Design, implementation, and evaluation of a community financing scheme for hospital care in developing countries: A pre-paid health plan in the Bwamanda health zone, Zaire

Nigeria's primary health care program relies on village health workers (VHWs) to provide simple curative and preventive services to largely rural underserved communities. Despite the reported need for these services, there is increasing evidence that VHWs often take leave of their jobs as a result of low patient demand, competing time interests, and less than adequate supervision. This paper describes the use of a simple operations research (OR) approach [1] to assist rural health program managers design strategies for reducing VHW attrition. It illustrates the feasibility and potential utility of employing the Nominal Group Technique (NGT) to draw on the experience and judgment of a variety of health professionals in arriving at local program decisions. This OR approach to problem solving resulted in a feasible and acceptable strategy which is now being implemented in southern Gongola State, Nigeria.

Reducing attrition among village health workers in rural Nigeria

PURPOSE To show the results of operational research techniques applied to the cataract service of a public university hospital in Brazil. METHODS. Using a heuristic approach for operational research, a study was designed to evaluate, develop solutions, and validate the implemented modifications to optimize service performance. RESULTS. Following implementation of the solutions and modifications, 24.9% more patients were examined and 39.9% more cataract surgery was performed than during a similar period prior to implementation. Solutions were provided by group discussion among service professionals and based on common sense, possibility of prompt implementation, and the use of available resources and fixed costs. CONCLUSION. The results of this study show the importance of operational research to a public cataract service wishing to improve its performance with simple and efficient solutions.

Optimization of a university cataract-patient care service in Campinas, Brazil.

In quest of useful health care decision models for developing countries

Improving the delivery of primary health care (PHC) services in developing countries requires the solution of a variety of complicated decision problems. Heuristic decision models are well suited for generating solutions to such problems in many developing countries where formidable financial, logistical, and personnel limitations make it difficult to satisfy the data and computational requirements of classical operations research (OR) models. Moreover, many PHC service delivery problems may substantially violate the assumptions underlying these OR models. This paper reviews the use of a particular form of heuristic—the preference-based heuristic—in three PRICOR studies reported on earlier in this volume. In each study, the objective was to select the most promising strategy for mobilizing community resources to finance some or all of the costs of PHC. The paper argues that the use of preferences in the solution of such PHC decision problems is essential. Reasons for this include the increasing number of choices available to users of PHC services, the competition inherent in such a situation, and the critical importance of client acceptance of PHC interventions, if those interventions are to be effective. Limitations of preference-based heuristics are recognized. Nevertheless, by giving explicit attention to the values of clients and other relevant groups, such decision models can be a relatively simple, cost-effective way of helping to ensure a program design which is both technically feasible and personally acceptable to those most directly concerned.

Perspectives on preference-based heuristics in primary health care decision-making

Planning primary health care (PHC) services in developing countries often requires decisions to be made under complex circumstances and without full supporting data or adequate computational resources. Intuitive approaches in the spirit of operations research/management science models, termed heuristics, may prove useful in such situations. This paper describes a heuristic method used for selecting schemes by which communities might finance, in full or in part, their own PHC services. In low-income areas of Rio de Janeiro, Brazil, groups of service providers and consumers were asked to identify possible PHC financing schemes. They then chose a “best” subset of these schemes using methods which involved expressing their preferences, evaluating social and other constraints, and judging possible usefulness of outcomes. A sensitivity analysis showed that the model led to similar sets of chosen schemes independent of variations in selected inputs.

Carlos Augusto Barros Riberro

Papers

Designing primary health care financing strategies for low-income communities of Rio De Janeiro: A heuristic solution