Population-based planning

Population-based planning claims to adopt a bottom-up approach and usually involves multiple organisations. Such an approach requires authority and ability from planners to achieve cross-boundary cooperation. Resources ought to be allocated to health facilities in a way that can best meet consumer need. Planners – usually government agencies or joint councils – must develop a good understanding of the competency, capacity and willingness of various providers and consumers to execute the plan (Coakes & Kelly, 1997). Population-based planning tends to regard health promotion and disease prevention as priorities rather than focusing on treatment of diseases (Issel, 2009).

Institutional-based planning

By contrast, institutional-based planning adopts a top-down approach and is often anchored on a single organisation or group of organisations aiming to maximise gains (in terms of finance or health outcomes or both) from the invested resources. Such planning usually focuses on the extent to which a difference is made to those who receive or would receive the services (Issel, 2009) and tends to ignore those who are not covered by the services. Therefore, the benefit to overall population health may be limited and dependent on the scope of services that may be able to be delivered by the organisation. Many health organisations perform institutional-based planning for reasons of efficiency and/or cost-effectiveness (Eagar et al., 2001).

Reasons for planning

There are many reasons why health managers perform health service planning. Firstly, the health market is easily manipulated and distorted, and population health is simply too important to be left unplanned (Gage, 1979). The human population is characterised by rapidly changing morbidity and health needs due to prolonged life expectancy and scientific advancements. Despite this, many health technologies and products brought to the market lack scientific evidence support in terms of their efficacy (Vayda, 1977). Health provision is an example of a free market approach being problematic, because there is a distinct power and knowledge imbalance between consumers (patients) and suppliers (health professionals). Consumers often feel disempowered in health consumption decisions, as they often do not have a complete understanding of the issues. Suppliers have significant power, not only because of their inherent specialist knowledge, but also because they act as gatekeepers to treatments and drugs.

Secondly, a society can only offer services it can afford, and governments often have to meet competing demands from other services, such as defence and social welfare (Semple, 1977). Escalating health expenditure has become a public concern in Western countries, regardless of whether the method of financing is socialised or privatised, or a mixture of the two. Health service planning enables people within the system to collect anecdotal evidence of program effectiveness (Issel, 2009) and rationalise health expenditure.

Thirdly, there are several control measures growing out of planning, ‘from a centralized and directed kind to a decentralized, negotiating and bargaining type’ (Anderson, 1969, p. 345) for the purpose of achieving better quality care and reducing waste. And finally, in countries where public spending on health accounts for a large proportion of total health expenditure, health service planning becomes a political signal for accountability: by the end of 1970s, most developed nations had produced and commenced implementation of national health plans (Anderson, 1969; Gage, 1979).

Health service planning can be triggered when a particular health problem emerges as a public concern, when periodic strategic planning is performed in an organisation or when new funds have become available – or a new willingness to release them has emerged (Issel, 2009). It can also be triggered on the emergence of new evidence in relation to a particular service program.

In recent years, breast cancer screening services have attracted a great deal of debate among researchers, politicians and consumers. One would expect a screening program to reduce the overall mortality associated with this cancer; otherwise, it might produce the unnecessary burden of overdiagnosis and potentially unnecessary treatment to consumers (Gotzsche & Jorgensen, 2013). Although the World Health Organization acknowledges the effectiveness of mammography-screening for a 25 per cent reduction of mortality of breast cancer (Weedon-Fekjær, Romundstad & Vatten, 2014), this was challenged by some researchers in a Cochrane Review (Gotzsche & Jorgensen, 2013). Two research articles on the subject of mammography for reducing mortality of breast cancer were recently published in the British Medical Journal, with one claiming no effect (Miller et al., 2014) and the other claiming a significant effect (Weedon-Fekjær et al., 2014). Meanwhile, consumer demand for breast-screening services remains high, especially with the recent advent of high-profile celebrity disclosures increasing demand (Evans et al., 2014) and with breast-screening being one of the most successful of all cancer-screening programs (Sullivan et al., 2003). This has led to a potentially awkward situation for managers in deciding whether resources allocated to breast cancer screening should continue unchanged or perhaps be diverted to other services. The debate is expected to continue and is unlikely to be settled in the short term.

Management and health service planning

Health service planners

Health service plans ought to reflect the needs of target populations, which means that planners have to consider and balance the interests of various stakeholders (Gagliardi, Lemieux-Charles, Brown, Sullivan & Goel, 2008). The constantly changing models of service delivery add to the complexity. (Gauld, 2002). Issel (2009) argues that at least three areas of expertise are critical to health service planning: expert knowledge and experience of the health problems; research skills in epidemiology, social and behavioural science; and skills in fostering agreement across diverse constituents, capabilities and interests.

Consumer participation is essential in health service planning (Eagar et al., 2001; Issel, 2009; Thornicroft & Tansella, 2005), because it is an opportunity to foster effective provider–recipient interaction, with ideas and energies flowing towards the services, and results and respect from the services. Such two-way interaction facilitates implementation and, it might be hoped, contributes to ultimate consumer acceptance and satisfaction.

Participation of frontline health workers in planning processes is increasingly valued (Dyck, Tiessen & Lee, 2013; Thornicroft & Tansella, 2005). Medical practice in the Western setting has a long tradition of individual-based decision-making (Liu, Bartram, Casimir & Leggat, 2014). Since the very inception of health service planning, the failure of ‘government authorities’ to include frontline health providers has attracted criticism, because ultimately these personnel provide the services. Richards (1981) argues that general practitioners are best placed for participating in local health planning. There are many barriers to engaging consumers and frontline health workers in a meaningful way. A lack of trust, skill, time and effective mechanisms for provider participation is common in many health systems (Gagliardi et al., 2008; Liu, Liu, Wang, Zhang & Wang, 2013).

Decision-making

Health service planning often requires difficult decisions: priorities have to be established, and limited resources need to be directed towards identified priorities or needs. These decisions should reflect core values and principles that guide the overall planning processes. Those core values usually include accessibility, equity, efficiency, quality and effectiveness. Some (for example, efficiency versus accessibility) may come into conflict in planning (Eagar et al., 2001).

The pattern of stakeholder participation in planning processes dictates the values and principles adopted by planners. Issel (2009) summarises six approaches to stakeholder participation (see Table 30.1). Although these are not mutually exclusive, it is not uncommon for a responsible authority to favour one more than others, leading to a particular approach in the manner in which planning exercises are conducted. It would be more useful to see those ‘approaches’ as skills that are required under different circumstances to reach consensus.

Various stakeholders are given different opportunities to voice their concerns within these six approaches. A comprehensive rational approach pays particular attention to the balance and equality of stakeholder participation in planning. Both the communication action and advocacy approaches place significant weight on the concerns of those who experience the problems targeted by the planning, although the latter often depends on planning experts, who may misunderstand their constituents. Health professionals generally shape the incremental and apolitical approaches, whereas collective interests of health professionals are addressed in the strategic planning approach.

There is a consensus that governments should not intervene in the internal management decisions of service providers (Liu et al., 2014); however, it is hard, if not impossible, to avoid political influence, especially if the government is the primary funder of the service. Governments often want service providers to align their planning with a set of unified goals (Department of Health, 2011). Political agenda may also shape priority settings. For example, in the late 1990s, the Clinton administration in the United States put racial and ethnic disparities on the public agenda, leading to increasing service programs aiming at eliminating ethnic disparities (Issel, 2009).

Cultural values shared by the general public have a significant influence on decision-making in health service planning. For example, medical care services are more likely to be seen as an individual responsibility by people residing in the United States, whereas in Australia, Canada and many European nations, people would regard the provision of health services as a universal and therefore public good. In the Global Burden of Disease Study, people of workforce age used to be valued higher than the others (Sabik & Lie, 2008). This has recently been abandoned (Australian Institute of Health and Welfare, 2014), because of oppositions from some countries who argue that human dignity and social solidarity should not be displaced by economic productivity (Rosen, De Fine Licht & Ohlsson, 2014).

Frameworks for health service planning

Before detailed planning commences, a working group, often in the form of a consortium, needs to be established which ideally comprises from five to seven people (Issel, 2009). The group is responsible for devising a set of principles and core values to guide the planning process. This is perhaps the most important and most often neglected step. Failure to adequately define the scope of the planning will ultimately lead to a quagmire of well-intentioned but ultimately useless plans.

The ultimate goal of health service planning is to assure that the resources available to various health programs achieve the best possible outcomes with the greatest efficiency (Eagar et al., 2001; Gaston, 2005); however, defining outcomes in isolation is often difficult. Internationally, there is a trend to incorporate ideas generated from the public and communities into health planning goals (Issel, 2009).

Once desired outcomes are defined, they will be measured with indicators. Each indicator offers a certain perspective by measuring the effectiveness of the interaction aimed at the health problem. Common indicators used in health service planning measure frequency (prevalence and incidence) of problems, severity and duration of problems, and cost and frequency of use of services (Fazekas, Ettelt, Newbould & Nolte, 2010; Department of Health, 2011).

Health service planning is usually conducted in a cyclical manner, involving assessment of problems, prioritisation and implementation decisions (Fazekas et al., 2010; Gaston, 2005). Evaluation also forms an integral part of planning. It not only demonstrates the effectiveness of planned actions but also feeds into a new cycle of service-planning (see Figure 30.1).

Figure 30.1 Health service planning cycle

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