OPERATIONAL RESEARCH (OR)

Operational Research (OR)
Moderator: Prof. T. Gambhir Singh
Presenters: L. Janani
Bikash Debbarma
Date of presentation: 17/06/2020

 Definitions
 Evolution of OR
 How does OR differ from other
type of research?
 Why OR is important?
 OR technique
 Approaches for conducting OR
studies
 Who does OR?
 Steps of conducting OR studies
 Barriers to OR
 Journal & Societies related with OR
 Conclusion
 References
OUTLINE OF THE PRESENTATION

Research means a systematic investigation, including
research development, testing & evaluation, designed to
develop or contribute to generalizable knowledge
(45 Code of Federal Regulations (CFR), Part 46)

Biomedical & Health research means research including studies on
basic, applied & operational research or clinical research, designed
primarily to ↑ scientific knowledge about disease & conditions;
their detection & cause; & evolving strategies for health
promotion, prevention or amelioration of disease & rehabilitation
(New Drugs & Clinical Trial Rules, India, 2018)
RESEARCH

Purpose is theory testing and to produce
generalizable knowledge. Goal is to contribute to
knowledge base.
(CDC)
RESEARCH

The use of systematic research techniques for program
decision-making to achieve a specific outcome
(WHO – Framework for OR/IR in health &
disease control programs, 2003)
OR

OR helps policy-makers & program managers to
review, redirect & restructure programs that have been
in place for many years
(The Population Council, 2000)
OR

OR aims at studying the process by which programs are
implemented & interventions are delivered to intended
beneficiaries
(International Food Policy Research Institute, 2005)
OR

Research into strategies, interventions, tools or knowledge
that can enhance the quality, coverage, effectiveness or
performance of health system/programme in which the
research is being conducted
(The International Union against TB & Lung Disease)
OR

Any research producing practically usable knowledge which
can improve the program implementation regardless of the
type of research falls within the boundaries of OR
(WHO, 2008)
OR

Strategies undertaken to implement evidence-based
technologies, services, diagnostics or therapeutics in real-
life populations and contexts
(NIH, 2011)
IMPLEMENTATION RESEARCH

HEALTH SYSTEM RESEARCH (HSR)
The production of new knowledge, to improve how societies
organize themselves to achieve health goals
Service delivery Medical products & technologies
Information & Evidence Health workforce
Health financing Leadership & Governance
The Alliance for Health Policy & System Research (HPSR)

HSRIRORResearch domain
Users
PMs
HSMs & Policy makers
HCPs
Utility

OR IR HSR
Which locations
should be targeted for
delivering HIV
prevention services in
Equator province,
DRC?
How to improve
access to vaccination
among children who
are currently not
reached by
immunization
services?
To what extent do
health services reach
the poor? How can
this be improved?

The research that occurs before a program is designed
& implemented or while a program is being conducted
(The AIDS Partnership of California, 2003)
FORMATIVE RESEARCH

TRANSLATIONAL RESEARCH
It apply scientific investigation approaches to study how the
outputs of basic & applied research can be effectively
translated into practice & have an impact
(CDC)

Translation to
humans
Translation to pts
Translation to
practice
Translation to
population
𝑻 𝟏 𝑻 𝟑𝑻 𝟐 𝑻 𝟒
Pre-clinical
Phase 1 trials
FIH
Phase 2 & 3
clinical trials
Phase 4 clinical
trials
Health service
research
Population level
outcome studies
Controlled
environment Sample size

It examines a system
It requires collaboration
b/w managers & researchers
It succeeds only if the results
are used to make decisions
It addresses specific problem How does OR
differ from other
types of research?

‘Father of OR’
He did a research into the cost of
transportation & sorting of mail in
England’s Universal Penny Post in 1840
Charles Babbage
(1791-1871)

1948 - OR club was formed
1949 – OR unit was established
at Regional Research
Laboratory, Hyderabad
1950 – First OR journal
was published

1953 – OR unit was established
in Indian Statistical Institute,
Calcutta
1955 – OR Society of India
(ORSI) was created
1963 – ORSI started a
journal

Why is OR
important?
Important role to play in the success of program
It gives context-specific answers
Useful for coordinating the various activities
within an organization
It can aid in generating evidence based solution

Problem structuring Methods
& conceptual modelling
Areas of application in health
Soft System Methodology Outpatient service modelling
Strategic Options & Decision
Analysis (SODA)
Tele-health systems design
Validation Measuring patient/staff
satisfaction
Strategic Choice Analysis Strategic employment relations
(Source: NICE)

Mathematical approaches Areas of application in health
Queuing theory Waiting time/utilization
analysis
Location analysis Hospital placement
Meta-heuristics Staffing/Scheduling
Mathematical programming Resource allocation
(Source: NICE)

Simulation Areas of application in health
Discrete Event Simulation
(DES)
Redesign of clinical pathways
Waiting list issues
System Dynamics Identifying areas for policy
focus
Agent based modelling Modelling disease
spread/screening
Monte Carlo Demand estimation
(Source: NICE)

Queuing model
» Developed by A.K. Erlang in
1904
» Queue – a line that
persons/products have to wait in
» Channel – each person serving
an individual in the Queue

» Delays are the result of a disparity b/w demand for a
service & the capacity available to meet the demand
» Mismatch due to natural variability in the timing of
demands & the duration of time needed to provide
service

Fundamentals of queuing theory
» Assumption: there is no limit on the no. of the customers that
can be waiting for service (there is an infinite waiting room)
» It deals with system performance in steady-state
» Utilization:
𝐴𝑣𝑔.𝑛𝑜.𝑜𝑓 𝑏𝑢𝑠𝑦 𝑠𝑒𝑟𝑣𝑒𝑟𝑠
𝑇𝑜𝑡𝑎𝑙 𝑛𝑜.𝑜𝑓 𝑠𝑒𝑟𝑣𝑒𝑟𝑠 𝑡𝑖𝑚𝑒𝑠
∗ 100

Trade-off b/w average delay & utilization in a queuing system
Elbow depends on
variability & system size

Implications
» Avg. total capacity: No. of server times the rate at which each
server can serve customers (>than the avg. demand)
» Smaller the system, longer the delays will be for a given
utilization level

» Larger hospitals can operate at higher utilization levels
than smaller yet maintain similar levels of congestion
& delays
» Greater the variability in the service time the longer
the delays at a given utilization

Why queuing model is useful in healthcare?
To,
» Predict the level of congestion
» Determine how much capacity is needed to achieve
some desired level of performance
» Identify appropriate levels of staff, equipment, beds etc.
» Make decisions about resource allocation & the design
of new services

Simulation models
» Computer-based modelling
methodology
» Stimulate dynamic behaviours of
complex systems & interactions
b/w individuals & their
environments

Select & isolate certain features of reality to develop
a more/less idealized situation
Construct a model = Idealized situation + Real situation
The impact of changes on the total output can
thus be estimated

We can simulate,
» No. of pts arriving at a health caring centre on near future days
» Transportation of medicine to different areas
» Pt & doctors schedule so that their waiting time may be
minimized
» Sampling of pts of the same nature for analysing the
effectiveness of a new intervention

Does OR always require complex mathematical
modeling techniques?

Approaches for carrying out OR studies in public health
1. Secondary data analysis
E.g.
To determine the no. of smear examinations recorded in
laboratory registers that yielded one additional case of sputum
smear +ve TB following 2 –ve examinations

In this study 24 records from Moldova and 30
from Uganda were included
Data on the reason for examinations & the results
obtained for up to 3 examinations were included
To detect 1 additional TB case on a 3rd smear, 273
examinations in Moldova & 175 in Uganda were required

2. Primary level approach
» Exploratory/Diagnostic studies - help in problem
identification (e.g. Formative research, Need assessment)
» Intervention studies – before-after studies
» M’OR’E studies – evaluate ongoing innovative HIs
» Economic analysis

Who does OR?
Program implementers Researchers
Other stakeholders

Who does OR?
Other stakeholders
 Defining the problem
 Specifying when the study result
is needed for decision-making
 Ensuring the provider &
facilities cooperate with the
researchers
 Utilizing the findings in program
decision-making

Who does OR?
Other stakeholders
 Responsible for translating
the program problem into a
researchable problem
 Researchers from mix of
backgrounds

Who does OR?
Other stakeholders
Representatives from civil society
groups, NGOs, affected
communities

STEPS TO CONDUCT
OPERATIONAL RESEARCH?

PHASES / PROCESS OF OR
Planning Implementation Follow-Through

1. Organize the research group & advisory committee
2. Determine problems & frame research questions
3. Develop a research proposal
5. Identify funding sources & obtain support for OR
6. Establish a budget & financial management
7. Plan for capacity building & technical support
4. Obtain ethical clearance

• OR questions should relate to specific challenges
faced in implementing & managing health
programs
• Should emerge from discussions with program
managers, researchers and clients of the services
Testing possible
solutions
Considering
underlying
reasons
Identification of
the problem

1. Title page
2. Abstract/summary
3. Statement of research questions & objectives
4. Overview of the study area providing
information that is relevant to the problem at
hand, the communities involved and the
nature of the health system (Rationale &
importance)
5. Description of the intended research team
6. Ethical considerations & approval processes
7. Research methods
8. Plans for dissemination and use of findings
9. Budget for the proposed project &
justification
10. List of references for literature cited

• Approval of ethical & safety issues
from Institutional Review Board
• Informed consent form – signed by the
participants
• Risk & benefits
• Privacy & confidentiality

5. Identify funding sources & support
• Tropical Disease Research (TDR)
• Council for the Development of Social
Science Research in Africa
• Global Fund to Fight AIDS, TB and
Malaria
• International Bank for Reconstruction and
Development (IBRD, the World Bank)
• Bill & Melinda Gates Foundation
• International Development Research
Centre
• Rockefeller Foundation
• Welcome trust

Budget items for Operations Research
Research Costs
Implementation / Program
Costs
Institutional
Costs
• Personnel
• Supplies & materials
• Equipment
• Travel or
transportation
• Dissemination costs
• Educational materials for
clients & community
• Funds for mobilization
• Job aids for health care
staff
• Training programs for
implementers
• Commodities needed for
intervention
• Overhead
costs

• Capacity building can be done by senior researcher,
direct experience, organizing short courses
• Experts / consultants to work with the research team
for short periods of time

8. Monitor project implementation & maintain quality
9. Pre-test all research procedures
10. Establish & maintain data management & quality control
11. Explore together with stakeholders interpretations &
recommendations arising from research findings

• Work plan and regular meetings
• During implementation, the research team
probably needs to meet on a weekly basis
• Report to the advisory committee on a
monthly basis

Valid ?
Reliable ?
Necessary to test where they will be used in
the field, possibly in a different community
with similar characteristics
Two groups of people can be
involved in the pretesting process
Actual interviewers &
field assistants
Data management staff

Reflect the
objectives
Data entry & cross
checking
Review &
Supervision
ObservationTraining
Analysis

• Listing key findings
• Come up with a road map (Findings to
action)
1st meeting
2nd meeting
• Occur within a week after data entry
• A set of frequency tables or summaries
• Start assigning responsibilities
• Outline budget needs
Final step

12. Develop a dissemination plan
13. Disseminate results & recommendations
14. Document changes in policy &/or guidelines
15. Monitor changes in the revised program
16. Consider ways of improving the program that can
be tested through further research

• Dissemination activities must be
matched to the key audiences
• 2 types of audiences:
1) External
2) Internal
Dissemination plans: external audience
 Annual presentation of research
findings at national & international
conferences
 Publication of research findings
 Meetings with local & national
stakeholders
 Regular reports to funding agency
 Press release & briefings
Identifying & involving the most
effective advocacy voice

• Dissemination involves carrying out the suggested steps and
activities as planned
• The research team needs to involve the advisory committee as
mentioned
• Issues like timing, venue and opportunity need to be considered

• “Did the implementing/collaborating organization(s) “act on”
the results
• Implementation of the actual services of the intervention or
the activities to support those services

• Responsibilities of program managers & stakeholders
• Particular OR/IR which was carried out, effective or not in large scale
• The suggested & implemented changes in policy and procedures had
been any impact on program performance

During M & E, the new
strategy may find new problem
Start new OR process over
again with a new focus

During M & E, the new
strategy may find new problem
Start new OR process over
again with a new focus
Program
improvement is an
ongoing process

EXAMPLES OF OR IN PUBLIC
HEALTH IN INDIA
ANKUR Project: Field trial on HBNC to reduce neonatal mortality in India
•Conducted in Gadchiroli
district, Maharastra, 1993-1998
•39 intervention & 47 control
villages
•Introduced HBNC in the
intervention group
•Village health workers trained
& repeated visits to household
to detect and manage common
neonatal problems
• Baseline NMR was 62:58
(I:C)
• Net reduction of NMR & IMR
compared with the control
area, were 25·5 (62·2%) &
38·8 (45·7%) respectively
• Case fatality in neonatal sepsis
declined from 16·6% to 2·8%
after treatment by village
health workers

• Trial concluded:
Home-based neonatal care, including management of sepsis, is acceptable,
feasible, and reduced neonatal and infant mortality by nearly 50% among
our malnourished, illiterate, rural study population
HBNC is implemented under NHM in 2011 to reduce for reduction
of neonatal mortality through village health workers i.e ASHA
On this basis, ANKUR project (2001-2005) initiated in 7 sites by
ICMR, similar success achieved

EXAMPLES OF OR IN PUBLIC
HEALTH IN INDIA
Appreciative Inquiry (AI) in Leprosy?
•Wagh AN et al conducted OR to
assess the correctness of case
diagnosis in Bihar (LCDC) 2016-18
•AI involving the health care staff of
these 8 PHCs using the 4-D
framework (Discovery-Dream-
Design-Destiny)
• Mixed methods research with the
two validation exercises conducted
• The decline in false positive
diagnosis was estimated to be
about 9%

Study recommended that
• The program must focus on routine validation exercice in
future to improved the performance of the program
• Appreciative inquiry model must be included in different
orientation or refresher training

BARRIERS TO OPERATIONAL RESEARCH
Training and capacity building
• Trained uninterested staff
• Irregularities/absenteeism
• Unqualified person engage
Study protocol and publications
Ineffective research partnerships
• Wrong choice of research question
• Poorly designed studies
• Lack of writing & language skills
• No ethics clearance or exemption
• Inadequate experience
• Lack of joint ownership
• Partnership starts but fails with time
• Sideline research
Policy and practice
• Key decision and policy makers
were not involved
• The researcher invests until the
publication & goes no further
• Authorship is not inclusive

WHEN OPERATIONAL RESEARCH WILL
BE USEFUL?
Effective dissemination and accepted by wider scientific community
Implementation of the findings had an impact on program performance
or patient outcomes
Advocating for change to policy and practice
Program managers & stakeholders uses for decision making

M’OR’E
CONCLUSION
Identifying
problems
 Operational Research needs to
be integrated as an essential part
of monitoring & evaluation
efforts in Public Health
 Involvement of program
managers throughout the
research & use by policy
makers are two successful tools
of OR
OR Process

REFERENCES
• Operational framework. http://www.who.int/hiv/pub/operational/framework/en/index.html
• Global fund: operational research. http://www.who.int/hiv/pub/operational/globalfund/en/index.html
• Institute for Operations Research and Management Sciences. Operations research: the science of better. What
operations research is. http://www.scienceofbetter.org/what/index.html
• Sengupta PG, Mondal SK, Ghosh S, Gupta DN, Sikder SN, Sircar BK. Review on development and
community implementation of oral rehydration therapy. Indian J Public Health 1994;38:50-7.
• Kundu D, Chopra K, Khanna A, Babbar N, Padmini TJ. Accelerating TB notification from the private health
sector in Delhi, India. Indian J Tuberc 2016;63:8-12.
• Shewade HD, Nair D, Klinton JS, Parmar M, Lavanya J, Murali L, et al. Low pre-diagnosis attrition but high
pre-treatment attrition among patients with MDR-TB: An operational research from Chennai, India. J
Epidemiol Glob Health 2017;7:227-33.
• Bang AT, Bang RA, Baitule SB, Reddy MH, Deshmukh MD. Effect of home-based neonatal care and
management of sepsis on neonatal mortality: Field trial in rural India. Lancet 1999;354:1955-61.
• Wagh AN, Mugudalabetta S, Gutierrez NO, Padebettu K, Pandey AK, Pandey BK, et al. Does appreciative
inquiry decrease false positive diagnosis during leprosy case detection campaigns in Bihar, India? An
operational research study. PLoS Negl Trop Dis 2018;12:e0007004.
• Zachariah R, Harries AD, Ishikawa N, Rieder HL, Bissell K, Laserson K, et al. Operational research in
low-income countries: What, why, and how? Lancet Infect Dis 2009;9:711-7.

GOOD OPERATIONAL RESEARCH DRIVES
GOOD POLICY AND PROGRAMMING
Thank You

OPERATIONAL RESEARCH (OR)

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