Health Program Planning

CHSC 433Module 1/Chapter 3

UIC School of Public HealthL. Michele Issel, PhD, RN

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

1. List pros and cons of the types of planning identified by Beneviste.

2. Appreciate the challenges involved in being a health planner.

3. Understand where and how in the planning process involvement of stakeholders is appropriate.

Notice:

Lack of planning

on your part does not

constitute an emergency

on my part.

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)

Purpose of Planning

To determine the program prioritization and gain support for the program

Part of Cycle (on next slide)

Assessment of CommunityNeeds and Assets

Program Developmentand Evaluation Planning

Program Process TheoryImplementation

Participant-RecpientImpacts and Outcomes

Process EvaluationImplementation

Impact EvaluationImplementation

Trigger Event orOpportunity

Health ProgramPlanning

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

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

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

Planning Perspectives

According to Beneviste

According to Forester

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

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

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

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 ~ ?

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

From Perspectives to Priority

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

Prioritizing per Dever (1)

1 Determine size of health problem(s)

•Use health indicators :• mortality, morbidity, utilization,

satisfaction

•Use epidemilogy measures :• rates, proportions

Prioritizing per Dever (2)

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

Prioritizing per Dever (3)

3 Determine intervention effectiveness• Review literature on various possible

interventions, programs, treatments

• Use evidence-based practice guidelines

• Conduct pilot program with intervention

Logic Model of Public Health Assessment for Planning

Hampering factors(Assets and

INTERVENTIONS)

HelathProblem

HealthIndicators

Risk of:

Determiniant factors ofthe health problem

As demonstrated in

Contributingfactors to the

health problem

Antecedentfactors

Among target audience

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

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

Dever/Hanlon Approach

Implies apolitical and rationality to problem prioritization

Reality is that values, preferences, motive can surface and affect the process

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

Planning at macro level

Think across the Pyramid (developed by the Maternal and Child Health Bureau)

Health Policy formation is decision making

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

(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

Conclusion

Principles

Challenges

Roles of

Planners

Paradoxes

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

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

(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

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

Public Health Pyramid

Direct Health Care

Services____________________

Enabling Services___________________________

Population-Based Services___________________________________

Infrastructure Services

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

Data for Problem Size, Seriousness, Importance Across the Pyramid

Problem LEVEL

Problem Size Problem Seriousness Problem Importance

Individual Use epi data with an ecological approach

Epidemiologic data, Trends

Utility measures, Survey data, Focus groups

Enabling (services) (aggregate)

Use epi data

Demand data used to infer seriousness

Logic and theory underlying causes and consequences

Population (services)

Use epi data Normative perspective

Trends

Infrastructure Demand and Need data

Trends data relative to HP 2010 objectives, political perspective

Evaluation data