Strategic Planning in Health Care – General Approach
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STRATEGIC PLANNING IN HEALTH CARE -
GENERAL APPROACH
Doncho Donev, Neda Milevska-Kostova, Adriana Galan
THEORETICAL BACKGROUND
Applying the most advanced health planning and programming methods as well as the
improvement of the health system organization and performance represent permanent
matters of concern for every country.
One of the most famous examples of strategic thinking is the well-known dialogue
from Lewis Ca
oll's ‖Alice in the Wonderland‖:
―Cheshire Puss, ... would you tell me, please, which way I ought to go from
here?‖
―That depends a good deal on where you want to get to,‖ said the Cat.
―I don't much care where-‖ said Alice.
―Then it doesn't much matter which way you go,‖ said the Cat.
―- so long as I get somewhere,‖ Alice added as an explanation.
―Oh, you are sure to do that,‖ said the Cat.
This dialogue reflects very well the essence of a good strategy, which is about the
esults that should be achieved and what the ways are. Planning provides the direction and
the sequence of activities in accomplishing the goals and objectives. To make a good plan
it is necessary to know what are the results expected. In other words, an organization
without a strategy is like a ship without a rudder, going around in circles (1-3).
The Oxford dictionary defines strategy as ―planning and directing of the whole
operation of a campaign or war; plan, policy‖. According to this definition, strategy is
equivalent with plan and policy. Sometimes the terms are used as synonyms, but it would
e a slight difference between them. For instance, World Health Organization‘s (WHO)
definition of ―health policy‖ is: ―A formal statement or procedure within institutions
(notably government) which defines priorities and the parameters for action in response to
health needs, available resources and other political pressures" (2).
Debates in health care today
Health policy is an important and fast-growing area of debate not only within academics
and health professionals, but also within politicians, community groups, the media and the
public. This is due to the fact that health gets more and more importance in the whole
society, and new uncertainties appeared as a result of recent economic and social growth
and development; actually the basis for important policy debates. In the developed
countries, the health expenditure has risen to such levels representing about 10 per cent of
all economic activity and Gross Domestic Product (GDP). Other countries are expected to
follow this trend. The health sector has become the largest employer in the society due to
the explosion of medical opportunities. However, inequalities in health status and
accessibility of health care between countries and within countries are still present and
intensifying. The middle of the twentieth century was a period of triumphalism for
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METHODS AND TOOLS IN PUBLIC HEALTH 851
medicine, but there are signs that the confidence in the technical solution is close to the
end. Technocratic determinants of health care may condition the way in which the
operational level is working, but the overall shape of health care has much more to do with
political, social, economic and historical determinants than with technology (4,5).
The value of health care
Health care is a process which is not limited to the health sector. In the context of Western
medicine, health care is focused on the organised medical care of individuals. This
concern is realised through the application of medical technology by health care
professionals in an institutional setting. However, health care is not always clearly
distinguished from other activities to improve human life and not always valued first and
foremost for the production of health. Health care professionals may see their goals not in
terms of improving health, as the long-term objective, but rather in terms of managing an
organisation, which is sometimes shorter-term day-to-day goal. For some people health
care is a right, a human requirement which any decent society will make available for all
its members. For others, health care is to be seen as an expenditure and the health sector as
producing health care which is the subject of political struggle and capturing votes - a
commodity or resource for which people compete.
Beyond technical developments there is also growing recognition of the
importance of health for the overall objectives of the societies within the European
Community and
oader. Health is a key foundation stone of the overall Lisbon strategy of
growth, competitiveness and sustainable development. A healthy economy depends on a
healthy population. This is doubly important as the European population ages in the
coming decades and beside adding years to life it is necessary to add healthy life to years.
Development planners have often argued that health care should be viewed as an
investment in a healthier and more productive society. An alternative view sees organised
health care as a large industry. Health care may be distributed unequally in the society,
with favourized groups, defined by class, ethnicity, age or other attributes such as skills,
eceiving more than others. The issue of market-based approaches to health care versus
public sector-based approaches runs through all policy debates today configuring debates
about equity, development and sustainability (4,5).
Health policy
Policy should mainly focus on the vision for the future while learning from the past
experiences, outlining priorities, setting clear directions and the main objectives within the
given societal and economic context, and on the role of reaching consensus, and informing
people. Based on the general policy framework, the health plans, programmes and
strategies can be further developed, designing the way in which policy objectives will be
achieved, establishing short- and medium-term deadlines and setting clear responsibilities
for each actor involved. A wide range of policies can contribute to the improvement of
population health and healthier life, ranging from employment and social protection
strategies to risk factors control, health promotion and protection, and changes in the life
style of the population (2,5).
There are four important factors in the process of policy development and
implementation in health care and public health:
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1. identification of health risks/problems and preventive options,
2. intervention development,
3. policy development, and
4. policy enactment and assurance.
In practice, problem definition, political context, and the policy process are inextricably
intertwined, although exerting varying influences at different stages of the policy cycle.
Decision-making lies at the heart of the policy process (6).
Health strategy development
Situational analysis represents an important step of the pre-planning phase for a strategy
development. It actually evaluates the profile of population's health (can be a "target"
population) and the health care system in relation with the internal and external
environment. The assessment can be done based on available and reliable health
indicators.
The main goal of this step is to identify priority health problems based on valid
criteria. Another important goal is to provide data and information necessary to design
goals and objectives for the strategy. Data and information collected during this step cover
the following domains:
internal and external environment (review of economic, social and health
objectives and policies) - SWOT analysis;
health status and related determinants (mortality and mo
idity rates, disability,
urden of disease, life expectancy, lifestyle indicators, trends etc.);
health system (public/private institutions, accessibility for health care, population
coverage with services, patient flow within the health care system, etc.) resources -
human, material and financial (7-10).
If there is a functional and valid information system, health indicators constitute a
fundamental tool that generates evidence on the population health status and trends.
Inequalities in health can be also evaluated, which may - in turn -serve as basis for
highlighting the population groups with the highest health needs and identification of
critical areas. If existing, health indicators facilitate further monitoring and evaluation of
health objectives and goals set up by a strategy or program. The main output of this step is
epresented by a comprehensive review to inform the strategy, offering a comprehensive
picture of the existing situation. Data obtained through the situation analysis also provide a
enchmark against which to measure future trends (9).
Problem identification and priority setting process is based on existing health
system indicators, on special surveys, and on consensus research. It is actually a process of
comparisons and decision-making, based on special methods and techniques for ranking
the identified problems according to their importance. Limited resources require priority
setting to address competing demands across health system. In order to judge and
prioritise the identified problems three main criteria are commonly used:
problem's dimension and severity (incidence/prevalence, premature deaths,
potential years of life lost, burden of disease, trends, the size of the population at
isk, the impact on medical services, family, society, etc.);
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intervention capacity (knowledge on the disease/associated risk factors, prevention
possibilities);
existing resources for intervention (existing services, qualified personnel,
population accessibility to health services), (9,11).
Strategy formulation is the process leading to the establishment of national health
goals. It is crucial for a successful strategy that the goals are formulated through a
democratic process, involving a continuous dialogue with target population, as well as
with those actors who will have responsibility for its implementation (9,12).
Goals and objectives
A goal
Broadly, a goal is a statement of intended output (13). A goal represents a general aim
towards which to strive; a statement of a desired future state, condition, or purpose (14). A
goal differs from an objective by being