The Union’s Centre for Operational Research (COR) has successfully carried out a study to assess the successes and challenges in the implementation of the Primary Health Care System Strengthening Project in Sri Lanka. The study was funded by a grant awarded by the World Bank in October 2020. As part of the grant the COR built the operational research capacity of the programme managers in the Ministry of Health (MoH) involved in the project.
The five-year project (2018-2023), funded by the World Bank, aims to strengthen the provision of quality care through primary medical care institutions (PMCIs) in Sri Lanka, especially for people with non-communicable diseases (NCDs). There are about 1,030 PMCIs (divisional hospitals at district or sub-district level and primary medical care units in villages) in the country. The project is expected to invest in a minimum of 550 PMCIs throughout the country by 2023.
Uniquely, the project planned to register everyone in the country and empanel them all by issuing personal health numbers. This would improve the hospital information management system by enabling people to be tracked across the referral systems using electronic personal health records (PHR).
In 2019, the Project Management Unit, established within the MoH, reorganised 63 selected PMCIs to empanel the population and develop standards and processes to deliver quality care as envisioned. The COR’s operational research was intended to study and synthesize the insights and lessons learnt from reorganisation of these 63 PMCIs, to inform the reorganisation of the remaining 550 PMCIs by 2023.
The COR engaged Dr Manoj Fernando, from the Rajarata University, and Foundation of Health Promotion, a local research institution, to implement the study. The study involved a mix of quantitative and qualitative research methods, including in-depth interviews of patients, health care providers and programme managers. A team of nine research assistants and two research consultants collected the data.
All the data were captured using a mobile-based data capture tool. Data collection was monitored and validated virtually by the principal investigator from the COR and the local consultant. Despite challenges due to COVID-19 restriction during the data collection period (April to July 2021), data were collected on time by the research staff.
In August 2021, the COR submitted a detailed research report summarising the study results to the World Bank task team. The findings showed that despite COVID-19 related challenges, the project had made steady progress in reorganising the PMCIs, especially with empanelment of the population with personal health numbers and screening for NCDs.
Although the health care providers and public appreciated the interventions implemented, the qualitative exploration showed that there were several challenges in providing quality services as envisioned. Specific recommendations were therefore made in the report to overcome challenges related to the availability of trained manpower and medical equipment, maintaining uninterrupted supplies of essential drugs, delivering quality laboratory services, redressing grievances and empanelling and screening for NCDs.
The World Bank task team approved the report in October 2021. A dissemination meeting was convened later that month, at which key findings and recommendations from the study were presented to the main stakeholders from the MoH involved in implementing the project, including the Director-General of the Health Services.
In addition to the operational research study, the COR built operational research capacity of about twenty programme managers in the MoH. A course with two modules was delivered in line with the Structured Operational Research and Training Initiative (SORT IT) model, which provides hands-on training of public health professionals. The capacity-building programme had two modules conducted virtually. The first module focused the principles of research methods, developing a research protocol and using mobile-phone-based data capture. The second module focused on training in data analysis and report writing. The programme managers appreciated the course and provided >90% feedback score for both modules.
At the end of the course, a programme manager said: “I was engaged from the beginning of this training. This was a new strategy of training with a practical method of education. It is a pity that we are not using this operational research in our programme. As professionals, if we use operational research, we can improve a lot. The training was well structured and organised. This will be helpful to our budding community care physicians and junior medical officers. I understood a lot of jargon and terminologies with this training. Everything was explained clearly in simple language. I think this course will enable us to improve the health services in the country”.
The grant was officially closed in December 2021, with the COR submitting all the agreed deliverables in time. The World Bank task team and the Project Management Unit approved all the deliverables and appreciated the quality of work. Dr Hideki Higashi, Senior Health Economist, and Dr Deepika Eranjanie Attygalle, Senior Health Specialist, of the World Bank, wrote: “The task was highly complex and challenging that assessed whether the innovative project has been moving towards the intended direction in achieving the expected outcomes. Despite the obvious challenge in undertaking the operational research in the height of COVID-19 pandemic, The Union demonstrated its commitment with a great deal of creativity in overcoming any obstacles it may have encountered. In addition to delivering quality research outcomes, The Union has developed a solid approach and trained key government officials in conducting the operational research on their own for the rest of the project’s life. The team was truly impressed with The Union’s work”.