Wednesday, April 16, 2014

A thought about values as a professional planner.

Many years ago I left graduate school to participate in a health planning research project in South America. Before I left I had a chance to meet with a number of the faculty members and talk about the challenges I would be facing. One of them asked me how I would handle dealing with people with very different values about health in my new job.

I was pretty naive at the time. I still believe that there is a great deal of commonality in our values about health and illness. Those who differ from the norm seem to be aberrant. Only a small portion of the population commit suicide. People who seek pain are termed masochists. We came across people who sought out the death of their children, but seemed to do so in desperation facing extreme difficulties in raising them. The vast majority of people would rather be healthy than sick, would rather not face disabilities resulting from past illness, would rather live a long, healthy life than die early. Indeed, helping poor sick children even when they are strangers seems a widely shared value.

We did not discuss the larger question of how health planners deal with conflicts of interests. The tax payers who would rather not be taxed to pay for health services for the poor, the property owners who don't want health facilities located where they might reduce the value of their property, the health workers who want to work in pleasant locations rather than where they might be more needed, the vendors of drugs and equipment who want to maximize their sales and income rather even when doing so may not be the best use of money available for health services, and even the people who steal from health facilities all have objectives other than improving public health.

Of course, there remain issues. The World Health Organization has proposed "Disability Adjusted Life Years" (DALYs) as a good measure of health outcomes for a population, but that is a pretty rough indicator. The Pan American Health Organization long ago included a measure of "transcendence" in its planning methodology to reflect the fact that people (and electorates) are more concerned with some diseases than with others; polio was such a disease in the United States when we had a polio afflicted president and a March of Dimes to fight the disease. What rights to people have to health services, or to health? How does a health service system respond to the fact that health and sickness are often the result of factors outside of medical control?

In point of fact, working as a health planner at increasingly central levels I did find myself facing the second kind of value conflict -- personal benefits conflicting with public. However, it was generally a good approach to assume that I was focusing on improving the public health, reducing sickness and disability, extending life. I was lucky enough to find myself working with others who shared those values. Sometimes we were able to help advance those objectives.

As a health planner I was generally providing information to others who would make the decisions, and dealing with fairly limited issues. I was able to help people make a better decision as to where to build a city hospital, helped design a loan to build a rural health service (which succeeded in cutting child mortality in its service district in half in five years), and helped the World Bank and later the Carter Administration raise the importance of health in the foreign aid portfolio.

I suspect that other "sectoral planners" working in areas such as education, housing and transportation do well be keeping their eyes on the nominal objectives for their sector -- providing an effective service in a cost-efficient manner.

Of course, a harder problem comes for those at the top who are trying to balance many rights and many needs with a limited budget. and given relative freedom to innovate and move resources from one area to another, but forced to negotiate which many interests in developing final portfolios of legislation and programs.

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