Plans are nothing; planning is everything.In a previous post I mentioned my participation in a health planning research project in the early 1970s. Prior to that project, for a decade or more, the PAHO CENDES health planning method had been disseminated throughout Latin America; more than 2000 health officials had been trained in the method. While that had a beneficial impact of alerting many officials and health organizations of the need to do more, it seemed to yield few useful plans.
Dwight D. Eisenhower
In all, I spent something like eight years thinking about health planning in developing countries as an occupation. I worked in a number of countries, visited others, and had colleagues who worked in still others and told me what they found. I noticed some interesting things:
- Critical decisions were often about the construction of hospitals and health centers. Once built, these required staffing and budgets. The decisions seemed often to be political. In the Dominican Republic, for example, the dictator Trujillo had all the health centers built during his presidency built in the form of a "T" so that each would support his reign. Even when it was determined that a growing city needed a new public hospital, the decision of exactly where in the city would result in economic benefits for those who owned the land on which it would be built and indeed for those who developed surrounding areas and those who built the facility. I think the choice of location would then become political. So too, a newly elected legislator might try to get a health center approved and built in his district to bolster his chances of future election. A formal plan might not have much influence over such decisions.
- Manpower allocations were less formal than one might think. Of course a new hospital or health center would have a table of organization with so many doctors, so many nurses, nursing aids, and other workers. But then there would come a need for a doctor in a hospital, and someone would tell a doctor on the nominal staff of another hospital to go work where he was more needed; no formal changes would be made in the staffing pattern. Then there was corruption. For example, a senior official would issue instructions that someone be added to the staff roll of a regional hospital even though he was living in the capitol city or in another country, with no medical responsibility at all. The formal written plans simply didn't catch up or didn't count.
- I found a major, apparently modern hospital that did not have a modern cost accounting system. The heads of departments knew the direct budgets of their departments, and the senior staff knew all the direct costs. However, there was no accounting of indirect costs. For example, the internal medicine department knew the number of patients it treated and the costs of the salaries of its staff, but did not know how much the drugs it prescribed, nor the lab tests it ordered, nor the x-rays it ordered cost the hospital. Thus there was no way that total costs per service could be monitored, much less controlled.
- Students I taught did a study of Ministry of Health pharmacies in our region. They discovered that a significant portion of the prescriptions sent to those pharmacies could not be filled because the required drugs were not in stock; on the other had, a significant portion of the stock languished on the pharmacy shelves for very long periods since it was not in demand. There was no adequate system for managing the inventory and ordering of drugs. In another country, having lunch across the street from a hospital, I watched as a shipment of pharmaceuticals was delivered, and then as another truck pulled up and reloaded the pharmaceuticals; I was told that they would be delivered to a private drug store to be sold on the open market. In still a third country, a consultant we had hired to look at pharmaceuticals quit informing us that he had had threats against his life, and that apparently the organized illicit drug industry also controlled the local pharmaceutical wholesalers.
You can see that in systems with such gross malfunctions, health plans based on a theory of efficiently meeting health needs had little chance of being implemented. If a system is not well managed, it is not likely to be well planned.
A Counter Example
The USAID mission in the Dominican Republic was interested in the possibility of a health sector loan to that country. I was working in the Office of International Health at the time, and we were asked to help them look into that possibility. We had in process a desk study of the DR health sector which avoided going in cold.
We agreed with the mission to help conduct an assessment. A senior academic in the DR was selected to head the assessment team, which he recruited. We provided (Spanish speaking) consultants from the United States. The assessment looked at the health conditions, the health services and the things that had worked and had not worked in the DR health sector reform in the past.
The assessment identified a major unmet health need. There was very high infant and child mortality in the rural areas. It seemed that a rural health service focusing on immunizations, health education, and identification and referral of health emergencies in the target population of young children could do some real good and be affordable. The service could be based on community health promoters and delegated medical functions to auxiliary health workers. Political and administrative constraints likely to be encountered were identified, and alternative measures considered to resolve them.
In preparing the USAID project documents, in cooperation with assessment team members, we developed a preliminary design for a rural health service, a preliminary plan of action, and a basic budget to cover the projected costs. The project was approved by the DR government and USAID.
Very fortunately, Dr. Amiro Perez, the very man who had led the health sector assessment and participated in the planning of the loan, was named Minister of Health as the project began. He made the development of the rural health service a priority of his administration, having fully mastered all aspects of the assessment on which it was based and its planning. He recruited his deputy on the assessment to help manage the development and administration of the rural health service.
Five years later, Dr. Perez was able to report that the mortality rate in children under the age of five years in the rural area of the Dominican Republic had been cut in half as a result of the action of the new rural health service.