Health Program Planning

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Health Program Planning

• CHSC 433
• Module 1/Chapter 3
• UIC School of Public Health
• L. Michele Issel, PhD, RN

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Learning ObjectivesWhat you ought to be able to
do by the end of this module

• List pros and cons of the types of planning
  identified by Beneviste.
• Appreciate the challenges involved in being a
  health planner.
• Understand where and how in the planning process
  involvement of stakeholders is appropriate.

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Notice

• Lack of planning
• on your part does not constitute an emergency
• on my part.

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Planning is

• Effort to control social or collective
  uncertainty by taking action now to secure the
  future (Marris in Hoch, 94)
• Good planning is the popular adoption of
  democratic reforms in the provision of public
  goods. (Hoch,1994)

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Purpose of Planning

• To determine the program prioritization and gain
  support for the program
• Part of Cycle (on next slide)

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Brief History of Public Health Planning

• Environmental planning of water and sewer systems
  in antiquity
• Population planning with the advent of
  immunizations
• Blum advocated for rational approach for health
  planning
• Advocacy planning of the 1960's was a break with
  the rational approach
• Increasing attention on risks

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Risks and Protection

• Risk as a perception about possibilities of
  adverse event
• Active (requires behavior change) protection
• Passive (change in the situation or environment,
  not the person) protection
• Micro (individual) and macro (system) approaches
  to risk reduction

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Threats to effective risk reduction (Per Blum)

• Conceptual anemia
• Wishful thinking
• Social irresponsibility
• Failure to analyze problems
• Failure to examine possible interventions
• Failure to be conversant with the implementation
  pathways
• Blaming the victim

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Planning Perspectives

• According to Beneviste
• According to Forester

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Beneviste Planning Perspectives

• Comprehensive rational is systems approach
• Advocacy planning is client focused and citizen
  participation focused
• Apolitical politics uses technical knowledge to
  achieve compromises
• Critical planning is concerned with the
  distribution of power and communication
• Strategic planning focuses on the organization
• Incrementalism takes small, discrete steps

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Examples in Public Health (can you think of
other examples?)

• Comprehensive rational implementation of WIC
  program
• Advocacy planning CDPHs anti-violence
  planning, advisory boards
• Apolitical Evidence based approaches to
  medicine and health care
• Critical planning HIV/AIDS groups
• Strategic planning state health plan, local
  health department annual plan
• Incrementalism HP 2010

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Planning Perspectives Reasons to Reject per
Forrester

• Rational approach assumes means and ends are
  known, can anticipate the future
• Problem-solving technalizes social problems,
  assumes have solutions
• Cybernetic (systems) perspective does not account
  for norms and values
• Satisficing (meet minimum needs) perspective
  assumes a rational decision making

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Examples in Public Health (can you think of
other examples?)

• Rational approach State health plans
• Problem-solving Health educational programs
• Cybernetic State-wide immunization programs
• Satisficing ?

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Perspective Advocated by Forester

• Communicative action perspective
• Shapes attention of stakeholders
• Changes beliefs of stakeholders
• Gains consent of those with the problem and the
  solution
• Engendering trust and understanding of those with
  the problem

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From Perspectives to Priority

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Prioritizing A reality

• Traditional public health approach as typified by
  Dever who drew on Hanlon
• Utility measures as individual information for
  planning
• Resource allocation as a prioritization

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Prioritizing per Dever (1)

• Determine size of health problem(s)
• Use health indicators
• mortality, morbidity, utilization, satisfaction
• Use epidemilogy measures
• rates, proportions

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Prioritizing per Dever (2)

• Determine seriousness and importance of health
  problem (s)
• Compare epidemiology and normative data
• consider relative risk, odds ratio
• Use utility measures to get at perceived
  seriousness
• Conduct focus groups or surveys to assess
  perceived importance

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Prioritizing per Dever (3)

• Determine intervention effectiveness
• Review literature on various possible
  interventions, programs, treatments
• Use evidence-based practice guidelines
• Conduct pilot program with intervention

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Logic Model of Public Health Assessment for
Planning
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Health Resource Allocation 8 Step Strategy
(Patrick Erickson)

• 1. Specify the health decision
• 2. Classify health outcomes as health states
• 3. Assign values to health states by using
  preferences (i.e., utility measures)
• 4. Measure health related quality of life

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Health resource allocation strategy (continued)

• 5. Estimate prognosis and healthy years of life
• 6. Estimate direct and indirect health care costs
• 7. Rank costs and outcomes
• 8. Revise ranking of costs and outcomes

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Dever/Hanlon Approach

• Implies apolitical and rationality to problem
  prioritization
• Reality is that values, preferences, motive can
  surface and affect the process

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Ways to objectify the Hanlan/Dever Approach

• Educate group using critical or communication
  approach to planning
• Gain consensus on the process and decision rules
  about numbers
• Careful balance in composition of group doing the
  problem prioritization
• Have adequate resources to do all the steps
• Address data trustworthiness
• Consider variability in literature being used

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Planning at macro level

• Think across the Pyramid (developed by the
  Maternal and Child Health Bureau)
• Health Policy formation is decision making

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Characteristics of Health Policy Decision Making

• (1) Innovation within customary and implicit
  rules such that the new is subsumed within what
  is already familiar
• (2) Mutual adjustment by one department (or such)
  in response to the decision made by another
  department
• (3) Bargaining either through direct negotiation
  or using trade-offs to influence the decision
• (4) Move and countermove by departments (or such)
  in the fashion of taking unilateral action that
  forces the actions of another

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(continued)

• (5) Solutions exist and sometimes come before
  recognizing the problem, just waiting for a
  window of opportunity to be applied
• (6) The unanticipated consequences of one action
  can lead to the need for other health decisions
  that were in themselves unintended

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Conclusion

• Principles
• Challenges
• Roles of Planners
• Paradoxes

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Planning Principles

• Have visible, powerful sponsor
• Involve those affected in the planning
• Constitute a planning board
• Have well trained and skilled planning staff
• Be as objective as possible, given the context
• Use rationality as much as possible as basis for
  power

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Challenges in Planning

• Change is distasteful to those affected
• Health perspective does not reflect social values
• Politicians prefer cure, health planners prefer
  prevention
• Politicians have short term view, health planners
  have long term view
• Constituents inherently have conflicting
  priorities, preference, etc

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(Some) Roles of Planners

• Designer of planning technology, Assistor and
  systems facilitator, Problem solver, Inquirer
• Priority setter, Regulator, Decision maker,
  Builder of futures
• Educator, Expander of capabilities, Advocate,
  Activator, Power modifier
• Agency manger

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Planning paradoxes

• Planning is shaped by the same forces that
  created the problems
• The good of individuals and society
  experiencing the prosperity associated with
  health and well-being is bad to the extent that
  prosperity produces ill health
• What may be easier and more effective may be less
  acceptable

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Public Health Pyramid
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Planning across the Pyramid

• Individual Level person focused, direct
  clinical services
• Enabling services aggregate focused, indirect
  care services
• Population services population focused,
  services delivered to entire population
• Infrastructure level the health care
  organization, public health system

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Data for Problem Size, Seriousness, Importance
Across the Pyramid