EDUCATION FOR HEALTH SERVICES ADMINISTRATION

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1 There is no question of the need for skilled health administrators in all the myriad programs current today. Where are they to be trained and how? The papers that follow address themselves to these and related questions. EDUCATION FOR HEALTH SERVICES ADMINISTRATION 1. UNDERGRADUATE TRAINING FOR HEALTH ADMINISTRATION Marshall W. Raffel, Ph.D. THE search committee in a school of public health was seeking someone recently to head its department of public health administration. The committee invited a number of distinguished health professionals to advise it. "What type of person should head this department?" the committee asked each consultant, and each described a person with a philosophy and skills identical to his own. We all tend to think of ourselves as appropriate for the job we hold or seek. We believe, more often than not, that the educational and career development pattern we followed made us uniquely qualified for the position. Moreover, the people we try to hire are frequently carbon copies of ourselves, or at least trained in the environment and in the way we were trained. Certainly, their personal styles tend to be similar. Because most professionals in the health field have come up through the route of medicine or schools of public health or hospital administration, we tend to assume that what is needed is more of the same and, most definitely, professionals trained at the graduate level. One is moved to observe that the concepts of "the organization man" and "the man 982 in the grey flannel suit" are not restricted to industry and Madison Avenue. Time for Reappraisal The unmet need for skilled administrators is too great for us to accept, without questioning, the training patterns of the past. The time has come to reappraise training programs for health administration, and to ask: "Training for what?" The question is directed toward identifying the knowledge base and the skills necessary to perform successfully in the field of health administration. What knowledge is necessary to function effectively as an administrator in the health care field? What skills are desired? When asking these questions, I am not thinking of accountancy, personnel management, laundry management, or other middlemanagement functions. These are necessary skills common to many work environments. When speaking of health administration, I refer to policy administration of major health programs and agencies. It can be stated at the outset that, in most areas, clinical skill is not neces- VOL. 60, NO. 6. A.J.P.H.

2 EDUCATION FOR HEALTH ADMINISTRATION sary. The one-man health department is gone for most of the nation, and the need for a clinical specialist to find, prescribe, and administer no longer exists. Indeed, most of the major health problems today do not need clinical solutions, but rather political and economic solutions. The public and the politicians need to be sold on a program, and the money must be found and appropriated. The technical and clinical aspects of the solution are readily secured from the staff clinicians and from expert consultants. Speaking to this point in 1960, Roemer stated that "it is best to conceive of medical care administration as an aspect not of clinical medicine, but rather of administration. It deals with groups, and not as the doctor at the bedside with individuals. Its foci of concern are not biological or chemical, but rather interpersonal, economic, political, and social."' Hanlon reiterated this when he wrote that the "public health administrator typically finds himself called upon to make fewer and fewer decisions in the technical, professional, and scientific aspects of public health since he is too busy, or should be, with broader policy matters. Besides, he has or should have working for him many other experts who are better able to handle the strictly technical details. To the contrary, more and more of the public health administrator's time must be devoted to strictly administrative and managerial problems -how to obtain funds, how to get people to work together, how to deal with other parts of government and with the public, and similar nonpublic health or nonmedical matters."2 As Hanlon goes on to describe the traditional genesis of public health administrators, he notes that the rising health specialist "has now passed out of the orbit of the specialized public health spiral and has entered the larger orbit of public administration. He has become a public administrator with particular interest in health matters."3 The widespread acceptance of this thesis was evidenced by the report of the National Commission on Community Health Services when it stated: Modem programs of organized health care require specialized talent and training in the social and administrative sciences, as well as in the health sciences. Traditionally, the toplevel administration of health services has been under the almost exclusive direction of physicians. As programs of organized health services have increased in scope and complexity, it has become increasingly clear that the years of clinical training for physicians do not necessarily equip them for the task involved. Training in administration should be available for physicians who wish to enter administrative fields. Hospitals have pioneered in the use of nonmedical administrators. Through careful definition of administrative and clinical responsibilities, the administrator in many hospitals has been able to work in partnership with physicians to provide progressive administration of health services. In programs of community health service as well, informed, imaginative, and influential leadership by qualified administrators can achieve efficiency and fulfill the potential of these programs. Special emphasis must be given to securing and preparing toplevel health service administrators for responsible positions of leadership in health. This will entail selective recruitment and training that includes administrative management, economics, sociology, and political science.4 What the Health Administrator Needs to Know The implication of this for curricula in health administration is clear, and must be taken into account if the products of the training programs are to be effective. Specifically, this means that the health administrator should have a thorough understanding of the structure and dynamics of governments at the national, state, and local levels. First, how is our government organized and how does it function? Second, the health administrator needs to know about political processes-the forces that contend JUNE

3 to control government, the pressures that operate on those in and out of power, the special problems generated at the interfaces of the public and private sectors, and the ways to channel or direct political forces to facilitate the accomplishment of health goals. Third, the health administrator needs to understand the theory and practice of administration in public and quasi-public organizations, covering such areas as administrative theory, systems management, fiscal planning, management principles, legislative relations. Fourth, in view of the increased dependence on public finance, the health administrator needs to understand the basic elements of public finance, particularly in regard to revenue, expenditures, local and state tax systems, and intergovernmental fiscal relations. On the sociological side, the health administrator needs to understand the principles of social organization and social change, and the special problems in both urban and rural social structures. This is part of the knowledge base required of health administrators today. Why? Simply because government is playing a larger role in health affairs, and the health administrator has to be able to understand governmental processes if he is to work effectively with government. Bluntly. the question comes to whether or not the health administrator will be viewed by the bureaucracy and legislative officials as a knowledgeable comrade-in-arms or as an irresponsible health individual who is forever pressing unreasonable or unrealistic demands. The effective health administrator must be able to talk the language of the government officials, the legislators, the fiscal experts, and the public if he wishes to be heard, understood, and to get his way. Given this need, the health administrator's training should encompass these elements. However, if only these ele- 984 ments are part of his training, he will be no different from the multitude of administrators in education, welfare, natural resources, and agriculture. What makes the health administrator unique is his knowledge of and sensitivity to health affairs. Where does a future health administrator get this knowledge base? He does not get it appropriately in one cram course-or two or three. Most of the knowledge required traditionally is taught to undergraduates in colleges and universities, and takes nearly two years of solid course work. However, the undergraduate normally does not develop the knowledge and sensitivity to health affairs. This he traditionally acquires by going to a school of public health or hospital administration, assuming he is not diverted to other career areas which normally operate in undergraduate colleges (and most students are so di. verted). Health administration programs for undergraduates could effectively synthesize the work in political science, economics, and sociology in a health context. At Pennsylvania State University, we are doing this very thing. Students are counseled to political science at least through political behavior, state and local government, and bureaucracy and public policy. They are urged to take economics through state and local taxation, and advanced public finance. In sociology, they are advised to take such courses as population analysis, political sociology, and community organization. Following extensive study in these and related areas, the subject matter is tied together and applied by courses in health planning and administration. Students graduating will clearly be qualified to enter almost any school of public health or hospital administration, or may elect to do graduate study in the program developing at Penn State. A careful study of the undergraduate program at Penn State will in. VOL. 60. NO. 6, A.J.P.H.

4 EDUCATION FOR HEALTH ADMINISTRATION dicate that it does no violence to either the myth or reality of liberal education.5 Discussion Undergraduate programs are, of course, currently out of fashion. Some critics of the undergraduate approach cry out against attempts to tamper with the liberal educational process-an insubstantial argument, as college curricula are constantly being tampered with and have always been so. Moreover, it has not been established that a professional education program at the undergraduate level does significantly alter the intent or direction of a liberal education. In fact, if done well, it can give a relevancy to the liberal educational process which youth today is rightfully demanding. It has been my experience that the critics have in mind the undergraduate programs of another era, and fail to look carefully at what is being proposed today. Some critics also suggest that health administration requires a more mature person who, somehow or other, is found at the graduate level. These critics, of course, show their age. What they fail to recognize is that high school and baccalaureate educational systems have accelerated. Students in high school, for example, are now studying mathematics and science at a level previously taught in college. Concomitantly, colleges are teaching mathematics and science previously taught at the graduate level. The ability to do this stems, in part, from the over-all effectiveness of the primary and secondary educational systems in the country. Furthermore, university students today are more advanced than 25 and 30 years ago. This is due not only to accelerated formal educational processes, but also to the increased availability of educational books and magazines for leasure reading geared to facilitate their learning and to the advent of television, some of which is exceptionally good. One has only to cite the medicine and science sections of Time and Newsweek, the Time-Life Books, and the Sunday TV documentaries and news programs. Those of us who deal extensively with young people today are very sensitive to their increased sophistication. On the basis of these developments alone, a reevaluation of the role of undergraduate education for health administration should take place. The need to wait until the baccalaureate degree is in hand has disappeared. We are prolonging the educational process beyond reasonable bounds, and losing an opportunity to channel many undergraduates into the health professions because they have no real opportunity to experience them. I am not suggesting that an undergraduate effort is all that is needed. Rather, the knowvledge base and skills required for health administration indicate that an undergraduate effort is appropriate and can meaningfully guide students through a liberal arts curriculum, synthesizing the material in a relevant fashion for health administration application. Of course, it would be well to go on for graduate study to enlarge upon the knowledge base. An undergraduate curriculum will channel more students into graduate study and will do so with students who have a knowledge base particularly appropriate for health administration. On the other hand, the student who terminates with a baccalaureate degree will have been exposed to a health application of his studies. As a consequence, the health system will have a better chance to secure an appropriatelv trained person, one who will be useful in solving a critical manpower crisis and who will have the turn of mind that will facilitate entry on a career ladder leading to the top. This is not the only approach to education for health administration. When people come up through other routes, such as medicine, dentistry, or engineer- JUNE,

5 ing, then a modified pattern is required. Indeed, in some instances, it may be appropriate for an administrator to be qualified professionally in one of these fields. But, if we accept the knowledge base and skills necessary for modem health administration, then this has marked implications for the curricula in schools of public health and hospital administration. In some instances, their present curricula may not be applicable to today's needs or may need to be augmented greatly in political science, economics, and sociology. Further question is raised as to whether such subject areas should be taught within those professional graduate schools, or in the basic political science, economics, and sociology departments of the university. The criticism of some existing programs in health administration should not be interpreted as condemnation of their graduates. There is, in fact, a long and distinguished list of graduates who perform admirably as health administrators. They learned a great deal from experience, thus effectively compensating for whatever shortcomings there were in their own formal preparation. However, the process of producing these administrators could have been more efficient and more appropriate, and the graduates more effective much earlier in their careers. This is, after all, one of the objectives of formal education. Weaknesses in past and existing programs, coupled with the needed tools for effective health administration today, clearly indicate the emphasis which ought to be placed in future continuing education efforts. REFERENCES 1. Roemer, M. I. Medical Care Administration in the United States: Personnel Needs and Goals. A.J.P.H. (Jan.), Hanlon, J. J. Principles of Public Health Administration (5th ed.). St. Louis. Mo.: Mosby, 1969, p Ibid., p National Commission on Community Health Services: Health Is a Community Affair. Cambridge, Mass.: Harvard University Press, 1966, p. 88f. 5. See Appendix to this paper. For a more complete description of the Pennsylvania State University program in Health Planning and Administration, see the author's paper, Undergraduate Programs for Training Health Planners and Administrators. Pub. Health Rep. 84: (Oct.), APPENDIX The Pennsylvania State University, College of Human Development Program for Major in Biological Health (130 credits required for the baccalaureate degree) I. General Education Requirements (53 credits) Credits A. Communication skills 9 B. Biological and Physical Science 18 C. Social and Behavioral Sciences 6 D. Arts and Humanities 6 E. Courses selected from B, C, and D 10 F. Physical Education 4 II. Requirements for the Major (51 credits) Health Planning and Administration Option 1. Required Courses: H.P.A. 101 (3), H.P.A. 410 (3), H.P.A. 430 (3). H.P.A. 431 (3), H.P.A. 432 (3), and 6 credits of health planning field projects (H.Dev. 321). 2. Courses selected with adviser's approval to develop competence in health planning and administration, and understanding of the community context in which services are delivered. III. Electives (26 credits) A. Courses in Human Development At least 3 credits in each division of the college outside the student's major VOL. 60. NO. 6, A.J.P.H.

6 EDUCATION FOR HEALTH ADMINISTRATION B. Free electives to complete requirements for graduation H.P.A Introduction to Medical Care Organization H.P.A Principles of Public Health Administration 11 H.P.A Principles of Health Planning H.P.A Health Planning Methods H.P.A Health Service Evaluation. Dr. Raffel is Professor of Health Planning and Director, Division of Biological Health, College of Human Development, Pennsylvania State University, University Park (State College), Pa This paper was presented before a Joint Session of the Association of Management in Public Health and the Health Officers Section of the American Public Health Association at the Ninety-Seventh Annual Meeting in Philadelphia, Pa., November 11, II. COMMUNITY PLANNING FOR NEW PARTNERSHIPS IN HEALTH ADMINISTRATION Thomas M. Dunaye, M.P.H., F.A.P.H.A. THE past decade has been one of the Tmost progressive in American health policy: new opportunities for community participation, health partnerships, and comprehensive planning have promised a challenging future in the field of health administration. If these public commitments are to match their expectations for improved health practice, it will also be a future filled with new demands for better education and continuous training of all allied health personnel. Such a task can only be accomplished by the creative application of these same concepts to the entire system of our nation's educational resources; it can no longer be solely the job of traditional institutions for professional health training. We must look to a new interdisciplinary approach. The Graduate Department of Community Planning at the University of Cincinnati is an example of precisely such an effort to develop training programs for a broad variety of community health workers, relying as much or more upon the ingenuity and resources of others as those of its own. This department views its educational responsibilities as extending well beyond the formal curriculum of graduate training to develop professional agents of planned change for the many settings in community service, including comprehensive health planning. Its classrooms and laboratories are the entire university and surrounding Cincinnati communities, with their diverse constituencies of urban people, organizations, and problems. Before elaborating further on this particular design to expand the educational potential of community health services, perhaps we should examine first the two essential concepts that must be applied effectively if the interdisciplinary approach is to have utility. These most critical factors are "partner- JUNE,

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