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The national health planning cycle

There are numerous reasons that national health policy reform is complex. This video discusses what needs to be considered before change can occur.
PETER ANNEAR: National health policy reform is complex. And we need to be realistic. We need to understand issues like policy space, the policy cycle, opportunities for change, global versus national actor priorities. So health care reforms are driven not only by the political agenda. There are many diverse and underlying drivers of health care reform. And some of these might include things like a desire to move towards universal health care; some of the underlying social, economic, and technological changes, demographic change that may affect service delivery, any mismatch between actual performance and the rising expectations of society in general, the poor quality of health outcomes; inflation in the cost of health care.
Or it simply may be a need to maintain the system’s basic functions to mend cracks as they emerge, cautiously introduce new initiatives, and other such things. So think about this. You might be required to plan for new challenges related to, for example, health security and universal coverage. You would need to consider a range of things– infectious disease control and health system preparedness, changes in health financing, and so on. So the approach has to be systematic. Generally we begin this process with an understanding that the current context is favourable for getting more value from national health policies, strategies, and plans. Remember, it’s always necessary to begin with realistic assessment of current national capacities.
There is a lot of confusion about the use of terms in this area of health system strengthening. Policy, plan, strategy, program– what do these things mean? This diagram comes from the WHO framework that we’ve just mentioned. And it helps us to develop a common definition of terms, which we need so that we share a consistent planning language. So policy refers to vision and broad policy directions. Strategy is an overall plan for achieving a goal and generally supported by an operational plan and a budget. Then we have national health policy. And that comprises broad areas– a situation analysis, health system values. It comprises policy directions, generally over a five-year period into the future. We have the national health strategic plan.
And this is perhaps the crux of the issue. This is where the real work takes place. National health strategic plan is the implementation frame for the national health policy. And it’s constructed according to health system categories. The medium-term plan is a bridge between the strategic and operational plans and generally covers a two- to three-year period, generally after a midterm review. The operational plan occurs at district level. And it refers to the managerial and the short-term implications of planning. Here on this slide, we have one framework. But there are many others. Planning must often deal with risk. In fact, in general, it must. These are approaches to routine planning that we’ve just been talking about.
But we need to consider unforeseen but not unforeseeable events. UNICEF has done quite valuable work in risk-informed programming guidance.
The basic ideas behind this risk programming guidance is this: risk is defined as a disaster that hasn’t happened, at least not yet. Risk is a disaster that hasn’t yet happened. There are no natural disasters, only natural hazards. So risk is the hazard times the vulnerability. So vulnerable populations are most at risk. Now, some common examples might be climate change or conflict. And these are increasingly generalised and increasingly prevalent. So keep in mind the risk factors. The guiding principle is to strengthen resilience through proper preparation, which means planning and capacity building. Now, let’s look at some of the critical elements. I can’t stress enough that effective policy development is built on a well-informed, concrete, precise, and insightful situation analysis.
We must begin with what we have. And we must recognise that quick blueprint approaches to planning will not be helpful. Begin with what we have in the country setting where we’re working. What is needed is a plan derived from the actual situation while using the policy tools we are presenting here within the policy space available. So what is policy space? Policy space is the freedom to design and implement public policies. This may be inhibited by different factors like, for example, constraints associated with national economic and social development priorities. They may put resources in areas that are not in the health sector.
It may be affected by the influence of globalisation, for example, through trade or the activities of global actors who may themselves impose their decisions over this or that country. Items like tobacco sales come into this category. The food industry, donor agencies are all in this category. So we’re talking about the degree of autonomy in the regulation of health care compared to government-wide decision making and regulation. If the health care lacks autonomy and rules are made by a central government, that may be a problem. Another item, another issue to think about is the role of public health policy makers in national decisions, including planning and investment, a similar problem with government-wide decision making.
Another issue is the extent and influence of markets within the health sector, which themselves– the private market itself may deprive governments of real influence, especially where the private market is dominant and strong and, essentially, where the private market is unregulated. So there are many different models of policy making. But there are common elements. And they are illustrated here in the policy cycle. This diagram nicely illustrates the policy cycle. You will have seen something like this before. But this diagram is a little different to others. The usual steps and categories are here, from problem definition to evaluation around the cycle. And they are pretty much self-explanatory. It’s important to follow these carefully and sequentially.
Here we introduce two additional categories, the categories of ethics and politics. And these influence every step. Ethics points us to a consideration of issues that are not purely within the health system– that is, a broader understanding of underlying philosophies. Sometimes these are unconscious. And they affect policy decisions. Politics introduces us to a range of skills and processes that may be needed in order to have a genuinely effective policy adopted. Remember, if things don’t fall into place, you may have to begin the reform cycle again. It’s not always possible to get the right outcomes first time through the cycle. And many interventions simply need to be tested. Policies can be flawed. And that means outcomes will be flawed.
Or some results, both good and bad, may simply be unanticipated. So don’t think once the plan is made everybody will come on board. As well, there are vested interests. And some stakeholders may undermine performance for this or that reason. Or the conditions in which we’re planning may simply have changed. So reform is not a one-time event. It’s not possible to know accurately the outcomes of interventions that follow planning or to make new plans for change and improvement if we do not have the data on current programs and their outcomes. It means here the lesson is prepare for the evaluation process before implementation begins. And include monitoring and evaluation activities in the plan design.
And collect data during the implementation of the plan.

In this video a recent review of priority-setting processes in low-and middle-income countries (LMICs) was recommended (Hipgrave et al. 2014) – the paper is provided in the reference list below for those who are able to access the full paper. The authors found that no existing formal priority-setting process could be recommended for LMICs based on evidence of effectiveness or feasibility.

They also found that frequently, contextual or system challenges strongly influenced the priority-setting process such that neither the process of planning, nor the outcomes, were satisfactory. Limited data and resources, dominance by powerful stakeholders, and conflicting priorities and overlapping responsibilities between different levels of the health system were some of the frequent reasons for planning process failures.

Have you been involved in health planning at any level in your country? What were the main obstacles to good planning you observed? Please post your response in the comments section below (remembering to mention your country).

Reference list
Hipgrave, D, Alderman, K, Anderson, I & Soto, E, 2014, ‘Health sector priority setting at meso-level in lower and middle income countries: Lessons learned, available options and suggested steps’, Social Science & Medicine, vol. 102, pp. 190-200.
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