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WORLD HEALTH ORGANIZATION
ORGANISATION MONDIALE DE LA SANT~
REGIONAL OFFICE FOR
THE WESTERN
PACIFIC
BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
REGIONAL COMMI'I"I'EE
TECHNICAL DISCUSSIONS ~RC19iTDl
Nineteenth Session Manila 1-8 October 1968
I}
Sep~ber
Rev.1
1968
;.-
OlUGINAL: ENGLISH
NATIONAL HEAI1l'H PLANNING: A MEI'HOOOIOOICAL APPROACH AND AS AN AJ:tIIINISTRATIVE TOOV.
A.A. Angara. M.D. Assistant Director of Health Services WHO Regional Office for the Western Pacific
1aaCkgrOund document for reference use at the technical disaussions on "Health Planning as an Administrative Tool".
CONI'ENTS
1
INTRODUCTION
................................................................................ ........................................................................... .
1
2
EVOWTION OF THE MODERN APPROACH TO I1E.A.LTI1 PIANNING 2.1 History 2 2
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2.2 3
General principles of the modern approach
•.••....
4
THE PLANNING PROCESS :;.1 3.2 Pre-pla.I1niIlg ................................................................ Plaxmil'lg strateg;r .............................................................. . o. . . . . . . ..
7 7 8
3.3 Illustration of a health planning methodology: the PAHO/CENDES approach •••.••••••..•.••••••.••
9
e,
3.).1 The diagnosis stage ••. . . . • . • • . . • • . • • . . • • . • 3.3.2 Preparaticn of the plan ••..•..•..•.••...•. 3.3.3 Implementation (or execution) .•.•••.•..... 3.3.4 Evaluation and revision ••.•.•••..•••.••••.
9 14 18 19
4
PLANNING AS AN ADMINISTRATIVE TOOL 4.1 4.2
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19 20 21 22
Influence on organization and administration Opportunities for inter-agency collaboration 4.3 A means for enlisting community participation 4.4 Plenning not a formula but a tool................ REFERENCES
23
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25
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WPR/RC19/'l'Dl Rev.l page 1 1. INTRODUCTION
People in many countries recognize the need to improve the living standards of the general population. despite the setbacks experienced current decade. logical advances beir~
The feeling prevails
by
individual countries during the
This recognition issues from the continuing technomade which, with the broadening educational
base and better means of disseminating new knowledge and information obtaining in many countries, are making more people aware of the better future that lies ahead. More and better facilities for health constitute an important aspect of improved living standards. needs) ~~
As with other sectors, de~ands
hO~'lever,
there exists at the moment a gap between health available resources. can be considerable:
(not to speak of
In the developing countries this gap
the number of deaths which occur without medical
attendance are exceedingly high, and many people, especially among the young, are doomed to illness and even death because of the lack of sanitary facilities and the unavailability of medical attention. Ir.
the developed countries, where more and better facilities are available, the resources for health care are frequently unable to keep up with the rising health demands resulting from changing health conditions such as longevity, stresses of modern life, etc. Resources may not only be scarce but they may also be handicapped because of their specificity. hospital. A paediatrician cannot easily be reassigned to the geriatric field nor can a schoolhouse be easily converted into a There may be certain constraints which limit the full use of available resources, e.g., geographical or transportation barriers may make a health centre or hospital inacceSSible to a substantial segment of the population. Another is the inefficient use of resources such as a water supply system which has no budgetary proviSions for connexion to houses along its route.
lIn matching demands •••
In matching demands with resources, certain options may be open,
viz.. to add the resources required, to increase performance efficiency. or to develop a cOll\bination of both. planning. Among the developing countries of today, many goverments embark on socio-economic planning as a means of accelerating their development. One of the tasks of development planning is how to allocate limited resources to planned activities in a broad area, thereby cutting across sectors. Thus, national health administrations are obliged to justify rationally their activities in order to secure their allocation. Whether frOll\ the overall develolXllental aspect or from a desire to make the most use of their limited resources, national health administrations are increasingly planning their health activities on a long-term basis. The exercise has immediate internal implications; the process necessarily involves an examination of the health administration machinery and implicitly recognizes the possibilities of a change, as its organization is essential to plan implementation. One problem of planning concerns methodology. It Hould be desirNeverown by able to have a methodology employing the modern approach of systematic analysis and quantification whioh receives general acceptanoe. theless, a few countries have already started developing using the modern approach. 2. EVOllTTION OF '!HE MODERN APPROACH TO HEALTH PIANNING t.~eir
The analytical process which helps
in making a choice from among these alternatives is the essence of
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2.1 History In tracing the history of planning in the western world, Stebbins c1tes Hippocrates as an urban health planner "rho, 2500 years previously, laid. do"m certain health criteria in the founding of cities. During
the Middle Ages planning was concerned with the quarantine control of /the pestilential •••
e
~Rev.l
page :; the pestilential diseases, while in the 19th century attention was given to bacterial diseases control following the medical discoveries of that period. With the advent of the 20th century, planning for health services broadened in response to the rapid advances in medicine and technology and the growth of industrialization, urbanization and international cormnerce. ../' '
The magnitude of the health needs and problems
accompanying these trends spurred community participation in health • In the United Kingdom and Scandinavia, health services for disease prevention and treatment were introduced under govern~ent
auspices.
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In the United States of America, voluntary and private health organizations played and continue to play prominent roles concurrently with government action. Thus, community health services have spread rapidly and this development has culminated in the establishment of health ministries in many countries. Various health schemes have also been developed. the cost of sickness. Germany, in
the time of Bismarck, adopted social insurance as a means of meeting In the United States of America, government provisions for health care have been considerably supplemented by voluntary health organizations and private health insurance schemes. In the United Kingdom, the national health service act nationalized medical care after World War II. Earlier, the Union of Soviet Socialist At present, various Republics adopted the policy that all persons are entitled to preventive and curative care at the Government's expense. schemes for providing personal health care have been introduced and are operating in Virtually all countries of the world. The increasing rate of population growth in recent decades has been brought about by sustained ,birth-rates, decreased mortality and the consequent increase in the longevity of the population. This has introduced a new dimension to the needs and problems of health services; it is a factor that \r.Lll necessarily influence future planning. /2.2 General .••
WPlVRC19/TDl Rev. 1 page 4 2.2 General principles of the modern approach Planning is necessarily influenced by the social, economic and administrative situation obtaining in the country. In countries with a mixed economy of public and privately-owned enterprises, the economic plan serves as a guideline for development. The central planner exercises his functions through co-ordination and promoting co-operation between the operating enterprises to attain plan goals. The means used by the planner, particularly in developed and industrialized countries, is by a process of continuous adaptation
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of selected government instruments (e.g., budgetary outlays, investments, wage rates, taxations, etc.). In the developing countries, where private enterprises are not as strong, long-term allocations of investment and/or public outlays (e.g., expenditures under a government budget, foreign aid, etc.) are made with the aim of general economic growth. In socialist countries, the means of production is owned by the people (or government) and the authority vested at the central level ensures unity of the whole economy. acquires the force of law. There is also a difference in the allocation of resources to health. The established guideline in the Union of Soviet Socialist Republics is that economic considerations must never be uppermost where health problems are concerned and that medical benefit should be the deciding factor. In other economies, the ultimate goal may be similar, but the resources may be as scarce as they are in the
Once the economic plan is approved
by the highest political authority, accomplishment of the targets
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developing countries or their execution may be more complicated in view of the mixed economy. A number of countries feel that this problem may be alleviated through recourse to comprehensive health planning. /Despite differences •••
w!'tVlm9/'i'Dl page 5
Rev.1 .
Despite differences, the principles underlying contemporary health planning are similar. Health planning is viewed as a dynamic and Duran describes health continuing process which is repeated in cycles.
planning as "involving a systematic approach •••• with a fim resolve to bring about changes" as may be determined by the goals of the health
policy.
By
health policy is meant any planned action decided at the
highest government level for the health protection of the population. Health protection in its broadest context would include the prevention of disease or disability and the restoration (through curative and/or
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rehabilitative means) and promotion of health. further the aims of health protection.
Planned action for
health would embrace measures taken (technical , administrative) to
The essence of health planning would correspond to Michael et al's description of the Planning-Programming-Budgeting System (PPSS) adopted by the Federal Government of the United States of America and which
reflects the general approach ot' other countries as
\Ole
11:
II
a process
by which the objectives and resources and the inter-relationship among them are taken into account to achieve a coherent and comprehensive programme of action for an organization. of goals are effected. II consist of: (1) collection and analysis of data to increase knowledge of the health situation; fomulation of objectives and determination of their prioritie~
The inputs are related to
the results so that more efficient and effective methods of attainment The elements compriSing the systematic approach
--
(2)
including targets within the planning period;
(3) selection of techniques (or means) among alternatives based on cost-effect analYSis to accomplish the objectives; (4) allocation of resources to priority objectives to be carried out with the most efficient techniques; and
(5) continuing review
evaluation of the objectives,
teChniques and targets accomplished in relation to the plan goals. lIn the collection •••
~HC19/T.Dl
Rev.l
page 6 In the collection and analysis of data, extensive the deductions and general conclusions of such logy, statistics, accounting and practical economics. us~
is made of as epidemio-
discipline~
The data are
obtained from official sources and this may be supplemented with sample surveys of the private sector as in the case of the health manpower study in ~1ina
(Taiwan) by Baker et al, or, as in Czechoslovakia, by stu~v
an experimental
of a representative sample of the population
in order to determine the interaction of factors conditioning future trends in morbidity and the demand for medical care. Objectives have a rational and social base. target over a specific period. immunize period. ~
An obje¢tive may
issue from an analytical process and may be formulated with a quantified For example: it may be desired to number of susceptibles against diphtheria within a five-year
The social determinant is a political decision ip. response to
a community demand; for instance, under the "benefit of progress IT principle (i.e., the tenet that all segments of society are entitled to the benefits of technological and social progress), it may be decided to introduce and maintain a health centre in a remote and isolated area regardless of the fact that it may not be economical to operate. Another influencing factor is the principle of comple.. mentarity, i.e., when certain objectives must be executed simultaneously to satisfy a public demand as exemplified in the provision of both preventive and curative services in the national health organization. The selection of techniques among alternatives includes consideration of their possible implications on the objectives of the plan. The determinant in'makir~ the choice is cost-effect, i.e., the most favourable effect at the least cost. Indices are generally used under the plan as a basis for target setting, quality of per"fol~ance and evaluating accomplishments. In some countries foreign and international indices may be adopted in! tially. In others, temporary norms recommended by a :group of experts are used at the beginning and replaced later by more realistic / standards •••
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WPR/RCl9/TDl Rev.l page 7 standards formulated by experiment or from the experiences gained in
planning as in Latin America.
The formulation and use of indices
are prominent characteristics of planning in the Union of Soviet Socialist Republics. Periodic evaluation enables stock-taking of the targets accompliShed and of the means used in accomplishing them.
Objectives are also reviewed
in relation to the plan goals.
Changes in the health situation are noted
and their possible effects on the plan are assessed with a view to making adjustments where necessary in order to ensure that the plan goals are being pursued. New knowledge or experience may affect standards and Revision of standards may also entail adjustments these may be revised.
in some of the techniques and targets. The allocation of resources is an attribute of health policy and the systematic analYSis employed helps in clarifying factors relevant to decision making • Ultimately, decision by the highest political In the contaxt of rational analysiS, it authority is influenced by the rational analysis and by the social goals of the overall plan. may be added that while the allocation for health in the Union of Soviet Socialist Republics is in the end determined by the criterion of medical benefit, decision is also influenced by the principle of maximum efficiency for minimum expenditure in the organization and administration of the health services.
3. 3.1 Pre-planning
THE PIANNING PROCESS
There is a pre-planning stage during which certain requiSites are given attention. At this stage, government's interest in health planning is ascertained.
In the presence of a national
develo~~ent
planning policy, such interest is impliCit and steps are taken to organize the health planning sector. Sometimes this step is difficult or complicated because national administrations may change often. /I.egislation or an •••
WPR/RC19/TDl Rev.l
page 8 Legislation or an executive order may be needed to enaple a health planning unit and/or an advisory committee on health pla.rurillg to be created. Consultative and co-ordination development planning body. duties of the staff. may be required. Pre-planning should also facilitate access to and the use of health services records as these are essential to planning. As with any community-wide activity, the public should be acquainted with the steps being taken for health pla.ruring the reasons why. 3.2 Planning strategy Where national development planning is an established policy, there is a central planning body responsible for the formulation and continuing evaluation of the national development plan. than not, health'l',ould be a sector of the national plan. More often The inter~~d
mecr~isms
are established with
other agencies having health-related functions and with the national Operational arrangements should ensure that planning proceeds with the least interference with the regular Health staff at all levels need orientation on the planning process and for this activity an extra budgetary outlay
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given
pretation and application of the national development planning policy in respect to the sectors is a responsibility of the relevant Minister or department head. These officers also direct and approve the sectoral plans before they are submitted to the national planning body and eventually to the highest political authority. A national development plan, and consequently its sectors also, may consist of long-term (ten-twenty or more years). medium-term (four-seven years) and annual plans. A long-term plan fashions in A medium-term plan perspective form the organizational and investment proposals to accomplish the goals of the entire plan period. articulates into the long-term framework the plan of action for its /shorter-term •••
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~19~1 Rev.l page
9
shorter-term objectives: this plan often reflects the accent of the current government administration even though the long-term goals may remain the same. medium-range plan. The annual plan, together with the annual budget, At the end of each planning year, an evaluation is should present the details applicable to the operational year of the made of the target accomplishments, the efficiency of the techniques used and other items, on the basiS of which revisions may be made in the plan for the ensuing year.
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In general, health planning is undertaken at three levels: local,
on account of differences in needs, problems and resources; regional, to supervise and to allocate resources to local plans, and to undert&ce regional plans; and national, to assist the health authority in formulating the health policy, to supervise and allocate resources to the regions, to undertake vertical programmes (e.g., training, malaria eradication), to formulate and test standards and norms and to maintain liaison and collaborate with th& government overall planning body.
3.3 Illustration of a health planning methodology: the PAHO/CENDES approach The collaborative effort in 1962 of the Pan American Health Organization and the Centre for Development Studies of the Central University of Venezuela resulted in the formulation of a planning methodology, popularly known as the PAHO/CENDES Methodology. Since publication of this work in 1965, entitled "Health Planning: Problems of Concept and Methodology", critiques of the methodology have appeared in the literature. Because of the wide use made of this methodology L~
in the developing countries of Latin America and the Caribbean, it has been selected as an illustration of a planning methodology document. this In this approach four stages are recognized, viz., diagnosis,
preparation of the plan, implementation (or execution), and evaluation and revision.
3.3.1 The diagnOSiS stage corresponds to what traditionally is referred to as the "definition of the health problem". This stage /involves a review •••
~9~1
Rev.l
page 10 involves a review of the health condition, its assessment, and a prognosis of mat the health condition is likely to be within a specific time period. 3.3.1.1 The review of health condition This requires good sources of information. The most readily avail-
-, -
able are the health services records, vital statistical reports and other related information usually obtainable from official agencies. The data should cover a reasonable period (say, five years) in order to secure a more reliable and representative information. Genera.l or ~
special health surveys may be conducted to secure needed information or to supplement and/or verify that available from the official records. The study of the characteristics of the population entails consideration of the level of health. As better criteria for this are Mortality not yet available, use is made of mortality and morbidity figures until such time when better means of measurement can be adopted. figures are used in the analysis of reducible diseases, while morbidity figures are in general used as a yardstick of the community demand for medical care. Mortality data are expressed by cause and age, In Latin America,
mortality analysis is simplified somewhat by classifying one or more diseases into individual groups called "health hazards" which. although varying in etiology, may have a common or similar form of transmission or conditioning factors and are, therefore. specific health measures. ~lorbidi ty figures are also classified by cause and age, sL~ilarly
vulnerable to
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The
usual sources of information for these are the records of hospitals and dispensaries or outpatient clinics.
Consideration of ~nvironmental factors affecting the health situation includes the physical, economic and social aspects. This exercise employs the classical epidemiological &18.lysis which is familiar to most health workers. IOther observations
WPa(RCl9VlDl Rev.l page 11 other observations, including information from regions and local areas, have relevance to planning. Information on population clustp.rs not reached by the health services because of physical barriers (distance, inaccessibility) are needed to plan the expansion and development of these services. Identification of sites and sizes of population groups with and without water supplies and waste disposal systems is not only important epidemiologically but also useful in making cost estimates of health investments. Knowledge of population attitudes is essential and the availability of certain indices is useful
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(e.g., literacy rate, helps in determining the feasibility of initiating community health programmes by educational means). The determination of the impact of health policy on the health situation is one of the principal tasks of diagnosis. with assessir~
It is concerned
the efficiency with which allocated resources are
currently contributing to health as well as the allocation changes necessary to accomplish desired results in the future. By
resources are meant all the capital and labour which are They are utilized with a view to eliminating
allocated to health. the community.
or modifying the causes adversely affecting the level of health in A task or activity is an organized effort designed to modify or remove factors that contribute to a health hazard (e.g., vaccination) \~le a technique or method consists of a series of tasks which are employed to combat a health hazard (e.g., vaccination and epidemiological investigation in the prevention of diphtheria). of resources combined in accordance \,Ii th established criteria to perform a special function (e.g., for the task of vaccination, the instrument unit would be a vaccination-hour). The term instrumentation is applied to the determination of the exact distribution of the total resources into operational or functional units (i.e., instruments) capable of carrying out specific tasks. The process includes an analYSis of the attributes of each task (Viz., Each task is carried out by an instrument measured in units which is made up
I quantity,
...
W~19/TDl
Rev.l
page 12
quantity, composition,
con~entration
or the number of times Ithe task
must be performed to accomplish a desired action, and population coverage) and its corresponding instruments (viz., composition, quantity, output and degree of use). the entire period of the study. This exercise must be performed in To calculate the volume ~
eaoh of the existing health faoilities of the planning area and oover cost of among The the resources for each task, an assessment of their distri~tion
the different departments of the health services must be made.
outcome of the exercise leads to the determination of the quantity and cost of the resources used in the attack against each specific
health hazard during the period under study. The next step is to determine the cost of preventing a death or effecting recovery from a specific disease. resources. This will provide information on the degree of efficiency in the ourrent use of the available Effioienoy is a relationship between cost and effeot and may be expressed in terms of the "number of deaths prevented" or
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"number of sick people reoovered" in return for eaoh unit Qf money invested. Certain procedures and illustrations are sugges~ed
in the
PAHO/CENDES methodology for the oalculation of these values. The values obtained for the actual techniques in use will reflect the observed efficiency of the health policy in a given health hazard. It is then compared with the standardized value of the efficiency of that teohnique as may have been adopted by the planning authority. The findings offer a means for guiding fUture action and is a usefUl guide in making a decision on the resource allocation. It should be noted that the procedures for calculating deaths prevented or oures effected are applicable only to the reducible group of health hazards (i.e., conditions which can be prevented or cured). They do not apply to the non-reducible group (i.e., those which have no definitive means of prevention or cure) as present knowledge gives no assurance that any remedial action t~n against them will be successfUl. Consequently, the values obtained on the /quantity of the •••
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WPRIRC19/~ Rev.l
page 13
quantity of the types of services rendered for the non-reducible group during the diagnosis stage are taken as the the minimum demand for medical care in the community which must be satisfied. services. The allocation requirements are based on the cost per case treated in the different The decision is admittedly arbitrary but it may be justified if the resources are employed as effectively and economically as present knowledge and experience will allow. The assessment of the health situation (or "evaluation" in PAHO/CENDES methodology) will require standards for making comparisons to obtain an objective judgement as to whether or not the health situation is satisfactory. be
Ideally, the construction of a model
reflecting the component factors influencing the level of health would useful. Unfortunately, the extent of relationships between this Consequently, the areas of level of health and other influencing factors is virtually unknown, e.g., water, housing, education, etc. comparison are restricted to the relative advantages of the various alternative uses of resources, or, in other words, to the area of health policy itself. In principle, a suitable standard is one which gives the maximum value of results obtainable with given resources. The application of this principle would entail the study of how the resources are distributed among the various activities, what techniques are applied in each of these activities, and to what extent each available instrument is used to best advantage. Then a comparison is made of the results obtained in (1) if the resources terms of the reduction in mortality and morbidity:
had been allocated in a different manner, (2) if they had been employed at full capacity, and (3) if inefficient techntques had been replaced. These comparisons may not be possible until the plan is implemented although the planner may gain an approximate idea of the order of magnitude of their differences at the diagnostic stage. The assessment procedUres would suggest that while at the beginning of planning, norms (formulated on the baSis of past experience and/or the qualified / opinion of the
WPBjRC19/TD:l Rev.l page 14 opinion of the experts) may be justified, efforts should be taken by means of operations research and from actual experience to formulate standards which can be further improved over time. It is desirable that a prognosis of the health situation should be made. This is a judgement of what may happen in the future There is assumed an accurate knowunder a given set of conditions.
ledge of the present state of affairs and of certain foreseeable circumstances which may modify the future condition. period. Two
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The time to be
covered in the prognostication should at least span the planning hypotheses are used in making the prognosis, viz., that the present situation (health level, conditioning factors, resources in relation to the population) will continue its observed trend; and that certain factors (e.g., environmental) will be subject to foreseeable changes (e.g., broad developmental programmes of other sectors) the effects of which can be estimated. The prognosis serves as a baseline for comparing the effects of changes in the health policy when new or modified objectives are introduced and, therefore, also for future evaluation. One problem in making a prognosis is the inadequacy in the quantity and quality of health information in many developing countries. In view of this, administrative steps should be taken so that better information becomes available in future planning. 3.3.2 Preparation of the plan Completion of the diagnostic stage facilitates the formulation of the national health policy which involves the adoption of the objectives and the allocation of resources. for inclusion in the plan. 3.3.2.1 Objectives Programmes to carry out the objectives based on the approved health policy are then developed
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It will be recalled that a distinction is made between the reducible and non-reducible groups of health hazards. For the first, /priorities are •••
---priori ties are established. be satisfied.
w~~ Rev.l
page
15
The second group is recognized as
reflecting the minimum community demand for medical care which should
In the reducible group, the relative importance in the community of each specific health hazard is assessed on the basis of its magnitude (proportional mortality in per cent. in relation to the importance. ~tal
mortality), vulnerability to prevention and/or treatment, and social Consideration is then given to the individual cost of The principle adopted preventing a death from each of these conditions.
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in assigning priority to this group is that the ranking health hazards Which will cost the least in preventing a death will be tackled first and so on down the line according to available resources. 3.3.2.2 Allocation of resources The guiding principle is, first, to allocate the resources to meet the medical demands (hospitalization, consultation) corresponding to the non-reducible group of health hazards (including a residual number coming from the reducible group) and second, to use the balance of the resources for the reducible group according to priority. Resource allocation to planning areas is based on the local diagnosis and on the observed differences among them. There should be awareness of the fact that there is in each planning area a given quantity of human and physical resources already available to which are added the annual operational outlays and new investments. 3.3.2.3 Health manpower reqUirements Manpower requirements of the health services will normally be covered in the proposals from the planning areas. this is obtained by instruments. analysi~
Information on
of the composition of the instruments observed composition of the instruments
and from the corresponding schedules for the standardization of the A review of ~~e
will indicate immediate needs While the annual programmes of work will point to the number and type of individuals to be added progressively. /:u,cal plans •••
WPlVRC19/Tl>1 Rev. 1 page 16
Local plans should present their manpower requirements' according to category: physicians, nurses, sanitary inspectors, etc. Regional authorities should consolidate and co-ordinate local personnel needs as indicated by the respective plans, adding the personnel required £or executing activities at the regional level. The same procedure is followed at the national or central level which will also prepare a list or schedule broken down into regions and by type of need, both immediate and £uture. The schedule of personnel needs prepared at the central level is then compared with probable availabilities. other sectors are taken into account. The projection o£ health manpower need and availability will provide a guideline for planning to the educational sector and enable the health authority to expand properly training activities for which it is responsible. In this exercise, the teaching capacities of educational institutions and the demands from
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3.3.2.4 Guidelines in plan formulation In the absence of criteria for resource allocation among the sectors, recourse is taken in local planning to prepare a minimum and a maximum health plan. The minimum plan is intended to maintain at A least the existing level of health and prevent its deterioration. maximum plan has the aim of realizing the maximum level of health feasible in the minimum of time at the least cost. should additional resources materialize. Local planning should generally follow the principles already discussed. It should endeavour to develop or improve local criteria and standards as will permit better evaluation o£ the actions taken and reduce the element of arbitrary decision. In considering resources, account should be taken of the installed capacity already available. The existence of both plan proposals will permit the adoption of an intermediate plan
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An estimate
shoul~ be made
/of additional •••
~RC19/TDl
Rev.l
page 17 of additional demands arising from the anticipated population increases and which can be met through new investments and/or improving or introducing new techniques. Calculation of new requirements should include consideration of: (a) latency of instruments wherein results may come later; (b) inadequacy of organizational machinery to accomplish desired targets which may entail a re-calculation; (c) introduction of a new element or innovation which may radically affect the plan itself. e.g., medical discovery in therapy. It should be appreciated, however, that the continuity of the
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planning process enables the appropriate handling of these problems as they arise. Apart from the basic criteria connected with resources allocated in reducible and non-reducible health hazards, planning should also take into account the community aspirations for health and make provision for health services extension in isolated areas. Regional planning entails allocation of resources. co-ordination. supervision and undertaking regional programmes. Allocation of resources to local areas involves decisions as to whether minimum, intermediate or maximum local plans will be undertaken and for which criteria should
.>.
be established.
wcal plans are co-ordinated and supervised throughout Regional pro-
the process by the regional health planner in accordance with the appropriate administrative set-up and procedures in force. grammes are introduced when they can be more effectively executed at this level than locally. e.g., health personnel training, reference services, etc. In sumrnary, the regional plan submitted to the central
health planning authority consists of local plans (which may range from the minimum to the maximum) and regional programmes. Likewise, tile national plan consists of regional plans plus centrally directed programmes (e.g., malaria eradication, certain types of training, etc.). J
The national planner prepares the frame/comm1tments •••
work of the national health plan which should include international
WPR/RC19/'l'Dl Rev;l page
18
comltments.
He formulates also the guidelines for the allocation of The
resources as well as for the plann1ng methods, including standards for instrumentalization to be carried out at lower levels. national planner participates with the national development planning authority and the other sectors in the preparation of investment projects and in drafting legislation and regulations to faoilitate the execution of the tasks proposed under the plan. Overall supervision for the development and evaluation of the health plan, including consideration of plan revisions, is also a function of the central health planning body. Finally, the national planning officer maintains liaison and works closely with the national development planning authority and with related sectors and interprets to them the goals and the methods of the health policy.
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3.3.2.5 Discussion and decision A requirement of the completed plan is that it must be feasible, internally consistent, and efficient. The consistency must not only lie within the health plan itself but be in relation to the overall policy and organization of the national development plan. ;'!he central planning authority ensures that the various sectoral plans'are consistent with the overall development policy and strategy before incorporating them in the national plan. It is desirable that the
national health planner should prepare alternative plans entailing financial allocation at lesser and at greater amounts than the proposed plan. Such a step will permit ready adjustments in the event that the total funding for planning suffers a change as a result of revisions in the revenue estimates. Implementation (or execution) Proper implementation depends upon a good organization and administration. Good administration requires the involvement in planning of the health workers who will be implementing the plan.
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/Competent supervision •••
Wl1Vl\C19/TDl Rev. 1 page 19 Competent supervision is required to see to it that the objectives are being pursued with the appropriate teohniques. Shortfalls in performance should be identified and remedies instituted. Implementation requires oommunity involvement which is gained if the population is informed or otherwise involved in the planning process. Evaluation and revision The plan needs regular evaluation. Changes in the health
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situation may require a revision of the objectives or their targets, or a modification of techniques. Experience and new discoveries may The dynamic nature of the lead to the adoption of better standards or norms which enhance performance and thus lessen unit costs. health situation necessarily entails changes Whioh the built-in evaluation mechanism should not fail to detect. 4. PLANNING AS AN ArMINISTRATIVE TOOL
Planning is a function of administration and operationally the two are inter-dependent. Planning is essentially programme-oriented A programme is
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and needs an administration for its execution.
construed as consisting of all activities designed to accomplish an objective or group of related objectives of the plan and the latter is, in prinCiple, designed to carry out effectively the administration's functions. Apart from programme delivery, which is an accomplishment of the health policy, the planning process offers other assets to administration. These include improvements in the organizational structure further to programme delivery. In addition, the and operation, and increased opportunities for inter-agency co-operation
which contribute
planning process, together with the plan it formulates, offers a means for enlisting community support to health activities Which the health administration is always endeavouring to rally. /The mechanics
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WPR/RC19/T.Dl Rev.l page 20 The mechanics of plan developnent (and consequently of the programmes) have already been discussed. It is now proposed to consider briefly the other applications of planning in administration. 4.1 Influence on organization and administration Information on the health condition gained during the diagnosis stage is augmented by such built-in mechanisms of planning as improved collection, quality and analysis of the records system, information retrieval and dissemination, and the periodic evaluation eXercise. From these mechanisms a ready source of information is obtained which helps in making administrative and technical decisions. The analytical approach inevitably leads to the study ·of the structure and operation of the health organization. of staff, apart from other considerations. AnalySis of the techniques involves the assessment of the compoSition and utilization Questions of o'lter- and under-staffing in relation to targets, as well as their efficient utilization. come under scrutiny and the problems revealed pave the way for their solution. Health agencies which plan necessarily adopt the prinCiples and tools of planning, e.g., critical analySis, cost-effect criteria in selecting techniques, evaluation; the effeot is to help staff in improving performance of their various activities. Administrative performance is further improved when efficient techniques are used. terms. In the past, techniques were introduced in the field without pre-testing and were assessed in generally empirical Such an approach is fast giving way to pre-testing in pilot areas with the result that techniques are more effective, economical and more locally suited in the context of the prevailing situation. Resources which otherwise would be wasted are thereby conserved for better plan use. The health agency should make facilities available (e.g., pilot areas) for operational research in developing and pretesting techniques as well as for continually improving standards. /Functional •••
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VPB/RCl9/'ml Rev.l page 21 Functional units must also engage in research which should be built into their own organizational make-up. Internal co-ordination and co-operation among the functional units are promoted. This is helped by the fact that the staff through orientaAnother reason is that tion/training in health planning are better able to recognize each other's roles in the larger frame of overall plan goals. the performance of the functional units can be measured and their problem areas pin-pointed; thus, the team spirit for accomplishment is stimulated and the units are able to act more intelligently and co-operate with each other in undertaking their individual tasks. The administration is continually under pressure to support and justify the budgetary outlays for health. It has been said that the The health traditional budget looks only one year ahead and gives no indication of future spending in relation to current expenditure. plan, on the other hand, offers concrete justifications as it is able to show programmatically the relationship between outlays and results (or input to output). The ideal budget for planning is the programme budget. a perspective of the total resources requirements covered in each programme of the plan. and
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This offers
the targets to be by.pr~e,
In the health sector, the health
planner is thus able to match costs and results, programme made. f __ ~
from which he can derive informed judgements on the priorities to be Likevdse, inter-sectoral comparison of programmes is made In the health sector, the programme The health possible for the overall planner.
budget offers a ready source of information on programmes based on the application of the "benefits of progress" principle. planner is thus able to see and match costs with other programmes and this helps him determine the extent to which this prinCiple can be supported especially Mlen resources are scarce.
4.2 Opportunities for inter-agency collaboration {
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The health authority very often has statutory and other meanS of liaison and even CO-Ordination with other agencies. In practice, /however •••
WPR/RCl9/TDl Rev.l page 22 however, many such relationships have limited scope while others may be of an ad hoc kind. Two bodies are frequently associated with planning in the health agency, viz., the health planning unit and the advisory colllllli ttee on planning. The health planning unit would necessarily have continuing working relations with the central planning body and with other sectors. Through these links the health authority acquires increased sources of information. duplication Such arrangements should also minimize possibilities of and
offer opportunities for collaboration in areas of
mutual interest. An advisory planning committee is useful even when a health planning unit is already established. or investment in health. Its membership should include representative elements or groups in the community having an interest A comm1 ttee of this kind provides a forum and
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for the exchange of information and views on important health questions including expressions of health demands problems. reactions to current health In some countries, this type of committee has been employed
as a medium for co-ordinating health allocations being received from private sources. Co-ordination should work both ways. While health shbuld attract The areas of collabora-
the participation of the other agencies, it should also make itself available to the activities of other agencies. tion with the other sectors are widening. In the past, health colla-
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borated in various ways with education and community development. The continuing technological advances and the social progress being achieved increasingly points to the need for collaboration with commerce and ind1.lstry, public works, labour, transportation, etc.
4.3 A means for enlisting community participation The COmmunity should ideally be involved in all stages of planning. This can be promoted through membership of community leaders J
lin
the adviSOry •••
WPIV'RCl9/'l'Dl. Rev.l page 23 in the advisory planning bodies and through consultations and discussions on health matters with community groups. It will be useful to inform the community of the progress of planning. Reports should be factual and accurate; the contents should An This is include both the positive and negative results of the plan. objective report promotes the confidence of the public. essential before its support can be obtained. The information made available should be disseminated through the
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regular channels of information and education of the health agency • The appropriate functional unit.s should be sensitive to community reactions and sensibilities to certain programme aspects in order that they can more realistically define their approaches to enlist community support.
4.4 Planning not a formula but a tool From the foregoing it will have been noted that the plan comprehends the whole health endeavour and that planning is intimately bound up with administration. Planning cannot be a formula for decision-making. a limit to the analytical approach. for health care confront He must therefore The social
context of health introduces a complexity of variables which imposes f.1oreover, various community demands the public health administrator requiring rational choices as l'1e11 as the social· Thus planning cannot also
decisions other than the choices offered by the analytical approach. sift~ throug.'1.
demands which he can ill-afford to ignore. affecting the plan will ultimately be made.
substitute for leadership upon whose judgement and intuition decisions
Nevertheless,planning by nature of its process serves as an effective administrative tool through which the public health administrator is able to sharpen his knowledge and understanding of health conditions and this help him in making decisions. Despite the limits of present knowledge and facilities, planning can be very involved; it may include the use of the computer in sorting / and analysing •••
WPR/RC19/TDl Rev.l page 24 and analysing the mass of health data and information aVailable.
It
is on the other hand possible and even desirable to undertake planning even when there are limited sources of information and when the resources are modest, such as are frequently seen in developing countries. Once started, the planning process generates continuing internal organizational and administrative improvements which facilitate the more rapid attainment of plan goals.
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·. it1:P.B,IECJ..~ Rev.l
page 25
REFERENCES
1.
Baber, T.D. & Perlman, M. (1967) Health manpO"iler in a developing economy: Taiwan. Press, Baltimore A case study in planning, Johns Hopkins
2.
Barkhuus, A. (1967) Review and annotations on national health planning methodologies: (In preparation) Report of a WHO study, Geneva
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3.
Duran, H. (1966) Methodology for health planning in latin America, Expert COIIIIl1i ttee on National Health. Planning in Developing Countries, 27 September -
3 October 1967, Geneva
(Unpublished document
NHP/INF/66.2) 4. Michael, J .M., Spatafore, G. & Williams, E.R. (1967) An approach to health planning, Pub!. Hlth Rep. CVl§l.sh~
82:12, p.l063 5. Pan American Health Organization/Regional Office of IrlHO (1965) Health planning: problems of concept and method, Washington D.C.
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6.
Stebbins, E.L. (1968) History and background of planning, (Unpublished lecture in the National Health Planning Course, School of Hygiene and Public Health, Johns Hopkins University, Baltimore)
7.
World Health Organization (1961) Planning of public health services: Fourth report of the Expert Committee on
Public Health Administration, Geneva (Wld Hlth Org. techno Rep. Ser., 215)
8.
World Health Organization (1967) National health planning in developing countries: Report of a WHO Expert Committee,
Geneva (WId HUh Org. techno Rep. Ser., 350)