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Case study of health goals development in the province of British Columbia Chomik, Treena Anne 1999

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C A S E STUDY OF H E A L T H GOALS D E V E L O P M E N T IN THE PROVINCE OF BRITISH C O L U M B I A by TREENA A N N E CHOMIK B.A. , The University of Alberta, 1987 M.P.H. , The University of Hawaii at Manoa, 1989 A THESIS SUBMITTED IN PARTIAL F U L F I L L M E N T OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE F A C U L T Y OF G R A D U A T E STUDIES (Interdisciplinary Studies) We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH C O L U M B I A November, 1998 © Treena Anne Chomik, 1998 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. 1 further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of (-irt,f/in'/h>. ^nAUX ( Tk^^/it^h^r^Q^JS The University of British Columbia Vancouver, Canada Date (W^**^ DE-6 (2/88) ABSTRACT Health promotion research and practice reveal that goal setting and monitoring have gained increased acceptance at international, national, provincial/state, regional and local levels as a means to guide health planning, promote health-enhancing public policy, monitor reductions in health inequities, set health priorities, facilitate resource allocation, support accountability in health care, and track the health of populations. The global adoption of health goals as a strategy for population health promotion has occurred even though few protocols or guidelines to support the health goals development process have been published; and limited study has occurred on the variation in approach to health goals planning, or on the complex, multiple forces that influence the development process. This is an exploratory and descriptive case study that endeavours to advance knowledge about the process and contribution of health goals development as a strategy for population health promotion. This study seeks to track the pathways to health goals in British Columbia (BC) and to uncover influential factors in rendering the final version of health goals adopted by the government of BC. Specifically, this study explores the forces that obstructed and facilitated the formulation and articulation of health goals. It considers also implications of health goals development for planning theory, research and health promotion planning. Data collection consisted of twenty-three semi-structured interviews with key participants and systematic review of BC source documents on health goals. Data analysis uncovered nearly 100 factors that facilitated or obstructed the BC health goals initiative, organized around three phases of health goals development. Key factors influencing the premonitory phase included (a) government endorsement of health goals that 11 addressed the multiple influences on health, (b) expected benefits of health goals combined with mounting concern about return on dollars invested in health, and (c) effective leadership by a trusted champion of health goals. Key influencing factors in the formulation phase included (a) the positioning of the health goals as a government-wide initiative versus a ministry-specific initiative, (b) the "conditioning" of the health goals process through the use of pre-established health goals and "orchestrated" consultation sessions, and (c) the make-up and degree of autonomy of the health goals coordinating mechanism. The articulation phase of health goals development revealed several influencing factors in relation to two chief issues that characterized this phase: (a) the lack of specificity of the health goals, and (b) the variable portrayal of the "health care system" as a priority area in the BC health goals. This study also revealed several concessions and trade-offs that characterized the B C health goals process. For example, the formulation of health goals that addressed the broader health determinants yielded health goals without the capacity for measurement, (b) the operational and bureaucratic autonomy of the health goals coordinating mechanism led to feelings of alienation from the health goals process and product among some branches of the Ministry of Health and some established health interests, and (c) the use of pre-determined health goals and the delivery of educative sessions based on the determinants of health generated claims of bias and a lack of trust and fairness in consultation processes and mechanisms. 111 TABLE OF CONTENTS Abstract i i List of Tables xi List of Figures xii Chapter 1: Introduction •• 1 Statement of the Issues 2 Acceptance of Health Goals 4 Accountability in Health 4 Health Reform 5 Perceived Contributions of Health Goals 6 Variations in Approach to Health Goals Development 7 Complexity of Health Goals Development Process 10 Role of Theory in Health Goals Development 12 Study Rationale and Purpose 13 Research Questions 14 Potential Benefits of the Study 15 Study Context 16 Initiating the Health Goals Process in BC 16 The Foundation of the BC Health Goals 18 Phases of the BC Health Goals Development Process 19 Chapter 2: Review of the Literature 22 Part A: Planning Theories and Models Related To Health Goals Development 22 Grand Theories of Planning 23 The Rational Model 23 The Incremental Model 25 The Mixed Scanning Model 27 Allison's Models 29 Grand Theory Assumptions Relevant to Health Goals 31 iv Three Key Theoretical Issues in Health Goals Development 34 Health Determinants: From Health Education to Ecology to Population Health 34 Expression of Ecological and Population Health Models in Health Policy.. 39 Health Determinants and Health Goals 41 The Centralization-Decentralization Continuum and Health Goals Planning 42 Balancing Centralized and Decentralized Approaches in Health Planning.. 43 Centralized-Decentralized Health Goals Development 46 Resource-Based and Population-Based Planning 47 Resource-Based Planning and Health Goals 50 Health Planning Models 51 Management-By-Objectives 52 Management-By-Objectives in the Health Field 54 PERT Model 56 PRECEDE-PROCEED Model 57 PRECEDE-PROCEED and Health Goals Planning 59 P A T C H Model 62 M A T C H Model 65 A P E X P H and Model Standards 67 Summary of Part A Review of the Literature 70 Part B: Factors and Themes of Health Goals Development 72 A Note on Terminology 74 Phases and Factors of Health Goals Development 75 Premonitory Phase of Health Goals Development 75 Proposition 1 76 Prevailing Circumstances 76 Health System Environment 79 Proponents and Skeptics 82 Perceived Benefits 84 Triggers 88 Formulation Phase of Health Goals Development 90 Proposition 2 91 Levels and Sectors 91 Coordinating Mechanism 94 Strategic Approach 97 Consultation and Participation 100 Core Contributions 103 v Time and Budget 105 Data 106 Articulation Phase of Health Goals Development 109 Proposition 3 ••• 110 Specificity & Methods 110 Priorities Addressed 115 Health Determinants Scope 121 Late Stage Developments 125 Summary of Part B Review of the Literature - 129 Chapter 3: Method 131 Characterizing the General Methodology 131 Construction of the Conceptual Framework 134 Rationale for a Conceptual Framework 134 Sources in the Construction of the Conceptual Framework 135 Three-Step Process Undertaken in the Construction of the Framework 136 Characterizing the Conceptual Framework 140 Application of the Conceptual Framework 141 Data Collection: Sample, Instrument and Methods 141 Preparing for Data Collection 141 Sampling Strategy 142 Data Collection Instrument 144 Approach to Interviewing 145 Conducting the Interviews 146 Data Collection: B C Source Documents 148 Securing the Data 148 Data Analysis: Data Reduction, Display, and Analysis Procedures 149 Overall Analytic Strategy 150 Transcription of Taped Interviews 151 Coding of Interviews and Source Documents 152 Detailed Data Analysis and Write-Up 154 Assessing the Quality of Case Study Research 156 Limitations of the Study 159 Chapter Summary 160 v i Chapter 4: Findings 162 Part A : Factors Influencing Health Goals Development in the Premonitory Phase 163 Theme 1: Prevailing Circumstances 164 Theme 2: Health System Environment 166 Emergent Dimensions 170 Theme 3: Proponents and Skeptics 171 Theme 4: Perceived Benefits 177 Emergent Dimensions 180 Theme 5: Triggers 182 Part B: Factors Influencing Health Goals Development in the Formulation Phase 185 Theme 6: Level and Sectors 186 Emergent Dimensions 191 Theme 7: Coordinating Mechanism 193 Theme 8: Strategic Approach 199 Theme 9: Consultation and Participation 207 Emergent Dimensions 215 Theme 10: Core Contributions 216 Theme 11: Time and Budget 221 Theme 12: Data 225 Emergent Dimensions 228 Part C: Factors Influencing Health Goals Development in the Articulation Phase 233 Theme 13: Specificity and Methods 233 Emergent Dimensions 245 Theme 14: Priorities Addressed 248 Theme 15: Health Determinants Scope 264 Theme 16: Late-State Developments 268 Emergent Dimensions 272 Chapter 5: Conclusions and Implications 275 Discussion of Key Findings: Influential Factors 275 Key Influencing Factors in the Premonitory Phase 275 Government Endorsement of Broad-Based Health Goals 275 Expectations for Health Goals 277 Leadership by a Trusted Champion of Health Goals 277 V I I Key Influencing Factors in the Formulation Phase 279 "Government" Health Goals Versus "Ministry of Health" Health Goals 279 Conditioning the Health Goals Process 282 Make-Up and Autonomy of the Health Goals Coordinating Mechanism 284 Key Influencing Factors in the Articulation Phase 286 Lack of Specificity ofthe B C Health Goals 286 A Glance at Other Jurisdictions 289 Health Services as a Priority Focus Area in the B C Health Goals 290 Trade-Offs and Health Goals Planning in B C 292 Implications for Planning Theory 295 Considering the B C Health Goals Process in Relation to the Grand Approaches to Planning 296 Aims and Strategic Procedures of the Planning Process 296 Accommodation of Multiple Interests in the Planning Process 298 The Role of the Public Interest in the Planning Process 300 Considering the BC Health Goals Process in Relation to Two Procedural Models in the Health Field 301 Management-By-Objectives 302 Assessing the Fit Between the BC Case and the M B O 302 Assessing the Lack of Fit Between the B C case and M B O 304 What Does the B C Case Have to Say About the M B O Model? 305 The PRECEDE-PROCEED Model and Health Goals Development 307 Assessment ofthe Fit ofthe BC Case Against the PRECEDE-PROCEED Model 307 Fit on the Procedural Level 309 Modification ofthe PRECEDE-PROCEED Model Based on The BC Health Goals Process 314 Implications for the Health Goals Framework 318 The Health Goals Framework and the BC Case Study on Health Goals 318 Suggested Modifications of the Health Goals Framework, Phase One 320 Suggested Modifications of the Health Goals Framework, Phase Two 324 Suggested Modifications of the Health Goals Framework, Phase Three 327 Significance of the Fit or Lack of fit Between the BC Case and the Health Goals Framework 329 Implications for Research 330 Further Inquiry Linked to the Premonitory Phase of Health Goals Planning 330 Further Inquiry Linked to the Formulation Phase of Health Goals Planning 331 v i i i Further Inquiry Linked to the Articulation Phase of Health Goals Planning 334 The Health Goals Framework and Further Research 335 Additional Implications for Health Promotion Practice 336 Scenarios for Health Goals Planning 337 References •• 341 Appendices Appendix A : Allison's Models of Planning 353 Appendix B: Listing and Description of Health Determinants 354 Appendix C: Multiple Theories That Characterize Population Health Promotion Models 355 Appendix D: Six Sample Jurisdictions and Associated Health Goals Initiatives Encompassed by the Literature Review 356 Appendix E: Study Conceptual Framework: Health Goals Framework 358 Appendix F: Case Study Variation by Type and Design 360 Appendix G: Linking Research Conditions to Research Strategies 362 Appendix H : Philosophical Underpinnings of This Study 364 Appendix I: Examples of Case Studies, Adapted From Yin, 1994 366 Appendix J: Operational Definitions of Framework Themes 367 Appendix K : U B C Ethical Review Consent Form 379 Appendix L: Letter of Introduction 380 Appendix M : Interviewee Consent Form 382 Appendix N : Master Interview Guide: Main Questions 383 Appendix O: Coding Scheme 385 Appendix P: Case Study Protocol 389 ix Appendix Q: Case Study Database 394 Appendix R: Considerations for the Case Study Researcher 395 Appendix S: Establishing Representativeness of Views 396 Appendix T: Provincial Stakeholder Organizations Participating in the BC Health Goals Development Process 397 Appendix U : Regional Health Boards Participating in the BC Health Goals Development Process 398 Appendix V : Health Goals, Version I, October 1994 399 Appendix W: Health Goals, Version II, November 1995 400 Appendix X : Health Goals, Version III, June 1996 401 Appendix Y : Health Goals, Version IV, June 1997 402 Appendix Z: Health Goals, Version V, December 1997 403 x l i s t o f tab les Table 1: Health Goals For British Columbia 19 Table 2: Contrasting Population Health Promotion and Individual Health Promotion 38 Table 3: M A T C H Model 66 Table 4: Steps for Model Standards 70 Table 5: Premonitory Phase of Health Goals Development 90 Table 6: Formulation Phase of Health Goals Development 109 Table 7: Articulation Phase of Health Goals Development 128 Table 8: Rationale for Case Study Strategy 134 Table 9: Characterizing the Health Goals Framework 141 Table 10: Study Sample 143 Table 11: Factors that Facilitated and Obstructed the BC Health Goals Development Process: The Premonitory Phase 183 Table 12: Factors that Facilitated and Obstructed the BC Health Goals Development Process: The Formulation Phase 230 Table 13: Illustration of the Mix of Goals, Objectives, Indicators, Targets, and Strategies for Multiple Versions of BC Health Goals 246 Table 14: "Health Care System" Across Multiple Versions of BC Health Goals 256 Table 15: "Population Subgroups" Across Multiple Versions of BC Health Goals 261 Table 16: Factors that Facilitated and Obstructed the BC Health Goals Development Process: The Articulation Phase 273 xi LIST OF FIGURES Figure 1: PRECEDE-PROCEED Model 317 Figure 2: Modification of the PRECEDE-PROCEED Model, Phase 3, Based on the B C Health Goals Initiative 317 Figure 3: Fit Assessment of B C Case Against Health Goals Framework: The Premonitory Phase 319 Figure 4: Fit Assessment of BC Case Against Health Goals Framework: The Formulation Phase 322 Figure 5: Fit Assessment of BC Case Against Health Goals Framework: The Articulation Phase 326 Xll C H A P T E R 1: I N T R O D U C T I O N Goal setting and monitoring have gained increased acceptance as a strategy for population health promotion and disease prevention over the past two decades. Various jurisdictions have adopted health goals to promote health-enhancing public policy, guide health planning, set health priorities, monitor reduction in health inequities, focus attention on the broad determinants of health, track the health status of populations, or some combination of these purposes. Health goals provide an operational framework to support program and policy planning and to establish parameters for decision making about the health of people. A complex, social-political process, setting health goals and targets strives to articulate expectations for health, quantify anticipated health-related outcomes, and delineate roles and responsibilities for improving the health of populations. As a strategy for population health promotion, setting goals for health usually precedes a series of steps that includes establishing objectives, identifying indicators, setting targets for improvement, and incorporating measurement and monitoring systems.1 Goal setting constitutes a hierarchy of action that begins with the articulation of broad, visionary statements which capture expectations for health gains, followed by increasingly specific actions of what must be accomplished in order to meet goals, as well as mechanisms to monitor and track progress toward goals. This exploratory and descriptive case study examined the health goals initiative in the province of British Columbia (BC). While the health goals process typically comprises three 1 The terms "goals", "objectives", "targets", "indicators", and "strategies" are often used interchangeably and carry different meaning in different jurisdictions that have adopted a health goals approach to population health promotion. Definitions of these terms and an explanation of how they are applied within the context of this study are provided in Chapter 2, in the section titled "Note on Terminology." 1 stages — the development stage, the implementation stage, and the monitoring stage -- this study focuses on the development stage only. The development stage considers the prevailing context for health goals, the processes undertaken to formulate health goals, and the final articulation (content) of health goals. In its simplest sense, this study addresses how health goals are formulated and what health goals come to say. The aim of this study was to identify and describe those factors that have theoretical and practical import in the formulation of health goals and to examine how various factors influence the final articulation of health goals for a population. This study explores the forces that obstruct and facilitate the effective formulation and articulation of health goals and considers implications of health goals development for planning theory, research and planning practice in population health promotion. More specifically, this study tracks the pathway followed in the development of health goals for the province of British Columbia, and examines what factors were influential in rendering the final version of health goals that were adopted by the government of BC. The study aims to advance our understanding of the formulation and contribution of health goals as a strategy for the promotion of population health. Statement of the Issue Early indications of health goals as a strategy for population health promotion appeared in the late 1970's in the US. A comprehensive framework for health was outlined in Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention (US Dept. Of Health, Education & Welfare, 1979a). This publication, inspired in part by the Lalonde report, A New Perspective in the Health of Canadians, disclosed a shift in emphasis from health care to health promotion and disease prevention and was led by the US Public Health Service. Their 2 work was detailed in the release of Promoting Health/Preventing Disease: Health Objectives for the Nation (US Department of Health and Human Services, 1980). This publication delineated 225 specific objectives and targets for improving the health of Americans for a ten-year period. At about the same time, the international conference on primary health care, held at Alma Ata in 1978, established a policy framework of Health For All which called for all citizens of the world, by the Year 2000, to attain a level of health that would permit socially and economically productive lives. The Declaration of Alma Ata (WHO, 1978) defined the features of Health For All as a global strategy, formally adopted in 1981 by the Member States of the World Health Organization (WHO, 1981). In 1985, WHO's European Regional Office published its first round of health goals in Targets for Health for All 2000 (World Health Organization Regional Office for Europe, 1985). This report was updated in 1991 based on broad consultation among European member states (WHO: Regional Office for Europe, 1991). Other countries and regions followed in the adoption of health goals and targets including Eastern Europe, Africa, South East Asia, the West Pacific, Australia, Sweden, Germany, and Mexico (McGinnis, 1984). It is interesting to note that even though all Canadian provinces and territories have developed provincial health goals, health goals have not been established at the national level in Canada. Pinder (1994) notes that various calls for national health goals have been made over the past two decades. National goal setting was advocated as early as 1974 in A New Perspective on the Health of Canadians (Lalonde, 1974). Other calls for health goals came from the A d Hoc Committee on National Health Strategies (Health Canada, 1982), the Canadian Public Health Association (1984, 1987, 1992), and the Canadian Journal of Public Health (Spasoff, 1987). Most recently, a report to Health Canada's Population Health Promotion Division on the status and application of health impact assessment in Canada recommended the establishment of 3 national-level health goals as a prerequisite to health impact assessment (Frankish et al., 1996a). Although many jurisdictions have adopted health goals as a national, state or regional strategy for population health, limited research and documentation has surfaced on the factors that influence the health goals development process. Several issues support the argument for a comprehensive examination of the health goals development process. These include (a) the broad acceptance of health goals as a planning and policy tool for population health promotion, (b) the complexity of health goals development, (c) the variations in approaches to health goals development, and (d) the role of theory in health goals development. Acceptance of Health Goals Beginning in the early 1980's, several OECD and other industrialized countries instituted a planning-by-objectives approach to health policy. Three factors influenced the broad-based appeal of health goals as a strategy for population health promotion worldwide:2 (a) an increasing emphasis on accountability in health, (b) reforming health systems by shifting the emphasis from resources to outcomes, and (c) the perceived contributions and underlying assumptions of health goals as a population health promotion tool. Accountability in Health The past decade has seen increased emphasis on accountability and evidence-based decision making in the clinical health care setting with the institutionalization of utilization review and clinical outcomes research (Chernichovsky, 1995; McKinlay et al., 1989). A similar The broad acceptance of health goals refers to the number of jurisdictions worldwide that have formulated health goals or that adopted a health goals approach; this does not include any judgment about health goals implementation or longevity within a given jurisdiction. 4 emphasis exists in the public health sector where a shift in focus from service provision to health outcomes has occurred (Eyles and Birch, 1993; Frankish et al., 1996a; Ratner et al., 1997). To attain political and financial support, health programs are expected to demonstrate a beneficial impact on health status, or on those factors that influence health. Expectations to demonstrate impact are largely a reflection of spending constraints at all levels of government, as allocation of resources for health and social goods compete with growing pressure to control government debt and deficit. Within this context, health goals offer a means by which health promotion and population health programs can demonstrate health gains, and thereby rally continued support. Health Reform The reforming of health systems around the globe has further contributed to the wide acceptance of the health goals approach. Health goals offer tangible strategic direction to reforming health systems that typically evolve within an environment of uncertainty as health services move from acute to community settings; as clinical care becomes more interdisciplinary; and as localized, democratic models of health decision making become institutionalized. Health goals, objectives and targets set out tangible parameters for change to support the reorientation of health systems in health reform. The wide acceptance of health goals as a strategy for population health promotion may also reflect a shift from resource-based planning which tends to rationalize and justify existing resources and activities in health, toward population-based planning, where planning is based on the needs of the population and strives to optimize resources for the improved health of people (Frankish et al., 1996a; Ratner et al., 1997). 5 Perceived Contributions and Assumptions of Health Goals The potential contributions of health goals to health planning and policy making have increased their acceptance in jurisdictions around the world. The published literature and source documents from several jurisdictions highlight these multiple contributions. Health goals are viewed by some as a means for making service provision decisions and creating health system efficiencies by encouraging collaborative action and reducing fragmentation and duplication (Australian Department of Health, 1994). Others perceive health goals as an effective mechanism to support decision making about resource allocation, to enhance accountability, to promote quality information systems, and to reorient health systems from health services to health outcomes (Lyons, 1995). Health goals may also help to identify achievable improvements in health status and reducible inequities in health, and to provide a basis for setting priorities (British Columbia, 1995). Providing a framework for improving the health status of people and communities, allowing increased attention to the multiple influences on health, and setting guideposts for health-enhancing public policy are seen as additional contributions of health goals in some jurisdictions (Saskatchewan, 1994). Finally, health goals are viewed by some as a framework for health planning, as a road map for policy direction, and as a basis for health impact assessment of programs and policies (Frankish et al., 1996; Ratner et al, 1997). The underlying assumption of health goals by jurisdictions that have adopted a health goals approach — that health goals guide more efficient allocation of resources toward the improved health of populations ~ has contributed also to their broad acceptance. Health goals, objectives and targets are envisioned as links in a "causal chain" where the ultimate end is to improve health and quality of life. Notable improvements in health and quality of life (or lack thereof) require tracking over time and across interventions, programs and policies to 6 demonstrate impact. Surveillance systems, with health goals and targets as cornerstones, offer means by which programs can be monitored for impact. Health goals support surveillance by clearly articulating the anticipated improvements in health and quality of life within a given jurisdiction over a set period of time. The utility of health goals in guiding effective surveillance further accounts for the world-wide acceptance of health goals as an effective strategy for population health promotion over the past two decades. Variations in Approach to Health Goals Development The World Health Organization's Health For A l l policy encouraged a planning-by-objectives approach as a means to plan, evaluate and monitor the health of populations (World Health Organization, 1991). The global encouragement for health goals, however, came with few developed guidelines or protocols to support health goals planning. This led to significant variation in the health goals development process among jurisdictions that have adopted health goals. Variations occur in how health goals are developed, that is, in the processes and procedures drawn on to formulate health goals; as well as in health goals articulation, in relation to the number and kinds of issues addressed in health goals. Many of these variations might be necessary to fit the process to regional variations in political structures and traditions, resources, and levels of support. The lessons from these variations, however, need documentation and comparison. Although variations in approach to health goals development occur along several dimensions, at least two deserve mention early on. (Chapter 2 provides a full discussion on these issues.) The first significant variation relates to the degree to which the proximal and distal determinants of health are considered in health goals. Any one health determinant may be 7 proximal or distal depending on: (a) the immediacy of the event to the health impact, (b) the degree to which an individual may exert influence over the determinant, (c) the individual's life stage or circumstance, and (d) the singular or cumulative effect of risk factors for health outcomes. The degree to which proximal and distal determinants of health are featured in health goals varies across jurisdictions that have adopted the health goals approach. The variation may be conceptualized along a continuum with one end representing what may be called a "health-targeted" approach to health goals development, and the opposite end representing what may be called a "health-determinants" approach to health goals development. In the health-targeted approach; health goals, objectives, and targets focus on the more proximal influences on health which include those factors that influence health that have historically been viewed as under the individual's control or relate to the more immediate environmental influences on health of individuals or populations. Health goals in the health-targeted approach tend to address issues related to preventable illness and injury, disability, morbidity and mortality, risk factors, health protection, and health promotion and disease prevention. In this approach, health goals development is concentrated in the health sector (including a larger role for public health vis a vis medical care), although input is often sought from multiple sectors; and issues and strategies associated with health goals fall most heavily within the mandate of the health sector or health system. Interventions aimed at meeting goals for improved health remain within the reach of public health and preventive health services. Finally, the health-targeted approach to health goals relies principally upon established health status indicators to track changes in health status and to monitor population health gains. At the other end of the continuum, the health-determinants approach to health goals extends beyond proximal influences on health to focus more on those factors commonly referred 8 to as the broader determinants of health. Generally, the broader determinants of health constitute those that are further removed in space or time from an individual and his or her immediate environment; and include global social, economic and environmental influences on health. Within the health-determinants approach, the health sector coordinates health goals development, but the process relies more heavily on significant participation from other sectors. In the health-determinants approach, health goals tend to address issues that extend farther beyond the traditional health sector or health system and interventions to meet health goals require action from several sectors. In this approach, the development and articulation of health goals is a shared initiative between health and other sectors and the proposed advances in population health are the responsibility of multiple sectors. Finally, the health-determinants approach measures and monitors health status improvements by both traditional health status indicators, as well as by social, economic and environmental indicators. Although a distinction is drawn between a health-targeted approach and a health-determinants approach to health goals development, both approaches in real-life application settle for some middle range of comprehensive planning with targets and intermediate objectives scattered along the continuum. Health goals development may vary also along a centralized - decentralized continuum. Planning processes can be placed on a continuum which spans the range of planning approaches from' centralized to local, with many shades between. Typically, health goals planning combines these two approaches, where different aspects of the planning process relate more closely to one pole than the other. Elements of the planning process that influence its characterization as centralized or decentralized include the following: who participates in the process, who has control over resources, the level of buy-in from stakeholder groups, what kind of decision latitude is available to whom, who does the editing and report writing, and the level at which the 9 planning processes is coordinated and managed. The degree to which a health goals process is centralized or decentralized may influence the way in which the health goals development process proceeds; and, how the health goals are ultimately articulated. (Subsequent chapters discuss this issue in greater detail). Variations in approach to health goals development may be beneficial by promoting creativity and flexibility and encouraging the adaptation of health goals to the unique characteristics and needs of each jurisdiction. Conversely, a limited availability of well-developed guidelines, protocols or modelling practices to support the development process may result in inefficiencies, promote disharmony and conceptual confusion, and further complicate an already challenging process. Regardless of the approach taken to health goals ~ whether it be a health-targeted or health determinants approach, or a centralized or decentralized approach — implications arise for the articulation of health goals for a population. This study examines how the "pathway to health goals" in British Columbia influenced the articulation of the final version of goals that were adopted by the Cabinet of BC. Additionally, this study generates hypotheses about how a different approach or pathway may have led to a different rendition of health goals for BC. This study also draws conclusions about how other jurisdictions might improve upon the BC health goals experience. Complexity of the Health Goals Development Process Developing health goals is a complex process that attempts to accommodate various interests and expectations to reach agreement on priority health and health-related issues. Adopting a health goals approach may have significant implications for established health 10 interests by potentially shirting the focus of the health care system from health services to health outcomes; it may also lead to the redistribution of power and resources from special interests to broader purposes of population health promotion (Dimatteo et al., 1995; Hunter, 1996). One expectation of the health goals process is that through conciliatory and participatory mechanisms; health goals, objectives, targets and strategies will be established to prioritize health issues, reduce health inequities, improve accountability, and ultimately enhance the health of populations. But, getting there means working through a complex web of processes, procedures and mechanisms. Formulating health goals is a demanding process even when health goals are focused solely on health issues which fall within the mandate of the health sector. The challenge becomes even greater when planners take on a larger-than-health focus by addressing social, economic and environmental influences on health. Health goals development that incorporates the broad determinants of health challenges traditional processes and players in the health sector, increases the mix of interests and orientations involved, and requires new collaborative and interdisciplinary approaches to health planning (Nutbeam et al., 1993). Although some literature exists that surveys factors that influence the health goals exercise (Green et al., 1983; Lyons, 1995; Nutbeam & Wise, 1996; Nutbeam et al., 1993) less attention has been paid to examining the interplay between the various factors that characterize health goals development and the resultant effect on health goals articulation (or the content of health goals). This study offers a comprehensive, systematic analysis of those factors that contribute to health goals development. Specifically, this study examines and describes the multiple forces that facilitated or obstructed the development and articulation of health goals in the province of British Columbia. 11 Role of Theory in Health Goals Development The role of planning theory in health goals development is often implied in jurisdictional source documents on health goals. Source documents typically include informational and public relations materials developed and disseminated by jurisdictions that have adopted a health goals agenda. The published academic literature on health goals offers more insight into the types of planning models and approaches that guide health goals planning. Some reference is made to goal-setting in the grand planning theories, such as the rational model of planning. The link between health goals planning and theory is more explicit, however, in those planning models that are more procedural in nature and that speak directly to the application of goals and targets. Examples of these models include, management-by-objectives (Lee, 1981; McConkey, 1975; McGinnis, 1984), the PRECEDE-PROCEED model (Green & Kreuter, 1991), the PERT model (American Public Health Association, 1966), the P A T C H model (Nelson et al., 1986; Steckler et al., 1992), and others. (Chapter 2 provides a full discussion of these models.) Understanding the role of theory in health goals development provides insight into the fit between empirical cases of health goals development and various established planning models or theories. By examining the health goals development process in British Columbia, this study helps to uncover those factors with theoretical importance to health goals planning. Further, this study examines the fit of the British Columbia health goals experience against various established planning models. Specifically, it examines ways in which the British Columbia health goals exercise reflects or differs from various aspects of the established planning models; and suggests ways in which the established models may be enriched, adjusted or extended to guide goal setting in the health field. 12 Study Rationale and Purpose As detailed in the section above, the following issues support a comprehensive examination of the health goals development process: (a) the wide acceptance of health goals at international, national, provincial/state, regional and local levels with minimal application of well-developed protocols or guidelines to support the health goals development process; (b) limited study ofthe variation in the approach to health goals development (other than at the national level) and the relationship between the pathway or approach to health goals and the articulation or content of health goals; (c) limited analysis of the complexity of the development process including factors that facilitate and obstruct health goals planning; and (d) limited efforts to assess the fit between real-life experiences of goal setting in the health field and the established or traditional models of planning. The purpose of this study is to advance knowledge about the process and contribution of health goals development as a strategy for population health promotion. If health goals are to be an effective strategy for population health promotion, greater knowledge is required to support and inform the health goals development process. This means increasing our understanding of those factors that facilitate and challenge the health goals process. This study identifies the multiple forces that come into play in health goals planning and seeks to improve our understanding of how health goals planning can yield health goals that are both reflective of population needs and priorities, and achievable. Unless the health goals development process is guided by practices and procedures that are capable of sustaining and supporting the effort, and unless the process yields health goals that can be achieved; investments into health goals as a strategy for population health promotion cannot be justified. Procedurally, a health goals (conceptual) framework guides the case study investigation 13 of the health goals development process in the province of British Columbia. The framework evolved from a review of the literature on various planning models, goal setting in the health field, and source documents from six national and state/provincial jurisdictions that have adopted a health goals approach. The health goals framework organizes and consolidates what is known about the health goals development process. It captures key practices, procedures and mechanisms and delineates the major themes and dimensions that characterize the health goals development process. The health goals framework is then applied to the British Columbia experience to guide observations and data collection as well as data analysis. Finally, the health goals framework offers an outline for the presentation and discussion of study findings. Research Questions This study is an exploratory and descriptive investigation of the health goals development process in the province of British Columbia that proposes to answer the following research questions: Implications of the Case for Theory. 1. What factors, as perceived by participants in BC, obstructed or facilitated the formulation and articulation of health goals that were considered for submission, or adopted by, the Cabinet of the government of British Columbia? Implications for Modification of Planning Models: 2. Which aspects of the BC health goals setting exercise fit best with the established planning models and what does the BC experience suggest for the application of existing models for goal setting in health? 14 Implications for Research: 3. What recommendations can be drawn from the goal-setting experience in British Columbia to guide and inform further study on the formulation and articulation of provincial health goals? Implications for Practice: 4. What implications for planning practice can be drawn from this study for the formulation and articulation of health goals in other jurisdictions and at the regional or local level in British Columbia? Potential Benefits of the Study This study has the potential to influence key groups within the health sector. This study may benefit policy makers by encouraging them to apply health goals as a means to promote accountability and evidence-based decision making in government, and by offering a rationale for inter-ministerial and intersectoral approaches to policy planning. By making clear those factors that influence the health goals development process, this study provides jurisdictions contemplating health goals a framework for planning. Further, this study supports jurisdictions that have already adopted a health goals approach by providing a mechanism to refine existing health goals as well as a framework for the formulation of subsequent goals, objectives and targets for health. This study supports also the work of provincial health organizations in planning and setting organizational level priorities in areas of health that are of interest to them. Although this study examines and describes the health goals development process at the provincial level, implications may be drawn also for the development of health goals at the regional and local levels in the province of BC and within other jurisdictions. This study may be 15 useful to health care practitioners by outlining the implications of adopting a determinants of health approach to health care practice and related implications for interdisciplinary and collaborative practice approaches. Finally, academics and researchers may benefit from this study by its advancing the theoretical foundation of health goals development, and identifying areas for theory, model, and instrument development for population health promotion, as well as generating research questions and hypotheses for testing in future research. Taken together, the intent of this study is to advance the knowledge and understanding of the health goals development process among those groups who plan for the improved health of populations. Study Context This section provides a summary overview of the British Columbia health goals process and discusses the initiation of the BC health goals process, the foundation of the BC health goals, and the various phases of the development process. Initiating the BC Health Goals Process The health goals development project in the province of British Columbia began in October 1994, three years after the release of the 1991 report of the BC Royal Commission on Health Care and Costs (BC Ministry of Health and Ministry Responsible for Seniors) which recommended that health goals be established for the health system. In a policy document entitled, New Directions for a Healthy British Columbia (BC Ministry of Health and Ministry Responsible for Seniors, 1993), the new government's response to the Royal Commission extended the recommendation for health system goals to include the development of population health goals, with a focus on the broad determinants of health. In outlining priority actions that 16 focus on better health for British Columbians, the New Directions policy recommended the establishment of "a clear set of health goals for the province that reflect our understating of how social, economic and environmental factors affect health, and provide a means of measuring our success over time" (p. 12). At about the same time, the government amended the Health Act (1996) to charge the Provincial Health Officer with the responsibility of reporting annually to the Legislative Assembly on the health of British Columbians "as measured against population health targets." Initially, the BC government envisioned a Provincial Health Council to assume responsibility for the development of measurable health goals and objectives. In 1994, the Cabinet of the government of BC decided not to proceed with a Provincial Health Council following strong resistance from opposition political leaders to the proposed Health Council Act. The BC government then asked the Office of the Provincial Health Officer to undertake a wide consultative process to develop provincial health goals which began in the spring of 1995. As referenced in several source documents from the Office of Provincial Health Officer, the expected contributions of provincial health goals and measurable objectives were: (a) to identify achievable improvements in health status and reductions in health status inequalities, (b) to focus attention on all the factors that influence health in addition to the health care system and broaden the agenda for action by all sectors concerned with the health of the population, (c) to provide a basis for setting priorities, linking public policy decisions and investments to desired health outcomes, and helping to ensure accountability for those investments and outcomes; and (d) to establish a framework for action by many different sectors inside and outside government. By recognizing the many influences on health including social, environmental and economic factors, the health goals for B C were intended to serve as a tool to stimulate and encourage collaborative action by all ministries of the government of BC, as well as non-17 government organizations from many sectors. The health goals were not to be considered the sole responsibility of the health services sector, nor of the government alone. Rather, the need for intersectoral collaboration within government and between government and non-government partners was recognized as a prerequisite to the effective formulation of health goals for BC. The Foundation of the BC Health Goals Three issues grounded the B C health goals initiative. First, the adoption by the B C government in New Directions for a Healthy British Columbia (1993 ) of the 1984 World Health Organization's (European Region) definition of health which stated that: Health is the extent to which an individual or group is able, on the one hand, to develop aspirations and satisfy needs; and on the other hand, to change or cope with the environment. Health is therefore seen as a resource for everyday life, not the objective of living; it is seen as a positive concept emphasizing social and personal resources, as well as physical capacities. Second, the articulation of an overall mission of the provincial health goals which aimed "to maintain and improve the health of British Columbians by enhancing quality of life and minimizing inequalities in health status" (British Columbia, OPHO, 1995). Finally, six key principles underlie the BC health goals and guided the health goals development process. They include: (a) collaborative action among individuals, communities, non-government organizations, communities, all levels of government, and Aboriginal peoples for the achievement of health goals; (b) public participation in decision making for implementation actions to achieve health goals, (c) respect for diversity of cultures, historical roots, and preferences and choices, and (d) equitable access to needed and appropriate health services and a balanced approach to government expenditure on health services and on other influences on health (British Columbia, OPHO, 1995). 18 The B C health goals development process reported here spanned nearly 3 years and yielded several versions of health goals. The six health goals that constitute the final version of health goals for BC are listed in Table 1 below.3 Please refer to Appendix Z for a full listing of the final version of health goals and associated objectives. Table 1: Health Goals For British Columbia Goal 1: Positive and supportive living and working conditions in all our communities Goal 2: Opportunities for all individuals to develop and maintain the capacities and skills needed to thrive and meet life's challenges and to make choices that enhance health. Goal 3: A diverse and sustainable physical environment with clean, healthy and safe, air, water and land. Goal 4: An effective and efficient health service system that provides equitable access to appropriate services. Goal 5: Improved health for aboriginal peoples. Goal 6: Reduction of preventable illness, injuries, disabilities and premature deaths. Source: Health Goals For British Columbia, Ministry of Health and Ministry Responsible for Seniors, 1997 Phases of the BC Health Goals Development Process Late in 1994, about 50 people from various organizations and sectors participated in the drafting of a preliminary set of health goals that was coordinated by the Office of the Provincial Health Officer. These goals served as the basis for wide consultation to reflect the interests and 3 The various renditions of health goals and the genesis of each is referenced in greater detail in Chapter 4; and included in Appendices V through Z. 19 priorities of people and communities throughout the province. While the various phases of the health goals process are described in detail in later chapters, a summary of the six phases that comprise the development process is presented here: Phase 1 involved input from provincial government ministries who provided comment on the preliminary health goals, identified areas within their sector where measurable objectives could be developed, and suggested data sources and advice on indicators for measuring progress. Phase 2 included input from provincial stakeholder organizations who were suggested by the representatives of all provincial ministries. Over 100 representatives of provincial stakeholder organizations attended a series of half-day meetings conducted by the Office of the Provincial Health Officer, and about 50 organizations responded in writing on ways to improve health goals and made suggestions for objectives and methods to measure progress. Phase 3 entailed preparation of a public discussion paper entitled, Health Goals for British Columbia: Identifying Priorities for a Healthy Population (1995) which included input from the first two phases on draft health goals, objectives and a preliminary set of measurement indicators. This paper also served as the source for public consultations in phase four. Phase 4 involved public consultations through regional health boards which consisted of full day meetings in each of the 20 health regions and involved approximately 1,300 people including members of the public and representative of various government and non-government agencies in health and other sectors. Phase 5 constituted finalization of the proposed health goals and objectives based on public consultation input and targeted discussion with ministries and sectors that proposed revisions. Development of measurement indicators and targets continued during this phase. 20 Phase 6 entailed cabinet submission and adoption of the provincial health goals and an expectation by the Office of the Provincial Health Officer for direction on how to proceed with the implementation of health goals. At the time of writing of this thesis, provincial health goals have been adopted by the Cabinet of the government of British Columbia and the Office of the Provincial Health Officer is organizing to develop and implement actions to be undertaken by government and non-government partners from various sectors toward the attainment of the BC health goals. 21 C H A P T E R 2: R E V I E W O F T H E L I T E R A T U R E This chapter reviews the literature in two sections. Part A reviews the literature on planning theory that relates to the health goals development process. According to Cooper (1989), a theoretical literature review presents the theories offered to explain a particular phenomenon, compares them in relation to breadth and the nature of their assumptions, and makes assessments about which theory is most powerful and consistent with the issue under inquiry. Part B of this chapter attempts an integrative research review that summarizes and draws conclusions about the key, multiple factors known to characterize, influence or contribute to health goals development. The integrative research review synthesizes the past evidence on the issues; presents the state of knowledge concerning the issues, and highlights gaps in the literature and raises question about issues that remain unresolved (Cooper, 1989). Part B is structured around a set of propositional statements that organizes and summarizes the literature on the multiple factors that influence the health goals development process. PART A : PLANNING THEORIES AND MODELS RELATED TO HEALTH GOALS DEVELOPMENT This part of the literature review discusses the theoretical basis of health goals development. It provides: (a) an overview of four grand theories of planning relevant to health goals development, (b) a discussion of three key theoretical issues associated with health goals planning, and (c) a review of various procedural health planning models pertinent to health goals planning. 22 Grand Theories of Planning This section reviews key assumptions and characteristics of four schools of planning thought: (a) the rational model, (b) the incremental model, (c) the mixed scanning model, and (d) Allison's models. An examination of the major schools of planning thought facilitates the understanding of the historical roots of goals-based planning in the health field. The intent of this section is to introduce the grand theories of planning that have guided the development of more procedural, practice-based health planning models (to be discussed later), which themselves can be considered progenitors of health goals planning. The Rational Model The rational planning model (also referred to as the rational-comprehensive model) is characterized by an orderly, logical progression from diagnosis of a condition or problem to actions taken to alleviate or improve it (Walt, 1994). The rational perspective views planning as an objective science that is based on cooperation among decision makers and takes place for the mutual benefit of those involved. The rational planning model assumes that planning advances through a rational series of steps to make the "best" possible choices for future action toward some vision of the "good life" for all concerned (Dror, 1973). Rational planning provides a theory on the way policy makers ought to behave when making decisions and planning for the future (Walt, 1994). Decision makers go through a logical process to reach a decision that effectively achieves a given end, based on the examination and analysis of relevant facts, values and theories (Gilbert & Specht, 1977). Most often the problem or situation is thoroughly assessed and its scope, incidence and seriousness specified in great detail. Data collection is central to the planning initiative; typically, investigations are conducted 23 to collect information on what has been done regarding the problem within the planning jurisdiction as well as how other jurisdictions have addressed similar problems or situations. Under the rational planning model, planners proceed through the following steps to reach the best possible decision: 1. Clear problem identification where the problem or issue under consideration is separated from other problems or compared with other problems. 2. Clear delineation of goals that aim for consistency across organizational or planning units. Planning groups clarify the goals and values that guide the planning process and rank them according to some measure or judgment of importance (for example, health equity goals may receive a higher ranking than health efficiency goals). 3. Generation of possible solution alternatives for addressing the issue or problem. 4. Comprehensive examination of each solution alternative including assessment of potential consequences in costs and benefits. 5. Comparison of each alternative and its consequences to other alternatives. 6. Choice of the solution alternative (and associated consequences) most aligned with expressed values and most likely to maximize goal attainment. _ Some people question the usefulness of rational models and argue that the ability for decision makers or planners to act rationally is limited by various factors (Walt, 1994). For example, planners do not often face clearly defined problems or issues. Issue uncertainty jeopardizes the identification of alternatives and consequences and breaks down the logical flow of the rational planning process. Secondly, the practical considerations of time and access to information may impede planners in their attempt to make an exhaustive analysis of alternatives and consequences. Thirdly, planners or decision makers are not value free; they bring their 24 prejudices and preferences to the planning table, which may limit or screen the identification of solution alternatives (for example, the reluctance of a conservative to consider a "liberal" solution). Further, in many cases, past plans or policies dictate future plans or policies and movement on policy is especially constrained when past investments or commitments must be honoured, which may impede the otherwise rational process of working toward the best solution. Finally, the rational planning model does not fully consider social and political influences. Cervero and Wilson (1994), recent writers on planning, do not discount the role of rationality in planning, but believe that the greatest downfall of the rational approach is its lack of attention to political interests and power relations: This is not to say that planners do not act rationally ... But it is to say that comprehensive notions of scientific rationality as underlying planning theory fundamentally fail to understand how planners act in the real world, for this mode of rationality lacks the crucial ethical, political, and structural dimensions that make sense of planners' actions in a context of interests and power (p. 177). Regardless of its limitations, the rational planning model has significantly influenced planning in the health field more than in some others (such as education, in which Cervero & Wilson were writing the foregoing quotation). It is traceable to several health planning models relevant to health goals planning. The management-by-objectives model is an example of rational planning that has been applied in several health goals initiatives world-wide.4 The Incremental Model The incremental planning model (also referred to as the incrementalist model or the political model) is a response in part to the rational model (Walt, 1994). Unlike the rational 4 Management-by-objectives characterizes the US Objectives for the Nation and Healthy People 2000 initiatives as well as other health goals initiatives that have been reviewed as part of this chapter. The management-by-objectives model is considered one of the progenitors of heath goals planning and is discussed in detail later in this chapter. 25 planning model, the incremental model integrates the political dimensions of planning with the more technical aspects of planning. Incrementalism recognizes that planners and decision makers make decisions within a political context characterized by conflict and negotiation which introduces limitations and challenges to the planning process. Plans and policies therefore, are political outcomes, negotiated by interest groups with varying perspectives, aims and power. An incrementalist perspective focusses planning on small changes to existing policy rather than large changes or consideration of major future policies which are more likely to be considered within the rational (comprehensive) planning perspective. Planning is envisioned as a continuous process where plans are revisited for ongoing adjustment. Few problems therefore are solved for all time or in any single attempt or program. Under incrementalism, policy planning proceeds with small serial steps, each similar to the one before, with ongoing "successive limited comparisons" (Walt, 1994). Each planning step is governed by the consideration of what actions can be taken to bring about the desired change with the least possible disruption to the status quo. Goals may or may not be clearly delineated in the incremental model of planning. The reluctance to be clear on goals may reflect an awareness that goal definition precipitates conflict rather than agreement or consensus (Walt, 1994). In the incremental model, goal selection and the means of implementation are not distinct from one another; plan development and plan implementation occur in simultaneous cycles. This differs from the rational planning model where goals are clearly stated and the delineation of goals does not include evaluation or selection of means; that is, plan development is held separate from plan implementation. Also, unlike the rational model, formulating a coherent set of values to guide planning does not occur in incrementalist planning insofar as values, like plans, are fluid, and change with time and experience. Additional characteristics of the incremental planning model include (Gilbert & 26 Specht, 1979): (a) consideration of only a limited number of alternatives for addressing a problem where there is no optimal alternative, (b) choice of solution options that differ only marginally from existing policies, (c) consideration of only the most significant consequences for each alternative, and (d) striking consensus among decision makers about the option chosen is more important than ensuring the "best" decision, as is the case in the rational planning model. Charles Lindblom (1959), likely the most recognizable incrementalist, in his classic work, The Science of Muddling Through, described the decision-making process as one of "disjointed incrementalism" or "muddling through." To Lindblom, "partisan mutual adjustment" influences the policy process; it is a process of bargaining, negotiation, and adjustment between different interest groups to impact policy outcomes. What is feasible politically, Lindblom argued, is incremental or marginal changes to existing policies or programs. Incrementalism focuses the analysis of problems and issues on what is familiar and reduces the number of factors decision makers must consider. Lindblom's beliefs on the nature of policy making remained constant over a twenty year span. In his later essay, Still Muddling, Not Yet Through, Lindblom (1979) argued that incrementalism had become orthodoxy; reaffirming that in policy making, only small, incremental steps are ordinarily possible: "It is more likely that decision makers get better at doing things incrementally than doing things in different ways, many ... believe that for complex problem solving it usually means practicing incrementalism more skillfully and turning away from it only rarely" (p. 517). The Mixed Scanning Model Etzioni (1967) introduced the mixed scanning approach to policy planning as an attempt to find a middle position between the rational and incremental approaches. Mixed scanning 27 combines the research and fact-gathering elements of the rational approach with the small-step, consensus-building elements of the incremental approach (Gilbert & Specht, 1977). First, "broad-angle scanning" provides an overview assessment of the situation or condition and relevant data are collected and analyzed (although not to the degree of the rational model). This is followed by an exercise in "narrow-scope scanning," which examines in detail only a limited number of alternatives or options available to address the situation or condition (representative of the incremental approach). The mixed scanning model differentiates between fundamental decisions and incremental decisions. Planners make fundamental decisions by exploring the main alternatives available to them in view of their goals and values. An overview understanding is feasible, and details and specifications are not included. Incremental decisions are made but within the context provided by fundamental decisions and the overview. Thus, according to Etizoni: Each of the two elements in mixed scanning helps to reduce the effects of the particular shortcomings of the other; incrementalism reduces the unrealistic aspects of rationalism by limiting the details required in fundamental decisions, and contextualizing rationalism helps to overcome the conservative slant of incrementalism by exploring longer-run alternatives" (p. 93). Etzioni developed the mixed scanning model as an effort to reconcile the imperfections of the rational and incremental approaches. Henrik Blum (1983) advocated a similar planning approach which combines various planning styles into what he called developmental planning. In the developmental approach, normative planning, which focuses on goal attainment, is combined with guided and articulated planning, which centers on problem solving. Developmental planning attempts to bring short-term and long-term purposes together; it bases goal setting on society's value system and uses it to guide immediate and long-range planning initiatives. "In addition to defining major goals and 28 planning to reach them, [developmental planning] uses the same goals as a source of guidance for problems solving... thus, current problems are addressed by solutions that are designed to be compatible with desired large-goal directions" (p. 224). Developmental planning sets forth goals and strives to reach them both directly and incrementally, and the choice between these approaches is driven by the political outlook of the community and the nature of the situation being addressed. In this way, it combines efforts to be values-based and solution-generating within the existing political and planning context. Allison's Models Graham Allison's (1971) classic book, Essence of Decision: Explaining the Cuban Missile Crisis, provides a useful typology to assist in the study of decision making, planning and policy making. Model I and Model III of the Allison typology are similar to the models discussed above. Model I, the Rational Actor or "Classical" Model, similar to the rational school of thought, views planning and policy as a rational output where the decision maker or planner is considered to a be a unitary purposeful actor. Model III, the Governmental (Bureaucratic) Politics Model, similar to the incremental model, views planning as a political resultant and addresses the interaction between various political groups and interests, and considers personalities, stakes, stands , influence and power of actors. Allison's Model II, the focus of this discussion, views the planning process through an organizational lens. Referred to as the Organizational Process Model, Allison's Model II considers planning as an organizational output whereby planning reflects conflicting organizational goals and the formal traditions and practices of participating agencies or organizations. Appendix A summarizes the three models that comprise Allison's typology. 29 Within Allison's Model II, the "organization" is a bureaucratic unit of government which operates within its own standard operating procedures and deals with multiple interorganizational issues between itself and other bureaucratic units. Although the model acknowledges that organizations outside of government may be a part of the planning process, most planning and policy making takes place within government bureaucracies or agencies. For this reason, the governmental, bureaucratic organization is positioned at the nucleus of Allison's Model II. Allison's Model II rests on organizational theory, and more precisely, that branch of organizational theory that takes as its focus the decision-making process. A distinguished figure in this area has been Herbert Simon (1960), whose work on "bounded rationality", has greatly influenced Allison's conceptualization of Model II.3 Allison's Model II, the Organizational Process Model, poses three major questions about the planning process: 1. What organizations are involved in the planning process? 2. Which organizations traditionally act on the problem or area of concern and with what relative influence? 3. What repertoire and standard practices, procedures and activities do these organizations have for generating alternatives to deal with problems and for implementing alternative courses of action? Central to Allison's Model II is the view that planning is an output of organizational practices and procedures and inter-organizational accommodation; and organizational procedures and activities are largely a reflection of elected government officials whose preferred ways of seeing the world are incorporated into bureaucratic operations. Elected government leaders then 3 Bounded rationality questions the ideal conditions assumed in the rational planning model and describes how decisions in real life planning situations are actually bounded (limited) by the complexity ofthe planning issues as well as by time and resource constraints. 30 define an organization's capacity; and their influence sets organizational routines and practices. Within this context, planners represent organizational actors positioned within loosely allied organizations on top of which elected, government leaders sit. Planners work within organizational units (bureaucracies), each one perceiving problems, processing information, and performing activities relatively independent of the other. Being responsible for a defined, narrow set of problems relevant to one's own organization encourages organizational parochialism. This slows organizational learning and change; encourages organization procedures, priorities and issues to remain constant; and leads to only marginal adaptation of existing programs, plans and activities. Planning and decision making under Allision's Model II is conducted within a set of constraints posed by organizational/bureaucratic units such as standard operating procedures, ongoing programs, and interorganizational relations. Allison's Model II views goal setting as a mechanism to define acceptable performance for the organization or bureaucracy. The model acknowledges the importance of developing interorganizational or interagency goals to guard against role conflict between organizations and to facilitate organization-wide planning and decision making. Grand Theory Assumptions Relevant to Health Goals Planning The four major schools of planning thought discussed above rest on three assumptions that are particularly relevant to the process of health goals development: (a) assumptions about the achievement of consensus, (b) assumptions about the degree of centralized or decentralized planning (while this concept is introduced here, it is discussed in greater detail later in a later section), and (c) assumptions related to the role of the "public interest" in planning. 31 According to Gilbert and Specht (1979), the rational planning model assumes that a general consensus on means and ends that serves societal common good can be achieved. Development of the "best plan" is a matter of working through technical problems that will be solved by research and analysis of relevant data. A centralized planning mechanism that is able to address the "large picture" is more effective in accomplishing this kind of analysis than a group of decentralized units with more limited access and vision. The incremental school of thought rejects the likelihood that consensus can be achieved around big or broad issues, but asserts that agreement is achievable on proposals for incremental change (Gilbert & Specht, 1979). A decentralized planning mechanism is best suited under this model by accommodating local decision making. The planning mechanisms must be flexible and versatile to allow input from different interest groups. This model accommodates the interests of many players and allows for opposing groups to protect their interests by putting forth their own plans as a means to compensate for the shortcomings of others. The mixed scanning model allows for greater or lesser degrees of consensus around planning issues (Gilbert & Specht, 1979). This flexibility is translated into planning mechanisms. Consensus around specific or particular issues can take place at a decentralized level whereas more general policy directions, where a more moderate degree of consensus is acceptable, are best decided upon centrally. Gilbert and Specht (1979) share an example from urban planning whereby a city-wide master plan is set by New York City and serves as a framework for "mini-plans" to be developed by neighbourhood planning boards. This arrangement, according to Gilbert and Specht, "allows for flexible responses tailored to local needs and wishes, while 4-continuing to keep the 'big picture' in view" (p. 75). Gilbert and Specht (1977) argued that the "public interest" represents another 32 fundamental philosophical issue that distinguishes the various schools of planning thought. How the public interest is defined is a function of whether one adopts the individualistic or unitary conception of public interest or common welfare (Wootton, 1945). According to the individualistic view, there is no such thing as the public interest, "rather there are different publics with different interests, which makes the justification of planning on the basis of shared interests and mutual benefit a rather tenuous matter" (Gilbert & Specht, 1977, p. 20). From this perspective, public interest is transitory; it changes as new groups and interests enter to influence the planning process. The unitary view of the public interest holds that there are communal interests shared by the vast majority. "These interests are common ends that are more valuable in defining the public interest than the unshared ends of individuals and groups" (p. 20). In terms of the planning theories highlighted here, the rational model of planning rests on a communal or unitary conception of the public interest; where planning is undertaken for the common good and more weight is attached to common ends than to unshared ends, even though the individuals who entertain the ends may themselves attach more importance to unshared ends (Banfield and Meyerson, 1955). The incremental model of planning adopts the individualistic view, where the public interest is a momentary compromise and is an outcome of competing positions and interests; it is negotiated among competing interests and is therefore fluid. The relevant ends that are sought in the incremental planning process are those of individuals, whether shared or unshared. "The ends of the plurality 'as a whole' are simply the aggregate of ends entertained by individuals, and decisions (for) the public interest are consistent with as large a part of the whole as possible" (Banfield and Meyerson, 1955, p. 323). The interest of the community, the public interest, equals the sum of the interests of the various members who comprise it. 33 Gilbert and Specht (1977) recognized the fundamental nature of the public interest in the planning process: "These different views of the public interest are not merely concepts upon which scholars ruminate; they are powerful ideas that influence the course of action in social planning" (p. 21). The various conceptualizations of the public interest pose significant implications for the planning process - who is involved, whose voice is heard, what priorities are identified, and what techniques and procedures are applied. Three Key Theoretical Issues in Health Goals Development The discussion above summarizes the broad schools of thought that influence health planning generally. Later, this chapter discusses those planning models more directly related to health goals planning that are typically more procedural in nature and give greater consideration to the application of goals and objectives. Before the discussion moves to specific health planning models, however, this chapter touches on a few key relevant issues to the health goals planning exercise. These include: (a) the evolution of health promotion theory in relation to the broad determinants of health; (b) the degree of centralization or decentralization that characterizes the planning exercise; and (c) the shifting focus from resource-based planning to population-based planning models. Health Determinants: From Health Education to Ecology to Population Health Our knowledge about the factors that influence health has evolved over the past two decades. Today, especially within the Canadian context, much of the discourse on health occurs under the rubric of "population health" which addresses the "broad determinants of health." Typically, the broad determinants of health refer to the social, economic, and environmental 34 factors that influence health. Although significant evidence supports the relationship between the broad determinants of health and health status, less has been demonstrated to be causal in nature. It may be more accurate therefore, to use language that implies a correlation between these factors and health; rather than language which implies a deterministic or direct relationship. However, insofar as the term is widely accepted by public health practitioners in Canada and commonly incorporated in the health planning literature, "broad determinants of health," will be used in this paper to refer to the social, economic and environmental influences on health. Greater inclusion of the broad determinants of health in health planning and policy parallels the evolution of health promotion theory from health education to ecological models. Although the ecological view of health can be traced back to the earliest days of public health,4 it came into prominence as a result of the growing awareness of the limitations posed by those health education approaches restricted to changing the behaviour of individuals whose health was at risk.5 The central limitation of health education that encouraged the adoption of ecological models centred on a commitment to the guiding philosophy of an individual's responsibility for health and an associated reliance on behaviour and lifestyle interventions; combined with limited consideration of the social, economic and environmental influences on health. According to Green (1996), although the intent of self responsibility for health may be positive by encouraging increased individual capacity to contend with factors affecting health, "initiatives to promote 4 The historical roots of the ecological perspective in public health date back to the mid 1800's with Dr. John Snow's removal of the London Broad Street pump handle and the subsequent host-agent-environment epidemiological triad which informed effective ecological interventions for over a century. Further, Green (1996) tracks the intellectual roots of the ecological perspective and reveals its use in medical sociology, psychology, human and medical geography, and education. 5 Limitations were not associated with health education models alone, but as well with most models of medicine, nursing and patient care during this era. The limitations of health education pertained especially to patient education, school health education in adolescent problems, and media campaigns addressing only the knowledge, attitudes or beliefs of the individuals at risk. 35 health by placing the responsibility exclusively on the shoulders of the individual have the effect of blaming the victim of poor health and social conditions" (p. 19). Health, therefore should be a shared responsibility among individuals, their families, community, government, and corporate and volunteer sectors (Green, 1995). A central assumption that defines the ecological model is that health is a product ofthe interdependence between the individual and the ecosystem subsystems that surround him or her including family, community, culture, physical and social environment (Blum, 1974; McLeroy et al., 1988). Within the ecological perspective, the principle of reciprocal determinism operates, whereby an individual's functioning is mediated by behaviour-environment interactions (Green, 1996). The complex interdependencies of elements that influence health means that health promotion efforts must be directed at multiple levels and multiple sectors that comprise an individual's or community's environment (Green, 1996). Ecological approaches to health promotion and planning feature interventions directed at changing interpersonal, organizational, community and public policy factors which support or encourage healthful behaviours and conditions of living. While the ecological model extends the action of health promotion, it does not discount the health education approach. Rather, the ecological perspective folds health education into its design and recognizes health education as a significant contributing influence to health and health promotion, alongside the social, economic and environmental determinants of health. Green and Kreuter (1991) defined health promotion in a way that clearly marries the two approaches to health promotion. Health promotion is "the combination of educational and environmental supports for actions and conditions of living conducive to health" (p. 14). This definition includes health education as one component of health promotion. 36 Today, discussion on the broad determinants of health occurs under the umbrella of "population health." Discourse on "population health" began in the early 1990's, particularly in Canada and Australia. Similar dialogue is occurring in the United States and other countries under the rubric of the new public health," which, like population health, draws attention to the broad determinants of health and strategies to improve health at the aggregate or population level. Population health has been defined as "the epidemiological, social and environmental condition of a community that minimizes morbidity and mortality, enables the community to adapt to changing environmental circumstances, ensures equitable opportunity to contribute productively to the community, and achieves an optimal and sustainable quality of life within these bounds" (Green, 1996).6 Generally, health determinants that serve as the foundation to the population health model include: (a) income and social status, (b) social support networks, (c) education, (d) employment and working conditions, (e) physical environment, (f) biology and genetic endowment, (g) personal health practices and coping skills, (h) healthy child development, and (I) health services (Minister of Supply and Services, 1994). (See Appendix B for a brief description of each of these nine health determinants.) Inclusion of the broad health determinants into population health planning models has resulted in models that are theoretically diverse (such as the PRECEDE-PROCEED model, Green & Krueter, 1991), informed by various social and behavioural science perspectives at the individual, interpersonal and community levels (Glanz & Rimer, 1995); as compared to health education models which draw largely upon individual level theories of health promotion such as the health belief model, the consumer information processing model, and the 6 Others have defined population health as "a broad framework for studying the determinants of health, health outcomes and health interventions" (Rafuse, 1995). Finally, population health may be considered, "an approach that addresses the entire range of factors that determine health and, by so doing, affects the health ofthe entire population" (Hamilton & Bhatti, 1996). 37 stages of change model. (See Appendix C for a listing and description of the multiple theories that characterize population health models). The relationship between population health and health promotion has been vigorously debated over the past few years. Some people believe that the concepts and principles of population health and health promotion are fundamentally the same; others believe that population health represents a new paradigm for health. In his address to the Fourth Canadian Conference on Health Promotion in Montreal in June 1996, Dr. Lawrence Green commented on the unique characteristics of individual health promotion and population health promotion while acknowledging the likely contributions of each. Health promotion, for example, can offer population health various established strategies and interventions, and population health can offer health promotion a multiplicity of epidemiological and economic techniques. The contrasting characteristics of population health promotion and individual health promotion are summarized in Table 2 below, recognizing that in practice each depends on elements of the other. Table 2: Contrasting Population Health Promotion and Individual Health Promotion Population Health Promotion Individual Health Promotion Defines population as unit of analysis Individual as unit of analysis Focus is on distal determinants of health Focus in on proximal determinants of health Intersectoral action Health sector is the primary point of intervention Policy and organizational levers Education and behavioural levers Societal conditions and health equities Quality of life as the ultimate outcome as the ultimate outcome Source: Dr. Lawrence W. Green, Fourth Canadian Conference on Health Promotion, Montreal, June, 1996 38 It is generally accepted among scholars today that achieving a balance between population health promotion and individual health promotion that is appropriate to the circumstances is more important than engaging in discourse that attempts to dichotomize them. Clearly, a key issue of population health for health goals planning is the degree to which the multiple factors that influence health are incorporated into health goals and the opportunities and challenges this poses to health goals formulation, articulation and adoption. Expression of Ecological and Population Health Models in Health Policy Several national and international policies in health promotion over the past two decades have embraced an ecological perspective of health. The International Conference on Primary Health Care held in Alma-Ata, in 1978 adopted an ecological perspective in its declaration and recommendations for primary health care. The declaration put forth twenty-two specific recommendations that emphasized that health development is essential for social and economic development, that the means for attaining them are intimately linked, and that actions to improve the health and socioeconomic situation should be regarded as mutually supportive. The Declaration at Alma Ata (WHO, 1978) defined the features of the global Health For A l l strategy which called for all citizens of the world, by the Year 2000, to attain a level of health that would permit socially and economically productive lives. This strategy also set the foundation (as discussed in Chapter 1) for the health goals approach to population health planning that: has been adopted by many countries around the world over the past three decades. The classic Canadian document, A New Perspective on the Health of Canadians (Lalonde, 1974), explored how factors other than health care influenced and contributed to population health; and identified human biology, lifestyle, the environment, and the availability 39 of health services as key influencing factors. Two other documents, Achieving Health for All: A Framework for Health Promotion (Epp, 1986) (also known as the Epp Framework) and the Ottawa Charter on Health Promotion (WHO, 1986), further developed the ecological perspective of health. The Epp Framework proposed three challenges to reaching the goal of Health For All in Canada including health inequities, methods for preventing injuries, illness, chronic conditions and related disabilities; and the ability of individuals to manage and cope with chronic conditions, disabilities and mental illnesses. Three mechanisms were proposed: mutual aid, self-care, and the creation of healthy (sic) environments; as were three implementation strategies including fostering public participation, strengthening community health services and coordinating healthy (sic) public policy. Similarly, the Ottawa Charter on Health Promotion (WHO, 1986) referred to health determinants as pre-requisites for health and recognized that access to better health cannot be ensured by the health sector alone. The Ottawa Charter defined health promotion action as building "healthy public policy," creating supportive environments, strengthening community action, developing personal skills, and reorienting health services. Finally, the Healthy Cities initiative of the WHO's European Region, built upon the principles of the Epp Framework and the Ottawa Charter and has been credited by some writers as fuelling the diffusion of the ecological approach in health promotion (Green, 1996). Recently, a discussion paper entitled, Strategies for Population Health: Investing in the Health of Canadians (Minister of Supply and Services Canada, 1994), prepared by the Federal/Provincial/Territorial Advisory Committee on Population Health, set the stage for a national discussion on population health in Canada. It lays out broad population health strategies on which the provincial, territorial and federal governments could collaborate for the improved 40 health of Canadians. Further, the book, Why Are Some People Healthy and Others Not (Evans et al., 1994), has recently compiled current research on the multiplicity and interrelationship of factors that influence health. This work offered a comprehensive account of the available evidence on the key factors and conditions that influence health. Also, the Canadian Institute for Advanced Research, commonly associated with the "population health movement," has received international recognition for the development of a population health model which recognizes the complex and interactive factors that determine health (Evans & Stoddard, 1990; Mustard & Frank, 1991). Finally, the report Population Health Promotion: An Integrated Model of Population Health and Health Promotion (Hamilton & Bhatti, 1996), traced and combined the various streams of health promotion over the past two decades and proposed a model to support planning for population health promotion at national and regional levels in Canada. These documents and authors provide only a sampling of those who have contributed to the ongoing evolution of population health promotion in Canada and other countries. Health Determinants and Health Goals Planning for health goals requires making decisions about which and how many factors known to influence health become incorporated into health goal statements. Variation in the approach to health goals planning may be conceptualized, as introduced in Chapter 1 (p. 8), along a health-targeted / health-determinants continuum. The published and source document literature on health goals provides evidence of both kinds of approaches or pathways to health goals. (Part B 7 of this chapter offers an extensive 7 Part B of this chapter offers a comprehensive review of the health goals initiatives of six exemplar jurisdictions with the aim to identify and describe the multiple factors that influence and contribute to the health goals development process. Health determinants is one of the areas covered as a part of this review. 41 discussion of the role of health determinants in health goals development.) For example, Health of the Nation, the health goals initiative of England, falls more to the health-targeted end of the continuum where health goals and objectives focus on health status issues and preventable illness including coronary heart disease and stroke, cancers, mental illness, sexual health, and accidents (England Department of Health, 1992). Alternatively, the health goals initiative in the province of Saskatchewan aligns more closely with a distal health-determinants approach to health goals development. In Population Health Goals for Saskatchewan (Saskatchewan, 1994) priorities addressed in health goals include the multiple factors that influence health such as supportive families and communities, healthy (sic) physical environment, health promotion, consideration of the broad determinants of health, social justice and equity, and shared responsibility for improved health (Saskatchewan, 1994). Health goals, like the planning theories that underpin them, vary in the degree to which they incorporate the proximal and distal determinants of health, as represented in the health-targeted and health determinants approaches respectively. One point of interest centres on the challenges and opportunities presented by each approach and the resultant trade-offs and implications of choosing one pathway (to health goals) over another. The Centralization - Decentralization Continuum and Health Goals Planning The degree of centralization or decentralization of the planning process is a key issue in health goals development. Centralized planning, also known as controlled planning (Green & Frankish, 1995), is characterized as planning that takes place "at one central seat, presumably the key political centre of the given community, such as the city council for the city, or by the national government for all sectors of endeavour or all regions of the nation functioning under it" 42 (Blum, 1974, p.382). Decentralized planning "occurs at many centres such as by sectors of endeavour or by regions or by segments within a given community or society" (Blum, 1974, p. 382). Henrick Blum (1974) identified over sixty "modes of planning," some of which have particular bearing on the centralization-decentralization question. For example, what he refers to as participative planning includes extensive involvement of all interested or potentially interested parties at various or all aspects of the planning process (Blum, 1974). Additionally, Blum refers to elitist planning (characterized by other writers as expert-driven planning) as planning carried out by people who are thought to have some specific attribute which qualifies them to direct the planning such as knowledge, social status, or some heavy investment in the planning issues. Finally, Blum identifies top-down planning where "concern with the broader societal or national level goal setting is done at high levels, from which more locally carried out planning stems for smaller or more local issues" (p. 386); and bottom-up planning where "planning and goal setting for specific or local issues are used as the basis on which broader or higher level goals and plans are built" (p 381). These various planning modes, as identified by Blum (1974), represent in many cases parallel and possibly confounded terms for what other writers may refer to as centralized and decentralized approaches to planning. Balancing Centralized and Decentralized Approaches in Health Planning Health promotion is inherently interdisciplinary and intersectoral and depends on the action of multiple forces including federal, state or provincial governments, local and multinational corporations, professional groups, communities and citizens (Green & Frankish, 1995). According to Green and Frankish (1995), effective health policy making and health 43 planning requires a "bifocal view of the world;" where many health promotion initiatives are legislated centrally and depend ultimately on individuals, families and local groups for their application (Green & Frankish, 1995; Green & Shoveller, 1996). This duality of central plans or policies and reliance on local implementation challenges health planning. Decentralization of the planning process is widely considered to be an effective means to address this challenge. Decentralized planning in health promotion implies a preference for local rather than national control over priority actions for various population health concerns. The recent movement toward decentralization might be attributable in part to efforts by central governments to distance themselves from previous financial commitments to regional or local health initiatives. Favourable perceptions for decentralized approaches may reflect also the increasing demand for local autonomy over health decision making, elevated doubt among citizens about the role of governments, and increasing anti-government sentiment or loss of confidence among the public (Green & Frankish, 1995). The health planning and health promotion literature documents several benefits of decentralized planning in health promotion. For example decentralized planning means that decision-making power rests closer to home, encourages partnerships and alliances at the local level, increases community and citizen empowerment, and promotes a sense of ownership of health goals and programs. These presumed advantages have led to commentaries in the health promotion literature (Bracht & Tsouros, 1990; Green & Raeburn, 1988; Tsouros, 1990) that favour local, decentralized planning approaches over central initiatives in health promotion planning (Green & Shoveller, 1996). However, decentralized approaches to health promotion planning face several challenges and limitations. Decentralized planning places greater burdens of fiscal responsibility for health 44 on local governments; as demonstrated in Canada where provinces (which have jurisdiction over health) have received less federal transfer payments to support health systems, leaving fewer funds available for regional and local health promotion efforts (Green & Frankish, 1995; Green & Shoveller, 1996). Further, planning at the local level may involve individuals who lack the necessary training and skills to develop plans and to accommodate complex political and social dimensions into the planning process (Green et al., 1995; Siler-Wells, 1988). Also, decentralized planning at its theoretical best draws upon local citizens as volunteers for work that is often very labour-intensive and may lead to an over-representation of more affluent and retired people and professionals, challenging the goal of full community representation on planning committees and boards (Lomas & Veenstra, 1995; Wharf Higgins, 1997). Decentralized planning means also that lower planning levels are accountable to higher planning levels which leads to concerns among local planners of a loss of control over community programs and resources (Green & Frankish, 1995; Green & Shoveller, 1996). Finally, where local initiatives are successful, central agencies encourage them to be used as models and refer other groups to them for support or technical assistance, without providing the resources necessary to meet these added responsibilities (Green & Frankish, 1995; Green & Shoveller, 1996). Movement toward decentralized planning approaches has led to a call in health promotion for balance between personal, organizational, community and centralized control in health promotion planning (Green & Frankish, 1995). The health promotion literature documents contributions of central governments. Hancock (1989) recognized that governments serve to promote understanding and recognition of perspectives on health and to set health goals and provide infrastructure and capacity; by providing funding, defining roles, providing training, and providing exemplars or centres of excellence that local constituencies can model. In this way, 45 central governments can strengthen local or community action in health promotion by improving the existing community health sector and by reinforcing community control over health planning decisions and resources. Green and Frankish (1995) acknowledged similar contributions of centralized governments to health promotion planning including (a) listening to the people and their concerns, (b) providing leadership and resources in disease prevention and health promotion initiatives, and (c) supporting infrastructure needs so that communities can maintain momentum and commitment in pursuit of population health gains. So while decentralized models have become popularized in health promotion planning, finding the right mix between personal, organizational, community and centralized controls remains a challenge to health planning and health promotion practice. Centralized-Decentralized Health Goals Development The literature on health goals points out that in most cases health goals planning in the early phases of the development process is situated within the government or political centre of the jurisdiction planning for health goals; this is usually followed by some moving out of the planning process to regional or local levels. Evidence to support this comes from the health goals experience of six sample jurisdictions reviewed in Part B of this chapter. Notable is the health goals initiative in the United States which varied in the level of centralization between the first round of health goals to develop the 1990 Objectives and the second round of goal setting to formulate the Year 2000 Objectives. The first round of goal setting was centralized in the US Public Health Service followed by modelling and adaptation at the state and local level. The second round involved, to a much greater extent, starting the national effort through the involvement of states and regions. Similarly, the health goals 46 initiatives in Australia, England and the province of Saskatchewan were characteristically centralized — centred within an academic institution^ a national department of health, and a provincial health council respectively. Of interest is how the mode of planning may influence the processes undertaken to develop health goals as well as the outcome or products of the health goals planning effort. Of particular interest to this study, is the relationship between the centralization-decentralization continuum of health goals planning and the subsequent articulation of health goals in terms of their measurability, the kinds of health priorities they addressed, and the range of health determinants that are considered. Part B of this chapter further discusses these issues as well as other modes of health planning relevant to health goals development. Resource-Based and Population-Based Planning Planning for population health reflects a shift from resource-based planning which tends to rationalize and justify existing resources and activities in health, toward population-based planning, where planning is based on the needs of the population and strives to optimize resources for the improved health of populations (Frankish et al., 1996a). Resource-based planning aims to accommodate the demand for health services, procedures and resources in the most efficient manner possible. Resource-based planning starts with an assessment of health resources and attempts to match the supply of resources with the demand for health services. Resource-based planning revolves around the assets controlled by the health system, mainly hospitals, technology, and medical personnel, rather than the health needs of the population. According to Green (1996), the problem with the resource-based approach to health planning is that "it tends to perpetuate and expand resources whether they are needed or not" (p. 25). When 47 planning is based on allocating among providers resources that are distributed largely on the basis of past resource allocations, little consideration is given to the characteristics of the needs of the population being served or the outcomes achieved; the resources then become an end in themselves. Population-based planning methodologies respond in part to the difficulties posed by resource-based planning models. Population-based planning endeavours to address effectively the health needs of the population, rather than to meet the ever-increasing demand for health services, procedures and technologies. Demand-based planning is especially distorted when the population's demands are controlled in large part by providers or suppliers of resources (especially when health care is market-driven) such as physician's control of referrals, prescriptions, lab tests, and high technology diagnostics (Herzlinger, 1997). Population-based planning can be described as "a process which determines health needs and establishes resource requirements based upon an assessment of the risk levels and the health status of a given population" (Tannen & Liebman, 1978). Population-based planning starts with the population and assesses what the population needs followed by an assessment of resources available and needed to meet those needs (Green, 1996). As with any attempt to differentiate between approaches, most real-life planning initiatives probably adopt some aspects of each of these approaches. Certain phases characterize each planning model. Resource-based planning starts with the selection of the services to be studied or reviewed; selection is based on issues related to (over or under) utilization or to the deterioration of a service or facility (Tannen & Liebman, 1978). A review of current and past service utilization trends follows in order to forecast the future demand for the service. Then the projected demand is compared to the current capacity of the 48 service or facility. Finally, the projected demand is matched with the expected supply to determine what kinds of adjustments to resource allocation are necessary to accommodate the forecasted utilization. Population-based planning proceeds through the following four phases (Green, 1996): (a) the identification of a specific human population, (b) an assessment of causes of the health needs including risk factors (such as alcohol, tobacco use, poor diet, or physical inactivity) and risk conditions or determinants of health associated with risk factors (such as poor living and working environments, inadequate housing, or secure incomes); (c) the strategic application of knowledge and data about the causes identified in the second phase which leads to the identification of policies or programs aimed at addressing the factors that influence health; and (d) the evaluation of the programs planned to meet the population health needs and related adjustment to programs or procedures to improve upon their construction or delivery. While much of health planning is moving toward population-based planning models, several challenges exist and most of them centre on data-related issues (Tannen & Liebman, 1978). Any assessment of a population's health status and risk conditions and factors requires ongoing collection of accurate and adequate data in usable form. Without such data systems, planning on an ad hoc basis can become costly and time-intensive. Further, population-based planning tends to incorporate an analysis of the broad determinants of health which places greater data needs in areas that fall beyond the traditional health sector, further compounding data availability and access problems. Also, population-based approaches necessitate sophisticated measurement strategies including the development of valid and reliable indicators of health status to assess population health needs as well as indicators to serve as proxies for health-care or health service needs (Eyles & Birch, 1993). Continued effort to improve data systems and 49 measurement strategies must parallel the increasing application of population-based planning methodologies in the health field. Resource-Based Planning and Health Goals The wide acceptance of health goals as a strategy for population health promotion may reflect a shift from resource-based planning toward population-based planning. Health goals planning and population-based planning share two important aims: (a) to consider the multiple factors that influence health in the planning exercise, and (b) to encourage a shift in focus from health services or resources to health outcomes. Population-based planning lends itself to the consideration of the multiple factors that influence health and the full array of services, not just illness care. According to Tannen and Liebman (1978), resource-based planning tends to be drawn increasingly into the assumption that the purpose of the health system and health planning is to treat illness. Consequently, there is little attempt to link resources to the health status of the population or to the risk factors and conditions that influence health. In contrast, one objective of population-based planning is to detect and minimize risk to the health of a population. This goes well beyond a medical model of health, and necessitates a look at the social, environmental and economic characteristics of a population. Similarly, the literature on health goals acknowledges that most jurisdictions that have adopted a health goals approach incorporate the broad determinants of health into their health goal statements, although this tendency is more explicit in some jurisdictions than others. The health goals initiatives of the province of Saskatchewan and Australia for example, fully integrate the multiple factors that influence health. (Further discussion on health determinants in health goals follows in Part B of this chapter). 50 Encouraging a shift in focus from health services to health outcomes accounts for another shared objective of health goals planning and population-based methodologies. With the health of populations as its focus, population-based planning directs attention to health outcomes rather than health care. By defining groups in the population who share risks and targeting programs at the multiple factors that contribute to i l l health, population-based planning "facilitates health maintenance by directing preventive health care programs directly at high-risk populations and can be used to orient the health system toward promotion, prevention and primary care activities" (Tannen & Liebman, 1978, p. 54). Health goals hold similar potential. In efforts to implement population-based planning in one of the Canadian provinces, proponents argued that "one ofthe guiding principles for achieving the vision of health in Ontario is that planning should be driven by health goals, that is, by health outcomes based on the health needs of the population (Eyles & Birch, 1993, p. 113). By focusing attention on the improved health status of populations, health goals encourage the creation of health promotion and prevention programs. Health goals thereby help to steer the emphasis away from health services to health gains, and importantly, to strike a balance between treatment, rehabilitation, and health promotion / disease and injury prevention services, programs, and policies. By moving beyond the medical model of health, health goals and population-based planning encourage the consideration of the broad determinants of health in planning for the improved health of populations and facilitate a reorientation of the health system from health services to population health gains. Health Planning Models So far, this chapter has presented a discussion on the grand planning theories related to 51 health goals development including the rational, incremental, mixed scanning and Allison models; followed by a discussion on three key theoretical issues associated with health goals planning including the broad determinants of health, the degree of centralization of the planning exercise, and the shifting focus from resource-based to population-based planning models. Moving from the general to the specific, we now enter into a discussion on planning models that are more procedural in nature - those that give greater consideration to the application of goals, objectives and targets. Some of these models may be regarded as progenitors of the health goals planning approach and include: (a) management-by-objectives, (b) the PERT model, (c) the PRECEDE-PROCEED model, (d) the P A T C H model, (e) the M A T C H model, and (f) the A P E X P H and Model Standards models. Management-By-Obj ectives Management-by-objectives (MBO), a philosophy of scientific management and planning, emanates from the business and military/defence sectors and has been widely accepted in both private and public settings over the past twenty-five years.8 The central objective of management-by-objectives in business is to identify and meet organizational goals and objectives that ultimately impact productivity, profit, performance and positive outcomes. The underlying assumption of the management-by-objectives model is that "the best way to manage things is to involve people in setting objectives and then direct needed resources toward them in an organized manner" (Lee, 1981, p. 3). Further, the management-by-objectives model rests on the The concept of management-by-objectives was first introduced by Peter Drucker in 1954 in his classic book The Practice of Management. MBO was also linked to the defense sector in the US with the introduction of systems analysis by the then Secretary of the Department of Defense, Robert McNamara, in the 1960's followed by the adoption of the MBO philosophy throughout the federal government. MBO has been widely accepted as a management and planning methodology in the business sector since the early 1970's . 52 belief that individuals in the workplace are most effective when they understand the work they are doing, what they are working toward, and what the expected final results will be (Garrison & Raynes, 1980). The best way to meet these conditions is to set measurable goals and objectives and to hold parties accountable for their monitoring and attainment. The management-by-objectives approach aligns with the rational model of planning. It is based on logical, systematic steps to solve problems and make decisions that provide managers with the tools to measure the effects of their management and planning efforts (Garrison & Raynes, 1980). Various alternative terms refer to the management-by-objectives approach and include, "administration-by-objectives," "management-by-objectives and results," "planning-programming-budgeting system (PPBS)," "zero-based budgeting," and "management- by-objectives and priorities." (Lee, 1981). Management-by-objectives features goal setting (Benge, 1975; Lee, 1981; McConkey, 1975; Odiorne, 1965; Richards, 1986). Distinguishing characteristics of the management-by-objectives model relevant to goal setting include the following: (a) stating objectives in specific, measurable and attainable terms, and in ways relevant to managers and workers; (b) establishment of performance standards (targets) for assessing achievements of objectives, (c) goal consistency across organizational levels (horizontal consistency) and among organizational levels (vertical consistency); (d) involvement of all levels of the organization and the inclusion of technical expertise in goal development and attainment; (e) emphasising continuous feedback and recognition for successful performance and goal attainment where improved results are realized by comparing actual and expected performance results; (f) focusing attention on output and results versus activities; and (g) linking goal attainment to reward, reimbursement and gratitude. 53 Additionally, progress toward stated goals ordinarily occurs incrementally and intermediate steps are established to evaluate ongoing progress toward objectives. Further, the management-by-objectives approach continually asks questions as to whether proposed objectives are, in reality, achievable in light of other planning initiatives underway in interrelated parts of the system or organization (Richards, 1986). Finally, the most important predictor of success of the adoption and implementation of the management-by-objectives model is the level of commitment to the value and operations of M B O by top level managers who encourage the model's application within a corporate culture of acceptance (Migliore & Martin, 1994) Management-By-Objectives in the Health Field The management-by-objectives model has been applied for different purposes in two distinct settings in the health field: (a) in hospitals and health care organizations where M B O has been used mainly as a management tool; and (b) in the areas of health promotion, disease prevention and population health where M B O is most commonly applied as a planning tool. In health care settings, management-by-objectives has been widely accepted as a mechanism for results-oriented management among health managers and planners. Continuous quality improvement (CQI) and quality assurance (QA) are increasingly instituted at the organizational or acute care levels as a means of tracking progress toward improved quality of health care. Garrison and Raynes (1980) evaluated the ability of the M B O strategy to assist mental health managers in a community, mental-health outpatient clinic in Massachusetts in meeting administrative needs. The results of the study demonstrated that "management-by-objectives can be a potent administrative tool in increasing organizational effectiveness and staff productivity and has potential for use as a performance-based reimbursement system for staff (p. 54 127). Garrision and Raynes (1980) credited the M B O approach with secondary benefits as well: "Perhaps as important as achieving specific objectives was the process that had started in which staff at each level began to think in a much more disciplined manner about what had to be accomplished" (p. 128). Additional benefits attributed to the application of the M B O model in this study included increased understanding among staff of work expectations, more precise and useful planning initiatives, improved communications based on a common performance and progress framework, and improved problem identification and organizational priority-setting. Management-by-objectives underpins long-term planning and the goal-setting approach in population health and health promotion. Parallelling the M B O methodology, many goals-based health promotion policies clearly state measurable expectations for improved health, encourage broad-based participation in goals development and attainment, set performance measurements or targets for health gain, incorporate means for tracking progress toward goal attainment, and institute accountability mechanisms for goal accomplishment. To a lesser extent, some health goals initiatives link goal attainment to resource allocation9 — a central characteristic of the M B O strategy in the private and business sectors. In most health promotion programs and policies the management-by-objectives model is implied, in others it is made very explicit. The 1980 publication of Promoting Health/Preventing Disease: Objectives for the Nation, set forth 226 measurable objectives reflecting a conscious decision by the US Public Health Service to apply management-by-objectives as a mechanism to develop and then monitor progress on preventive health on a national level. An expressed need for a high level of specificity and measurability of objectives that 9 Goal attainment is linked to resource allocation in the US federal initiative whereby the annual budgets of the agencies of the US Public Health Service are allocated based upon their anticipated contributions toward the health objectives for the nation. (More on this in Part B.) 55 would allow for the tracking of the health of the American population over time represented a driving force behind the US health goals initiative. A commitment to management-by-objectives increased the likelihood that the US health objectives were not stated in ambiguous terms. The Australian health goals initiative adopted a similar approach to goal setting where all goal statements are quantified by setting specific targets for improved health status within set periods of time. Reflecting on the Australian health goals and targets initiative, Nutbeam and Harris (1995) noted that the Australian effort "reflected an approach to target setting which had been established in other countries, notably the United States" (p. 53). Clearly the role of management-by-objectives in goals-based health policies is undeniable. PERT Model Like management-by-objectives, the Program Evaluation and Review Technique (PERT), is a management model introduced in the 1950's by the industry and defence sectors. PERT has been applied chiefly in relation to program implementation in the health field, although it has provided some support to program planning (American Public Health Association, 1966). PERT is a form of graphic network analysis that provides a visual overview of a plan of action, indicating the goals to be attained, the inter-relationships among activities necessary to meet program goals, factors that may challenge goal accomplishment, and key completion points that must be met. PERT's greatest advantage reflects its ability to provide a "visual estimate of what needs to be done in a program, how long it will take, and what kinds of activities must be carried out, when and by whom" (p. 87). Most of the contemporary planning software packages available commercially are patterned after a PERT approach to visualization of pathways to outcomes desired. 56 PERT requires the clear identification of program goals and objectives, and then charts a course to their accomplishment. In her work with PERT in the health field, Arnold (APHA, 1966) acknowledged the role of objectives in this model: "The first step in [the PERT] network analysis requires that the end objective be defined precisely. Unless a specific objective can be precisely defined, it is impossible to plan adequately what needs to be done to meet this objective or to determine whether the program has been completed or successful" (p. 9). Under the PERT model, clear goals and objectives guide planners in their activities, directions and time lines. By making explicit the need to articulate specific, measurable objectives, PERT and M B O may be considered two of the earliest progenitors of the goal-setting approach in the health field. PRECEDE-PROCEED Model The two models discussed above originated outside the health field and were adapted for application to health planning. The discussion that follows reviews key planning models with a goal-setting dimension that have been developed specifically for planning in the health field. PRECEDE-PROCEED is a planning and evaluation model that has been widely applied in health promotion and disease prevention. The model is theoretically diverse and has evolved over the past thirty years from many bodies of research including family planning, geographic and demographic studies, sociomedical studies in health services research, epidemiology, social psychological research in health education, and research in the areas of patient education, self-care, mutual aid, and public health (Green & Kreuter, 1991). Over seven hundred applications of the PRECEDE-PROCEED model have been published in the academic and professional literature addressing a wide range of health issues including injury prevention, cancer, smoking AIDS, patient education, sex education, and worksite and school health promotion. The 57 PRECEDE-PROCEED model is diverse also in the variety of locations in which it has been applied such as clinical and health care settings, schools, workplace and occupational settings, and community settings (Green & Kreuter, 1991; Green & Kreuter, 1999 in press). Two fundamental propositions underpin the PRECEDE-PROCEED framework: (a) health and health risks are caused by multiple factors; and (b) because multiple factors determine health, efforts to effect behavioural, environmental, and social change must be multidimensional or multisectoral (Green & Kreuter, 1991). Based on these assumptions, the PRECEDE-PROCEED model "provides systematic procedures, arrayed in a conceptual framework of causal relationships, to assess the determinants of health of the population" (Richard et al., 1996, p. 319). It begins with the identification of the ultimate social benefits or quality of life, and then works backward in the causal chain to health; assessing the behavioural, environmental, educational, organizational, administrative, and policy determinants of health (Green & Kreuter, 1991). PRECEDE-PROCEED comprises six basic phases. The PRECEDE framework encompasses phases and steps which assist planners to work through the multiple factors that influence health status and to arrive "at a highly focused subset of those factors as targets for intervention" (Green & Kreuter, 1991, p. 22). The formulating of objectives also occurs in PRECEDE, as does the development of criteria for evaluation. The PROCEED framework is comprised of steps for developing policy and initiating the implementation and evaluation process. In this way, the PRECEDE and PROCEED frameworks "work in tandem....The identification of priorities and the setting of objectives in the Precede phases provide the objects and criteria for policy, implementation, and evaluation in the Proceed phases" (Green & Kreuter, 1991, p. 22). 58 More specifically, Phase 1 of the PRECEDE-PROCEED model, Social Diagnoses, entails a full assessment and disclosure of the social, economic, demographic and environmental conditions of a population and declares quality-of-life or social goals. Phase 2, Epidemiological Diagnoses, involves the identification and prioritization of specific health goals or problems that relate to the social goals of a population. Phase 3, Behavioural and Environmental Diagnoses, links health-related behavioural and environmental factors to priority health problems and specifies goals and targets for their change. Phase 4, Educational and Organizational Diagnoses, includes an analysis of factors predisposing, enabling and reinforcing specific health-related behaviours or lifespan development and lifestyles, and factors enabling environmental change; and specifies objectives for their attainment. Phase 5, Administrative and Policy Diagnoses, is an assessment of the strengths, challenges and barriers to successful intervention and program implementation and the identification of "available" versus "needed" resources; and the setting of objectives for change in organization policy, communications and practices of professionals or others influencing the predisposing, enabling and reinforcing factors. Phase 6, Implementation, the intervention is delivered and ongoing. Phase 7, 8 and 9, Evaluation, involves a systematic evaluation of the program or intervention including process, impact and outcome evaluation respectively. PRECEDE-PROCEED and Health Goals Planning Phase 2 of the PRECEDE-PROCEED model, the Epidemiological Diagnosis, is highly relevant to health goals planning at a national, provincial or state, and local level. (This section centres its discussion on Phase 2; other phases of the model are discussed in greater depth in relation to health goals planning in the final chapter.) The epidemiological diagnosis develops 59 health objectives based on an understanding of a population health issue or problem with the aim to prevent disease and promote health and well-being (Green & Kreuter, 1991; Frankish et al., 1996b). The epidemiological diagnosis builds from the Social Diagnosis phase which considers the demographic, social, economic and environmental costs of health problems and their consequent influence on the quality of life of a population. The social diagnosis reminds planners that data examined in an epidemiological diagnosis must be viewed within the context of quality-of-life-concerns for their citizens. It must also consider the social, political, and environmental contexts and the living conditions of residents of a jurisdiction (Frankish et al., 1996b, p 5). In the epidemiological diagnosis the central question becomes, "What evidence exists that there is a need for change in the level or nature of specific health problems in a defined population" (Frankish et al., 1996b, p.5). Three purposes characterize the epidemiological diagnosis: (a) to provide empirical support for addressing a priority health problem; (b) to demonstrate the magnitude of particular health problems, and (c) to establish specific, measurable health objectives to address priority health issues. To meet these aims, the epidemiological diagnosis is comprised of the following three steps (Green & Kreuter, 1991): Step 1 assesses and evaluates available prevalence and incidence data to determine which populations are in greatest need of programs or interventions. Three approaches may be used to gather necessary data in the epidemiological diagnosis: (a) the use of existing local data, i f available, (b) the collection of new data through, for example, community surveys, and (c) the application of model-based or synthetic estimates through measures such as normative comparison (where data are compared from similar communities, or based on extrapolation from provincial or national data adjusted to the local demographics), or trend analysis (where a region uses existing statistics from previous years as a benchmark against which to project targets for improved health). 60 Step 2 compares identified health issues or public health problems which are rated on three dimensions: (a) the prevalence or incidence of health problems that may have an effect on quality of life issues for that region, (b) the causal importance in terms of their potential influence on quality of life issues, (c) and the potential for change, that is, their ability to influence population health. Step 3 formulates health objectives which "allows for the conversion of epidemiological data into a reasonable direction and level of effort for a program or policy initiative to follow" (Frankish et al., 1996b, p. 14). Ideally, objectives are established for the highest priority health issues and problems that a population seeks to reduce. Health objectives must be relevant, specific, and measurable: " A health objective should state who (the target population) will change how much (% of target population) of what (health improvement) by when (e.g., year)" (p. 15). The question of "how much" implies setting targets for improved health status; typically, this is the most difficult aspect of objective setting. Five approaches to target setting may be considered: (a) historical comparisons where targets are based on the extrapolation of levels on an indicator from past and present levels to future estimates, (b) normative comparisons where targets are set based on the level of performance on an indicator achieved by similar programs, interventions, or policies in comparable jurisdictions or settings (normative standards are often referred to as benchmarks); (c) theoretical standards where targets are based on what research and theoretical evidence would suggest is reasonably achievable; (d) ideal or absolute standards where targets aim for complete eradication of the problem or universal achievement of the health goal; and (e) compromise standards where targets are negotiated through some adjudication of the other four methods. 61 Health planners undertaking health goals face a challenging and complex process. The advantages of the PRECEDE-PROCEED model for health goals development is its ability to organize and focus health planners in the data collection and assessment stages of health goal formulation, to give full consideration of the multiple factors that influence health, and to set forth linked strategies for meeting goals and targets. The data examined in the epidemiological phase of PRECEDE-PROCEED provide the evidence on which to set goals and design population health programs and policies. The goals and objectives developed as a part of this phase establish expected levels or targets for improved health; they also frame the parameters for subsequent process and outcome evaluation of health promotion programs, policies and interventions. By carefully working through the various stages of diagnosis and assessment, the PRECEDE-PROCEED model enhances the likelihood that health planners will formulate health goals that are relevant, appropriate, realistic, and measurable. By providing planners with a well-tested mechanism for formulating objectives, PRECEDE-PROCEED is a health promotion model deserving of consideration by jurisdictions contemplating a health goals approach to population health promotion. PATCH Model P A T C H , an acronym for Planned Approach To Community Health, offers a practical step-by-step approach for facilitating collaborative, community-based health promotion planning. Based on the principles of health education program planning (Green et al., 1980), P A T C H was developed by the US Centres for Disease Control (CDC) as a mechanism "through which state and local health agencies can involve local communities in diagnosing and solving their own 62 health promotion needs" (Steckler et al., 1992, p. 174). Grounded in the diagnostic planning principles of the PRECEDE model, P A T C H is "designed to translate the complex methods of community intervention to communities via the state health agency" (Green & Kreuter, 1991). By embracing the P A T C H process, communities organize themselves for action, collect, analyse and interpret local data, set priorities and objectives, and implement and evaluate community health interventions. Specifically, the P A T C H process consists of the following eight phases (Nelson et al., 1986; Green & Kreuter, 1991; Steckler et al., 1992): 1. Initiation of a community health promotion idea that involves the CDC, the state health department, the local health agency, and the community. 2. Selection of a community site, local coordinator, and creation of a core group or community coalition to guide and manage the community health promotion project. 3. CDC workshop training on health promotion needs and community diagnosis methods. 4. Data collection to assess health status of the community; data collection includes morbidity and mortality information, community opinion information, behaviour risk factor information, and other information as determined by the community. (Community data are typically compared against national and State data.) 5. Workshop training on data interpretation, data presentation, and program p