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The Institute of Health Systems (IHS) Hyderabad is a research,
training and development institution, established in 1990 under the
Societies Registration Act. The Institute's mission is to build
itself as a premier school of public health focussed on India's
health sector development. The Institute has sought to work towards
this goal on a self financing basis. There are four major areas of
activity, namely (a) research and consultancy, (b) training, (c)
health informatics, and (d) public services.
For more details of clarifications, write, fax or e-mail to:
The Communications and Services Officer,
The Institute of Health Systems,
HACA Bhavan, Hyderabad, AP 500004, India.
Fax: 91-40-3241567; E-mail: ihs@ihsnet.org.in
http://www.ihsnet.org.in
| Date: 24
December, 2001 |
Director, IHS |
Contents
| 1 |
Research and
Consultancy |
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National Burden of
Disease (NBD) |
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Health System
Performance Assessment (HSP) |
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Health Care Quality
Assurance (HQA) |
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Health Sector Reform |
| 2 |
Human Resource
Development (Training) Services: |
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Health System
Operation |
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Health System
Research Methodology |
| 3 |
Health
Informatics |
| 4 |
Public Services |
Research and Consultancy
National Burden of Disease (NBD):
The Andhra Pradesh Burden of Disease (APBD) Study was started in
1993, immediately after publication of the Global Burden of Disease
Study results in the World Bank's World Development Report, 1993.
The Institute was just about three years old then. Hence the APBD
study was launched in collaboration with the Administrative Staff
College (ASCI) of India. Since then the Institute has pursued many
connected areas of research to build national capacity in
quantification of disease burden. These include studies on; (a)
causes of death, (b) health status measurement, (c) indirect
estimation of mortality by smaller areas, and (d) descriptive
epidemiology. Studies on causes of death started with a pilot study
on the accuracy of cause of death reports under the survey of cause
of death (SCD) rural scheme. The Institute's work resulted in
publication of a landmark article in the National Medical Journal of
India about the performance of the cause of death reporting system
in India 1.
The study highlights the poor state of cause of death reporting
system in the country, identifies its weaknesses and calls for
action to improve the system. The Institute has developed a computer
software for processing of cause of death reports by municipal
health offices, state vital statistics offices as well as research
and analysis teams2.
Health status measurement is an important step in quantification of
disease burden due to non fatal health outcomes. As the prevalence
of non communicable diseases increase, the need for health status
measurement will be increasingly important in biomedical research as
well as clinical medicine. Ideally, burden of disease estimates
should use community valuation of different health states. Since
community level health state valuation tend to be difficult and time
consuming, most disease burden studies use expert rated disability
weights. The AP Health State Valuation (APHSV) study conducted by
the Institute in 1999 was the first community valuation of a set of
health states in a developing country. Conventional measures of
premature mortality, like infant mortality rate (IMR) continue to
play an important role in health policy. Reduction of IMR is an
important goal set by the National Health Policy. Currently the
Sample Registration System (SRS) is the primary source of IMR
estimates in the country. Unfortunately the SRS does not provide IMR
estimates for smaller areas below the state level. Availability of
IMR estimates for small areas will facilitate identification of
areas with very poor population health status and targeting of
public health programmes. The District Family Health Survey (DFHS)
piloted by the Institute studied the feasibility of generating IMR
estimates at the sub district level. The results were revealing. For
example, it was found that one area of the three pilot districts had
IMR as high as 125 / 1000 live births compared to the state average
of 66/1000 live births. In other words, the IMR in this division was
almost twice the state average IMR. Identification of such high
mortality risk areas, it is hoped, will help in better targeting of
public health interventions.
Descriptive epidemiology is about understanding the natural
history of diseases, estimation of disease frequency and mapping of
known risk factors. These are important contributors to estimation
of disease burden. They help in identifying linkages between risk
factors and disease burden. For example, the Institute's study
comparing prevalence of morbidity and nutritional status of child
labour and other children did not show any significant difference.
Another project of the Institute produced a water quality data set
of Andhra Pradesh using results from official investigation of water
quality. The data set would further research on water borne diseases
in the state. The recently concluded, collaborative project on
indoor air pollution would help build an exposure atlas of indoor
air pollution. Other studies in this area include analysis of
seasonal pattern and geographic localization of gastroenteritis in
AP, malaria trend in the state, etc. Another example is the pilot
study on socioeconomic impact of asthma 3,
which provided useful insights for the WHO task force on global
strategy for asthma management.
.
The efficiency by which various components of the health system
deliver their services has a significant impact on the cost of
health care. A more efficient health system would mean that more
health care services are provided for the same level of resource
use. Improving efficacy of health systems through operations
research and performance assessment is one of the important missions
of the Institute. Keeping with this mission, the Institute has
fostered many research areas such as (a) periodic analysis of
hospital performance, (b) patient satisfaction surveys, (c)
responsiveness surveys, and (d) national health accounts. The
Institute has been providing since, 1997, to the AP Vaidya Vidhana
Parishad, monthly reports containing analysis of hospital
performance along with qualitative reports based on visits to
selected hospitals. Another area of health system performance
assessment research is based on survey of patient's satisfaction.
Since 1999, the Institute has been conducting patient satisfaction
surveys in selected public hospitals in AP at half yearly intervals.
These surveys provide useful feedback on functioning of different
areas in the respective hospital and helpful insights about
patients' preference. The study on structure and dynamics of private
health sector in AP included a patient exit interview component to
compare the level of satisfaction among patients attending private
and public health care institutions respectively. An early
responsiveness study was the demand and satisfaction survey in
Mauritius. Recently the Institute completed the AP Health System
Responsiveness study which collected data from state wide
representative sample of households. The survey was designed to
assess responsiveness of the health system to health care client.
National Health Accounts (NHA) allow assessment of overall health
system performance and provide important insights about allocation
of resources to and within the health sector. The Institute's
research program on NHA started with analysis of government
expenditure on health in Andhra Pradesh. Allocations to various
components within the health sector like the primary, secondary and
tertiary level services have also been examined. The Institute's
work on government expenditure analysis facilitated publication of
AP Budget data on disk. The Institute of Health Systems was one of
the contributors to the first budget data on disk published by the
government of AP in 1998.
Health Sector Reform:
Health sector reform is a sustained process of fundamental change
in policies and institutional arrangements of the health sector,
usually guided by the government. Any meaningful reform process
ought to be based on evidence and information about the current
state of affairs, and potential effect of alternative policy
choices. Many of the Institute's research activities take place with
the objective of generating evidence and information for health
policy. For example, the study of hospital autonomy, documented the
experiences of the AP Vaidya Vidhana Parishad in Andhra Pradesh.
Some studies in this area describe and compare different health
systems mainly in the developed (organisation of economic
cooperation and development, OECD) countries 8.
Many studies have been taken up to understand the Private Health
Sector including both forprofit and nonprofit health care
institutions. An early study taken up by the Institute was about the
management of financial resources in voluntary health agencies9.
The study on social evolution of hospitals and its relevance for
health policy10
was an example of history of health care and its current policy
relevance. An electronic database of all health care institutions in
AP, called the Andhra Pradesh health institutions data base11
(APHIDB), is maintained by the Institute to facilitate research in
health care policy. This database provides a readily available
sampling frame of health care institutions in the state. In 1998,
the Institute conducted a workshop on Private Health Sector in AP,
attended by different stake holders. The workshop took stock of the
current state of private health sector in AP and provided some
policy recommendations. In 1999, the Institute started a more
detailed study to understand the structure and dynamics of the
private sector in Andhra Pradesh. The study was commissioned by the
Government of India, Ministry of Health. This study collected data
from within AP and reviewed literature from elsewhere in the world.
The study found that there is hardly any difference in terms of
efficiency and quality of care between private for profit, non
profit and public health care institutions. Public and nonprofit
health care institutions are clearly more accessible to the poor.
One advantage of private forprofit health care institutions is their
quick response to changing demand for services. The study recommends
encouraging nonprofit health care institutions, and development of
quality assurance infrastructure. Recently, the Institute conducted
a workshop involving core players in health sector for development
of health sector reform strategy in Andhra Pradesh. Another health
sector reform project is about preparation of state action plan for
reproductive child health services and sector reform.Human Resource Development (Training) Services
The IHS is developing academic programs and offering training
services to build interdisciplinary skills for more efficient health
system. Public health related training services fall broadly into
two groups namely, (a) health system operation, and (b) health
system research methodology. In addition, the Institute organizes
training programs in health informatics, which is described later.
Health System Operation:
The IHS has involved itself in development of human resources for
better health care in Tribal and remote areas. The Institute's work
on Tribal area health services started with an early study on
potentiality and relevance of herbal and traditional medicine on
health care in tribal areas. The Institute built an ethnobotanical
database on medicinal flora in Tribal areas of Andhra Pradesh (MEDFLOR).
These research activities were followed up by developing special
course and teaching materials to train nonformal health workers in
Tribal areas. Some training programs were organised in Bhadrachalam
ITDA areas. Thereafter, training programs for medical officers and
community development officers were organised in Paderu ITDA area.
These activities lead to the development of more regularly offered
training program on Managing Primary Health Care in Remote Areas (MPHCR)
designed specifically to benefit medical officers, ITDA officials,
PHC Extension officers in Tribal Areas. This two week program builds
required skills in organisational behaviour, public administration,
rapid assessment of health situation, program management, monitoring
and evaluation, accounting and financial management, working with
tribal communities, disciplinary procedures, conduct rules, and
office procedures. The program also reinforces selected technical
aspects of important public health problems more commonly
encountered in remote areas. Nine batches of PHC officers have been
trained so far in managing primary health care in remote areas
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Health System Research Methodology:
These programs are designed to build national and regional health
system research capacity. To generate required evidence and
information for health policy, the Institute has sustained research
on estimation of National Burden of Disease. The Andhra Pradesh
Burden of Disease study, initiated by the IHS happens to be the
first National Burden of Disease taken up immediately after
publication of the Global Burden of Disease study results through
the World Development Report (WDR), 1993. Results of the AP Burden
of Disease Study was published in 2000. The IHS is the only centre
in the South and East Asian region with substantial expertise in
national burden of disease studies. Recognising this, the Indian
Council of Medical Research (ICMR) chose the Institute to train its
scientists in burden of disease study methodology and research on
causes of death. Two batches of scientists from various ICMR
laboratories have been trained in National Burden of Disease Study
methodology.
Information about causes of death is an important input for
estimation of disease burden. The Institute has sustained research
program on causes of death in India. Based on knowledge and skills
gained from its research, a suite of programs on various aspects of
cause of death coding and research has been developed to meet the
needs of different people involved in generation of cause of death
statistics. These include programs for training of doctors in
reporting cause of death, training for municipal health officers and
vital statistics personnel about collection, compilation and
collation of cause of death statistics, and cause of death research
methodology for scientists. A training program on Processing
and Research Information System for Mortality (PRISM) data
was held in the month of March, 2001. The Indian Council of Medical
Research (ICMR) has identified the IHS to organise workshops on
cause of death research methodology for its scientists. Two
scientists from the National Institute of Epidemiology, Chennai have
been trained in cause of death research methods.
Other training programs on health system research methods
include; (a) Designing and Implementing Health State
Valuation studies; (b) Introduction to Methods of Epidemiology;
(c) Academic and Business Communication (ABC)
workshops; etc. Health Informatics
Application of information technology to the health sector has
tremendous potentiality for efficacy of health care delivery
institutions and provision of cost-effective health care. Health
care delivery institutions will need and use information technology
to meet their client demands and stay competitive, since, the future
for them lies in cost-effective health care. General purpose
information technology solutions are usually inadequate for
specialised needs of the health sector. That is why a host of
solutions, standards and services are emerging to meet needs of the
health sector. Application of information technology to the domain
of health care delivery is referred to as Health Informatics. The
Institute has been making concerted efforts to build the health
informatics infrastructure (HII) in India. Major HII activities of
the Institute are (a) human resource development for health
informatics, (b) health informatic standards, and (c) health care
identification systems.
To build skilled manpower for health informatics, IHS runs three
different kinds of training programs such as system administration,
health care software development and personal computing skills for
health care professionals. The certificate course on Health Intranet
System Administration (CHISA) consists of a phase of full time study
for 3-4 months followed by on the job internship for 11-12 months.
Every year a batch of upto 30 students are taken. Two distinct
streams of students may enter the course first is Initial career
i.e., graduates with basic computer education seeking to build a
career in health care service and health informatics sector, and the
second is Mid-career i.e., Health care institution personnel seeking
to diversify their skills and move on to the health informatics
area. The course coverage includes; personal computer hardware,
networking essentials, network operating system, introduction to
health care institutions, problem solving skills, and personality
development. These students are prepared to provide day to day
management of computer network in a health care institution or
health care software development facility. So far, three batches of
students have been trained out of which, two batches have passed out
and the third batch is in the internship phase. These students have
so far enjoyed a very high placement rate of more than 75%, mostly
in the open market.
The certificate course in health care software development (HCSD)
is designed to develop domain knowledge in health care field among
computer software engineers. Participants in the course learn about
health informatic standards like the Health Level Seven (HL7),
general functioning of health care institutions from the information
system perspective and various types of health informatic solutions.
So far, two batches of students have passed. The Institute also
provides health care software development internships to real life
project experience in health care related software development
projects. Here again placement record of the Institute's students
and interns has been more than 90%. In addition, IHS offers short
courses on health informatic standards to meet the needs of health
care software industry in the country. Its courses on HL7 standards
has been attended by software engineers from many private health
care software solution providers. The Institute is an Institutional
member of the HL7 organisation, which is an international
professional organisation for development and use of health
informatic standards.
A major determinant of the rate of adoption of information
technology in the health care sector is the personal computing skill
of health care professionals. If doctors, nurses and other health
care professionals are comfortable with personal computing, the rate
of information technology adoption in health care institutions is
likely to be faster. Towards this goal, the Institute incorporates a
personal computing component in all its training programmes and
takes up fully dedicated training courses in use of personal
computers by health care professionals. Inputs on EpiInfo (WHO
software on epidemiological information system) as a part of the
training on Managing Primary Health Care in Remote areas is an
example of the former. The program on smart use of computers by
health executives is an example of the later.
IHS has recently adopted a regulation for setting up a health
care identifier (HCId) system, which will be an useful
infrastructure for electronic transfer of information between health
care and related institutions.
The Institute also develops soft wares to meet needs of health
system research. In addition software for health care institutions
are developed as a part of the Institutes educational program of
developing human resources in health informatics. Following is a
brief overview of some of the software products being developed at
the Institute.
- BDAP (Burden of Disease Application Project): It is developed
to allow epidemiologists and demographers to estimate disease
burden for a given population. The application was commissioned
by the World Health Organization.
- PRISM (Processing Research Information System for Mortality
data): It allows for entry of cause of death reports and
provides services for review of individual reports by trained
personnel, tabulation of data and generation of statistical
reports.
- HiMan-2000 (Health Information Manager - 2000): it is an
application to log hospital statistics, admission and discharge
data and send them across a wide area network, using HL 7
compliant messaging format.
- HiMan Central (Health Information Manager - Central): It is
the central server application that receives periodical reports
from individual hospitals and allows for generation of
management information system at the head office.
- StaTools: It is a suite of statistical tools to meet common
tasks needed by faculty and researchers at the Institute. Some
tools included are (a) a tool to generate a random list, (b) a
program to draw a sample based on probability proportionate to
size (PPS), etc.
Public Services
One of the goals of the Institute of Health Systems (IHS) is to
build local capacity for generation and use of evidence and
information for health policy to realize the broader goal of overall
socioeconomic development. Usage of evidence and information for
policy is to predicate on awareness by general public and knowledge
among the public health community, of results from health system and
related studies. Towards this end, the IHS has been striving to
provide opportunity to persons interested in improvement of the
Andhra Pradesh health system to share and learn from the insights of
top class intellectuals and public health analysts. The Institute
arranges public health lectures, whenever there is an opportunity of
having the time from reputed health system researchers and health
policy analysts. Title of the lecture is identified in consultation
with the visiting public health analyst. The public health lectures
are open to any one interested in the subject. Admission is free.
The events are publicized through posters, notices and news paper.
In addition, special invitations are sent out to members of the IHS,
public health officials, news media persons, and opinion leaders in
the medical and health community.
People are gradually recognising the bibliographic niche being
cultivated by the IHS library. Although the library is small, it has
some collections in the area of health economics, health system
research etc. not easily available elsewhere in Hyderabad. As of
December 2001, the Institute had 37 associate members, mostly taken
to access the library facility. The library services about 323
retrievals per month. The Institute, as a matter of principle,
publishes all its research and consultancy outputs through working
papers, reports, datasets, or monographs. These publications are
available to public for a nominal price, to cover cost of
publication. List of IHS publications are provided in the IHS
capacity statement, which is updated from time to time as well as
through the Institute's web site at www.ihsnet.org.in. Publications
can be obtained personally from the Institute's Front Office or by
writing to the Communications and Services Officer.
The Institute maintains a database of health care institutions in
Andhra Pradesh, called the APHIDB. It includes public and private
health care institutions. The database is accessible to health
system researchers and members of public to facilitate health system
research and public policy debate. The database has been very useful
in the design and implementation of many research programs in the
Institute.
1
Mahapatra Prasanta and Chalapati Rao PV. Cause of death reporting
system in India: a performance analysis. National Medical Journal of
India. 2001; 14(3):154-62.
2 PRISM, the Processing and
Research Information System for Mortality Data.
3 Mahapatra Prasanta, Murthy
K.J.R, Kasinath P.C & Yadagiri R: Social, economic &
cultural aspects of Asthma: An exploratory study in Andhra Pradesh,
India. Working Paper 3/1993.
4 Mahapatra Prasanta and
Rajaratnam Sailaja. Assessment of demand for accreditation services
in Hyderabad. A pilot study. IHS Working Paper. 1994; WP(6).
5 Nanda Lipika. Quality
management of the private health sector: a study of the expressed
need for regulation in Andhra Pradesh. Journal of the Academy of
Hospital Administration. 2000 Jul; 12(2):23-31.
6 Srilatha S. Institute of
Health Systems. An enquiry into the quality of reproductive health
care provided in private hospitals and nursing homes and women's
perception in Andhra Pradesh. Quality assessment study in private
hospitals in Andhra Pradesh. Hyderabad; 1998 Sep.
7 Mahapatra Prasanta;
Sridhar P., and Rajshree KT. Structure and dynamics of private
health sector in India A study in Andhra Pradesh, 2000. Hyderabad:
Institute of Health Systems; 2001.
8 Mahapatra Prasanta.
Aggregate allocation to health sector and health system effect:
experiences from OECD countries. IHS Working Paper. 1998; 23:1-17.
9 Mahapatra Prasanta;
Management of financial resources in voluntary health agencies.
Working Paper 2/1991.
10 Mahapatra Prasanta.
Social evolution of hospitals. How is it relevant for health policy?
Bulletin of Indian Institute of History of Medicine; XXIV:177-201.
11 Institute of Health
Systems; Andhra Pradesh health institutions data base (APHIDB)
(Private and Public). A technical note. IHS Working Paper 11/1997.
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