a definite form of service cannot be determined from the beginning and in which epidemiology can be used to design and conduct experiments and pilot implementations to guide subsequent decisions.

Step 6. Evaluation The evaluation component contains three areas of concern: costs, activities, and outcomes. These are more commonly called fiscal, process, and outcome evaluation. 1) Fiscal evaluation focuses on and determines cost accountability. 2) Process evaluation determines program activity in terms of the following:

Population that receives the benefits by age, sex, race. Or other demographic variables Program organization, staffing, and funding Program location and timing

Process evaluation is a measure of program effort or proposed activities rather than a programs effects or results. 3) Outcome evaluation delineates program objectives in term of effects to determine whether a change in health status occurred as a result of the effort The following observations are relevant to the program evaluation: Most management decisions are based on intuition rather than on facts The purpose of evaluation is to answer the practical questions of administrators who want to know whether to continue s program, to extend it to other sites, to modify it, or to close it down. Evaluation is more productive when it is a continuous process with a continuous feedback loop to the administrators, supervisors, and program managers who make decision. Epidemiology directly contributes to health program evaluation in at least two ways. First, the ideal design for evaluation remains the controlled clinical trial. Second, the measures of outcome are almost necessarily epidemiological measures of the health status of the population. In this regard, the contribution and use epidemiology is essentially the same as that described In step 1, to which the cyclical nature of the planning process now returns the operation.

Summary The chapter examined the role epidemiology in health services management, first by looking at the different uses of epidemiology, then by analyzing the nature of management. The central theme of management is decision making. A global planning process whose aim is essentially to aid managerial decision making was described. It was note that this planning process and the management process basically correspond. The planning process was used to examine epidemiologys contributions to health services management. Specifically, the planning process

has outlined the various levels of health planning as they relate to the policies, strategies, and operations applied to wellness model. Emerging out of this process is the population-based health planning approach that provides a blueprint for health services manager to focus on population in communities. Finally, health services managers are provided needs assessments methods for incorporation into the population-based prespective.