Health Program Planning

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

2. 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.

3. Lack of planning on your part does not constitute an emergency on my part. Notice:

4. 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)

5. Purpose of Planning To determine the program prioritization and gain support for the program Part of Cycle (on next slide)

7. 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

8. 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

9. 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

10. Planning Perspectives • According to Beneviste • According to Forester

11. 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

12. Examples in Public Health (can you think of other examples?) • Comprehensive rational ~ implementation of WIC program • Advocacy planning ~ CDPH’s 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

13. 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

14. 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 ~ ?

15. 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

16. From Perspectives to Priority

17. 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

18. Prioritizing per Dever (1) • Determine size of health problem(s) • Use health indicators : • mortality, morbidity, utilization, satisfaction • Use epidemilogy measures : • rates, proportions

19. 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

20. 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

21. Logic Model of Public Health Assessment for Planning

22. 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

23. 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

24. Dever/Hanlon Approach • Implies apolitical and rationality to problem prioritization • Reality is that values, preferences, motive can surface and affect the process

25. 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

26. Planning at macro level • Think across the Pyramid (developed by the Maternal and Child Health Bureau) • Health Policy formation is decision making

27. 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

28. (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

29. Conclusion • Principles • Challenges • Roles of Planners • Paradoxes

30. 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

31. 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

32. (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

33. 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

34. Public Health Pyramid

35. 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

36. Data for Problem Size, Seriousness, Importance Across the Pyramid