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UBC Theses and Dissertations

A framework for development of a provincial health plan, British Columbia Hsu, David Hsing-Sheng 1983

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A FRAMEWORK FOR DEVELOPMENT OF A PROVINCIAL HEALTH PLAN: BRITISH COLUMBIA by DAVID HSING-SHENG HSU B.Sc, The University of British Columbia, 1974 M.D., The University of British Columbia, 1977 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OE SCIENCE in THE FACULTY OF GRADUATE STUDIES Department of Health Care and Epidemiology We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA March 1983 0 David Hsing-Sheng Hsu, 1983 I n p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s f o r an a d v a n c e d d e g r e e a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e t h a t t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s t u d y . I f u r t h e r a g r e e t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may be g r a n t e d by t h e h e a d o f my d e p a r t m e n t o r by h i s o r h e r r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . D e p a r t m e n t o f H e a l t h C a r e and E p i d e m i o l o g y The U n i v e r s i t y o f B r i t i s h C o l u m b i a 1956 Main Mall V a n c o u v e r , Canada V6T 1Y3 D a t e A p r i l 22,1983 ABSTRACT The p u r p o s e o f t h i s t h e s i s was t o d e v e l o p a f ramework f o r a P r o v i n c i a l H e a l t h P l a n i n B r i t i s h C o l u m b i a . A number o f f a c t o r s a r g u e f o r t h e n e c e s s i t y o f a c l e a r , c o m p r e h e n s i v e s t a t e m e n t o f t h e g o a l s and o b j e c t i v e s f o r t h e h e a l t h c a r e s y s t e m : c o m p l e x i t y o f t h e h e a l t h c a r e s y s t e m ; r i s i n g h e a l t h c a r e c o s t s ; r i s i n g consumer e x p e c t a t i o n s ; and p r e s s u r e s f r o m s p e c i a l i n t e r e s t g r o u p s . The d e v e l o p m e n t o f t h e f ramework f o r a P r o v i n c i a l H e a l t h P l a n i s b a s e d , f i r s t l y , on an u n d e r s t a n d i n g o f t h e p l a n n i n g p r o c e s s ; and s e c o n d l y , on an a p p r e c i a t i o n o f t h e components ( and t h e i r r e l a t i o n s h i p s ) o f t h e h e a l t h c a r e s y s t e m . A c c o r d i n g l y , t h e l i t e r a t u r e on t h e s e two a r e a s i s r e v i e w e d i n some d e t a i l . The p l a n n i n g p r o c e s s c a n b e s t be u n d e r s t o o d by r e f e r e n c e t o a m a t r i x , where p l a n n i n g c a n t a k e p l a c e a t l e v e l s r a n g i n g f r o m t h e l o n g - t e r m and p h i l o s o p h i c a l t o t h e d a y - t o - d a y d e l i v e r y o f h e a l t h s e r v i c e s . P l a n n i n g c a n a l s o be done i n a v a r i e t y o f modes o r a p p r o a c h e s , r a n g i n g f r o m t h e s t r i c t l y r a t i o n a l t o i n c r e m e n t a l , ad hoc m e a s u r e s . Components o f t h e h e a l t h c a r e s y s t e m a r e , i n g e n e r a l t e r m s , " h e a l t h r e s o u r c e s " , " h e a l t h s t a t u s " , " r e q u i r e m e n t s f o r h e a l t h s e r v i c e s " , and some " p r o c e s s o f r e s o u r c e a l l o c a t i o n " . A p r o v i n c i a l H e a l t h P l a n , as p r o p o s e d by t h i s t h e s i s , a d d r e s s e s a s p e c i f i e d p l a n n i n g l e v e l ( " p o l i c y p l a n n i n g " ) , and emp loys a v a r i e t y o f p l a n n i n g modes i n d e v e l o p i n g o b j e c t i v e s f o r t h e components o f t h e h e a l t h ( i l ) c a r e s y s t e m . C e r t a i n a s s u m p t i o n s a r e made i n t h i s t h e s i s r e g a r d i n g t h e d e f i n i t i o n o f " h e a l t h " , t h e r o l e o f t h e M i n i s t r y o f H e a l t h , and t h e r e g i o n a l i z a t i o n o f t h e h e a l t h c a r e d e l i v e r y s y s t e m f o r p l a n n i n g p u r p o s e s . W i t h i n t h e s e c o n s t r a i n t s and a s s u m p t i o n s , t h e f ramework f o r a P r o v i n c i a l H e a l t h P l a n c o m p r i s e s t h e f o l l o w i n g h i e r a r c h y o f e l e m e n t s : V a l u e s a b o u t t h e h e a l t h c a r e s y s t e m ; L o n g Term O b j e c t i v e s ; B a s e l i n e O b j e c t i v e s ; S h o r t Term O b j e c t i v e s . V a l u e s a b o u t t h e h e a l t h c a r e s y s t e m a r e s t a t e m e n t s c o n c e r n i n g g e n e r a l p r i n c i p l e s i n f o u r a r e a s : (1) d e f i n i t i o n o f h e a l t h and t h e r e s p o n s i b i l i t y o f t h e h e a l t h c a r e s y s t e m ; (2) s o c i a l j u s t i c e a s a p p l i e d t o t h e h e a l t h c a r e s y s t e m ; (3) r o l e s o f g o v e r n m e n t , p r o f e s s i o n s , and i n d i v i d u a l s w i t h i n t h e h e a l t h c a r e s y s t e m ; (4) e f f e c t i v e n e s s and e f f i c i e n c y o f t h e h e a l t h c a r e s y s t e m . O b j e c t i v e s ( w h e t h e r L o n g T e r m , B a s e l i n e , o r S h o r t Term ) a r e s p e c i f i e d l e v e l s d e s c r i b i n g t h e components o f t h e h e a l t h c a r e s y s t e m , and r e s u l t f r o m a j u d g e m e n t a l p r o c e s s w h i c h c o n s i d e r s f a c t o r s o f " l e g i t i m a c y " , " f e a s i b i l i t y " , and " s u p p o r t " f o r t h e i s s u e u n d e r c o n s i d e r a t i o n . L o n g Term O b j e c t i v e s , w i t h a t h r e e t o f i v e y e a r t i m e f r a m e , a r e d e t e r m i n e d by c o n s i d e r i n g d a t a a b o u t t h e p r e s e n t and p r o j e c t e d s t a t e s o f t h e h e a l t h c a r e s y s t e m i n l i g h t o f s t a t e d V a l u e s a b o u t t h e h e a l t h c a r e s y s t e m . B a s e l i n e O b j e c t i v e s a r e t h o s e m i n i m a l l y a c c e p t a b l e l e v e l s f o r components o f t h e h e a l t h c a r e s y s t e m , b e l o w w h i c h t h e r e i s g e n e r a l ag reement i n B r i t i s h C o l u m b i a t h a t r e m e d i e s s h o u l d be i n s t i t u t e d as an u r g e n t p r i o r i t y . S h o r t Term O b j e c t i v e s , w i t h a one y e a r t i m e f r a m e c o i n c i d i n g w i t h t h e g o v e r n m e n t ' s f i s c a l y e a r , a r e d e t e r m i n e d c o n s i d e r i n g V a l u e s a b o u t ( i i i ) t h e h e a l t h c a r e s y s t e m , s p e c i f i e d l e v e l s o f b o t h L o n g Term O b j e c t i v e s and B a s e l i n e O b j e c t i v e s , d a t a on t h e h e a l t h c a r e s y s t e m , and community e x p r e s s i o n a b o u t h e a l t h p r o b l e m s and p r i o r i t i e s . Whereas L o n g Term O b j e c t i v e s and B a s e l i n e O b j e c t i v e s a r e a r r i v e d a t by t h e c e n t r a l p l a n n i n g a u t h o r i t y , S h o r t Term O b j e c t i v e s a r e d e t e r m i n e d i n l a r g e p a r t by t h e r e g i o n a l p l a n n i n g a u t h o r i t y . The D e l p h i method i s e x p l a i n e d and p r o p o s e d as a r e l a t i v e l y s i m p l e , b u t e f f e c t i v e , a p p r o a c h t o f a c i l i t a t e community i n p u t c o n c e r n i n g h e a l t h p r o b l e m s . The d e v e l o p m e n t o f e a c h o f t h e p a r t s o f t h e f r a m e w o r k f o r a P r o v i n c i a l H e a l t h P l a n i s d i s c u s s e d , and a t i m e f r a m e f o r d e v e l o p m e n t o f a P r o v i n c i a l H e a l t h P l a n i s s u g g e s t e d ( a p p r o x i m a t e l y 22 months ) . F u r t h e r s t e p s t o w a r d s t h e d e v e l o p m e n t o f a P r o v i n c i a l H e a l t h P l a n f o r B r i t i s h C o l u m b i a a r e a l s o o u t l i n e d . ( i v ) TABLE OF CONTENTS Abstract p. i i L i s t of Tables p. v i L i s t of Figures p. v i i Acknowledgement p. v i i i Chapter I. Rationale for a P r o v i n c i a l Health Plan p. 1 A. Complexity of the Health Care System p. 1 B. R i s i n g Health Care Costs p. 7 C. Rising Consumer Expectations p. 13 D. Special Interest Groups p. 15 E. Purpose of Thesis p. 15 Chapter I I . Review of General Planning p. 18 A. Rational Planning p. 19 B. Incrementalisra . p. 25 C. Middle-range Approach p. 29 D. Planning Levels p. 31 E. Other Planning Models p. 40 Chapter I I I . Review of Health Planning p. 45 A. Models p. 45 B. Health Resources p. 58 C. Health Status p. 65 D. Requirements for Health Services p.71 E. Resource A l l o c a t i o n . . . . p . 8 1 F. Previous B.C. Health Plans p. 101 Chapter IV. Proposed Scope of a P r o v i n c i a l Health Plan: B.C. . .p.106 A. Planning Levels p. 106 B. Government ( M i n i s t r y of Health ) Perspective p. I l l C. Regionalization and the P r o v i n c i a l Health Plan p.117 D. Boundaries of "Health" p. 123 Chapter V. Proposed Framework for a P r o v i n c i a l Health Plan: B.C. p.131 A. Values, As Applied to the Health Care System p. 134 1. P o l i t i c a l and S o c i a l Ideologies p. 137 2. Group Ideologies p. 161 3. Application of Value Statements p. 170 B. Long Term Objectives p. 171 1. Data Base p. 171 2. Process of Determining Long Term Objectives p. 183 3. Form and Application of Long Term Objectives p. 191 C. Baseline Objectives p.200 D. Short Term Objectives p.204 1. Obtaining Community Input: The Delphi Method Applied . .p.205 2. Process of Determining Short Term Objectives p.211 3. Application of Short Term Objectives p.216 Chapter VI. Conclusions and Future Directions p.220 Bibliography p. 231 Appendix. Review of the Delphi Method p.249 (v) LIST OF TABLES Table I. Components of the Health Care System p. 55 Table I I . B.C. Hos p i t a l Beds, 1981 p. 59 Table I I I . B.C. Health Manpower, 1981 p. 59 Table IV. Determination of Health Needs and Demand p. 81 Table V. C r i t e r i a f o r Resource A l l o c a t i o n p. 95 Table VI. Int e r n a t i o n a l Comparison of Infant M o r t a l i t y p.189 ( v i ) LIST OF FIGURES Figure 1. O r g a n i z a t i o n a l D e c i s i o n Process p. 23 Figure 2. Hierarchy of O r g a n i z a t i o n a l Plans p. 33 Figure 3. Planning Levels p. 34 Figure 4. Planning Mode-Level Matrix p. 34 Figure 5. Conceptual Model of Planning p. 35 Figure 6. Planning Model f o r "Wellness and H o l i s t i c Health" p. 39 Figure 7. Planning Mode-Level-Outcome Ma t r i x p. 40 Figure 8. MEDICS Macro-model p. 48 Figure 9. MEDICS Flow Model p. 49 Figure 10. Micro-econometric Model of the Health Care System p. 50 Figure 11. The IAASA Model of the Health Care System p. 51 Figure 12. The Health Care D e l i v e r y System p. 52 Figure 13. Health Planning Model of the Health Care System p. 53 Figure 14. F u n c t i o n a l Chart of a P u b l i c Health System p. 54 Figure 15. The Ba s i c Systems Model p. 57 Figure 16. Conceptual Model of the Health Care System p. 57 Figure 17. The Resource Component of the Health Care System p. 61 Figure 18. Taxonomy of the Health Care System p. 64 Figure 19. Requirements f o r Health Services p. 78 Figure 20. RAWP Determination of R e l a t i v e "Need" p. 87 Figure 21. Outline of the Proposed Framework f o r a P r o v i n c i a l Health P l a n p. 131 Figure 22. Development Process f o r Health Systems Plans p.133 Figure 23. Gap A n a l y s i s Applied to Strategy Formulation i n Health Care p.135 Figure 24. Determination of Values p. 136 Figure 25. A p p l i c a t i o n of P o l i t i c a l / S o c i a l Ideologies p.144 Figure 26. Determination of Long Term Objectives p. 171 Figure 27. Determination of B a s e l i n e Objectives p.202 Figure 28. Determination of Short Term Objectives p.204 Figure 29. Framework f o r a P r o v i n c i a l Health Plan p.223 Figure 30. Timeframe f o r Development of a P r o v i n c i a l Health Plan P.229 Figure 31. The P r o v i n c i a l Health Plan i n the Context of the Health Care System p.230 ( v i i ) ACKNOWLEDGEMENTS I would l i k e to express my deep a p p r e c i a t i o n to Dr. John Milsum, whose kindness, encouragement, a t t e n t i o n to d e t a i l , and clear-headed t h i n k i n g have guided me throughout t h i s c h a l l e n g i n g and rewarding experience. Many thanks a l s o to Dr. Lar r y Moore, who gave me many u s e f u l i n s i g h t s and p r a c t i c a l a d v i c e ; and to Dr. Anne C r i c h t o n , whose i n t e r e s t and experience i n h e a l t h p o l i c y and h e a l t h planning have been a major i n f l u e n c e on me i n w r i t i n g t h i s t h e s i s . S p e c i a l thanks are due my parents, who have given me much moral support towards completing t h i s t h e s i s . And of course, bouquets to the l a d i e s who helped type and e d i t , Mrs. Bowacks and Mrs. de Raadt. ( v i i i ) 1 Chapter I. RATIONALE FOR A PROVINCIAL HEALTH PLAN A number of factors argue strongly for the necessity of a P r o v i n c i a l Health Plan. There i s most obviously the sheer size and complexity of the health care system. Compounding t h i s are r i s i n g health care costs i n the face of an o v e r a l l economic downturn. Moreover, despite budgetary constraints public expectations of the health care system remain high, and i f anything are increasing. Special problem groups and i n t e r e s t groups i n p a r t i c u l a r are demanding health services as " r i g h t s " . I .A. Complexity of the Health Care System A more detailed outline of components of the health care system i s presented i n Chapter I I I . In general terms, there i s i n B.C. a wide array of health manpower, f a c i l i t i e s and programs providing a range of health services to a diverse population of 2.7 m i l l i o n . There are over 28 d i f f e r e n t health occupational groups, including 5,000 physicians; 25,000 nurses; 1,600 d e n t i s t s ; altogether i n t h i s province there are over 50,000 people i n health professional or a l l i e d professional groups. A d d i t i o n a l l y , many other persons s t a f f health f a c i l i t i e s and programs i n support functions. For example, the Hospital Employees Union has a membership of 23,000. O v e r a l l , 10% of the p r o v i n c i a l work force are i n the health care system. Methods of payment of health manpower groups include wages or s a l a r i e s , contracts, and f e e - f o r - s e r v i c e payments, which further complicates the p i c t u r e . As might be expected with so many health manpower groups, there i s 2 often overlap of roles and r e s p o n s i b i l i t i e s , with accompanying tensions and c o n f l i c t . The h i s t o r i c a l pattern of ophthalmologists-optometrists-op t i c i a n s , and dentists-dental mechanics-dental technicians are two prominent examples i n B.C. F a c i l i t i e s s i m i l a r l y display a great d i v e r s i t y . There are over 300 f a c i l i t i e s i n B.C., ranging from 10-bed Diagnostic and Treatment Centres to the 1000 bed Vancouver General H o s p i t a l . Functions span personal and intermediate care, extended care and acute care h o s p i t a l s . In the acute care hospitals there i s further s p e c i a l i z a t i o n of services, e.g. Intensive Care Units, Burn Units, Paediatric Surgery Units. Associated with the f a c i l i t i e s are numerous sophisticated and expensive pieces of equipment. Cooperation among h o s p i t a l s , even i n the same regional h o s p i t a l d i s t r i c t , may or may not e x i s t . The importance of coordinating the acute h o s p i t a l with other community f a c i l i t i e s (e.g. long term care f a c i l i t i e s ) has resulted i n a decision by the Ministry of Health to meld these two areas of re s p o n s i b i i t y under the Assistant Deputy Minister of I n s t i t u t i o n a l Services. Numerous programs could also be l i s t e d (e.g. Emergency Health Services, Public Health). These require combinations of health manpower groups i n a v a r i e t y of s e t t i n g s . The above l i s t e d health manpower, f a c i l i t i e s , and programs are provided to a diverse population. Each age grouping - i n f a n t , pre-school, school age, adult, senior c i t i z e n - has p a r t i c u l a r health problems unique to i t . There are moreover d i f f e r e n t ethnic groups, such as the Native Indian or Chinese-Canadian population, who may have spe c i a l needs because of c u l t u r a l or language d i f f e r e n c e s . 3 U n f o r t u n a t e l y , i t w o u l d seem t h a t t h e v a r i o u s h e a l t h manpower g r o u p s o f t e n a r e not c o o r d i n a t e d ; t h a t h e a l t h manpower i n g e n e r a l i s o f t e n not c o o r d i n a t e d w i t h f a c i l i t i e s and p r o g r a m s ; and t h a t manpower, f a c i l i t i e s , and p rog rams a r e not r e l a t e d to t h e h e a l t h needs of t he p o p u l a t i o n . Examples of t h i s l a c k of c o o r d i n a t i o n and i n t e g r a t i o n a r e f r e q u e n t l y c i t e d . They c a n i n g e n e r a l be c a t e g o r i z e d as s t a t e m e n t s t h a t some s e r v i c e o r a c t i v i t y i s p r o v i d e d i n e f f i c i e n t l y , o r t h a t some s e r v i c e o r a c t i v i t y i s n o t t h e most e f f e c t i v e a p p r o a c h to s t a t e d g o a l s and o b j e c t i v e s . Examples of " e f f i c i e n c y " t y p e s t a t e m e n t s a r e : (1) u s e of h i g h l y s k i l l e d (and p a i d ) h e a l t h manpower f o r t a s k s w h i c h c a n be done by l e s s e r t r a i n e d manpower; ( 2 ) u s e of e x p e n s i v e a c u t e - c a r e beds f o r Long Term C a r e p a t i e n t s ; ( 3 ) " u n n e c e s s a r y " l a b o r a t o r y t e s t s , done r o u t i n e l y r a t h e r t h a n f o r s p e c i f i c i n f o r m a t i o n ; ( 4 ) i n - p a t i e n t s u r g e r y f o r c a s e s t h a t c a n be done on a d a y - c a r e b a s i s ; ( 5 ) l e n g t h y h o s p i t a l i z a t i o n ( e . g . p o s t - p a r t u m ) when p a t i e n t s c a n be d i s c h a r g e d to Home C a r e ; (6) " u n n e c e s s a r y " s u r g e r y f o r e l e c t i v e p r o c e d u r e s ; (7) use of e x p e n s i v e b r a n d name d r u g s i n s t e a d of g e n e r i c e q u i v a l e n t s ; (8) C a n a d i a n r e q u i r e m e n t s f o r d r u g t e s t i n g w h i c h may d e l a y i n t r o d u c t i o n of new p r o d u c t s , used a l r e a d y f o r many y e a r s i n o t h e r j u r i s d i c t i o n s ; (9) t e n d e n c y t o " h i g h - t e c h " m e d i c a l c a r e i n p l a c e of c l i n i c a l e x a m i n a t i o n and j u d g e m e n t . (10) m a i n t e n a n c e o f s m a l l e r h o s p i t a l s w i t h l o w o c c u p a n c y r a t e s ; Examp les of " e f f e c t i v e n e s s " t y p e s t a t e m e n t s a r e as f o l l o w s : (1) s h o r t a g e of s k i l l e d n u r s e s to s t a f f s p e c i a l t y u n i t s w i t h i n t h e 4 acute h o s p i t a l sector; (2) expansion of the U.B.C. medical school i n the face of probable "over-supply" of physicians i n the province; (3) m a l d i s t r i b u t i o n of health manpower, e.g. physicians, with a disproportionate concentration i n urban areas; (4) emphasis on curative, " c r i s i s " oriented care (including the r e l i a n c e on drugs) rather than screening, prevention, r e h a b i l i t a t i o n , and l i f e s t y l e changes i n areas such as smoking, alcohol abuse and poor n u t r i t i o n ; (5) tendency to professional and i n s t i t u t i o n a l care, rather than family and i n d i v i d u a l r e s p o n s i b i l i t y for health; lack of personal information on health care and use of e x i s t i n g services; (6) d u p l i c a t i o n of resources instead of a t i e r e d r e f e r r a l system. The v a l i d i t y of these statements could be debated; the remedy for these e f f i c i e n c y and effectiveness problems may be much more complicated than these b r i e f statements suggest. However, i t s t i l l seems a reasonable presumption that the health care system i n B.C., given these and many other problems, could be better coordinated and integrated. This i s not meant to imply that B.C.'s health care system i s i n f e r i o r compared to other j u r i s d i c t i o n s . O v e r a l l , i t i s probably as good, i f not better than most. The United States, for example, suffers the same ( i f not more ) c r i t i c i s m s . The preamble to PL 93-641, U.S. l e g i s l a t i o n e stablishing national guidelines for comprehensive health planning, stated that despite massive f e d e r a l spending, equal access to health services had not r e s u l t e d . Indeed, there continued to be a m a l d i s t r i b u t i o n of resources and less than optimally e f f e c t i v e d e l i v e r y systems i n the face of increases i n health care costs 5 ( United States, Department of Health, Education, and Welfare 1979a ). Fuchs ( 1974 ) noted that the United States' major health care problems related to cost of care, access to care, and r e l a t i v e l y poor l e v e l s of health status compared to other j u r i s d i c t i o n s and among subgroups within the U.S. Sweden i s often taken as a country with a model health care system. Yet, i t too i s i n " c r i s i s " , with r i s i n g health care costs, an emphasis on s p e c i a l i z e d technological medicine, twice the number of h o s p i t a l beds per population as the United States, etc. ( Diderichsen 1982 ). Past studies and reports i n B.C. have focused upon p a r t i c u l a r aspects of the health care system, e.g. the Hospital Role Study by the Ministry of -Health, and the Post-Basic Nursing Study by the Health Manpower Research Unit at the U n i v e r s i t y of B r i t i s h Columbia. However, to achieve the coordination and i n t e g r a t i o n of various components of the health care system, a more global approach i s needed. In large part, t h i s i s due to the unique c h a r a c t e r i s t i c s of health care d e l i v e r y . One cannot r e l y on the "market" to regulate the complexity of the health care system. There are d i s t i n c t i v e economic features of health care which d i s t o r t market forces: (1) health care i s a mixture of consumption and investment elements, (2) provider induced demand and the t h i r d party insurance system are of major importance i n health care, (3) e x t e r n a l i t y e f f e c t s and i n d i v i s i b i l i t y e f f e c t s e x i s t , (4) consumer ignorance, or r e l a t i v e information asymmetry between the consumer and provider, i s the general r u l e , (5) health care may be considered a " r i g h t " rather than a commodity, (6) health and medical education and research often cannot be r e a d i l y separated from service costs ( Berman 1977; Klarman 1975 ). Of p a r t i c u l a r importance i s consumer ignorance. Patients are a t y p i c a l consumers since, despite the trend towards 6 greater public information on health matters, generally the patient lacks the information necessary to make an informed judgement as to either quality or quantity of health care to be purchased. Parsons ( 1952 ) noted that asymmetry in the patient -practitioner relationship exists not only in information available, but also in class, culture, and site of interaction. These factors give the health practitioner a marked advantage and dominant role. For the patient the perceived threat to personal safety, not to mention physical and mental dysfunctions, makes informed judgement d i f f i c u l t at precisely the time services are required. Because of this, health practitioners — most notably physicians, but certainly others too — are called upon to act on behalf of the patient, i.e. an agency relationship. However, there is an inherent conflict of interest in simultaneously providing a paid service to the patient and judging the quality and appropriateness of that service. Evans ( 1974 ) suggests that a fee-for-service setting ( for physicians ) "creates strong economic incentives for the physician to overemphasize the supply of his own services to the exclusion of substitutes and to bias patient's 'choice' of services towards those which yield the highest net revenue per time unit for the physicians" ( p. 163 ). Moreover, there is l i t t l e competition in the health care system, with most professional groups specifically proscribing advertising. Many others, e.g. Abel-Smith ( 1976 ), have come to similar conclusions about the functioning of the health care system "market". Thus, le f t to i t s e l f , the health care system has l i t t l e likelihood of self-adjustment and regulation. It would be misleading optimism to suggest that development of a Provincial Health Plan would in i t s e l f automatically ensure a better health 7 care system for B.C. However, i t i s abundantly clear that any large complex system requires d i r e c t i o n s and objectives i f i t i s to achieve i t s o v e r a l l goals. Development of a P r o v i n c i a l Health Plan provides this d i r e c t i o n . The urgency and timeliness of developing such a plan r e s u l t from a number of pressures on the health care system. Perhaps the most important of these.certainly the one most often c i t e d , i s the increasing cost of health care. I.B. Rising Health Care Costs Canada, spending approximately 7% of i t s GNP on health care, devotes proportionately less than countries such as the U.S., Sweden, the Netherlands, and Germany, who spend about 10% of t h e i r GNP. On the other hand, countries such as Great B r i t a i n at 6% of GNP, devote a smaller proportion ( Abel-Smith 1981 ). B.C.'s health care costs can be estimated by reviewing the budget of the Ministry of Health over the past few years ( B r i t i s h Columbia, Min i s t r y of Health Annual Reports ). 1975/76 $ 892.3 m i l l i o n 1976/77 $ 976.0 m i l l i o n 1977/78 $ 1,094.4 m i l l i o n 1978/79 $ 1,315.0 m i l l i o n 1979/80 $ 1,490.6 m i l l i o n 1980/81 $ 2,000.0 m i l l i o n Health care costs are growing faster than the p r o v i n c i a l economy, as i s seen by comparison with the GDP data below ( B r i t i s h Columbia, Ministry of Finance 1981 ). 8 Gross Domestic Product 1977 $ 25,137 m i l l i o n 1978 $ 27,894 m i l l i o n 1979 $ 32,264 m i l l i o n 1980 $ 36,635 m i l l i o n The percentage increase i n the Ministry of Health budget was 1.8 times that of the increase i n gross domestic product over the period 1977 to 1980. In the f i v e years following 1976/77, the percentage increase i n the Ministry of Health budget was 1.4 times that of the increase i n the t o t a l government budget. The Ministry of Health w i l l have spent i n excess of $2.3 b i l l i o n during f i s c a l 1982/83, over $6 m i l l i o n per day! Economic forecasts for the next few years are gloomy, suggesting that increase of government revenues w i l l continue to lag behind increases i n health expenditures. Negotiations are taking place on the Established Program Financing (EPF) agreement, the fe d e r a l contribution to the provinces for health and post-secondary education. There i s an avowed Federal i n t e n t i o n to slash i t s EPF contributions by $1.5 b i l l i o n . If t h i s occurs, the pressure on p r o v i n c i a l revenues w i l l be i n t e n s i f i e d . The government of B.C. estimates that f e d e r a l i n i t i a t i v e s to reduce EPF expenditures would r e s u l t i n loss of some $100 m i l l i o n to B.C. Abel-Smith ( 1976 ) notes the main causes for growth, i n r e a l terms, of health service expenditures i n western nations: increase i n government health insurance and services; r i s i n g consumer expectations; labour intensive nature of health care; expansion of medical technology; increasing e l d e r l y population; changing disease patterns ( with more chronic and 9 degenerative diseases ); and inappropriate use of health s e r v i c e s . The extensive government involvement i n provision of health services i s discussed i n Section IV.B.l., and consumer expectations i n Section I.C. The labour intensive nature of the health care industry makes i t p a r t i c u l a r l y s e n s i t i v e to wage and salary increases. There appears to be a c o r r e l a t i o n between the number of physicians and t o t a l health care costs, and B.C. has the highest number of doctors per capita i n Canada. D i r e c t l y these costs stem from the approximately $ 100,000/year earnings per physician i n B.C. I n d i r e c t l y , these costs a r i s e from the diagnostic and therapeutic interventions i n i t i a t e d by physicians. In t o t a l , i t has been estimated that a physician generates $250,000 to $500,000 i n health care costs annually. B.C. has recently seen an increase of the physicians' fee-schedule of 40% spread over two years. Other health manpower groups have also within the past one or two years won substantial wage hikes, e.g. the registered nurses' l a s t contract was for 44% over a two year period. The Hospitals Employees Union, the Health Sciences Association are other major negotiating groups pressing for higher wages and s a l a r i e s . Groups that previously were not organized are becoming so, r e s u l t i n g i n higher wage demands. For example, one reason for the increase i n Long Term Care costs i s the increasing wage scales won by workers. The p r o v i n c i a l government's wage r e s t r a i n t program ( Compensation S t a b i l i z a t i o n Program ) should temper wage settlements over the next two years. However, since the t o t a l d o l l a r s spent on health care are already s u b s t a n t i a l , and given that 75-85% of these r e l a t e to wages and s a l a r i e s , even modest percentage increases w i l l translate into s i g n i f i c a n t increases i n absolute d o l l a r amounts. The i n c r e a s i n g l y sophisticated technology of the health care system 10 also c a r r i e s an expensive price tag. GT scanners are the most notorious example of expensive technology (up to $1 m i l l i o n c a p i t a l and $200-300,000 per year operating c o s t s ) . B.C. has about a dozen head and body scanners. A d d i t i o n a l l y , open heart surgery, renal d i a l y s i s / t r a n s p l a n t , intensive care u n i t s , etc., a l l contribute to the cost. As Cohen and Cohode ( 1982 ) point out, even low c a p i t a l cost items such as f e t a l monitoring units often have si g n f i c a n t cost implications, either i n the operating costs or i n the generation of other more expensive health services. Unlike industry, technology i n the health care system tends not to substitute c a p i t a l f or labour, with r e s u l t i n g increase i n p r o d u c t i v i t y . Rather, higher " q u a l i t y " of service i s provided and somewhat paradoxically, new technology often requires a d d i t i o n a l health manpower. Less p u b l i c i z e d , l e s s expensive procedures are s i g n i f i c a n t cost factors i f done on a widespread basis. For example, a study of laboratory costs at Vancouver General Hospital indicates a f i v e - f o l d increase i n costs, the overriding factor being increased u t i l i z a t i o n of services per capita over the past ten years. The laboratory costs per acute care admission have increased 253% between 1972 and 1979. About half of t h i s increase can be attributed to i n f l a t i o n . Of the remaining f a c t o r s , the major impact i s increased i n t e n s i t y of t e s t i n g . Thus,in CPI adjusted dollars,the cost per acute care admission increased from $42.80 to $101.50 (Hardwick 1981). The United States experience with r i s i n g h o s p i t a l costs i s i n s t r u c t i v e . Cver the period 1955-1968 the 265% increase i n cost could be a t t r i b u t e d to population increase (32%), increased u t i l i z a t i o n (38%), increased wages (80%), increased labour and supplies or services input per patient day (30% and 76% respectively) ( Maxwell 1975 ). Costs associated with c a p i t a l construction w i l l also continue. New 11 acute care f a c i l i t i e s and renovations/additions w i l l cost hundreds of m i l l i o n s of d o l l a r s over the next few years, ( over $400 m i l l i o n for 1981/82 ). Long term care f a c i l i t i e s s i m i l a r l y w i l l see new construction i n the hundreds of m i l l i o n s of d o l l a r s i n B.C. The costs noted above w i l l be required j u s t to maintain e x i s t i n g service l e v e l s given the increase of population. Estimates by the Central S t a t i s t i c s Bureau show the following population projections for B r i t i s h Columbia: 1980 2,640,116 1985 2,975,176 1990 3,307,133 1995 3,625,063 Importantly however, the population increase w i l l be s e l e c t i v e . It has been estimated that 8.6% of the Canadian population was over age 65 i n 1977, and that by 1996 there w i l l be 3.2 m i l l i o n Canadians over age 65 ( Bennett and Krasny 1977 ). H i s t o r i c a l l y , B.C. has had a higher proportion of e l d e r l y than the Canadian average. Projections suggest that the 65+ population w i l l increase by 33% between 1981 to 1991 i n B.C., from 290,000 to 385,000 ( Lawrence 1982 ). An even larger increase i n the over age 65 w i l l occur a f t e r 2011 when the post war "baby boom" enters that age group. The increased demand for health services w i l l be greater than simply extrapolating t o t a l population increases. The e l d e r l y tend to have not only a greater number of health problems, but also health problems requiring more treatment. They require one and one-half to two times the medical treatment as compared to a younger population (e.g. age 15-24), and require eight times the number of h o s p i t a l bed days, compared to a population under age 45 ( United States, Department of Health, Education and Welfare 1976a ). In B.C., during the f i s c a l year 1980/81, the Ministry of Health spent $666 m i l l i o n on health care services for those 65 years and older, i . e . 10.7% of the population accounted f o r 34.7% of the budget ( Lawrence 1982 ). The growth of the Long Term Care program gives some sense of the costs of caring for the e l d e r l y . In the f i v e years since i t s inception, the program increased i t s c l i e n t load from 17,000 to 43,000. The costs i n 1978 were $75 m i l l i o n , compared to over $210 m i l l i o n i n 1981. At present, i t seems u n l i k e l y that s c i e n t i f i c or technological breakthroughs w i l l be made which would dramatically diminish the need for health s e r v i c e s . In B.C. the leading causes of mortality are cardio-vascular problems, neoplasms, accidents (almost 40% being motor v e h i c l e ) , r e s p i r a t o r y , and digestive problems (B.C. Ministry of Health 1979). There are no ready "cures" for these problems and the e x i s t i n g state of s c i e n t i f i c knowledge holds no promise of simple s o l u t i o n s . Many of these problems are related to l i f e s t y l e and i n d i v i d u a l behaviour. Although there are encouraging trends (e.g. decrease i n cardiovascular m o r t a l i t y ) , unfortunately, judging from past performance there w i l l be no s i g n i f i c a n t changes i n the near term. It i s worth noting also that improvements i n mortality may lead to increased demand for health services, e.g. the prevalence of cardiovascular disease has increased. Not only w i l l there be increased demand for health services provided t r a d i t i o n a l l y by the health care system, but areas previously neglected or which may have been considered under another r e s p o n s i b i l i t y ( e.g. " c u s t o d i a l " or " s o c i a l problems" ) are now being seen as "health" problems: drug and alcohol abuse, mental i l l n e s s , s u i c i d e , homicide, venereal disease, e t c . The gravity of the budgetary constraints on the health care system i s 13 reflected in a number of changes undertaken by the Ministry of Health in recent years. There have been, for example, increases in Medical Plan premiums, daily hospital rates (paid by the patient), and in the "deductible" portion of a number of insured benefits. The growth of budgets of hospitals and programs receiving government funding has been restrained, resulting in bed closures and staff layoffs. The organizational structure of the Ministry of Health can be analysed in the shifting emphasis from a professional to a managerial/ administrative form. Campbell et al ( 1981 ) suggest that because of declining provincial revenues and rising costs, there was a shift in the Ministry of Health from "medical administration" to "health management". This was seen in the replacement of Dr. Key by Mr.P. Bazowski as Deputy Minister. Moreover, Campbell et al observed that "the Ministry of Health has quickly become dominated by professional managers with a strong commitment to cost containment and financial control and the new Deputy Minister ( Bazowski ) is recruiting into the Ministry more senior personnel who share his managerial and administrative orientation" ( p.33 ). I.C. Rising Consumer Expectations Not only w i l l more health services have to be provided — for reasons cited above — but there w i l l be increasing pressure for higher quality health services. McGregor ( 1981 ) sees this factor as the " f i r s t and most important" cause of increasing health care costs. It is not that the absolute level of health expenditures are (or w i l l be) inadequate compared to other parts of the world. Canada, and B.C., w i l l continue to have a health care system which is the envy of many other nations. However, as 14 Hirsch ( 1976 ) has noted, the demand for public ("social") goods increases with affluence; and health services are one such public good. In times of resource development, pressures for r e d i s t r i b u t i o n may be dissipated by the expectation that everyone's piece of the pie w i l l be increasing. This i s not so i n times of budgetary c o n s t r a i n t ; hence the pressures i n B.C. despite $2+ b i l l i o n being spent on health care services. Consumer expectations are r i s i n g as part of a larger movement in v o l v i n g many services, but including health care. Questions of iatrogenesis raised by I l l i c h , and less polemically by many other researchers, have resulted i n closer scrutiny of the health care system. For example, the effectiveness of coronary care units i n reducing mortality associated with myocardial i n f a r c t i o n has been se r i o u s l y questioned ( United States, Department of Health, Education and Welfare 1976a ). Widely disparate rates for c e r t a i n s u r g i c a l procedures (on the basis of geography) have suggested that much "unnecessary" surgery i s being performed. The r i s i n g number of malpractice cases i n Canada r e f l e c t s t h i s tendency to increased expectations. Cert a i n l y some of these expectations are misplaced. A major fac t o r i s s t i l l the myth of the omnipotence of medical science. Regardless of the v a l i d i t y of these expectations, they exist and translate i n t o pressures to provide health se r v i c e s . This may occur to the extent that these services are spoken of as " r i g h t s " : "Health care i s i n c r e a s i n g l y regarded not as a p r i v i l e g e of the more prosperous, but as a ri g h t of a l l " ( United States, Department of Health, Education and Welfare 1976a, p. 26 ). 15 I . D . S p e c i a l I n t e r e s t Groups I n B . C . , r i s i n g e x p e c t a t i o n s a r e v o i c e d i n a number of w a y s . T h e r e a r e demands f r o m r u r a l c o m m u n i t i e s f o r b e t t e r h e a l t h c a r e s e r v i c e s . The g e o g r a p h i c and r e g i o n a l d i s p a r i t i e s of h e a l t h c a r e s e r v i c e s a r e l i n k e d t o t h e d i s t r i b u t i o n of t h e p o p u l a t i o n , w i t h more s e r v i c e s and more s p e c i a l i z e d s e r v i c e s by v i r t u e o f t h e l a r g e r p o p u l a t i o n and r e f e r r a l c e n t r e s t a t u s of t h e Lower M a i n l a n d , and t o a l e s s e r e x t e n t t h e C a p i t a l R e g i o n a l D i s t r i c t . By c o m p a r i s o n , s e r v i c e s to r u r a l a r e a s a r e l e s s ; h o w e v e r , g i v e n t h e ease of c o m m u n i c a t i o n and a p h i l o s o p h y w h i c h assumes h e a l t h c a r e i s a " r i g h t " , demands f r o m r u r a l c o m m u n i t i e s a r e f o r e q u a l s e r v i c e s — o r a t l e a s t f o r more t h a n t h e y p r e s e n t l y h a v e . C e r t a i n g r o u p s a r e becoming more v o c a l and o r g a n i z e d t o o b t a i n s p e c i f i c h e a l t h c a r e s e r v i c e s and b e n e f i t s . They have p r o g r e s s e d f r o m " s o c i a l movements" t o become more o r l e s s l e g i t i m a t e i n t e r e s t / p r e s s u r e g r o u p s , e . g . t he p h y s i c a l l y d i s a b l e d and a d v o c a t e s f o r t h e m e n t a l l y r e t a r d e d . The l i s t o f d i s e a s e g r o u p s ( e . g . M u l t i p l e S c l e r o s i s S o c i e t y and S t r o k e A s s o c i a t i o n o f B . C . ) and v a r i o u s a d v o c a c y a s s o c i a t i o n s ( e . g . S o c i a l P l a n n i n g and R e v i e w C o u n c i l of B . C . and M e n t a l P a t i e n t s A s s o c i a t i o n ) i n B . C . i s l e n g t h y . The D i r e c t o r y of S e r v i c e s f o r G r e a t e r Vancouver l i s t s o v e r 40 pages o f " s e r v i c e s " , a l a r g e p r o p o r t i o n of w h i c h a r e s p o n s o r e d by s p e c i a l i n t e r e s t g r o u p s . I . E . P u r p o s e o f T h e s i s To r e c a p i t u l a t e , i n c r e a s i n g demands f o r h e a l t h c a r e t r a n s l a t i n g i n t o i n c r e a s e d h e a l t h c a r e c o s t s on t h e one h a n d , and e c o n o m i c and b u d g e t a r y c o n s t r a i n t s on t h e o t h e r , p r o v i d e t h e i m p e t u s to a d d r e s s f a i r l y u r g e n t l y 16 the complexities of the health care system. The concept i s not a new one; the Report of the Ontario Health Planning Task Force ( 1974 ) made a s i m i l a r statement: "Unless the a l l o c a t i o n of the resources available f o r health care i s c a r e f u l l y planned and co n t r o l l e d , these resources w i l l soon become inadequate to meet many of the health needs of Ontario's c i t i z e n s . This means that p r i o r i t i e s w i l l have to be set for the use of a l l health care resources - human and ph y s i c a l , as well as f i n a n c i a l . Viewed i n combination, these factors point to the need to develop an integrated, coordinated system of health services that w i l l provide high q u a l i t y health care on an accessible basis throughout the province. Duplication of services w i l l have to be eliminated, and coordination of programmes must be achieved to avoid further fragmentation and wasteful resource use" ( p. 4 ). Development of a P r o v i n c i a l Health Plan would be a major step towards an integrated and coordinated health care system. Weiss et a l ( 1975 ) discuss the many advantages a r i s i n g from both the process of developing a health plan, and the usefulness of the plan i t s e l f : programs and a c t i v i t i e s are linked to outcomes; longer timeframes are used for decision-making; i n e f f i c i e n c i e s are documented; values are integrated into the planning process; p a r t i c i p a t i o n i s broadened; communication i s increased through discussion; terminology i s standardized; b e l i e f s are tested; a c c o u n t a b i l i t y i s increased; data i s better organized; and evaluation i s f a c i l i t a t e d . The purpose of th i s thesis i s to describe a framework for the development of a P r o v i n c i a l Health Plan. It i s not to develop the plan i t s e l f . In other words, the thesis concerns i t s e l f with what Taylor ( 1972 ) has termed "planning the planning", and addresses what Dror ( 1971 ) has defined as "metapolicy" — p o l i c y about policymaking. In order to formulate a framework that takes into account the complexities and d i f f i c u l t i e s of plan development, yet remains clear and understandable to 17 t h e p l a n n e r s and d e c i s i o n - m a k e r s who w o u l d use t h e f r a m e w o r k , i t i s u s e f u l t o f i r s t r e v i e w c e r t a i n c o n c e p t s about t h e p r o c e s s o f p l a n n i n g . T h i s i s done i n C h a p t e r I I , f o l l o w i n g w h i c h C h a p t e r I I I d i s c u s s e s s p e c i f i c a s p e c t s o f h e a l t h p l a n n i n g . The c o n c e p t s d e v e l o p e d i n C h a p t e r s I I and I I I p r o v i d e t h e b a s i s f o r a p r o p o s e d f r a m e w o r k , d e t a i l s of w h i c h a r e p r e s e n t e d i n C h a p t e r V . However , s i n c e t h e t e r m " P r o v i n c i a l H e a l t h P l a n " may be v i e w e d d i f f e r e n t l y by v a r i o u s a c t o r s w i t h i n t h e h e a l t h c a r e s y s t e m , i t i s i m p o r t a n t t o e x p l a i n t h e s c o p e of t h e p r o p o s e d P r o v i n c i a l H e a l t h P l a n ; t h i s i s done i n i C h a p t e r I V . C l e a r l y , t h e f ramework f o r t h e p l a n ' s d e v e l o p m e n t i s u s e f u l o n l y to t h e e x t e n t t h a t the r e s u l t i n g p l a n i s t h o u g h t t o be u s e f u l . I f , f o r w h a t e v e r r e a s o n , i t i s f e l t t h a t t h e s c o p e of t h e P r o v i n c i a l H e a l t h P l a n as o u t l i n e d i n C h a p t e r I V i s o v e r l y r e s t r i c t i v e o r c o m p r e h e n s i v e , t h e n t h e p r o p o s e d f ramework f o r d e v e l o p m e n t of t h e p l a n may have t o be r e v i e w e d . C o n c l u s i o n s of t h e t h e s i s a r e summar ized i n C h a p t e r V I . As w e l l , s u g g e s t i o n s f o r f u t u r e r e s e a r c h and s t e p s t o w a r d s t h e d e v e l o p m e n t o f a P r o v i n c i a l H e a l t h P l a n w i t h i n t h e p r o p o s e d f ramework a r e p r e s e n t e d . 18 Chapter I I . REVIEW OF GENERAL PLANNING The f i r s t chapter of t h i s thesis has provided a r a t i o n a l e for a P r o v i n c i a l Health Plan, without specifying the form that i t might take, or indeed what planning approach can be used to develop such a plan. To better understand the planning approach adopted, a review of general planning i s now presented. Planning i s but one of many approaches to s o c i a l maintenance and change. Others, not addressed i n t h i s paper, include education, s o c i a l movements, and even revolution ( E t z i o n i and Etzioni-Halevy 1973 ). Planning has been described i n a v a r i e t y of ways. Steiner (1978 ) suggests an e a s i l y remembered, but somewhat broad, d e f i n i t i o n : planning i s the process by which decisions are made as to "what i s to be done, when i t i s to be done, how i t i s to be done, and who i s to do i t " ( p. 7 ). Others stress the future o r i e n t a t i o n of planning. For example, Newman ( 1958 ) states: "Speaking generally, planning i s deciding i n advance what i s to be done; that i s , a plan i s a projected course of action" ( p . 15 ). Dahl ( 1959 ) emphasizes the r a t i o n a l i t y of planning: "Planning i s more and more regarded as equivalent to r a t i o n a l s o c i a l a c t i o n , that i s , as s o c i a l process for reaching a r a t i o n a l decision" ( p. 340 ). Another aspect i s highlighted by Friedmann ( 1959 ) - the purpose of planning as progress towards a better s o c i e t y : "Planning i s nothing more than a c e r t a i n manner of a r r i v i n g at decisions and ac t i o n , the i n t e n t i o n of which i s to promote the s o c i a l good of a society undergoing rapid changes" ( p. 327 ). On reviewing these and other d e f i n i t i o n s of planning, Dror ( 1973 ) has attempted a synthesis: "Planning i s the process of preparing a set of decisions for action i n the future, directed at achieving goals by preferable means" ( p.330 ). Dror's 19 statement i s not nec e s s a r i l y the one correct d e f i n i t i o n of planning, but i t does express a common thread which underlies the great number of acceptable d e f i n i t i o n s . Banfield ( 1973 ) makes the same point: "The word 'planning' i s given a bewildering va r i e t y of meanings...Nevertheless, i t may be that there i s a method of making decisions which i s to some extent common to a l l these f i e l d s and others as w e l l . . . " ( p. 139 ). Cantley ( 1981 ) agrees that "although there are some differences of terminology between the various authors, there i s a f a i r l y high degree of consensus on the main features" ( p. 5 ). He goes on further to quote Drucker's ( 1959 ) d e f i n i t i o n of long-range planning, stated over 20 years ago: "The continuous process of making present entrepreneurial ( r i s k taking) decisions systematically and with the best possible knowledge of th e i r f u t u r i t y , organizing systematically the e f f o r t s needed to carry out these decisions, and measuring the r e s u l t s of these decisions against the expectations through organized, systematic feedback." Although there does seem to be a common thread which allows a meaningful general heading of "planning", there seems also a great number of disparate a c t i v i t i e s which might be subsumed under t h i s heading. For example, construction plans for a new h o s p i t a l , preparation of a budget and any e f f o r t towards developing a p r o v i n c i a l health plan, a l l involve "planning". The following sections b u i l d a framework for sorting out these various approaches and processes, which have a l l been l a b e l l e d "planning". II.A. Rational Planning As the name implies, the r a t i o n a l planning approach i s rooted i n 20 " r a t i o n a l " or " s c i e n t i f i c " methods of problem solving. It i s a t r a n s p o s i t i o n to the s o c i a l sciences of the methodologies of the engineer. In t e r e s t i n g l y , the phrase " s o c i a l engineering" has l o s t i t s popularity, but more neutral terms such as "systems a n a l y s i s " and "operations research" convey e s s e n t i a l l y the same notion. Banfield ( 1973 ) uses the concept of a "means-end" schema as a s t a r t i n g point for planning. This i s a model of r a t i o n a l choice, where an actor (either an i n d i v i d u a l or an organization) i s assumed to have c e r t a i n goals or "ends", and planning i s the process by which he r a t i o n a l l y s e l e c t s the "means" to a t t a i n those ends. The means generally e n t a i l some course of a c t i o n . Banfield l i s t s four steps i n t h i s planning process: (1) analysis of the s i t u a t i o n , (2) end reduction and elaboration, (3) design of course of action, (4) comparative evaluation of consequences. The f i r s t step, analysis of the s i t u a t i o n , involves consideration of the possible courses of action which could lead to the desired ends. As part of the a n a l y s i s , factors such as available resources, obstacles to plans, and other s i t u a t i o n a l factors must be taken into account. The second step, end  reduction and elaboration, i s the formulation or o p e r a t i o n a l i z a t i o n of the ends or o b j e c t i v e s . Banfield distinguishes between "active" and "contextual" elements; the active elements being those ends a c t i v e l y sought by the planner, whereas the contextual elements exist but are only i n c i d e n t a l to the plan. If during the elaboration of ends, there are c o n f l i c t s between ends, then the planner must "discover the r e l a t i v e value to be attached to each (end) under the various concrete circumstances envisaged i n the courses of a c t i o n " ( p. 141 ). The t h i r d s t e p , design of course of a c t i o n , i n v o l v e s proceeding from the more general o b j e c t i v e s to s p e c i f i c subobjectives which enable eventual attainment of aims. The f o u r t h step, comparative e v a l u a t i o n , i s e s s e n t i a l l y a c o s t - b e n e f i t approach to the consequences of a l t e r n a t i v e courses of a c t i o n . B a n f i e l d s t r e s s e s the importance of i n c l u d i n g both intended and unintended consequences i n t h i s e v a l u a t i o n . Stoner ( 1978 ) takes much the same r a t i o n a l approach to pla n n i n g , as a "more r a t i o n a l , fact-based procedure f o r making decisions...(which) allows managers and or g a n i z a t i o n s to minimize r i s k and u n c e r t a i n t y " ( p. 91 ). He also l i s t s four b a s i c steps to the planning process: (1) e s t a b l i s h g o als, (2) determine where you are ( r e l a t i v e to your g o a l s ) , (3) determine aids and obstacles to reaching your g o a l s , (4) develop a p l a n , The s i m i l a r i t y to B a n f i e l d ' s l i s t i s f a i r l y evident. However, Stoner does make a number of a d d i t i o n a l p o i n t s . He notes that i n p r a c t i c e , steps (1) and (2) are i n s e p a r a b l e , i . e . goals can be formulated only i n the context of the e x i s t i n g s i t u a t i o n . The d i f f i c u l t y of e s t a b l i s h i n g goals i s a l s o s t r e s s e d ; almost i n v a r i a b l y there are c o n f l i c t s and some choice or p r i o r i z i n g i s necessary. Stoner, i n d i s c u s s i n g step (4) (developing a  p l a n ) , a l l u d e s to the tendency to " s a t i s f i c e " r a t h e r than optimize when s e l e c t i n g among a l t e r n a t i v e courses of a c t i o n ; that i s , Instead of s e l e c t i n g the best a l t e r n a t i v e , the f i r s t acceptable a l t e r n a t i v e i s used. The systems a n a l y s t a l s o takes a r a t i o n a l approach to planning. For example, Reisman ( 1979 ) l i s t s seven steps to problem s o l v i n g : 22 (1) r ecogn i t ion of needs, (2) statement of problem, • (3) formulat ion of the value model, (4) synthesis of a l t e r n a t i v e s , (5) ana lys i s and t e s t i n g , (6) eva lua t ion , (7) decis ion-making, Most of the steps are va r i a t i ons of those already l i s t e d above. It i s worth noting that Reisman makes e x p l i c i t the formulat ion of a value model, a step which i s assumed by other r a t i o n a l p lanners , and thus often dealt with inadequately . He describes the value model as "a set of value r e l a t i o n s h i p s between the goal s , o b j e c t i v e s , c o n s t r a i n t s , and c r i t e r i a which are pert inent to a given problem" ( p . 239 ) . As values are by t h e i r nature e x t r a - r a t i o n a l , one can an t i c ipa te planning based on r a t i o n a l i t y w i l l encounter s i g n i f i c a n t problems at th i s step of the planning process . Another systems ana lys t , Van Gigch ( 1974 ) , presents a flow diagram o u t l i n i n g the o rgan iza t iona l dec i s ion process ( i . e . p l ann ing ) . 23 Search of Alternatives Problem Definition Fund of Knowledge KAlternative^ T \ /" Value of \ X, >M^0utOTTOOyH^Outcornel/1^-Alternative ^  4, Alternat ^"^-*-(^utcome O^H*^ Value of Outcome V„ Choice Stimulus Evaluation of Alternatives Criteria and Attributes Goals and Objectives Decision Models Learning Needs Outputs Satisfaction of Needs Evaluation of Results FIGURE 1: O r g a n i z a t i o n a l D e c i s i o n Process SOURCE: " O r g a n i z a t i o n a l D e c i s i o n Process i n A b s t r a c t Form" ( A f t e r Cyert and March, A Behavioural Theory of the Firm, 1963, p.127, P r e n t i c e - H a l l ) from A p p l i e d General Systems Theory Second E d i t i o n by John P. van Gigch. Copyright 1978 by John P. van Gigch. By permission of Harper & Row, Pub. Inc. The diagram repeats i n a f a i r l y compact way the process of problem d e f i n i t i o n (based on needs and a v a i l a b l e knowledge of the s i t u a t i o n ) , development and s e l e c t i o n of a l t e r n a t i v e s , and some e v a l u a t i o n of the se l e c t e d course of a c t i o n a f t e r implementation. I t i s u s e f u l to v i s u a l i z e the process as c y c l i c a l and ongoing, as implied by the closed loop nature the diagram. Taylor ( 1972 ) takes a more d e t a i l e d view of pla n n i n g , addressing himself s p e c i f i c a l l y to h e a l t h planning. He describes an eigh t stage sequence: (1) planning the planning and developing planning competence, 24 (2) statement of p o l i c y and broad goa l s , (3) data ga ther ing , (4) p r i o r i t y statement of hea l th problems, (5) o u t l i n e , with statement of major a l t e r n a t i v e proposa l s , (6) development of de ta i l ed plan with targets and standards, (7) implementation, as part of p lanning , (8) e v a l u a t i o n . T a y l o r ' s approach overlaps a great deal the approaches already d i scussed . For example, the statement of goals and problems, followed by development of a l t e r n a t i v e s , e t c . are ind ica ted i n the flow diagram shown i n Figure 1. However, Taylor also attempts to take in to account the Importance of the p o l i t i c a l m i l i e u , power groups, e t c . Thus, he comments on the optimal p o s i t i o n of the planning unit i n the government h ierarchy ( i . e . c l o s e l y associated with the admini s t ra t ive s t ructure but not d i r e c t l y involved with a d m i n i s t r a t i o n ) , and s tates that "planning p o l i c i e s and goals must be p o l i t i c a l l y determined". There i s much greater o r i e n t a t i o n i n T a y l o r ' s stages towards the implementation phase of the hea l th p l a n . This i s made e x p l i c i t i n the seventh stage, implementation as part of p l a n n i n g . He concludes that a balance must be struck between acceptance of innocuous plans confirming the status quo, and r e j e c t i o n of plans that are too i n n o v a t i v e . A good plan should "conta in the seeds of progressive change". T a y l o r ' s concern with the usefulness of the planning process i n the " r e a l world" - the relevance of r a t i o n a l planning to dec i s ion makers i n pos i t ions of author i ty - i s more f o r c e f u l l y expressed i n another school of thought, incremental i sm. 25 I I . B . Incrementalism The incrementa l i s t approach to planning argues that r a t i o n a l planning i s hopeless ly i m p r a c t i c a l . Donnison ( 1972, pp . 97 - 117 ) summarizes t h i s p o s i t i o n : It i s argued that long-range, synoptic or comprehensive ana lys i s of problems as complex as those that confront the s o c i a l policy-maker i s u sua l ly impossible because of the d izzy ing v a r i e t y of choices open to him, the profusion of t h e i r primary, secondary, and further repercuss ions , and the plethora of c o n f l i c t i n g i n t e r e s t s and pressures which must be accommodated before anything can be done. Put another way, the costs of gather ing , a n a l y z i n g , and i n t e r p r e t i n g a l l the information required to formulate and implement r a t i o n a l and comprehensive p o l i c i e s without i n t o l e r a b l e delays are too high for anyone to attempt the task. Lindblom ( 1973 ) i s the best known advocate of incremental i sm, and h i s model has s ix primary c h a r a c t e r i s t i c s : (1) there i s a focus only on those p o l i c i e s which d i f f e r incrementa l ly from e x i s t i n g p o l i c i e s , (2) even w i t h i n the scope of a l i m i t e d number of p o l i c y areas, only a r e l a t i v e l y small number of a l t e r n a t i v e s are considered, (3) for each a l t e r n a t i v e , only a l i m i t e d number of consequences are evaluated, (4) s ince changes are incrementa l , there i s constant adjustment and r e d e f i n i t i o n of the problem, (5) thus, no " r i g h t " dec i s i on i s f i n a l l y reached, only continuing ana lys i s and eva lua t ion , (6) the o r i e n t a t i o n i s therefore remedia l , and reac t ive rather than innovat ive and or iented towards future s o c i a l goal s . Lindblom ( 1973 ) terms t h i s process "successive approximation to some des ired ob ject ives i n which what i s des ired i t s e l f continues to change under 26 recons idera t ion" ( p . 163 ), or more s imply , "muddling through" . This s e r ie s of incremental changes protects against being w i l d l y of f the mark, thus avoiding a f u l l gain versus zero loss s i t u a t i o n . By l i m i t i n g ana ly s i s to incremental changes of p o l i c y , the process i s much s i m p l i f i e d . Thus, given the usual condi t ions of l i m i t e d resources and l i m i t e d human c a p a b i l i t i e s , the incrementa l i s t approach i s to be p r e f e r r e d . Lindblom makes the other major point that i t i s very d i f f i c u l t to c l a r i f y and p r i o r i z e va lues , and thus o b j e c t i v e s . He states that t h i s i s the f a t a l weakness of r a t i o n a l comprehensive p lanning ; planners or decision-makers seldom have a c lear i n d i c a t i o n of publ ic preference s ince i n most issues there i s l i t t l e publ ic d i scus s ion or i n d i c a t i o n of pub l i c preference . Moreover, the i n d i v i d u a l has d i f f i c u l t y ranking values at the abs t rac t , p h i l o s o p h i c a l l e v e l . Importance or r e l a t i v e weighting can be assessed only i n context , and thus p a r t i c u l a r p o l i c i e s must be stated and choices made among a l t e r n a t i v e p o l i c i e s which of fer d i f f e rent marginal combinations of v a l u e s . Lindblom (1973 ) c l a ims : "Somewhat p a r a d o x i c a l l y , the only p rac t i cab le way to d i s c l o s e one's relevant marginal va lues , even to onese l f , i s to describe the p o l i c y one chooses to achieve them" ( p. 157 ) . In a sense, one must s imultaneously choose both a p o l i c y to a t t a i n c e r t a i n ob jec t ives and the ob ject ives themselves. Lindblom considers the means-end approach inappropr ia te s ince there i s i n prac t i ce no way to determine ends without at the same time consider ing the means. In s i tua t ions where there i s dispute over the "correctness " of a plan (based on c o n f l i c t i n g v a l u e s ) , the c r i t e r i o n to be employed i n eva luat ion i s whether there i s agreement by the decis ion-makers . A l t s h u l e r ( 1973 ) supports Lindblom's contention that the "pub l i c 27 i n t e r e s t " i s not e a s i l y determined and that i m p l i c i t i n comprehensive planning i s the assumption that a "community's var ious c o l l e c t i v e goals can somehow be measured at leas t roughly as to importance and welded in to a s ing le h ierarchy of community ob j ec t ive s " ( p . 194 ) . The question looms whether th i s assumption i s v a l i d , given the d i f f i c u l t i e s i n e l i c i t i n g p u b l i c d i s cus s ion on major i s sues , the need for expert ise and data to r e a l l y understand the complexity of an i s sue , and the lack of organized groups or spokesmen to whom a planner can r e f e r . A l t s h u l e r ( 1973 ) s t a t e s : " In t r y i n g to persuade p o l i t i c i a n s to commit themselves to the p o l i c y v i s i o n s of p lanners , defenders of comprehensive planning must contend that the p o l i t i c i a n s w i l l benef i t t h e i r const i tuents by doing so. To the extent that the planners themselves lack comprehensive perspect ives , however, t h i s contention becomes less and less p l a u s i b l e " ( p.202 ) . E t z i o n i ( 1973 ) s i m i l a r l y questions the assumptions i m p l i c i t i n the r a t i o n a l approach about the c o n t r o l exerc i sed by the decis ion-maker. He points out that there i s often no agreement upon a set of values that give c r i t e r i a by which to evaluate a l t e r n a t i v e s , e s p e c i a l l y as values are both affected by, and a f fect the decis ions made. In p r a c t i c e , questions of fact become confused with questions of va lue , and the means and the ends cannot always be separated. Although at f i r s t glance i t may appear that the incrementa l ! s t approach to planning i s the preferable one, a number of authors provide cogent arguments as to the f a l l a c i e s and weaknesses of Lindblom's model. Donnison ( 1972 ) points out that underlying any os tens ib ly incremental growth i s an i m p l i c i t master plan which determines the choice among incremental a l t e r n a t i v e s . There i s almost always some o v e r a l l plan which or ient s choice and decis ions to an ordered pat tern - i f viewed from a s u f f i c i e n t l y d i s tant 28 timeframe. An example of th i s i n the hea l th care f i e l d i s development of hea l th care insurance i n Canada. I f any s ingle event or dec i s i on i s analyzed, i t appears to be a r e s u l t of a "p le thora of c o n f l i c t i n g i n t e r e s t s and pressures" . Yet a re t rospec t ive ana lys i s ind ica tes a d e f i n i t e pat tern towards increa s ing government r e s p o n s i b i l i t y i n assuring adequate insurance coverage of hea l th care cos t s : Nat ional Heal th Grants (1948), Hosp i ta l and Diagnost ic Services Act (1957), Nat ional Medical Care Insurance Act (1966). Within each of the provinces , extension of coverage continues , e . g . Pharmacare, Dent icare . Donnison also warns against undue r e l i a n c e on an incrementa l i s t approach s ince a number of programs are inherent ly unsuitable for implementation by stages. E t z i o n i ( 1973 ) s i m i l a r l y argues that although the incrementa l i s t s concede the existence of fundamental decis ions which occur outside t h e i r model, they underrate the importance of such fundamental d e c i s i o n s . Even i f these decis ions occur rather i n f r e q u e n t l y , they set the d i r e c t i o n s for incremental changes i n the years f o l l o w i n g . He also points out that Lindblom's model assumes a p l u r a l i s t i c s o c i e t y , ignor ing the problems of under-representat ion by the poor or other minor i ty groups. Fa lud i ( 1973 ) disputes that incrementalism should serve as the normative model for p l anning : "The flaws i n Lindblom's argument are that he completely replaces v a l i d i t y as a c r i t e r i o n for decis ions with agreement, that he absurdly magnifies theory, and that he i d e n t i f i e s rat ional-comprehensive with another form of planning which I s h a l l c a l l b l u e - p r i n t p lanning" ( p . 117 ) . Fa lud i further notes that incrementa l i s t s maintain that var ious groups are able to cont inous ly adjust t h e i r i n t e r e s t s ( i . e . what Lindblom terms "par t i s an mutual adjustment" ) but do not spec i fy how those groups themselves a r r i v e at consensus as to what i n fact are 29 t h e i r own i n t e r e s t s . Neither incrementalism nor r a t i o n a l i s m can c la im to be the "best" approach to planning i n a l l in s tances . Conceptually these two modes of planning can be considered as l y i n g at opposite poles of a continuous spectrum. This dichotomy of r a t i o n a l approach versus incrementa l i s t approach i s analagous to Friedmann's ( 1973 ) concept of developmental versus adaptive p l anning . Developmental planning involves a high degree of autonomy with respect to se t t ing of ends and choice of means; adaptive planning accepts that most decis ions are heav i ly contingent on the act ions of others external to the planning system. Regardless of the l a b e l l i n g , the d i f ference of these two approaches should be f a i r l y c l e a r . As with most instances of opposing approaches to any issue or problem, there are those who advocate a middle-range compromise. I I . C . Middle-Range Approach E t z i o n i ( 1973 ) advocates an approach to planning which combines the advantages of both r a t i o n a l planning and incremental i sm:"each of the two elements i n mixed scanning helps to reduce the e f fects of the p a r t i c u l a r shortcomings of the o ther ; incrementalism reduces the u n r e a l i s t i c aspects of r a t i o n a l i s m by l i m i t i n g the d e t a i l s required i n fundamental dec i s ions , and contexuating r a t i o n a l i s m helps to overcome the conservative s lant of incremental ism by explor ing longer-run a l t e r n a t i v e s " ( p . 225 ) . This "mixed-scanning" approach suggests a truncated ana lys i s over a broad range of sec tors , thus permit t ing an overview at reasonable cos t . Coupled with t h i s would be a f u l l de ta i l ed review of a l i m i t e d number of s ec tor s . The r e l a t i v e amounts of truncated and de ta i l ed review would depend upon the 30 context i n which the planning takes p lace , taking in to account those i n power, whether the planning environment i s changing r a p i d l y , and on the c a p a b i l i t y to implement any decis ions that would r e s u l t . Know ( 1979 ) describes four basic kinds of planning contexts : systems, partnerships , a l l i a n c e s , and i n d i v i d u a l a c t i o n s . Systems involve c lose contact with p o l i c y makers who se lect goals and c o n t r o l implementation. Partnerships describe a s i t u a t i o n where each p a r t i c i p a n t submits plans to a bargaining process . A l l i a n c e s depend upon an a b i l i t y to mobi l ize pub l i c support needed, with long range planning compromised to incremental adjustments. Although Myerson ( 1973 ) was wr i t ing i n the context of community p lanning , i t i s worth not ing the functions he suggests for middle-range p lanning : (1) c e n t r a l i n t e l l i g e n c e , (2) pulse t a k i n g , (3) p o l i c y c l a r i f i c a t i o n , (4) de t a i l ed development p l a n , (5) feed-back review. The c e n t r a l i n t e l l i g e n c e funct ion disseminates re levant information to providers and consumers. Pulse-taking refers to detect ion of trends and a ler tness to p o t e n t i a l problem areas . This leads to p o l i c y c l a r i f i c a t i o n , i e . adjustments of p o l i c y through c l a r i f i c a t i o n of the impl i ca t ions of a l t e r n a t i v e s . The d e t a i l e d development plan would have a f i ve to ten year time h o r i z o n , and would serve as the l i n k i n g mechanism between longer-range planning and incremental p lanning . The middle-range approach to planning i s s i m i l a r to Coleman's ( 1975 ) concept of " p o l i c y r e s e a r c h " . He saw th i s as a guide to ac t ion and 31 decis ion-making, unl ike " d i s c i p l i n e research" which i s more academical ly o r i e n t e d . Thus i n p o l i c y research, " p a r t i a l information ava i l ab l e at the time an ac t ion must be taken i s better than complete informat ion a f ter that t ime" ( p . 22 ) and the "value of research re su l t s l i e i n a high p r o b a b i l i t y of g i v i n g approximately the r i g h t guides to a c t i o n , rather than i n t h e i r d e r i v a t i o n from, or correspondence t o , a good theory" ( p . 23 ) . Boudreau ( 1976 ) , i n d i scuss ing reasons why the s o c i a l sciences do not appear to have inf luenced hea l th p o l i c i e s , makes the same point that academic researchers may have to compromise s c i e n t i f i c method i n favour of relevance and t i m e l i n e s s . Diagrammatical ly , the range of approaches to planning could be out l ined as f o l l o w s : Rat iona l Middle-range Incremental »•< > • Before making use of th i s typology, i t i s necessary to consider the d i f f e r e n t h i e r a r c h i c a l l eve l s at which planning takes p l ace . I I . D . Planning Levels Cr ichton ( 1981 ) suggests a paradigm showing stages i n the process of t r a n s l a t i n g s o c i a l phi losophies in to s o c i a l s e r v i c e s . From a government perspect ive the hierarchy i s as f o l l o w s : Philosophy Ideologies Government P o l i c y Planning Admini s t ra t ive Planning Program Planning Service De l ivery 32 In order to s i m p l i f y , numerous feedback loops and i n t e r a c t i o n s between l e v e l s have not been diagrammed. Of p a r t i c u l a r i n t e r e s t to planners i n government are the l eve l s of government p o l i c y planning and admini s t ra t ive  p lanning . Government p o l i c y planning involves " s e l e c t i o n of broad i d e o l o g i c a l goa l s , determination of p r i o r i t i e s on i d e o l o g i c a l grounds, cons idera t ion of the 'general w i l l ' , development of d e f i n i t i o n s , categories and c l a s se s , development of l e g i s l a t i o n and regu la t ions , and development of standing plans" ( p . 279 ) . The importance of l inkages to ideolog ies and the p o l i t i c a l s i t u a t i o n i s s tressed by H a l l ( 1972 ) : "The p lanner ' s des i re to d ia s soc ia te himself from the p o l i t i c a l process r e f l e c t s a misunderstanding of h i s primary r e s p o n s i b i l i t i e s , which have been s u c c i n c t l y defined as the ' i l l u m i n a t o r of choices for the p o l i t i c a l dec i s ion-maker ' " ( p . 125 ) . Admini s t ra t ive planning further spec i f i e s what has been genera l ly out l ined i n p o l i c y p lanning , but with emphasis upon negot iat ions as to s t ruc ture s , processes , and resource a l l o c a t i o n and management. A d d i t i o n a l l y , i t i s at th i s l e v e l that there i s development of contracts of s e r v i c e . These functions and developments continue at the program planning l e v e l , and eventua l ly r e su l t i n serv ice d e l i v e r y . At t h i s l e v e l , "p lanning" or " p o l i c y " takes the form of a l l o c a t i o n and r a t i o n i n g of i n d i v i d u a l s e r v i c e s . A comparable h i e r a r c h i c a l approach to planning l eve l s i s taken by Stoner ( 1978 ) , although the terminology d i f f e r s somewhat. His o u t l i n e i s shown i n Figure 2 . 33 Purpose I Miss ion Object ives S trategies Single use plans Prog f^m^^u^ge t~ "~^ro j ect Standing plans P o l i c i e s Standard Procedure Rules & Regulations FIGURE 2: Hierarchy of Organ iza t iona l Plans James A . F . Stoner, Management, (&I97S, p .99. Reprinted by SOURCE: permiss ion of P r e n t i c e - H a l l , I n c . , Englewood C l i f f s , N . J . The purpose of an organiza t ion i s i t s primary ro le as defined by s o c i e t y ; the miss ion i s more l i m i t e d i n scope, being what the o rgan iza t ion sees as i t s broad aims. The ob jec t ives are those ends which enable the organiza t ion to carry out i t s mi s s ion . S tra teg ies are the broad programs for achieving the o b j e c t i v e s . Fol lowing from the s t ra teg ie s are t a c t i c s , the de ta i l ed a l l o c a t i o n of resources to achieve s t r a t eg i c goa l s . These t a c t i c s can take the form of s i n g l e use plans or standing p l ans . As a r e s u l t of t a c t i c a l p lans , i n d i v i d u a l s w i l l be engaged i n c e r t a i n types of a c t i v i t i e s and s e r v i c e . Planning l e v e l s can be cor re l a ted with the organ iza t iona l h i e r a r c h y ; the higher planning l e v e l s correspond to higher l e v e l s of the o rgan iza t ion c h a r t . Thus, i f a business o rgan iza t ion i s used as the reference p o i n t , an approximate mapping might be as shown i n F igure 3. I f another o rgan iza t ion i s used, d i f f e r e n t t i t l e s could be subs t i tuted but the basic pat tern remains unchanged, e . g . w i t h i n the B . C . M i n i s t r y of Hea l th : Cabinet , Min i s t e r of H e a l t h , Deputy M i n i s t e r , Ass i s tant Deputy M i n i s t e r s , Executive D i r e c t o r s . 3 4 P h i l o s o p h y I d e o l o g i e s P o l i c y P l a n n i n g A d m i n i s t r a t i v e P l a n n i n g P u r p o s e B o a r d o f D i r e c t o r s M i s s i o n C h i e f E x e c u t i v e O f f i c e r O b j e c t i v e s E x e c u t i v e V i c e - p r e s i d e n t S t r a t e g i e s V i c e - p r e s i d e n t of F u n c t i o n a l A r e a P r o g r a m P l a n n i n g T a c t i c s G e n e r a l Manager S e r v i c e D e l i v e r y S u p e r v i s o r s FIGURE 3 . P l a n n i n g L e v e l s However , i t i s o n l y t h e g e n e r a l c o r r e s p o n d e n c e w h i c h s h o u l d be s t r e s s e d ; p e r s o n n e l a t one l e v e l of t he o r g a n i z a t i o n s t r u c t u r e w i l l be i n v o l v e d i n a number of d i f f e r e n t p l a n n i n g l e v e l s - t h e mapping above m e r e l y i n d i c a t e s the o r g a n i z a t i o n a l l e v e l where a c e r t a i n p l a n n i n g l e v e l i s most o f t e n u n d e r t a k e n . I f t he c o n c e p t of p l a n n i n g l e v e l s i s combined w i t h t h e t y p o l o g y of p l a n n i n g a p p r o a c h e s d i s c u s s e d e a r l i e r i n t h i s p a p e r , a m a t r i x r e s u l t s w h i c h c a n be used as a f ramework t o c l a s s i f y t h e g r e a t range of p l a n n i n g a c t i v i t i e s w h i c h c o n f r o n t t h e p o l i c y a n a l y s t o r p l a n n e r . T h i s m a t r i x i s shown b e l o w : PLANNING APPROACH R a t i o n a l M i d d l e - r a n g e I n c r e m e n t a l A B C PLANNING LEVEL 1) P h i l o s o p h y 2) I d e o l o g i e s 3 ) P o l i c y P l a n n i n g 4 ) A d m i n i s t r a t i v e P l a n n i n g ) 5) P r o g r a m P l a n n i n g 6 ) S e r v i c e D e l i v e r y FIGURE 4 . P l a n n i n g M o d e - L e v e l M a t r i x 35 There has been a tendency to equate p o l i c y planning with r a t i o n a l p l ann ing , and serv ice d e l i v e r y or program planning with incremental p l anning . The matrix suggests that any planning l e v e l i s subject to a range of planning approaches. Thus a r a t i o n a l s c i e n t i f i c approach may be taken i n planning services or programs, or p o l i c y planning may be done on an ad hoc incremental b a s i s . Using t h i s matrix as a framework allows a synthesis of var ious other models of the planning process . It i s worthwhile noting that Friedmann ( 1973 ) has formulated a conceptual model for the ana lys i s of p lanning . His diagram i s reproduced i n the fo l lowing f i g u r e . Tradition Intuition Wisdom Ends given Ends variable I General ends u Specific ends i .j Rationality^ I Substantially I Bounded [ r — ~i utopion and I Functionally S sto t.olly i ide£,00jeai 1^  rational thought rational thought I tftought Maintaining system balances Inducing system tronsformation A1 locative planning : Innovative planning; "Central guidance cluster "islands of chonge System performance FIGURE 5. Conceptual Model of Planning SOURCE: J . Friedmann, A Conceptual Model for the Ana ly s i s of Planning Behaviour. In A . F a l u d i (ed), A Reader i n Planning Theory. Pergamon Press , 1973, p.349. 36 The components and r e l a t i o n s h i p s appear f a i r l y i n v o l v e d , but p l ac ing h i s concepts i n the matrix c l a r i f i e s the system. Friedmann describes two forms of p lanning : developmental and adapt ive . Developmental planning i s equivalent to r a t i o n a l planning (and thus corresponds to the A c e l l s i n Figure 4 . ) ; adaptive planning to incremental planning (and thus the C c e l l s ) . He does q u a l i f y developmental planning as "not only t e c h n i c a l , but a l s o , and to a large degree, a p o l i t i c a l f u n c t i o n " , and that planning must meet needs i n t e r n a l to the p o l i t i c a l process ( e . g . symbolizing progress , or e s t ab l i sh ing a n a t i o n a l consensus/unity ) . This q u a l i f i c a t i o n can be seen as a s h i f t to a middle-range approach. The balance p o i n t , or the l o c a t i o n on the planning approach spectrum depends on a number of f a c t o r s : "Technica l p lanning , there fore , moves temporari ly into the foreground whenever goals are c l e a r , widely h e l d , and deemed to be important; whenever i n such a s i t u a t i o n system performance i s bel ieved to depart s i g n i f i c a n t l y from the norm and whenever, given a l l of these cond i t ions , expert judgement coupled with a v a r i e t y of c o n t r o l mechanisms i s held to be more e f f ec t ive than p o l i t i c a l manipulat ion" ( p . 353 ) . Friedmann ( 1973 ) discusses a number of other concepts re la ted to planning theory . He notes that th inking can be " r a t i o n a l " or " e x t r a - r a t i o n a l " . He further states that r a t i o n a l i t y can be "bounded" or "nonbounded". Bounded r a t i o n a l i t y re fers to r a t i o n a l decision-making wi th in cons t ra int s of the s i t u a t i o n , i . e . to be as r a t i o n a l as poss ib le given the existence of i n t e r e s t groups, p o l i t i c a l oppos i t ion the economic system, e x i s t i n g information systems, the bureaucrat ic s t r u c t u r e , e t c . But t h i s i s e s s e n t i a l l y a d e s c r i p t i o n of a middle-range planning approach. Friedmann 37 makes a d i s t i n c t i o n between " f u n c t i o n a l r a t i o n a l i t y " and " s u b s t a n t i a l r a t i o n a l i t y " . Funct iona l r a t i o n a l i t y refers to a r a t i o n a l approach with respect to means on ly , whereas subs tan t i a l r a t i o n a l i t y re fers to a r a t i o n a l approach with respect to both means and ends. This idea i s e a s i l y incorporated in to the matrix by consider ing that for any p a r t i c u l a r " end" , the "means" are opera t iona l i zed at a lower planning l e v e l . Thus, funct iona l r a t i o n a l i t y would describe a s i t u a t i o n where an incremental approach i s taken at a c e r t a i n planning l e v e l , followed by a r a t i o n a l approach at the next lower planning l e v e l . For example, a " p o l i t i c a l " dec i s ion may be made to expand a medical s c h o o l . Although th i s ob ject ive may not be r a t i o n a l ( i . e . i n c e l l 3A of the matrix i n Figure 4.) the planning for such an expansion may be quite r a t i o n a l ( e . g . c a l c u l a t i o n of a d d i t i o n a l lab space and teaching s t a f f required ) and re su l t i n the most c o s t - e f f e c t i v e way of achieving the stated g o a l . Jantsch ( 1972 ) discusses a planning approach which stresses some of the same points as the approach adopted i n th i s t h e s i s : (1) i n t r o d u c t i o n of normative th inking and valuat ions into p lanning ; (2) system design a c e n t r a l fea ture ; (3) appropriate planning l e v e l s for a given s t r u c t u r e : p o l i c y p l a n n i n g ; s t r a t e g i c p l a n n i n g ; and t a c t i c a l or opera t iona l p l ann ing . The f i r s t point i s discussed at length i n descr ib ing the development and a p p l i c a b i l i t y of Values i n the P r o v i n c i a l Heal th P l a n , ( Sec t ion V . A . ) . The second point i s r e f l e c t e d i n development of a conceptual model of the hea l th care system ( Chapter I I I ) . The t h i r d point corresponds i n many ways to the hierarchy of planning l eve l s adopted i n t h i s t h e s i s . Since 38 t h e p l a n n i n g m a t r i x d e s c r i b e d has s i x l e v e l s , t h e r e i s n o t an e x a c t p a r a l l e l w i t h the p o l i c y , s t r a t e g i c , and o p e r a t i o n a l l e v e l s ; o r t h e c o r r e s p o n d i n g p o l i c y , s y s t e m s , and p r o j e c t p l a n n i n g l e v e l s d e s c r i b e d by Reeves e t a l ( 1979 ). F o r e x a m p l e , a c c o r d i n g t o D e v e r ( 1980 ), who a d o p t s J a n t s c h ' s c a t e g o r i z a t i o n , t h e p o l i c y p l a n n i n g l e v e l embodies " v a l u e s , g o a l s and o b j e c t i v e s " . The p l a n n i n g m a t r i x , by c o m p a r i s o n , d i s t i n g u i s h e s be tween v a l u e s / g o a l s a t t h e i d e o l o g i c p l a n n i n g l e v e l , and t h e o b j e c t i v e s ( l o n g t e r m ) a t t he p o l i c y p l a n n i n g l e v e l . There i s , i n D e v e r ' s l e v e l s , l i t t l e a t t e n t i o n t o t h e range o f p l a n n i n g modes ( i . e . f r o m r a t i o n a l c o m p r e h e n s i v e p l a n n i n g t o i n c r e m e n t a l p l a n n i n g . ) I n s t e a d , he f o c u s e s on t h e r e s u l t s o r outcomes of t he d i f f e r i n g p l a n n i n g l e v e l s . These a r e t e r m e d : (1) " c r e a t i o n of i n s t i t u t i o n s " ; (2) " c r e a t i o n of i n s t r u m e n t a l i t i e s " ; (3) " o p e r a t i o n s " . I n o t h e r w o r d s , i n s t i t u t i o n s a r e t h e c o n c e p t u a l b a s i s of t h e p l a n n i n g (and i n the c o n t e x t of p l a n n i n g f o r t h e H e a l t h C a r e S y s t e m , t h i s w o u l d t a k e t h e f o r m o f c o n c e p t s e x p r e s s e d i n t h e V a l u e S t a t e m e n t s s e c t i o n of t h e P r o v i n c i a l H e a l t h P l a n ) , and c o n c e p t u a l f ramework f o r t h e H e a l t h C a r e S y s t e m . The i n s t r u m e n t a l i t i e s a r e t h e n the s t r u c t u r e s and mechanisms e n a b l i n g s e r v i c e d e l i v e r y o r o p e r a t i o n s , e . g . l e g i s l a t i o n , p r o g r a m s , h o s p i t a l s . The outcome a t the l o w e s t p l a n n i n g l e v e l s a r e t h e n a c t u a l o p e r a t i o n s o r s e r v i c e d e l i v e r y . The c o m b i n a t i o n of p l a n n i n g l e v e l s i s e x p r e s s e d d i a g r a m m a t i c a l l y i n F i g u r e 6 w i t h examp les c i t e d f o r H e a l t h Care ( Dever 1980 ). Note t h a t he c o n s i d e r s the i n s t i t u t i o n t o be t h e Community H e a l t h C a r e S y s t e m ; t h e i n s t r u m e n t a l i t i e s t o be c e n t r e s f o r h i g h l e v e l w e l l n e s s , e t c . ; and t h e o p e r a t i o n s t o be p u t t i n g h i g h l e v e l w e l l n e s s i n t o d a i l y l i v i n g . 39 H E A L T H V A L U E S D U A L I T Y OF U F E . PWDUCTIve L I F E . W E L L N E S S . FREEDOM FROM S I C K N E S S P O L I C I E S rYfTIHPnTiag Bigtt-lwv*l imllnmaa CrowtJt Prwvwnttorr tmie-*etuMlizMtim 1 M o r t a l i t y I J t a d u e s d N o r o i d i t y I a a d u c a d D i s a b i l i t y lncT—s*4 H a l l . (NORMS) S Y S T E M DYNAMICS ••inv—— Doing ' a a v i n y SrsiBLQEsasct 1 — 1 t h s y a t a j n o o n n r f l t d v i t h thm total p a r s o n f t o l i s c i e j C R E A T I O N OF I N S T I T U T I O N S Communlty s c a l e s c a r s • 9 * t e n V J S T R A T E G I E S OPERATIONS P O S S I B L E A C T I V I T I E S P h y s i c a l s x a r c i s s l u t r i e l o a a l s t r e s s a i n n — i i t J e i f - r e s p o m i b i i i t y f t f u c a t i o n AgPJnt. ACTIVITIES A u n i / i g , ByimUng, cycling* a t e . / v i C a a i n s , a a a l t J l foods; c o p i n y s J U l i a ; h e a l t h p h y s i c a l a n d . i l l i i m n u SYSTEMIC STRUCTURES • I E F F E C T I V E N E S S M E A S U R E S O t a r e e o f » » l l n « j s e d u c e d a s r s i d i t g , d i s a b i l i t y M s l l a a s s i n d e x , a a e l t h n a s a r d a p p r a i s a l O b j e c t i v e s C R E A T I O N O F I N S T R U M E N T A L I T I E S C l a n t a r s f o r * ffiyb-ievei tmllnmsB Molistic h e a l t h M e l l n e a * r e s o u r c e s E F F I C I E N C Y M E A S U R E S M a d u c a d h e a l t h c a r * a s p e a d i r u r e s V u n b e r o / p e o p l a i n v o l v e d i n high-i e v e l w v i i n « * a c t i v i t i e s OftrMTIOrS r u t c i n y a i y h - l e v e l imllnasM Into d a y - C o - d a y l i v i n g FIGURE 6. Planning Model for "Wellness and Holistic Health" SOURCE: As adapted from Jantsch, Technological planning and social  futures ( London: Associated Business Programmes,1972 ) p.16, in Dever, G.E.A., Community health analysis. Reprinted courtesy of Aspen Systems Corp. Copyright 1980. 40 This f igure i s reminiscent of the planning matrix shown e a r l i e r . There i s a more or less common axis (planning l e v e l s ) , but the planning matrix shows planning modes at d i f f e r e n t planning l e v e l s , whereas Dever's diagram shows planning outcomes at d i f f e ren t planning l e v e l s . Incorporat ing the l a t t e r into the planning matrix r e s u l t s i n a three-dimensional planning matr ix , as shown below: FIGURE 7. Planning Mode-Level-Outcome Matr ix I I . E . Other Planning Models Using the i n t r o d u c t i o n of Medicare i n the United States as a case study, Marmor ( 1973 ) i l l u s t r a t e s how p o l i c y or planning can be seen as a r e s u l t of act ions of r a t i o n a l ac tor s , as a re su l t of o rgan iza t iona l processes , or as outcomes of bargaining and nego t i a t i ons . Using the r a t i o n a l  actor per spec t ive , " p o l i t i c a l occurrences may be properly character ized as the purposive acts of na t iona l governments, to summarize the va r i ed a c t i v i t i e s of governmental representat ives as the nat ion transforms 'unwieldy complexity in to manageable packages'" ( p . 97 ) . Thus p o l i c y i s seen as r e s u l t i n g from act ions of r a t i o n a l decision-makers who seek 41 so lut ions to c e r t a i n problems or attainment of c e r t a i n goa l s . Centra l to such an ana lys i s are explanations as to goals , a l t e r n a t i v e s o l u t i o n s , and consequences of the act ions undertaken. The o rgan iza t iona l process  perspect ive sees actions as outputs of o rgan iza t iona l funct ioning i n a standard p a t t e r n . This ana lys i s focuses upon "patterns of statements, d i r e c t i o n s , and act ions of re levant agencies and departments" ( p . 10 ) and assumes an incremental change process . The bureaucrat ic p o l i t i c s  perspect ive sees p o l i c y as a re su l t of "outcomes of a ser ies of overlapping bargaining g a m e s . . . p o l i t i c a l bargaining among a number of independent p l a y e r s , of compromise, c o a l i t i o n , compet i t ion, and confusion among government o f f i c i a l s " ( pp. 103 - 104 ) . In order to undertand t h i s process , the analyst must be aware of the power and p o s i t i o n of the p r i n c i p a l p l a y e r s . Although Marmor's in tent i s to provide an a n a l y t i c a l framework, he chooses also to describe the i n t r o d u c t i o n of Medicare as best explained i n i t i a l l y by the r a t i o n a l actor perspect ive , then the o rgan iza t iona l process per spec t ive , and l a s t l y by the bureaucrat ic p o l i t i c s  pe r spec t ive . This suggests s t rongly that over time an issue may i n fact move from a r a t i o n a l planning approach (corresponding to a r a t i o n a l actor a n a l y s i s ) , to a middle-range approach (corresponding to o r g a n i z a t i o n a l process ana lys i s ) and f i n a l l y reaching an incremental planning approach (corresponding to a bureacra t ic p o l i t i c s a n a l y s i s ) . The matrix i n Figure 4. i s constructed i n such a way as to suggest that an issue w i l l "descend" the var ious planning l e v e l s , r e s u l t i n g eventual ly i n some sort of i n d i v i d u a l s e rv ice or a c t i v i t y ; Marmor's d e s c r i p t i o n implies that an issue may take a rather c i r c u i t o u s route , passing through various planning modes as wel l as through planning l e v e l s . I f th i s pathway does e x i s t , any attempts to move 42 from one planning l e v e l to another d i r e c t l y w i l l encounter r e s i s t a n c e . The matrix does not ind ica te whether a p a r t i c u l a r planning approach i s best for a p a r t i c u l a r planning l e v e l . Other factors must be taken i n t o account. It would be an o v e r s i m p l i f i c a t i o n to assume that the middle-range approach guarantees success . Using an organ iza t iona l process per spec t ive , A l f o r d ( 1972 ) examined a major U . S . c i t y and found that the "expansion of the hea l th care industry and the apparent absence of change are due to a s truggle between d i f f e ren t major i n t e r e s t groups operating w i t h i n the context of a market soc i e ty - profes s iona l monopolists c o n t r o l l i n g the major hea l th resources , corporate r a t i o n a l i z e r s chal lenging t h e i r power, and the community populat ion seeking better hea l th care" ( p . 128 ) . He describes the pro fe s s iona l monopolist as researcher , p h y s i c i a n , or other hea l th p r o f e s s i o n a l , who shares an i n t e r e s t i n pro fes s iona l autonomy and c o n t r o l of condi t ions of work. The corporate r a t i o n a l i z e r s include the medical schools , pub l i c h e a l t h , h o s p i t a l admini s t ra tor s , and government p lanners . They share an i n t e r e s t i n maintaining and extending the c o n t r o l of organizat ions over condi t ions of work of profess ionals to ensure achievement of o rgan iza t iona l goa l s . The community i s described by A l f o r d as being heterogeneous with respect to hea l th need, a b i l i t y to pay and organize , but sharing an i n t e r e s t i n obtaining maximum hea l th profes s iona l responsiveness, and a lso an i n t e r e s t i n access to high q u a l i t y hea l th care . There i s an inherent tension between the pro fe s s iona l monopolists and corporate  r a t i o n a l i z e r s , with the "equa l -hea l th" advocates of the community e a s i l y co-opted into one or other camp. A l f o r d ( 1972 ) concludes : "The r e l a t i o n s h i p between them ( corporate r a t i o n a l i z e r s ) and the pro fe s s iona l 43 monopolists i s symbiotic i n that the ever increas ing e laborat ion of the bureaucrat ic s t ructure i s j u s t i f i e d by the need to coordinate the expansion of hea l th care provid ing units at the bottom. No group involved has a stake i n the coordinat ion and i n t e g r a t i o n of the e n t i r e system toward the major goal of e a s i l y a c c e s s i b l e , inexpensive, and equal hea l th care" ( p. 145 ) . The important aspect of A l f o r d ' s ana lys i s i s that a middle-range planning approach ( i . e . the r a t i o n a l approach of the corporate r a t i o n a l i z e r s as constrained by s i t u a t i o n a l f a c to r s , power groups, e t c . ) was i n e f f e c t u a l . G i l b e r t and Specht 's ( 1974 ) c l a s s i f i c a t i o n of planner as technocrat , bureaucrat , or advocate, also provides c l a r i f i c a t i o n of the matr ix , or at l eas t for s p e c i f i c c e l l s of the matr ix . The technocrat i s a s p e c i a l i s t w i t h i n the hea l th care system having proper l inkages . The types of experts would include ep idemiolog i s t s , s o c i o l o g i s t s , e t c . Thi s type of planner and planning would be located under the r a t i o n a l approach column of the matr ix , u sua l ly at the p o l i c y or admini s t ra t ive planning l e v e l s . G i l b e r t and Specht see bureaucrat ic planning as t ry ing to introduce r a t i o n a l i t y , although not perfect ionism in to the hea l th care system. Its a c t i v i t i e s would be r e g u l a t i v e , a l l o c a t i v e , and o p e r a t i o n a l . The bureaucrat ic planner i s constrained by a great number of pressures : l o g i c a l d i f f i c u l t i e s , p sycholog ica l s t re s s , lack of data, e t c . In response, there i s a tendency to invoke defense mechanisms, such as s t e reo typ ing , adherence to ru les r i g i d l y , postponing a c t i o n , and p o l i t i c a l decis ion-making. As envisaged by G i l b e r t and Specht, th i s type of planning ( and presumably i t s associated p i t f a l l s ) i s located under the middle-range planning approach, u sua l ly at the program or admini s t ra t ive or pos s ib ly 44 p o l i c y planning l e v e l s . Advocacy planning accepts the p l u r a l i s t i c model inherent i n the incremental approach to p lanning . Thus, i t i s located under that column i n the matr ix . However, i t i s usua l ly only at the ideo log i c or p o l i c y planning l e v e l s that advocacy planning i s incrementa l . In the admini s t ra t ive and lower l e v e l s , advocacy planning could wel l take a r a t i o n a l or middle-range approach. Other planning models or theories could be c i t ed which focus on one or other of the c e l l s wi th in the matr ix . For example, Yarmolinsky's ( 1971 ) c l a s s i f i c a t i o n of trend measurement, advi s ing on p o l i c y cho ice , program development, t rouble shoot ing , and evaluat ion could be f i t t e d in to the matr ix . Stewart's ( 1963 ) l i s t of managerial ro les (emissar ies , d i scus ser s , t rouble shooters , backroom s p e c i a l i s t s ) , or Glennes ter ' s ( 1975 ) c a tegor i za t ion ( i n c r e m e n t a l i s t , manageria l , p l u r a l i s t ) , or Blum's ( 1974 ) l i s t of planning modes ( problem c o n t r o l , a l l o c a t i v e guidance, e x p l o i t i v e guidance, cons t ruct ion of a des ired future ) could also be analyzed i n terms of the matr ix . However, such d i scus s ion i s beyond the scope of th i s t h e s i s . 45 Chapter I I I . REVIEW OF HEALTH PLANNING On analyzing hea l th plans with a scope s i m i l a r to that proposed for the P r o v i n c i a l Health P lan , i t i s evident that a common conceptual scheme serves as the b a s i s . A number of models for the hea l th care system are out l ined below. Then t h e i r s i m i l a r i t i e s and common elements are d i scus sed . I I I . A . Models Before presenting the models themselves, i t may be appropriate to touch upon the general concept of models. Reisman ( 1979 ) s t a t e s : " A model i s no more than an abstract representat ion of a part of r e a l i t y " ( p . 16 ) . Deacon ( 1961 ) defines a model as "an a r t i f i c i a l representat ion of a system, a process , organism, or environment designed to incorporate c e r t a i n features of that system, process , organism, or environment according to the purposes which i t i s intended to serve" . A number of points should be kept i n mind when cons ider ing models of the hea l th care system. The model need not appear i n t u i t i v e l y a t t r a c t i v e ; i t may " f e e l " quite a r t i f i c i a l , yet be extremely useful i f v a l i d a t e d . The model represents only a se lected aspect of the r e a l system; the "correctness " of s e l e c t i o n depends very much on the purpose intended. For example, the purpose of MEDICS was "fundamentally that of a planning t o o l , to be used as a short-term p r e d i c t i v e a id i n t e s t ing various poss ib le in tervent ions and s t ra teg ie s . . . " (Quebec 1972, p. 2 ) . The importance of p r a c t i c a l a p p l i c a t i o n , rather than t h e o r e t i c a l elegance i s sometimes neg lec ted . Bergwall ( 1975 ) , on reviewing i n d e t a i l some 37 models of the hea l th care system , concluded that few of the models found r e a l l i f e 46 a p p l i c a t i o n because of a number of constra in ing f a c t o r s : few models were developed by hea l th planners ; data requirements were genera l ly onerous; models tended to be p r e s c r i p t i v e and comprehensive, with assumptions and complex conceptual frameworks; models did not r e f l e c t r e a l i t y ; funding for the development of the models did not imply funding for t h e i r a p p l i c a t i o n ; hea l th planners lacked f a m i l i a r i t y with systems and mode l l ing . The sp in-o f f s of modell ing e f for t s are perhaps more useful than the e f for t s themselves. Belanger et a l ( 1974 ) note : "The task of developing the model can focus human energies from diverse d i s c i p l i n e s on a set of common o b j e c t i v e s . Fur ther , i t leads to e x p l i c i t d e f i n i t i o n of data needs, and thus to the design of hea l th information systems" ( p . 414 ) . In the case of the P r o v i n c i a l Heal th P l a n , the purpose of presenting a conceptual model of the hea l th care system i s to provide a context for explanation and development of a p l a n , which i s not so much a d e s c r i p t i v e or p r e d i c t i v e t o o l as a management t o o l . Shigan ( 1979 ) notes that communication problems e x i s t between the dec i s i on maker and model b u i l d e r , rooted i n d i f ferences i n educat ion, experience, and approach to r e a l hea l th care problems. C l a r i f i c a t i o n of a s i m p l i s t i c model for the hea l th care system may bridge th i s communication gap. The development of hea l th care system modell ing i s reviewed by Campbell ( 1980 ) . He traces i n t r o d u c t i o n of systems analys i s during and a f ter World War I I , and i t s s p i l l o v e r into the hea l th area i n the 1960's, using s imula t ion , econometric, opt imiza t ion ( l i n e a r and non- l inear ) and Markovian flow models. In Canada, by the 1970's, a number of modell ing projects were r e c e i v i n g government support i n Quebec, Ontar io , and B r i t i s h Columbia. This burst of a c t i v i t y soon faded, and by the mid 1970's, 47 development had e s s e n t i a l l y ceased. The MEDICS model, developed i n Quebec, i s shown i n Figure 8 . , and i n more d e t a i l i n F igure 9. Using data on popula t ion , morb id i ty , and h e a l t h resource t rends , th i s model matches hea l th care demands and resources under the assumption that s c a r c i t y of resources r e l a t i v e to demand ex i s t s and w i l l continue to do so. The model also allows computer s imulat ions of p o l i c y i n i t i a t i v e s and the probable impact on th i s matching of hea l th care demands and resources ( Quebec 1972 ) . The Human Resources Research Centre (HRRC) Prototype Micro-econometric Model of the U .S . hea l th care system i s shown i n Figure 10. It draws upon supply/demand theory, r e l y i n g on the "market" to accomplish matching and based on " p r i c e " and " q u a n t i t i e s " of services ( Yett et a l 1979 ) . Although a c t i v i t y i n Canada diminished i n hea l th care system mode l l ing , the In te rna t iona l I n s t i t u t e for Appl ied Systems Ana lys i s ( IIASA ) has been developing a set of submodels of na t iona l hea l th care systems for hea l th planning purposes ( Shigan 1979 ) . This i s shown i n Figure 11. A l e s s t e c h n i c a l l y or iented approach, where the model of the hea l th care system serves more as a conceptual framework i s seen i n Figure 12. As might be deduced from the emphasis on h o s p i t a l s , th i s i s a model included i n a consu l tant ' s report to the M i n i s t r y of Health i n the area of h o s p i t a l planning ( Ernst and Whinney 1980 ) . In Figure 13 . , Reinke's ( 1972 ) model of the hea l th care system i s o u t l i n e d . It i s inc luded i n a text devoted to "hea l th p l ann ing" , and thus o serves as a conceptual framework that Reinke feels to be useful i n the planning process . Another model, shown i n F igure 14. takes a broader viewpoint i n def in ing " h e a l t h " ( Shigan 1979 ) . INCIDENCE OF MALADIES s HEALTH CARE DEMANDS (PRODUCTION FUNCTION) -} HEALTH CARE RESOURCES DEMAND: RESOURCE MATCHING SYSTEM SHORTAGES SHORTAGES AND EVALUATION OF PERFORMANCE 00 FIGURE 8: MEDICS Macro-model SOURCE: Quebec, A Program to Model the Health Care Delivery System of Quebec. Ministere des A f f a i r e s Sociales, 1972. 49 OEMOGRAPHIC MODEL P ( « , s ) k PHYSICIANS BY SPECIALITIES r 2 L i PARA-MEDICAL EQUIPMENT (l.eds) P k (a,s) > K ^  ( R E S O U R C E S ) * Rk (R) Mk(m) / > k (a,s,m) -1 PRIORITY UPDATING E PRODUCTICH FUNCTION MATRIX e (m,r) JOTAL DEMANDS BY PR I OR ITY I Jm) DR(m,r) 1 . D (m,r) rk • K TOTAL RESOURCE SkTm) ( U N S A T I S F I E D DEMAND) b . RESOURCE A L L O C A T I O N INCICENCE R A T E /J.(a,s,m) T k ( « ) K PERFORMANCE MEASURES (COSTJ F E N E F I T A N A L Y S I S ) RESOURCE UTILIZATION RATES >Vr) H FIGURE 9. MEDICS Flow Model SOURCE: Quebec, A Program to Model the Health Care Delivery System of Quebec. Ministere des A f f a i r e s S o c i a l i e s , 1972. 50 0 Consumers Age Sex Race Income PHYSICIAN SERVICES | Demands for patient visits | Markets for patient visits | j~ Supply of patient visits I I Demands for nonphysician manpower © 1 PHYSICIANS Age Specialty Activity U.S. or foreign graduate 0 HOSPITAL SERVICES | , Demands for patient days | [ Markets for patient days I I Supply of patient days ] Demands for nonphysician manpower / ' I HOSPITALS / Ownership / Size Length of stay © Markets for nonphysician manpower I Supply of nonphysician manpower 1 NONPHYSICIAN MANPOWER Registered nurses (by age) Licensed practical nurses Allied health professionals Other personnel FIGURE 10. Micro-econometric Model of the Health Care System SOURCE: D . E . Y e t t , L . Drabek, M.D. I n t r i l i g a t o r , & L . J . K imbe l l , A Forecas t ing and P o l i c y Simulat ion Model of the Health  Care Sector . Lexington Books, 1979, p . 7 . I d e a l Standards Supplied T r e a t m e n t and Preven-oy user j fcion P o l i c i e s (Ideal Modes of Care) Pop u l a t i o n Sub-Model Disease Prevalence E s t i m a t i o n Sub-Model Resource A l l o c a t i o n Sub-Model Resource Supply Sub-Model I n d i c a t o r s of P r e d i c t e d Performance of HCS Resource . P r o d u c t i o n , . _ , . _ . . \ by User P o l i c y Option) 1 Supplied - Numbers of p a t i e n t s t r e a t e d , as percent of disease prevalence - A c t u a l modes of treatment, r e l a t i v e to i d e a l s - A c t u a l standards of treatment, as percent of i d e a l s output of model s u p p l i e d to user FIGURE 11. The IAASA Model of the Health Care System »—• SOURCE: R . J . Gibbs, The IIASA Health Care Resource A l l o c a t i o n Sub-model: Mark I . In ternat iona l In s t i tu te for Appl ied Systems A n a l y s i s , 1978, p . 2 . SUPPLY FINANCING HOSPITAL FACILITIES HOSPITAL MANPOWER HOSPITAL SERVICES DEMAND HOSPITAL UTILIZATION FINANCING NON-HOSPITAL FACILITIES NON-HOSPITAL MANPOWER PATIEN MEDICA INFORM T L 1ATION i PATIENTS NON-HOSPITAL SERVICES NON-HOSPITAL UTILIZATION • i POPULATION AT RISK HEALTH STATUS DEMOGRAPHY SOCIO-ECONOMICS I I I I FIGURE 12. The Health Care Del ivery System Ln r-o SOURCE: Ernst & Whinney, Data Elements Manual/ Joint H o s p i t a l Funding Pro ject ,1980 . 53 Health Status Morbidity Population Needs Demands Disability Mortality 1 Rehabilitation Promotion Research Hnnovotion Treatment Financing II Tertiary Prevention Diagnosis Secondary! Prevention Primary Prevention Goals ond Priorities Alternatives / 71 Programs Human Physical Financial Problems Services Planning Resources FIGURE 13. Health. Planning Model of the Health. Care System SOURCE: W.A. Reinke (ed), Health Planning Qua l i t a t ive Aspects and  Quanti tat ive Techniques. Waverly Press , 1972, p ,64 . Socioeconomic (lnililinm Population | Agncultuie Transporl | Science & tech. |  ( National income j Standard of living Sphere of services n Natural conditions Landscape Natural foci of disease Demographic indices incidence and prevalence of diseases Disability Physical status Analysis of individual & community health Research on major problems Recommendations for practice Health education Preventive health surveillance Routine health surveillance Epidemic control Immunization Preventive screening Preventive care | Case-finding Primary & emergency care Diagnosis & assessment of working capacity | Care & rehabilitation Prevention of relapse Other functions Assessment of requirements Organization of work Further training Assessment of requirements Buildings & facilities [ Training | | Financing J Provision of instruments] 1& equipment Drugs, bio-preparations, etc. I j Collection of data on population health & medical care Ii ' Evaluation of information Ij Z | ij i j 1 • 1 Management decision making i '• 2- 1 t| -g | 3 [ i 5' 1 || n | i j -5 • tl 3 ! Planning & implementation » •j • Monitoring & decision making j j Links with other systems Genera? recommen-dations and restrictions FIGURE 14 . SOURCE: F u n c t i o n a l C h a r t o f a P u b l i c H e a l t h S y s t e m V e n e d i c t o v i n E . N . S h i g a n , D . J . H u g h e s , & P . I . K i t s u l , H e a l t h C a r e S y s t e m s M o d e l i n g a t I I A S A : A S t a t u s R e p o r t . I n t e r n a t i o n a l I n s t i t u t e f o r A p p l i e d S y s t e m s A n a l y s i s , T 9 7 9 , p 55 A l l of t h e mode ls d iag rammed , and o t h e r s too numerous t o l i s t , a r e composed of f o u r ( o r f e w e r ) ma jo r c o m p o n e n t s : (1) H e a l t h R e s o u r c e s , (2) H e a l t h S t a t u s , (3) R e q u i r e m e n t s f o r H e a l t h S e r v i c e s , (4) R e s o u r c e A l l o c a t i o n . The f o l l o w i n g t a b l e e x t r a c t s t h e r e l e v a n t components f r o m e a c h m o d e l u n d e r t h e a p p r o p r i a t e h e a d i n g : MODEL RESOURCES RESOURCE REQUIREMENTS STATUS ALLOCATION  MEDICS H e a l t h Ca re Demand&Resource H e a l t h I n c i d e n c e of I l l n e s s R e s o u r c e s M a t c h i n g Ca re Demand  I I A S A R e s o u r c e R e s o u r c e A l l o c a t i o n P o p u l a t i o n submode l S u p p l y Submodel Submodel D i s e a s e P r e v a l e n c e E s t i m a t i o n submode l E/W S u p p l y Demand U t i l i z a t i o n  REINKE R e s o u r c e s S e r v i c e s P r o b l e m s  HRRC P h y s i c i a n s M a r k e t s Consumers P h y s i c i a n s e r v i c e s H o s p i t a l S e r v i c e s N o n - p h y s i c i a n manpower  VENEDICTOV P e r s o n n e l S c i e n c e , P o p u l a t i o n R e s o u r c e s P r o p h y l a x i s , H e a l t h S t a t u s T r e a t m e n t  TABLE I : The components t a b u l a t e d d e m o n s t r a t e c e r t a i n r e l a t i o n s h i p s i n most o r a l l o f t he mode ls o u t l i n e d . T h u s , p o p u l a t i o n h e a l t h s t a t u s i s t r a n s f o r m e d 56 by some process to requirements for hea l th s e r v i c e s . The requirements i n turn undergo i n t e r a c t i o n with c e r t a i n hea l th services provided through hea l th resources ( which i n turn are determined by a resource a l l o c a t i o n process ) . In r e a l terms, th i s i n t e r a c t i o n can be thought of as the ac tua l serv ice p r o v i s i o n to p a t i e n t s . The re su l t s of serv ice prov i s ion ( i . e . the q u a l i t y and quantity of both services provided and the outcome i n terms of populat ion hea l th status ) become determinants of future resource a l l o c a t i o n p o l i c i e s and d e c i s i o n s . The r e l a t i o n s h i p among these components of the hea l th care system can be better understood by reference to a number of "systems" concepts . Every system has c e r t a i n generic c h a r a c t e r i s t i c s , which can be re la ted to p a r t i c u l a r components for s p e c i f i c systems ( Reeves et a l 1979 ) . Thus, the environment i s soc ie ty outside the defined hea l th care system. There are boundary condit ions as the hea l th care system inter faces with i t s environment. Inputs to the system are people with a given hea l th s tatus , and also those resources which are in j ec ted into the system. Outputs are people with a h o p e f u l l y , but not n e c e s s a r i l y , improved hea l th s ta tus . The system exh ib i t s c o n t r o l mechanisms, inc lud ing feedback and feedforward. Reeves et a l ( 1979 ) exp la in the importance of the c o n t r o l f u n c t i o n : "Th i s i s the element of the system that makes decis ions which w i l l a f fect the system's operat ions . These decis ions t y p i c a l l y af fect the quanti ty and nature of the inputs used, the s t ructure or funct ioning of the system's components (process) or both inputs and process . They are based on ana lys i s of feedback and feedforward i n r e l a t i o n to values expressed as c r i t e r i a and standards or as goal l e v e l s " ( p . 45 ) . The basic systems model i s shown 57 below: INPUT GENERATION INPUT PROCESS FEEDFORWARD OUTPUT FEEDBACK STANDARDS / DECISION RULES FIGURE 15. . The Basic Systems Model Using the same p a t t e r n , and synthes iz ing concepts contained i n the var ious models presented e a r l i e r i n F igures 8. to 14., a s i m p l i f i e d conceptual model of the hea l th care system, for the purposes of developing the P r o v i n c i a l Hea l th P l a n , i s shown below: £ PATIENT DYNAMICS HEALTH STATUS SERVICE PROVISION DET'N JREQ1 TS REQUIREMENTS HEALTH STATUS' RESOURCE GENERATION HEALTH RESOURCES •VALUES FIGURE 16. Conceptual Model of the Heal th Care System This system, as with a l l systems, w i l l have a number of funct ions 58 i n c l u d i n g : (1) system goal attainment, (2) system sel f-maintenance, (3) environmental adaptat ion, (4) i n t e g r a t i o n of subsystem e f f o r t s . The focus of the P r o v i n c i a l Heal th Plan i s to enhance funct ion (4 ) , and i n doing so, to further attainment of the goals of the hea l th care system. The key to a system's operations i s the cont ro l mechanism. For the s p e c i f i c case of the hea l th care system, that c o n t r o l mechanism can be considered as the a l l o c a t i o n of hea l th resources , where " a l l o c a t i o n " i s taken to mean not only d i s t r i b u t i o n of quant i ty , but determination of q u a l i t y and organiza t ion of the resources in to services and programmes. S ince , as diagrammed i n Figure 16 . , the components of the hea l th care system are f u n c t i o n a l l y r e l a t e d , i t i s necessary to consider not only the process of resource a l l o c a t i o n , but a l so hea l th s ta tus , requirements for hea l th s e rv ice s , and hea l th resources . Of these, hea l th resources i s conceptual ly the most s t ra ight forward . Heal th status i s less so, but there i s s t i l l some consensus as to d e f i n i t i o n . In contra s t , requirements and resource a l l o c a t i o n are f a i r l y complicated areas , wi th l i t t l e consensus as to the preferred approach i n e i t h e r def in ing or applying the concepts . I I I . B . Health Resources There i s perhaps less d i f f i c u l t y i n def in ing hea l th resources than i n de f in ing requirements because resources seem f a i r l y tangible and thus q u a n t i f i a b l e . S t r i c t l y speaking, only hea l th manpower, f a c i l i t i e s and equipment are " re sources " . However, f inancing i s a p rerequ i s i t e for both ; and patterns of o r g a n i z a t i o n , i . e .(Combinations of hea l th manpower and f a c i l i t i e s , are expressed as hea l th programmes or s e r v i c e s . For B r i t i s h Columbia, an inventory of the major hea l th resources would 59 inc lude the fo l lowing ( B r i t i s h Columbia ,Minis try of Heal th 1982): Hospi ta l s 51 hosp i t a l s of 1-50 beds 19 h o s p i t a l s of 51-100 beds 23 hosp i t a l s of 101-400 beds 7 h o s p i t a l s of 401-750 beds 1 h o s p i t a l of 750+ beds R e h a b i l i t a t i o n Hospi ta l s 486 beds 4 hosp i t a l s Extended Care Hospi ta l s 6,003 beds 36 hosp i t a l s of 1-50 beds 23 h o s p i t a l s of 51-100 beds 10 hosp i t a l s of 101-200 beds 7 h o s p i t a l s of 200+ beds Long Term Care F a c i l i t i e s 18,150 beds TABLE I I : B .C . H o s p i t a l Beds, 1981 Health Manpower ( D i v i s i o n of Health Services Research and Development Acute Care Hospi ta l s 12,066 beds 1982): Number of P r a c t i t i o n e r s Audio log i s t s and Speech Pathologi s t s 178 Biomedical Technologis t s and Engineers 119 C e r t i f i e d Dental Ass i s tant s 1,840 Chiropracters 292 Dental Hygienis t s 448 60 Dental Laboratory Technicians 325 Dental Mechanics 173 Dentis t s 1,670 Diagnost ic Medica l Sonographers 79 D i e t i t i a n s and N u t r i t i o n i s t s 444 Food Service Supervisors 134 Health Record Personnel 209 Licenced P r a c t i c a l Nurses 6,991 Medical Laboratory Technologists 1,953 Medica l Of f ice Ass i s tant s 569 Medical Radia t ion Technologis ts 925 Occupational Therapists 302 Optometrists 184 Osteopaths 6 Pharmacists 1,918 Physicians 5,690 Phys iotherapi s t s 1,274 Pros thet i s t s and Orthot i s t s 19 Psychologis t s 748 P u b l i c Health Inspectors 186 Registered Nurses 18,067 Registered P s y c h i a t r i c Nurses 1,780 Respiratory Technologists 60 TABLE I I I : B .C . Health Manpower, 1981 SOURCE: Health Services Research and Development, ROLLCALL 8 1 . U n i v e r s i t y of B r i t i s h Columbia, 1982 . 61 An ou t l ine of the resource component of the hea l th care system would thus i n c l u d e , i n general terms: | HEALTH MANPOWER 1 HEALTH PROGRAMMES - « HEALTH FACILITIES •« FINANCING 1 EQUIPMENT - * » FIGURE 17. The Resource Component of the Health Care Jystem The d e r i v a t i o n of these elements are not d e t a i l e d , but many models ex i s t which attempt to show the factors a f fec t ing hea l th manpower, f a c i l i t i e s , e t c . For example, IIASA have Manpower Education and Retra in ing Models, and Manpower Migrat ion Flow Simulat ion models ( Shigan 1979 ) . A simple inventory of resources i s inadequate to describe the hea l th resource component of the hea l th care system. There are a number of problems i n measurement of resources . For example, l i s t i n g only the ac tua l numbers of hea l th manpower personnel does not account for s p e c i a l t i e s wi th in a h e a l t h manpower group, e . g . there i s a s i g n i f i c a n t d i f ference between a dermatologist and a neurosurgeon. There are also d i f f e r i n g work patterns or caseloads amongst hea l th manpower and overlapping areas of p r a c t i c e . L i s t i n g ac tua l numbers of manpower also does not address the i ssue of manpower d i s t r i b u t i o n . There are s i m i l a r problems i n measurement of f a c i l i t i e s by l i s t i n g , for example, only h o s p i t a l beds. Capac i ty , independent of d i s t r i b u t i o n i s not taken into account, e . g . economies of s c a l e . Quality and i n t e n s i t y of serv ice are not shown i n a simple inventory . Spec ia l ty s p e c i f i c f a c i l i t i e s are not d i s t ingui shed i n counting t o t a l h o s p i t a l beds, nor i s the v a r i a t i o n of throughput taken in to account. Associated programs and s e r v i c e s , e . g . outpat ient s e rv ice s , may or may not 62 be r e f l e c t e d i n the s ize of the f a c i l i t y when expressed i n beds. There are a number of advantages to descr ib ing resources not only by the p h y s i c a l number of manpower or f a c i l i t i e s , but by s e r v i c e s . De l ivery of programs i s often service based, and the manpower and f a c i l i t i e s necessary for those services are thus l i n k e d . Discuss ion of services i s often more meaningful to p lanners , p rov ider s , p o l i t i c i a n s , e t c . P r i o r i t i e s , budgett ing, o rgan iza t iona l s t ruc ture s , often are es tabl i shed on the basis of s e r v i c e s , for example, Emergency Health Serv ices . The U .S . Department of Hea l th , Education and Welfare ( 1979a ) suggests information that may be useful i n descr ib ing a s e r v i c e : - presence or- absence ( by area or f a c i l i t y ) - capac i ty ( beds, caseload ) - a c t i v i t y ( v i s i t s , procedures, days ) - a v a i l a b i l i t y ( hours , seasons ) - resources l e v e l s ( manpower, f a c i l i t i e s , equipment ) - a c c r e d i t a t i o n or l i censure - average costs or expenditures - sources of funding. The ca tegor i za t ion of services can be based on d i f f e r e n t c r i t e r i a : g o a l s , l o c a t i o n , c l i e n t s , s p e c i a l i z e d resources , processing sequence ( primary, secondary, t e r t i a r y ) , times, funding source. For example, the ca tegor i za t ion used i n the IIASA model i s based on degenerat ion, i n f e c t i o n , progress of c i v i l i z a t i o n , or m a l n u t r i t i o n ( Shigan 1979 ) . Reinke ( 1972 ) c l a s s i f i e s hea l th services as primary, secondary, and t e r t i a r y . The Vancouver Heal th Department provides programs as prevent ion , p r o t e c t i o n , promotion, and community treatment serv ices 63 ( Weinstein 1981 ). The Cleveland Health Goals Committee studied nine areas: reproduction, n u t r i t i o n , dental and oral health, i n f e c t i o u s and communicable disease, trauma and safety, chronic diseases, handicapping conditions, m o b i l i t y problems and mental disorders ( Reinke 1972 ). MacStravic ( 1978 ) l i s t s services for basic health maintenance, for acute problems, or for chronic conditions. He adds that the information required for planning each type of service i s d i f f e r e n t , i . e . demographic data for maintenance, incidence data for acute problems, and prevalence data for chronic conditions. Hillboe et a l ( 1972 ) define the major problems of personal health as acute medical and s u r g i c a l i l l n e s s , chronic adult i l l n e s s ; mental disorder; c h i l d and maternal health, family planning, n u t r i t i o n ; i n f e c t i o n s ; accidents and occupational disease - environmental problems. Schwarz ( 1975 ) l i s t s provision of medical care: promotive health, care of 'at r i s k ' groups, care of presymptomatic disease, care of minor disorders, care of major disorders, management and r e h a b i l i t a t i o n , p r o vision for health. A d d i t i o n a l l y he considered the components of a personal health care system to be: acute i n p a t i e n t ; ambulatory; patient's house or emergency s i t e s ; long term , chronic, or r e h a b i l i t a t i o n u n i t s . Thus, he focuses both upon the setting of the service, and the service i t s e l f . Government Studies and Systems under contract to the then United States Department of HEW ( 1977b ), has developed a taxonomy of the health system for use i n health planning. It i s a three dimensional matrix which s p e c i f i e s service type, s e t t i n g , and s i x c h a r a c t e r i s t i c s for each s e r v i c e / s e t t i n g . The matrix i s shown i n Figure 18., for f i r s t - l e v e l services and s e t t i n g s . More detailed categorizations, i . e . , second and t h i r d l e v e l services and settings, were also developed and can be found 64 in their f u l l report. SETTINGS (y) SERVICES (x) Community Home, Ol .—4 • H X> o SI Ambulatory Short-Stay Long-Stay Free Standing Support Community Health Promotion and Protection j Prevention and Detection f For "x" services X j Diagnostic and Treatment f in "y" settings, \ an analysis of: * 1. Cost \ j Habilitation and Rehabilitation 2. Accessibility 3. Availability . 4. Acceptability , \ 5. Continuity / / Maintenance J \ 6. Quality jf j j Personal Health Care Support 1 1 i i i FIGURE 18. Taxonomy of the Health Care System SOURCE: R. Casterline, Public Health Service Regional Office, Region VII Position Paper. Region VII Health Planning Branch, 1977, p.26. The advantage of such a framework, i s to aid conceptualizing alternative possible organizations of the health system and arriving at alternative ways of intervening in the health system using innovative approaches ( U.S. Department of Health, Education and Welfare 1977b ). In other words, by focusing on services, settings, and the characteristics noted, i t becomes 65 obvious that given s tructures and p h y s i c a l resources are not the only way, or even the best way, to provide spec i f i ed s e r v i c e s . Adopting such a framework gives a comprehensive, consis tent way of looking at hea l th resources . Moreover, i t aids i n def in ing boundaries of what should be reasonably considered as hea l th resources . The services x se t t ing matrix complements, but does not rep lace , the more t r a d i t i o n a l l i s t i n g by resource component i n descr ib ing h e a l t h resources . Resource planning i s u sua l ly done i n terms of phys i ca l resources , e . g . number of hosp i t a l s and numbers of hea l th manpower, and thus the ac tua l resource must be spec i f i ed as we l l as the associated s e r v i c e . S i m i l a r l y , requirements for resources are often expressed i n p h y s i c a l terms, , ra ther than as s e r v i c e s . Although th i s may change over t ime, i t i s u n r e a l i s t i c to i n s i s t that a l l requirements be expressed i n terms of s e r v i c e s . Because of i t s f a m i l i a r i t y , p o l i c i e s governing resources , rather than s e r v i c e s , may be eas ier to understand and implement. In par t , t h i s r e s u l t s s ince one resource often provides a range of s e r v i c e s . For example, an acute care h o s p i t a l offers both inpat ient and outpatient s e r v i c e s . Budgeting, s ta f f a l l o c a t i o n , and h o s p i t a l p o l i c i e s c l e a r l y must be coordinated for a p a r t i c u l a r h o s p i t a l . I I I . C . Health Status S u l l i v a n ( 1966 ) observed near ly twenty years ago that hea l th , although spoken of as a s ing le d i r e c t l y observable and measurable c h a r a c t e r i s t i c , i n fact involves many p o t e n t i a l l y measurable c h a r a c t e r i s t i c s of a person or a popu la t ion . T r a d i t i o n a l l y , the c h a r a c t e r i s t i c used to measure community hea l th has been m o r t a l i t y . In the l a t e 1950's, a Study 66 Group of the W.H.O. recommended mor ta l i ty based measures as i n d i c a t o r s of h e a l t h : age-adjusted l i f e expectancy, crude death r a t e , and propor t iona l mor ta l i ty rate of those age 50 years and above. More r e c e n t l y , the EEC recommends use of three major i n d i c a t o r s : l i f e expectancy at b i r t h , infant m o r t a l i t y , prime age m o r t a l i t y ( Culyer 1978 ) . The usefulness of these t r a d i t i o n a l measures should not be underestimated. Lalonde's ( 1974 ) New  Perspectives on the Health of Canadians, which proposed s i g n i f i c a n t p o l i c y changes and r e d i r e c t i o n of the Canadian hea l th care system, based i t s c arguments and conclusions on mor ta l i ty data . Tonkin 's ( 1981 ) C h i l d Health  P r o f i l e ser ies s i m i l a r l y draws upon mor ta l i ty and morbidity data to make some useful observations about problem areas i n c h i l d r e n ' s h e a l t h . Data on b i r t h s and deaths as d i s c re te events are r e l a t i v e l y easy to de f ine , and although the recording and r e t r i e v i n g may not be s t ra ight forward , such data are s t i l l genera l ly accepted for i n t e r n a t i o n a l comparisons. However, based on c r i t e r i a for hea l th and s o c i a l i n d i c a t o r s proposed by Chen, Bush, and P a t r i c k ( 1975 ) i t i s evident that mor ta l i ty data i n i t s e l f are inadequate as i n d i c a t o r s of h e a l t h . Chen et a l state that an i n d i c a t o r should have a d i r e c t normative i n t e r e s t with a value component such that i f the i n d i c a t o r improves, soc ie ty i s "be t ter " o f f . A d d i t i o n a l l y , the index should be app l i cab le for p r i o r i t y s e t t i n g , p lanning , and evaluat ive research . F i n a l l y , an i n d i c a t o r should be s u f f i c i e n t l y s e n s i t i v e to detect most of the important changes i n hea l th s ta tus . They s tate i n p a r t i c u l a r that mor ta l i ty rate and l i f e expectancy i n themselves are inadequate to serve as i n d i c a t o r s of h e a l t h . This i s supported by Moriyama's ( 1968 ) ana lys i s showing r e l a t i v e s t a b i l i z a t i o n of mor ta l i ty rates i n the United States from the 1950's to the mid 1970's. 67 In order to provide a better p i c ture of hea l th s ta tus , morbidity based ind ica tor s have been used, e i ther alone or i n conjunct ion with mor ta l i ty data . T r a d i t i o n a l l y , th i s has taken the form of type and incidence of disease and/or prevalence of d i sease . For example, the "endemic-oriented morbidity index" i s a pa thophys io log ica l c l i n i c a l assessment of the prevalence of d i sease . The usefulness of morbidity data i s seen i n the use of " t r a c e r s " to assess community hea l th s t a tus . Kessmer ( 1973 ) suggests s i x tracers to evaluate hea l th care provided i n a community: middle-ear i n f e c t i o n and associated hearing l o s s , v i s i o n d i sorder s , i r o n - d e f i c i e n c y anemia, hypertens ion, ur inary t ract i n f e c t i o n s , c e r v i c a l cancer . C h a r a c t e r i s t i c s for s e l e c t i o n of t racers a re : (1) the t racer should have s i g n i f i c a n t funct iona l impact; (2) each should be wel l de f ined , easy to diagnose; (3) prevalency rate should be high enough for data from a l i m i t e d popula t ion ; (4) na tura l h i s t o r y var ie s with u t i l i z a t i o n and e f fect iveness of medical care ; (5) techniques of medical management should be wel l -def ined for at least one of the f o l l o w i n g - prevent ion , d iagnos i s , treatment, r e h a b i l i t a t i o n or adjustment; (6) e f fec t s of socioeconomic factors on each t racer should be understood. However, assessments of morb id i ty , although subject ive to the extent of disease symptoms, are not u sua l ly able to account for funct iona l c a p a b i l i t y and sense of wel l -be ing of the i n d i v i d u a l . On reviewing the l i t e r a t u r e on s o c i a l hea l th i n d i c e s , E l in son ( 1974 ) concluded that mor ta l i ty data and 68 biomedical measures of morbidity are inadequate measures of the l e v e l of hea l th i n economically developed count r i e s . He described current attempts to develop sociomedical hea l th i n d i c a t o r s : measures of s o c i a l d i s a b i l i t y ; typologies of presenting symptoms; measures which focus on behavioural expressions of s i cknes s ; research based on operat ional d e f i n i t i o n s of ' p o s i t i v e mental h e a l t h ' , 'happ ines s ' , and perceived q u a l i t y of l i f e . In other words, i n terms of the three types of evidence ava i l ab l e for est imating hea l th status ( c l i n i c a l , behav ioura l , subject ive ) , there has been considerable work i n behavioural measurement to supplement the more t r a d i t i o n a l c l i n i c a l measures. And more r e c e n t l y , subject ive measurement has progressed from disease symptomology to assessment of "wel lness" i n a s o c i a l context . This progress ion p a r a l l e l s White 's ( 19 67 ) l i s t i n g of hea l th s ta tus : Death, Disease, D i s a b i l i t y , Discomfort , and D i s s a t i s f a c t i o n . S o c i a l d i s a b i l i t y and behavioural expresssions of s ickness have r e l i e d on estimates of func t iona l a c t i v i t y . Chen and Bush ( 1979 ) l i s t a number of advantages i n doing so. Assessment of funct iona l states does not require extensive medical examination; i t conforms to t h e o r e t i c a l constructs of " h e a l t h " ; i t i s useful for eva lua t ion , inc lud ing assessing impact on family members; and i t enables eva luat ion across disease groups and populat ion groups. The United States Health Interview Survey separates symptoms of morbidity and d i s a b i l i t y , expressed i n terms of a c t i v i t y l i m i t a t i o n . Based i n part on the U . S . survey, Mushkin (1979) suggests the fo l lowing funct iona l c l a s s i f i c a t i o n : cured or i n remis s ion ; f u l l y funct ioning despite d i sease ; funct ioning with some l i m i t a t i o n ; capable of s e l f - ca re but major and other a c t i v i t i e s l i m i t e d ; not capable of s e l f - c a r e . Sanders ( 1964 ) discussed the 69 " f u n c t i o n a l adequacy of an i n d i v i d u a l to f u l f i l l the ro le which a hea l thy member of h i s age and sex i s expected to f u l f i l l " ( p . 1067 ) , and combined mor ta l i ty with func t iona l adequacy to ca l cu la te " e f f ec t ive l i f e - y e a r s " . S u l l i v a n ( 1971 ) described d i s a b i l i t y as any temporary or long term reduct ion or r e s t r i c t i o n of a person's a c t i v i t y . Based on t h i s , he c l a s s i f i e d persons as those with long-term n o n i n s t i t u t i o n a l d i s a b i l i t y , those with long-term i n s t i t u t i o n a l d i s a b i l i t y , and those with short-term d i s a b i l i t y . Katz ( 1963 ) developed the Index of A c t i v i t i e s of D a i l y L i v i n g , based on a b i l i t y to bathe, dress , feed, c o n t r o l bladder and bowels, go to the t o i l e t , and t r a n s f e r . Grogono and Woodgate ( 1971 ) suggested scoring pat ients according to ten i tems: work, r e c r e a t i o n , p h y s i c a l s u f f e r i n g , mental s u f f e r i n g , communication, s leep, dependency on others , feeding , e x c r e t i o n , and sexual a c t i v i t y . The Duke UNC P r o f i l e and the Sickness Impact P r o f i l e are more recent attempts to develop a hea l th status i n d i c a t o r / i n d e x based on func t iona l l e v e l . The Duke UNC P r o f i l e i s a 63 item instrument to measure hea l th status i n a primary care se t t ing along four dimensions: symptom s ta tus , p h y s i c a l func t ion , emotional f u n c t i o n , s o c i a l funct ion ( Parkerson et a l 1981 ) . The Sickness Impact P r o f i l e cons i s t s of .136 statements about hea l th- re l a t ed dysfunct ion or problems i n twelve areas of a c t i v i t y . It can be administered i n 20-30 minutes. This p r o f i l e has been used as an outcome measure i n t r i a l s of therapy for pat ients with chronic lung d i sease , emergency services for cardiac a r res t v i c t i m s , and home care for the c h r o n i c a l l y i l l ( Bergner et a l 1981 ) . Subject ive assessment of hea l th status with attachment of values to p a r t i c u l a r func t iona l l eve l s or types of morbid i ty , has been a recent innovat ion i n est imating hea l th s ta tus . The Alameda County Human Populat ion 70 Laboratory used a mailed quest ionnaire l i s t i n g items such as d i s a b i l i t y , symptoms, energy l e v e l s , as w e l l as the more usual s e l f - ca re items. Chen, Bush, & P a t r i c k ( 1975 ) have done extensive work i n developing an index of w e l l - b e i n g . Funct iona l c l a s s i f i c a t i o n i s based on three scales ( p h y s i c a l a c t i v i t y , m o b i l i t y , s o c i a l a c t i v i t y ) , which vary according to age group. A ser ie s of studies were done to assess the r e l a t i v e d e s i r a b i l i t y of funct iona l l e v e l s ( i . e . var ious combinations of the three scales) and ca l cu la ted on a value continuum from 1.0, for complete w e l l - b e i n g , to 0.0 for death. Further refinement i s a lso proposed where prognoses of var ious symptom complexes are taken into account i n c a l c u l a t i n g "value adjusted l i f e expectancy". Chen et a l describe th i s as "the equivalent of the expected dysfunct ion free years of l i f e " . The Wellness Appra i sa l Index and Heal th Hazard A p p r a i s a l , are further examples. In genera l , four methods of weighting are used: an a r b i t r a r y sca le ; p r o b a b i l i t y of death; a psychosomatic s c a l i n g ; von Neuman-Morgenstern u t i l i t y measures; or economic va luat ions ( Mushkin 1979 ) . Examples of na t iona l e f fo r t s to obta in some assessment of the hea l th status of i t s c i t i z e n s are the U .S . Nat iona l Heal th Survey, B r i t a i n ' s S o c i a l Survey, and the recent Canada Health Survey. This l a s t survey, with data c o l l e c t e d 1978-79 was a once-only p ro j ec t , ra ther than an annual survey as i n the United States or Great B r i t a i n ( Canada, Department of Nat iona l Health and Welfare 1981 ) . Through a combination of survey ques t ionna i re , in te rv iew, phys ica l examination and laboratory t e s t s , useful data were gathered and disaggregated by demographic and socioeconomic groupings. The fo l lowing information was obta ined: Risk Fac tor s : L i f e s t y l e - a l c o h o l use,tobacco use, phys ica l a c t i v i t i e s , seatbelt use, female preventive behaviour ( Pap smear, breast exam ) ; B iomedica l - immune s tatus , blood c h o l e s t e r o l , g lucose , u r i c a c i d , family h i s t o r y of d isease ; Environment- l e a d , cadmium, copper and z inc blood l e v e l s . Health Status : Reported h e a l t h - a c t i v i t y , short-term cond i t ions , accidents and i n j u r i e s , chronic cond i t ions , impairments, h e a r i n g / v i s i o n / d e n t a l s t a tu s ; Phys i ca l h e a l t h - blood pressure, ca rd iore sp i ra tory f i t n e s s , per cent body f a t , anemia, blood tests for l i v e r and kidney f u n c t i o n ; Emotional h e a l t h - p sycho log ica l w e l l - b e i n g , a l c o h o l re la ted problems. "Consequences": U t i l i z a t i o n - pro fe s s iona l providing care , l o c a t i o n of care , reasons care not sought, drug use, medical devices used. Condit ion impact- d i s a b i l i t y days. I I I . D . Requirements for Health Services Once the hea l th resources have been c l a s s i f i e d , the determination of hea l th services requirements spec i f i e s the l eve l s of s e r v i c e s . For example, i n the areas of h o s p i t a l s e rv i ce s , Butts and Ashford ( 1977 ) note : " F i r s t the planner i s required to define the terms of reference of the planning exerc i se by spec i fy ing the populat ion secured, the per cap i t a need, and the e f f i c i e n c y of the serv ices provided . Secondly, a procedure i s e s tab l i shed whereby these key measures may be t rans la ted into a requirement for h o s p i t a l beds and other in -pa t i en t and out-pat ient resources" ( p . 3 ) . However, the d e f i n i t i o n of "requirements" i s problemat ic . 72 In theory at l e a s t , meeting hea l th needs i s the ra i son d ' e t re for hea l th p lanning . As MacStravic ( 1978 ) s t a te s : " I t i s c l ea r that the general purpose of hea l th planning i s to i d e n t i f y needs and to use them as goals i n developing hea l th ac t ion s t r a teg ie s " ( p . 2 ) . Unfortunate ly , the term "needs" i s used for d i f f e rent concepts . For example, the Canadian Mental Health As soc i a t ion l i s t s the basic needs for middle-aged Canadians as: f r i e n d s , hobbies, s o c i a l s e r v i c e , r e l i g i o n , economic a c t i v i t y , s e c u r i t y , r e l a x a t i o n , e t c . Another usage of "need" , mentioned only to dispense with i t , i s to consider need as the discrepancy between the actua l and the i d e a l . This i s semantic confus ion, not widely accepted, but o c c a s i o n a l l y encountered. Or i t z and Parker ( 1971 ) suggest that a hea l th need ex i s t s e i ther when someone i s hea l thy , but preventive services can reduce the t r a n s i t i o n a l p r o b a b i l i t y of becoming unhealthy; or when someone i s unhealthy, and the t r a n s i t i o n a l p r o b a b i l i t y of becoming more healthy can be increased through diagnosis and therapy. In essence, t h i s suggests that a hea l th need i s a lack of " h e a l t h " — a c i r c u l a r argument at bes t . Boulding ( 1966 ) sees two approaches expressed i n the d i s t i n c t i o n between need and demand: "One's demand for medical care i s what he wants; h i s need for medical care i s what the doctor thinks he ought to have" ( p . 202 ) . Boulding ' s preference seems f a i r l y c l e a r , as evidenced by h i s observat ion that "only the slave has needs, the free man has demands" ( p . 208 ) . Je f fers et a l ( 1971 ) make a further d i s t i n c t i o n between need,wants, and demand ( pp. 46 - 63 ) : Need - " t h a t quanti ty of medical services which expert medical op in ion 73 bel ieves ought to be consumed over a re levant time period i n order for i t s members to remain or become 'hea l thy ' as i s permitted by ex i s t ing medical knowledge" Wants - " that quantity of medical services which i t s members f e e l they ought to consume ( at zero p r i c e , zero lo s t wages, zero wait ing t ime, zero access c o n s t r a i n t s , e t c . ) over a relevant time period based on t h e i r own psychic perceptions of t h e i r hea l th needs" Demand - " m u l t i v a r i a t e funct iona l r e l a t i o n s h i p between the quant i t i e s of medical services that i t s members des ire to consume over a re levant time per iod at g iven l eve l s of pr ices of goods and se rv ice s , f i n a n c i a l resources , s i ze and psycho log ica l wants of the populat ion as r e f l e c t e d by consumer tastes and preferences for ( a l l ) goods and s e r v i c e s " . Chambers et a l ( 1980 ) make roughly the same d i s t i n c t i o n , but do not l i m i t need to medical s e rv i ce s , and correspondingly , do not l i m i t determination on the basis of "medical op in ion" but r e l y on the broader des ignat ion of "exper t " . The same comments apply to wants and demand. A further concept i s added to the l i s t i n g of need, wants, demand, by Chambers et a l : use or u t i l i z a t i o n , r e f e r r i n g to the hea l th services a c t u a l l y provided . Butts and Ashford ( 1977 ), note that u t i l i z a t i o n , unl ike need or demand, i s c o n d i t i o n a l on access and a v a i l a b i l i t y of s e r v i c e s . I f one accepts the concepts expressed, then r e l a t i o n s h i p s between need, wants, demand, and u t i l i z a t i o n can be examined. For example, i f hea l th profess ional s recommend f l o u r i d a t i o n , but the " p u b l i c " re jec t s t h i s measure i n a referendum, then one might suggest that the need i s greater than the demand for th i s s e r v i c e . Or, pat ients may request medicat ions, such as minor t r a n q u i l l i z e r s , i n s i tua t ions where hea l th profess ionals f e e l there i s not 74 s u f f i c i e n t j u s t i f i c a t i o n given the s ide-e f fec t s and habi tuat ing proper t ie s of these drugs. One might then suggest that demand i s greater than need i n such ins tances . These concepts of need, demand, wants and u t i l i z a t i o n are extremely important i n the development of the P r o v i n c i a l Health P l a n . Each i s therefore discussed i n greater d e t a i l below. Shonick ( 1976 ) looks to the hea l th pro fes s iona l to define hea l th  need. For example, i n est imating need for h o s p i t a l s , he assumes that for a g iven populat ion with c e r t a i n hea l th ( or i l l - h e a l t h ) , there i s a prescr ibed number of pat ient days that would be used i f hea l th care was provided according to "standards of good hea l th care as present ly es tab l i shed by a consensus of the pro fe s s iona l leaders i n the var ious h e a l t h s p e c i a l t y f i e l d s . . . a n d being taught i n the hea l th pro fes s iona l t r a i n i n g schools" ( p . 19 ) . I m p l i c i t i n t h i s approach i s an assumption that hea l th needs are an ob jec t ive phenomenon, and that a consensus amongst "experts" as to what those needs are , can be obta ined. A c l a s s i c study using th i s approach was done by Lee and Jones ( 1933 ) . They determined frequency of occurrence of i l l n e s s i n the popula t ion , and then po l led experts to determine the amount of serv ice required to diagnose and treat each type of i l l n e s s . A d d i t i o n a l l y , the average number of services /hour by the provider and profes s iona l opinion as to the number of hours/year for each provider were determined. These estimates permitted c a l c u l a t i o n of the resources and services required o v e r a l l , e . g . they expressed a need for 135 physicians/100,000 populat ion and 4.62 general beds/1000 p o p u l a t i o n . The conversion by MEDICS of i l l n e s s episodes to resources i s a s i m i l a r approach using hea l th insurance data , e . g . average number of v i s i t s to phys i c i an s p e c i a l i s t / t i m e uni t ( Quebec 1972 ) . This type of study was repeated i n 1972 by Schonfeld ( 1972 ) for primary care phys i c i ans . An ear ly example, notable because i t was done i n B . C . , was the study by Hamilton and Associates ( 1949 ) . This study estimated needs for general acute h o s p i t a l beds based on a formula devised by the U .S . Commission on Hosp i t a l Care, adjusted for l o c a l condit ions ( s o c i a l , economic, geographic factors and r e f e r r a l patterns ) . The report estimated 8069 beds needed i n 1951 (6.71 beds/1000 popu la t ion ) , and 11,886 beds needed by 1971 (7.09 beds/1000 popu la t ion) . A s i m i l a r "expert" approach to determination of hea l th needs i s being developed by the IIASA HCS Model l ing Group ( Shigan 1979 ) . Information i s obtained about popula t ion , hea l th s ta tus , present l eve l s of care , and the t r a n s l a t i o n of hea l th condit ions in to needs for hea l th resources . Indices are c a l c u l a t e d , expressing the need for s p e c i f i c services per c a p i t a . These indices are derived from the opinions of experts , standards from o f f i c i a l rout ine s t a t i s t i c s , e . g . h o s p i t a l i z a t i o n rate or average length of s tay , or comprehensive s tud ie s . I m p l i c i t i n the above determinations of hea l th need i s the expectat ion that those l e v e l s of services should i n fact be provided . Unlike demand, wants, or u t i l i z a t i o n , need evokes a p r e s c r i p t i v e connotat ion : a need should be met or f u l f i l l e d . It i s conceptual ly useful to have a term for pro fe s s iona l and expert opinion as to the l e v e l of s e rv ice s , g iven ex i s t ing knowledge and technology, required to maintain a healthy popu la t ion . Unfortunately the same term, hea l th need, i s used to describe the l e v e l of services which soc ie ty ought to prov ide . This semantic confusion has permeated the hea l th planning l i t e r a t u r e and phi losophy. It i s not uncommon 76 i n the hea l th planning l i t e r a t u r e for hea l th need to be used synonymously with the goals or ob ject ives of the hea l th care system. For example, MacStravic ( 1978 ) s t a te s : "Ul t imate ly hea l th needs are determined by an i n t e l l e c t u a l and p o l i t i c a l process which sets and modifies the goals and standards for hea l th s e r v i c e s ; these goals and standards are then used to guide the development of the hea l th system" ( p . 8 ) . He goes on to define hea l th needs as the "manpower, equipment, and f a c i l i t i e s determined by organizat ions and communities to be requirements for maintaining and improving hea l th " ( p . 11 ) . Unl ike Know ( 1979 ) who l i n k s need to the p o s s i b i l i t y of e f f ec t ive remedial a c t i o n , MacStravic i s less concerned with whether i n fact a service makes a p o s i t i v e cont r ibu t ion to h e a l t h ; the percept ion of the serv ice as being required i s the determining f a c t o r . In f a c t , the concept of hea l th service requirements as determined by p o l i t i c a l means, or on the basis of community percept ion i s much c loser to the concept of demand. This thes i s supports reserving the usage of hea l th need for the l e v e l s of hea l th services deemed necessary by "experts" (or at l ea s t the majori ty of experts) on a t e c h n i c a l ba s i s . However, i t i s important to recognize that "experts" have t h e i r own values and b iases . As Wagner ( 1977 ) s t a te s , i t i s worthwhile taking a "c loser look at the sources of c r i t e r i a and standards to separate the t echn ica l judgements based upon formal or informal observat ion from value judgements based upon the s e l f - i n t e r e s t of a pro fes s iona l or group of p ro fe s s iona l s " ( p . 15 ) . Health demands have been defined e a r l i e r i n economic terms. However t h i s not ion of demand requires informed consumers, able to understand the "costs and p r i c e s " i n v o l v e d . In r e a l i t y , th i s i s seldom the case, and one i s l e f t i n the p o s i t i o n of hea l th planners or hea l th economists subs t i tu t ing 77 what they estimate other people or the pub l i c would want i f f u l l y informed. Another f a l l a c y i s to equate demand with u t i l i z a t i o n . Schwarz ( 19 75 ) defines demand i n the fo l lowing manner: "Demand comes i n two forms: 1) the voca l demands from the community for medical care to deal with t h e i r a i lments ; i i ) the demand, i n a less a r t i c u l a t e form, that a r i se s from the necess i ty to care for pat ients such as those i n coma or those involved i n acc idents " ( p . 149 ) . However, he then goes on to ca l cu la te demand us ing u t i l i z a t i o n data . Wants suffer the same conceptual d i f f i c u l t i e s as demand. It assumes an a r t i f i c i a l s i t u a t i o n of zero p r i c e , zero loss of wages, e t c . Again, t h i s i s seldom r e a l i z e d . To further confuse the i s sue , wants sometimes refers to the ac tua l community percept ion of the need for hea l th s e r v i c e s , without regard to assumptions such as 0 p r i c e and f u l l y informed consumer. It i s not need, yet because of the values attached to community p a r t i c i p a t i o n , i t may have s i g n i f i c a n t impact. U t i l i z a t i o n i s a much more e a s i l y understood concept. It i s measurable, and i n a j u r i s d i c t i o n such as B . C . , f a i r l y e a s i l y measurable. It would be a mistake however to assume u t i l i z a t i o n can always serve as a proxy for need.I f th i s were done - and i t often i s - a number of obvious cont rad ic t ions might occur . For example, greater u t i l i z a t i o n would nece s sa r i ly imply greater need, whereas th i s often means that a p a r t i c u l a r hea l th problem i s already rece iv ing considerable a t t e n t i o n . A l s o , i f u t i l i z a t i o n were to decrease, need could be sa id to decrease, but i n fact t h i s may r e f l e c t poor access to hea l th s e r v i c e s . U t i l i z a t i o n data are u s e f u l , given i t s ready a v a i l a b i l i t y , but should only be used as a subs t i tu te measure i f assumptions are w e l l understood. For example, 78 accuracy of u t i l i z a t i o n data depends on physic ians or hea l th profes s iona l s repor t ing accura te ly . MEDICS ca l cu la te s demands by applying u t i l i z a t i o n rates from hea l th insurance data to a given populat ion to a r r i v e at a morbidity f igure which i s transformed to resources r equ i red , based on production funct ion descr ib ing resources per i l l n e s s episode. However, the developers of MEDICS note i n Quebec, " there are conceptual ly t r i v i a l but p r a c t i c a l l y important d i f f i c u l t i e s ; for example, physic ians may accept the medicare card of a r e l a t i v e i f the p a t i e n t ' s i s not a v a i l a b l e " ( Quebec 1972, p . 11 ) . The var ious d e f i n i t i o n s of need, demand, want, and u t i l i z a t i o n , are i n a sense a l t e r n a t i v e t r ans l a t ions of hea l th status requirements for h e a l t h s e r v i c e s : expert o p i n i o n - — >-NEEDS HEALTH STATUS-•economic t rade-of f s --at 0 p r i c e 1 — DEMAND ->-WANTS •actual usage- -••.UTILIZATION FIGURE 19. Requirements for Health Services The r i s k s of using one or the other i n planning should be recognized . F e l d s t e i n and German ( 1965 ) point out that the planning of h o s p i t a l f a c i l i t i e s on the basis of recommended rather than ant i c ipa ted usage may re su l t i n too few, or too many beds being provided. Shonick ( 197 6 ) s i m i l a r l y observes that curtai lment of medical services i s not nece s sa r i ly associated with an increase i n resources a l loca ted for other serv ices which might e f f i c i e n t l y subs t i tute or mit igate the need for the c u r t a i l e d medical s e r v i c e s . As explained above, the var ious approaches to def in ing or 79 conceptua l iz ing requirements for hea l th services are often confused and used interchangeably . This thes i s proposes to use both the concepts of hea l th needs and demand i n the determination of Objec t ives . In other words, determination of requirements for hea l th services i s not so much a matter of s e l e c t i n g whether hea l th needs or demand i s the " c o r r e c t " d e f i n i t i o n , as i t i s a matter of drawing upon both expert opinion and consumer/community/ s o c i e t a l preferences . For example, the Alamo Area Counci l of Governments ( 1976 ) uses ep idemiolog ica l data , expert Task Forces , resource inventory , and a community perception of need ( us ing Nominal Group process ) to do a "hea l th needs" assessment and goals determinat ion. It i s t imely at th i s point to analyze how hea l th needs and demand are determined. There are d i f f e ren t planning modes a v a i l a b l e , depending on the data and resources a v a i l a b l e : r a t i o n a l p lanning , middle-range p lanning , and incremental planning modes. The most marked di f ferences i n determination of hea l th needs and demand occur when the r a t i o n a l planning mode i s used. As approximations are necess i tated by data, resource , and time c o n s t r a i n t s , the methodologies used for determining hea l th needs and demand begin to merge. In the r a t i o n a l planning mode, hea l th needs are determined genera l ly as : (1) determination of the hea l th status of a given popula t ion ; (2) expert determination of hea l th services ( type and amounts ) to address ( prevent, t r e a t , r e h a b i l i t a t e , e t c . ) the e x i s t i n g hea l th s ta tus ; (3) t r a n s l a t i o n of hea l th services needed into hea l th resource requirements, expressed i n terms of hea l th manpower, f a c i l i t i e s , equipment, and programs. In contrast to such an approach, the determination of demand i n the r a t i o n a l planning mode follows these general s teps : (1) determination of consumer preference for hea l th status or services offered by the hea l th care 8 0 s y s t e m ; (2) e x p e r t d e t e r m i n a t i o n of h e a l t h s e r v i c e s ( t y p e s and amounts ) t o a d d r e s s t h e p r e f e r r e d h e a l t h s t a t u s l e v e l s , and c o n s o l i d a t e d w i t h t h e p r e f e r e n c e s e x p r e s s e d f o r h e a l t h s e r v i c e s ; (3) t r a n s l a t i o n o f h e a l t h s e r v i c e s r e q u i r e d i n t o h e a l t h r e s o u r c e r e q u i r e m e n t s . Because of numerous c o n s t r a i n t s on a d o p t i n g t h e r a t i o n a l p l a n n i n g mode a p p r o a c h , l e s s e x a c t i n g and c o m p r e h e n s i v e p l a n n i n g must be u s e d . F o r e x a m p l e , a " s e r v i c e - t a r g e t s " m e t h o d o l o g y may be r e l i e d u p o n , e l i m i n a t i n g a d e t a i l e d d e t e r m i n a t i o n of h e a l t h s t a t u s and i t s t r a n s l a t i o n t o h e a l t h s e r v i c e s . The r e s u l t i n g e x p e r t d e t e r m i n a t i o n of h e a l t h s e r v i c e s " n e e d e d " , b a s e d on w h a t e v e r d a t a i s a v a i l a b l e , i s t h e n t r a n s l a t e d i n t o h e a l t h r e s o u r c e r e q u i r e m e n t s . The t r a n s l a t i o n of h e a l t h s e r v i c e s t o r e s o u r c e s may be o m i t t e d , p r o c e e d i n g d i r e c t l y t o a " r e s o u r c e p o p u l a t i o n r a t i o " ( e . g . p h y s i c i a n : p o p u l a t i o n r a t i o ) e s t i m a t e of r e q u i r e m e n t s . U t i l i z a t i o n may a l s o be used as an a p p r o x i m a t i o n of h e a l t h s e r v i c e s r e q u i r e d , a g a i n a v o i d i n g t h e d e t a i l e d d e t e r m i n a t i o n of h e a l t h s t a t u s and i t s t r a n s l a t i o n t o h e a l t h s e r v i c e s . The a d j u s t m e n t s t o the r a t i o n a l p l a n n i n g mode d e t e r m i n a t i o n of demand c e n t r e about a p p r o x i m a t i o n s t o consumer p r e f e r e n c e . Whereas a d e t a i l e d s u r v e y o r sample may be used i n t h e r a t i o n a l p l a n n i n g mode, a much s m a l l e r samp le w o u l d be u s e d i n t h e m i d d l e - r a n g e p l a n n i n g mode o r p e r h a p s even r e l i a n c e on t h e s t a t e d p r e f e r e n c e s of " r e p r e s e n t a t i v e s " s u c h as p o l i t i c a l l e a d e r s . A n o t h e r a p p r o x i m a t i o n , i n t h e i n c r e m e n t a l mode i s t o assume t h a t p r e f e r e n c e i s e x p r e s s e d i n t h e e x i s t i n g u t i l i z a t i o n p a t t e r n s . I n summary, t h e f o l l o w i n g t a b l e d i s p l a y s t h e p l a n n i n g a p p r o a c h e s c o r r e s p o n d i n g t o t h e p l a n n i n g modes as a p p l i e d t o d e t e r m i n a t i o n o f h e a l t h needs and demand. 81 PLANNING MODE Rat iona l Planning Middle-range Incremental NEEDS Health Status - Service Service Targets Resource: Resources Populat ion or DEMAND Consumer Preference Representative U t i l i z a t i o n Preference TABLE IV: Determination of Health Needs and Demand I I I . E . Resource A l l o c a t i o n Resource a l l o c a t i o n i s a d i f f i c u l t conceptual cha l lenge , and l i e s at the heart of any e f f e c t i v e p lanning . What are the c r i t e r i a for deciding that a p a r t i c u l a r hea l th problem receives c e r t a i n resources , while another hea l th problem receives fewer, or more? Many hea l th plans neglect to p r i o r i z e t h e i r requirements for hea l th services or do so i n such a way as to be u n r e a l i s t i c for purposes of resource a l l o c a t i o n . There i s of course always then an "unmet need" and request for more funds and se rv i ce s , without useful gu ide l ines as to which areas or programs should rece ive a v a i l a b l e funds. For example, the Los Angeles County Study of Health Care Needs uses u t i l i z a t i o n (and pro jec t ions ) to approximate need and an inventory of physic ians and f a c i l i t i e s to estimate ava i l ab le hea l th resources , but throughout the repor t , there i s no e x p l i c i t r ecogn i t ion of the importance of p r i o r i z a t i o n ( Los Angeles County Hosp i ta l Commission 1973 ) . Some planning models do not provide guide l ines for resource a l l o c a t i o n , but do al low ana lys i s of a l t e r n a t i v e scenar ios , g iven c e r t a i n p o l i c y 82 dec i s ions with regards to resource a l l o c a t i o n . For example, Povey's ( 1973 ) modell ing re ta ins a separat ion of resource category i n the matching process . A subroutine of the model generates episodes of morbidity r equ i r ing hea l th s e r v i c e s , and these episodes are then associated with the resources required i n order to determine i f there w i l l be a " shortage" . MEDICS uses a l i n e a r programming method to determine p r i o r i t i e s i n i t s modell ing of the hea l th care system ( Quebec 1972 ) . Di f ferent ob jec t ive functions can be chosen, and an optimal s o l u t i o n c a l c u l a t e d . To permit t h i s approach, the var ious resources ( manpower, f a c i l i t i e s , equipment ) are t rans la ted into d o l l a r equ iva lent s . Mathematical formulations are used to represent resource a l l o c a t i o n c r i t e r i a . Although the methodologies above do not d i r e c t l y provide guide l ines for resource a l l o c a t i o n and se t t ing p r i o r i t i e s , they can c l e a r l y f a c i l i t a t e the process . There does seem general acceptance of the importance of se t t ing p r i o r i t i e s , recogniz ing that requirements for hea l th services w i l l l i k e l y always exceed ava i l ab le resources . Thus, for example, the United States Department of Hea l th , Education and Welfare ( 1979a ) l i s t s some of the advantages i n se t t ing p r i o r i t i e s : (1) ind ica te s which problems or pro jects are to be dealt with f i r s t , (2) e l iminates unimportant or i n f e a s i b l e p ro j ec t s , (3) suggests which of competing a l t e rna t ive s should be chosen, (4) guides resource a l l o c a t i o n . The primary c r i t e r i a for determination of p r i o r i t i e s vary according to which approach i s adopted or preferred i n determination of requirements for hea l th s e r v i c e s . I f r e l i a n c e i s placed on a "needs" approach, attempts w i l l 83 be made to quantify or p r i o r i z e according to needs c r i t e r i a , with assumptions or estimations as to the r e l a t i v e importance or weighting of the var ious hea l th status condi t ions ( or more p r a c t i c a l l y , hea l th status i n d i c a t o r s ) . I f , on the other hand, r e l i a n c e i s placed on a "demands" approach i n determining requirements, attempts w i l l be made to p r i o r i z e on the basis of expressions of community preference. The needs c r i t e r i a w i l l r e l y on expert o p i n i o n ; the demand c r i t e r i a w i l l r e l y on lay o p i n i o n . Sect ion I I I . E . l . discusses p r i o r i z a t i o n on the basis of needs. Sect ion I I I . E . 2 . discusses p r i o r i z a t i o n on the basis of demand. Sec t ion I I I . E . 3 . attempts a synthesis and suggests an approach to be used i n the development of ob ject ives for the P r o v i n c i a l Health P lan . I I I . E . l . Resource A l l o c a t i o n based on need Belanger et a l ( 1974 ) described an approach to resource a l l o c a t i o n i n t h e i r modell ing for a Vancouver reg iona l hea l th care system: " In the r ea l system the ac tua l p r i o r i t y with which a p a r t i c u l a r person's demands are met i s presumably determined e i ther as an in terpersona l t r a n s a c t i o n , g iven the constra int s of resources i n the l o c a l r eg ion , or by a more impersonal process i n a large h o s p i t a l . Consequently, the model introduces a major conceptual s i m p l i f i c a t i o n i n that a l l resources and demands are separate ly determined i n t o t a l , before the resource-demand matching procedure i s tackled at a l l " ( p . 411 ) . P r i o r i t i e s were estimated for each i l l n e s s , and the s imulat ion model then matched the top p r i o r i t i e s u n t i l resources were exhausted. The unmet needs/demands were then given an upgraded p r i o r i t y for the next time period under c o n s i d e r a t i o n . The c r i t e r i a i n t h i s instance for each i l l n e s s were the rankings of disease items (from dandruff to leukemia) , 84 on the "seriousness of i l l n e s s s c a l e " . This scale was an e f for t to give weightings and therefore a l low c a l c u l a t i o n of p r i o r i t i e s by geometric averaging of i n d i v i d u a l scor ings , where a normative value of 500 was given for pept ic u l c e r s . The range of the scale i s i l l u s t r a t e d below: RANK SCORE 1 Dandruff 21 25 T o n s i l l i t i s 117 50 Mononucleosis 216 75 Kidney In fec t ion 374 100 Blood Clot i n Vessels 631 125 Cancer 1020 Another example of e f for t s to quant i fy , and thus p r i o r i z e , hea l th problems i s the Heal th Problem Index or "Q" index developed by the U .S . D i v i s i o n of Indian H e a l t h : Q= MDP + (274A/N) + (91.3B/N). The var i ab le s i n t h i s equation are explained below: M= age/sex adjusted mor ta l i ty rates for the target-popula t ion as a proport ion of age/sex adjusted mor ta l i ty rates for the reference popu la t ion . D= crude mor ta l i ty rate for the target populat ion P= years of l i f e l o s t using l i f e expectancy to age 65 for the target populat ion A= h o s p i t a l days for the target populat ion B= outpat ient v i s i t s for the target populat ion N= number of i n d i v i d u a l s i n the target populat ion 274 and 91.3 are constants to convert A and B to years per 100,000 popu la t ion . 85 The dominant v a r i a b l e i s m o r t a l i t y , with lesser c o n t r i b u t i o n from i n - p a t i e n t days ( which are weighted three times as heav i ly as outpat ient v i s i t s ) . Dever ( 1980 ) explains th i s index and numerous others i n greater d e t a i l , i n c l u d i n g : Wellness Appra i sa l Index, Health Hazard A p p r a i s a l , Z-score Addi t ive Model, L i f e Expectancy and Weighted L i f e Expectancy, and M o r t a l i t y Index. C a s t e r l i n e ( 1977 ) s i m i l a r l y attempts to quantify on the basis of need. She uses measures of "magnitude, emotional , s o c i a l and monetary costs of the problem to the community" ( p . 42 ) , and proposes cos t -benef i t and cos t-e f fect iveness c a l c u l a t i o n s based on such measures. New Zealand ( 1981 ) has r ecent ly indica ted that they are taking a populat ion based approach to a l l oca te ava i l ab le funds to h o s p i t a l s , with adjustments for age/sex, expected bed days based on Standard M o r t a l i t y Ratios and pat ient i n and outflows by r e g i o n . One of the most sophis t ica ted approaches to resource a l l o c a t i o n , taking a needs approach i s found i n Great B r i t a i n ' s Resource A l l o c a t i o n Working Party ( RAWP ) report ( Great B r i t a i n , Department of Health and S o c i a l Services 1976 ) . The RAWP was mandated to "review the arrangements for d i s t r i b u t i n g NHS c a p i t a l and revenue to RHA's, AHA's , and d i s t r i c t s r e s p e c t i v e l y with a view to e s t a b l i s h i n g a method of secur ing , as soon as p r a c t i c a b l e a pat tern of d i s t r i b u t i o n responsive o b j e c t i v e l y , equi tab ly and e f f i c i e n t l y to r e l a t i v e need and to make recommendations" ( p . 5 ) . In b r i e f , RAWP's approach involved three s teps : (1) measures of r e l a t i v e need to e s t a b l i s h share of ava i l ab l e revenue to each RHA ( i . e . a revenue " ta rge t " ) , (2) determination where each Author i ty was pre sent ly , r e l a t i v e to the 86 t a r g e t , (3) p h a s e d change t o w a r d s t h e t a r g e t . R e l a t i v e need i s based on numerous c r i t e r i a : s i z e o f p o p u l a t i o n , a g e / s e x m i x , m o r b i d i t y , c o s t s ( w h i c h w o u l d v a r y a c r o s s r e g i o n s , i n f l o w and o u t f l o w o f p a t i e n t s t o the r e g i o n , m e d i c a l e d u c a t i o n f a c t o r s , and c a p i t a l i n v e s t m e n t . F i g u r e 20 shows s e v e n s e r v i c e p o p u l a t i o n s and t h e w e i g h t i n g f a c t o r s u s e d . Mid-year estimates of geographic popul*tk>n for each region Non-psychlatrk inpatient services Population weighted by national usage by each age/sex group Weighted population multiplied by regional SMRt for certain condition!, SFRl for maternity Population adjusted for Inter-regional flow of patients and agency/ETM arrangements Al l dey-end out--petimt services Population weighted by national usage by each age/sex group Weighted population multiplied by overall regional SMRh Population adjusted for agency arrangements Mental Illness in patient services Population weighted by national usage by each age/sex group formarr ied! end non-marrieda Population adjusted for inter-regional flow of patients, agency/ETM arrangements and incidence of 'old long stay' patients Mental handicap in-petient «*rviees Population weighted by notional usage by each aga/iex group Population adjusted for inter-regional flow of patients, agency/ETM arrangements and incidence of 'old long stay' patient) Community services (excluding ambulance and F P C services) Population weighted by broad cost o f national usage by each age! group Weighted population multiplied by overall regional SMFuj Population adjusted for agency arrangement! Weighted populations combined proportionately to revenue expenditure on each service If appropriate to region, population adjusted for London Weighting Revenue available nationally for services distributed In proportion to each region'! weighted population Ambulance services Crude population FPC administration services Crude population Crude population multiplied by overall regional SMRt FIGURE 20. RAWP Determination of Re la t ive "Need" oo SOURCE: Great B r i t a i n , Sharing Resources for Health In England. Report of the ^ Resource A l l o c a t i o n Working Par ty , 1976, p .26. 88 T h e o r e t i c a l l y t h e n , a c c o r d i n g t o RAWP, " t h e r e v e n u e a v a i l a b l e f o r s e r v i c e s n a t i o n a l l y s h o u l d be n o t i o n a l l y d i s t r i b u t e d i n p r o p o r t i o n t o e a c h R e g i o n ' s w e i g h t e d p o p u l a t i o n to a r r i v e a t t h e r e v e n u e t a r g e t a l l o c a t i o n f o r e a c h RHA" ( p . 27 ) . In o t h e r w o r d s , a r t i f i c i a l s e r v i c e p o p u l a t i o n s a r e g e n e r a t e d by t h e c a l c u l a t i o n s , w h i c h may, and p r o b a b l y do no t c o i n c i d e w i t h a c t u a l p a t i e n t s s e e n . The RAWP p r o p o s e d a phased change t o w a r d s t h e c a l c u l a t e d r e v e n u e t a r g e t s , w i t h t h e r a t e of change dependent on t h e g r o w t h of NHS r e s o u r c e s . F l o o r s and c e i l i n g s on changes ( e i t h e r d e c r e a s e s o r i n c r e a s e s ) were p r o p o s e d . F o r e x a m p l e , i t i s s u g g e s t e d t h a t a maximum f i v e p e r c e n t i n c r e a s e f o r r e g i o n s be a l l o w e d f rom the p r e v i o u s y e a r ' s a l l o c a t i o n s . D i f f e r e n t i a l r a t e of change a r e i n d i c a t e d d e p e n d i n g on w h e t h e r a r e g i o n i s above o r b e l o w i t s r e v e n u e t a r g e t . The RAWP a p p r o a c h to a l l o c a t i o n of c a p i t a l f u n d s d i f f e r s somewhat f rom t h e i r t r e a t m e n t of o p e r a t i n g o r r e v e n u e f u n d s . I n summary, t h e s u g g e s t e d p r o c e d u r e i s t o v a l u e t h e e x i s t i n g s t o c k i n a r e g i o n and t o t o t a l t h e a v a i l a b l e NHS c a p i t a l ( e x i s t i n g s t o c k + new c a p i t a l f u n d i n g ) . The t o t a l NHS c a p i t a l i s t h e n a l l o c a t e d t o r e g i o n s u s i n g w e i g h t e d p o p u l a t i o n s ( s i m i l a r c r i t e r i a t o t h a t f o r r e v e n u e f u n d i n g ) , and p h a s e d change t o w a r d s t h e s e c a p i t a l t a r g e t s i s t h e n u n d e r t a k e n . The RAWP a l l o c a t e s i t s r e s o u r c e s t o R H A ' s , w h i c h i n s i z e a r e c o m p a r a b l e t o t h e e n t i r e p r o v i n c e of B r i t i s h C o l u m b i a . Thus , of more s i g n i f i c a n c e t o the d e v e l o p m e n t o f t h e P r o v i n c i a l H e a l t h P l a n a r e RAWP's p r o p o s a l s f o r a l l o c a t i n g f r o m RHA to A r e a H e a l t h A u t h o r i t i e s . However , a l l o c a t i o n t o t h e s e s m a l l e r r e g i o n s i s d e s c r i b e d w i t h many more c o n s t r a i n t s by t h e RAWP. A d d i t i o n a l p r o b l e m s i n c l u d e : q u e s t i o n s of r e g i o n a l s e l f - s u f f i c i e n c y and i n f l o w s and o u t f l o w s ; s e a s o n a l c h a n g e s ; a p p o r t i o n i n g " c e n t r a l " 89 admini s t ra t ive co s t s ; more d i f f i c u l t i e s i n phasing changes; need for more d e t a i l e d information ( although fewer age/sex groupings may be required ) ; p a r t i c u l a r l o c a l c h a r a c t e r i s t i c s ( e . g . centres of excel lence for teaching or re search) ; and d i sproport ionate impact of c a p i t a l p ro j ec t s . Butts and Ashford (1977) ra i se concerns about the RAWP methodology, quest ioning the i m p l i c i t assumptions that costs across s p e c i a l t i e s and age/sex groupings remain constant , and that Standardized M o r t a l i t y Ratios accurate ly r e f l e c t morb id i ty . They note i n p a r t i c u l a r the d i f f i c u l t y i n est imating inflows and outflows for smaller areas . I I I . E . 2 . Resource A l l o c a t i o n based on demand The approaches to resource a l l o c a t i o n presented up to t h i s point of the d i s cus s ion are very much associated with a determination of hea l th serv ices requirements based upon need. There i s r e l i ance on experts to p r i o r i z e hea l th problems, and thus derive c r i t e r i a or gu ide l ines for resource a l l o c a t i o n . Relying on such approaches e n t i r e l y i s u n l i k e l y to be acceptable for a number of reasons. In western s o c i e t y , the a l l o c a t i o n of resources i s done through a p o l i t i c a l process - not an expert determinat ion. The general p r i n c i p l e s and values i n support of such a mechanism are deeply ingrained i n s o c i e t y . There are no genera l ly accepted ob jec t ive c r i t e r i a by which to rank or p r i o r i z e hea l th issues and problems; there i s always an element of judgement and c h o i c e . The d i f f i c u l t y i s demonstrated i n obta ining consensus amongst experts as to the r e l a t i v e ranking of var ious hea l th issues and problems. Within a l i m i t e d f i e l d , ranking may be p o s s i b l e ; for example, experts may agree that immunization for measles, mumps, r u b e l l a i s more important than immunization for i n f l u e n z a . However, i t i s much more 90 d i f f i c u l t to assess whether immunization f o r measles, mumps, and r u b e l l a i s more, or l e s s , important than f l u o r i d a t i o n of the water supply. IIASA has developed a model of resource a l l o c a t i o n c a l l e d DRAM (Disaggregated Resource A l l o c a t i o n Module). Gibb's ( 1978 ) v e r s i o n s t a t e s that the main assumption of the model i s that i n a l l o c a t i n g i t s resources the Health Care System ( HCS ) attempts to "maximize a u t i l i t y f u n c t i o n whose parameters can be i n f e r r e d from observations on past a l l o c a t i o n s " ( p. 4 ). The demand i n p u t s are: (1) t o t a l number of i n d i v i d u a l s who could be o f f e r e d treatment, by category (from morbidity and population submodels). (2) the p o l i c i e s f o r treatment ( i . e . the f e a s i b l e modes of treatment f o r each p a t i e n t category - i n p a t i e n t , o u t p a t i e n t , d o m i c i l i a r y , e t c . ) (3) i d e a l standards of treatment f o r each p a t i e n t category and mode of treatment ( e.g. the length of stay i n h o s p i t a l f o r a given episode of i l l n e s s ) . The supply inputs are "amounts of resources a v a i l a b l e f o r use i n the HCS." The model assumes d i s t r i b u t i o n of l i m i t e d resources i n three dimensions: (1) number of p a t i e n t s of d i f f e r e n t types who are o f f e r e d treatment (2) the modes of treatment o f f e r e d , and (3) the standards at which treatment i s o f f e r e d . The model's outputs i n d i c a t e numbers of p a t i e n t s who re c e i v e treatment according to (1) to ( 3 ) . An assumption i s made about behaviour based on p r i o r i t i e s which can be derived from past HCS performance. The concept modelled i s that the "HCS achieves an e q u i l i b r i u m by balancing the d e s i r a b i l i t y of t r e a t i n g more 91 pat ients of one type against t rea t ing more of other types and against the d e s i r a b i l i t y of t rea t ing each type of pat ient at a higher average standard" ( Shigan 1979, p . 37 ) . This model addresses d i r e c t l y the issue of p r i o r i z i n g needs, but tends to accept h i s t o r i c a l and ex i s t ing a l l o c a t i o n s of resources as r e f l e c t i n g c e r t a i n p r i o r i t i e s , and would a l loca te future resources on that ba s i s . Other approaches are used to obta in an expression of current community preference, whether d i r e c t l y from commuity members, through t h e i r e lec ted representa t ives , or some other mechanism of community input . An approach, which has found wide usage i n p l u r a l i s t i c United States , i s to survey the community and/or pro fes s iona l groups/agencies, and p r i o r i z e by consensus or majori ty d e c i s i o n . Reinke ( 1972 ) ant i c ipa te s t h i s process i n h i s reference to broad goals and choice of " a l t e r n a t i v e problem p r i o r i t i e s and a l t e r n a t i v e programs or techniques for coping with the problems, with due cons idera t ion for the many p h y s i c a l , environmental , t e c h n o l o g i c a l , s o c i a l , c u l t u r a l , and p o l i t i c a l cons t ra in t s " ( pp. 6 6 - 6 7 ) . S i m i l a r l y Know ( 1979 ) described s o c i a l choice as " i n h e r e n t l y a p o l i t i c a l process, and s o c i a l planning requires mechanisms and s tructures through which in format ion , a u t h o r i t y , and preferences may be aggregated, and through which agreed s t ra teg ies may subsequently be disaggregated to create plans of implemention" ( p . 9 ) , and p r i o r i t i e s are based on a "blend of f ac tua l evidence about the past and present , upon t r a d i t i o n and law, upon changing value systems and expectat ions , and upon the degree to which resources are thought to be t rans ferable from one use to another" ( p. 15 ) . Thus, according to Know, the determination of p r i o r i t i e s for resource a l l o c a t i o n i s b a s i c a l l y e x t r a l o g i c a l . There i s r a r e l y a Pareto-optimal s o l u t i o n , and 92 when c o s t / b e n e f i t s f a l l unevenly, a d d i t i o n a l e t h i c a l p r i n c i p l e s are needed. For example, Rawls ( 1973 ) argues that c o l l e c t i v e d e c i s i o n s are f a i r only i f the l e a s t disadvantaged are made no worse, and Nozick ( 1974 ) argues that i n d i v i d u a l s should be f r e e from c o l l e c t i v e d e c i s i o n to e f f e c t t r a n s f e r s c o e r c i v e l y . An example of the community survey approach i s the Comprehensive Health Planning Agency of S.E. Wisconsin's "Health Areas P r i o r i t y of Concerns Questionnaire", mailed to a l l of i t s members (480 i n 1973).The r e s u l t s were very u s e f u l to the Program Development Committee, with the top f i v e concerns becoming f i v e major areas i n the Agency Work Program, over and above functi o n s mandated by Federal g u i d e l i n e s . I t i s of i n t e r e s t methodologi-c a l l y that 18 p o t e n t i a l h e a l t h planning areas were l i s t e d and the respondent was asked to l i s t h i s impression of the ten most important, w i t h a d d i t i o n a l space f o r comments. The top f i v e concerns were expressed i n terms of e i t h e r s e r v i c e s or f a c i l i t i e s , n o t i n terms of h e a l t h status problems. Another example of the community survey approach i s a 1978 study of he a l t h planning i n the P h i l a d e l p h i a area ( P h i l a d e l p h i a Health Management Corporation 1978 ). A consumer h e a l t h needs survey was done as part of the study to determine h e a l t h r e l a t e d behaviour patterns and community perception of h e a l t h care needs, problems, and p o t e n t i a l s o l u t i o n s . Of 953 qu e s t i o n n a i r e s , only 181 (19%) responded despite i n t e n s i v e follow-up. The f i v e most important s e r v i c e s according to the survey were p a e d i a t r i c care, preventive care, home v i s i t s by p h y s i c i a n s , s e r v i c e s f o r the e l d e r l y , and dental s e r v i c e s . The high cost of h e a l t h care was c i t e d as the most s i g n i f i c a n t b a r r i e r to access to s e r v i c e s . The S.E. Alabama Health Systems Agency ( 1976 ) asked i t s c o u n c i l 93 members to rate ( on a 1-5 scale ) 16 hea l th serv ice areas us ing factors of number of people a f f ec ted , seriousness of need, urgency of need, and q u a l i t y of l i f e . Another example of p r i o r i z i n g i s found i n a Consumer Health Needs Survey i n S.W. Louis iana ( Arcadiana Heal th Planning Counc i l 1974 ) . P a r t i c i p a n t s were asked to se lect from a l i s t of hea l th serv ices i n response to a ques t ion : "What kind of hea l th care ( se rv ice s ) would be most important fo r you and your household?" The study emphasized the extent of consumer hea l th educat ion, a v a i l a b i l i t y and access to hea l th f a c i l i t i e s , knowledge of e x i s t i n g i n s t i t u t i o n s and maternal and infant care . The Consumer Health Needs Survey sampled 250 f ami l i e s d iv ided in to three l eve l s of income, r u r a l v s . urban, and white v s . non-white ca tegor ie s . A personal interview was used to gather in format ion . Various organ iza t ions , i n c l u d i n g hosp i t a l s were a lso given a shorter ver s ion of the ques t ionna i re . The r e s u l t s of the survey suggested a p a r t i c u l a r need for non-emergency medical t r a n s p o r t a t i o n . Also i d e n t i f i e d were needs for consumer hea l th educat ion, maternal and infant care , and services for a number of s p e c i f i c hea l th c o n d i t i o n s . More complicated and s tructured approaches have also been used i n attempts to obtain community preferences . The r e v i s i o n and update of the South Caro l ina Comprehensive Health Plan attempts to e s t a b l i s h p r i o r i t i e s and recommendations based on a c o l l a b o r a t i o n of governmental and non-governmental hea l th organizat ions w i t h i n the s tate ( South Caro l ina 1975 ) . A l i s t i n g of hea l th needs of state-wide s i g n i f i c a n c e i s compiled (based upon state planning agencies , consumers, other hea l th o r g a n i z a t i o n s ) , fo l lowing which a forum would rate each need ( with accompanying recommendations to improve the hea l th of res idents ) on a scale of 10 to 1, 94 wi th 10 represent ing the highest or most important va lue . The points for each item are summed to derive a p r i o r i z e d l i s t i n g according to t o t a l score . Despite the many e f for t s using community surveys, which attempt to determine and p r i o r i z e requirements for hea l th s e r v i c e s , hea l th planning and resource a l l o c a t i o n continues to be r e l a t i v e l y i n e f f e c t u a l . The surveys, i n c l u d i n g the ones c i t e d above, do not consider the e n t i r e range of h e a l t h serv ices i n the region or area under c o n s i d e r a t i o n . Reasons for t h i s should be obvious ; the response rates c i t e d above would be even lower i f a complicated and lengthy l i s t i n g of hea l th problems were presented to the respondents. These surveys also confused the concept of hea l th needs and demand. Par t i c ipant s were not informed as to the hea l th needs of t h e i r community and asked to se lect or p r i o r i z e from these needs. Instead, the format suggested that the p a r t i c i p a n t s were themselves def in ing hea l th  needs. I I I . E . 3 . Resource A l l o c a t i o n , a Suggested Approach An important ques t ion , i n e f for t s to determine p r i o r i t y for a l l o c a t i o n of hea l th resources , i s whose p r i o r i t i e s are to be considered? Schwarz ( 1975 ) suggests c a l c u l a t i o n of p r i o r i t i e s based on loss and gain from each of f ive perspect ives ( p a t i e n t , f ami ly , community, hea l th s e rv i ce s , humanitar ian) . Know ( 1979 ) observes that the c r i t e r i a for pol icy-making and resource a l l o c a t i o n depend upon the perspective used. P o l i t i c a l a c c o u n t a b i l i t y w i l l r e l y upon c r i t e r i a of a c c e s s i b i l i t y , equ i ty , and i n d i v i d u a l p r o t e c t i o n ; while profes s iona l accountab i l i ty looks to 95 effectiveness, efficiency, standards, and meeting "needs". Also, i t has been suggested that "central" concerns are expressed in terms of "public are expressed in terms of individual needs and services. Blum ( 1974 ) discusses in considerable detail the c r i t e r i a to be used in setting priorities for health problems, taking a community perspective. He suggests that both the c r i t e r i a to be used, and the relative weightings attributed to each c r i t e r i a are "restatements of the general goals and of the health aims which the community (at whatever level) has already selected as the ends toward which the normative aspects of i t s developmental planning w i l l be working" ( p. 229 ). Blum concedes that there may be l i t t l e rational basis for these c r i t e r i a except as "pure value judgements." Four batteries of cr i t e r i a are proposed: (1) technologic concerns (2) health status goals (3) overall social goals or concerns (4) health planning concerns These are reproduced i n Table V below: accountability" ( e . g . geographical equity) whereas "peripheral" concerns CLASSES OF CRITERIA, THEIR WEIGHTS, AND RATING SCALE Criteria Weighting Rating Scale Technological Aspects* Technology Possible Technological Feasibility Manpower Requirements Balanced Attack on All Phases Absolute 5 3 Pass or Fail -10 to+10 -10to+10 of a Situation Balanced Attack on All Phases 3 -10 to+10 of the Environment S -10 to+10 Health Aspects Problem Likely to Go Away by Itself 5 -10 to +10 Probable Duration of Problem if Undisturbed 4 -10 to + 10 Deaths 3 -10 to +10 Disability 3 -10 to +10 Disease 3 -10 to +10 Discomfort and Pain 3 -10 to +10 Condition Size or Numbers 3 -10 to + 10 Condition Severity 3 -10 to +10 Condition Duration 3 -10 to +10 Distress or Danger to Others 2 -10 to +10 96 General Social Concerns Legal Conformance Ecology Environment Equity Resource Consumption Time to Consummation" Goal Conformance Public Concern Public Dissatisfaction Political Feasibility Flexibility" Speed of Change" Effecti vity Productivity Overall Costs Net Benefits Level Community Involvement Avoidance of Other Significant Predicted Problems Protection of Next Generation Balance of Quality fc Quantity Efficiency Cost-Benefit Ratio" Employment Esthetics Segregation Absolute 5 5 5 5 5 5 4 4 4 4 4 4 3 3 3 3 3 3 2 2 2 2 2 2 Pass or Fail -10to+10 -10 to+10 -10to+10 -10to+10 -10 to+10 -10 to+10 -10to+10 -10 to +10 -10to+10 -10to+10 -10to+10 -10 to+10 -10 to+10 -10to+10 -10 to+10 -10to+10 -10 to+10 -10to+10 -10 to+10 -10to+10 -10 to+10 -10to+10 -10 to+10 -10 to+10 Coordination between Levels of Government Coordination between Public & Private Interests Science Merit Can Others do the Necessary Planning? What Would People be Willing to Pay? No Other Way to Go Consideration to Special At-Risk Groups Planning Concerns Plan Conformance Leverage Public Education Re Planning Balanced Planning Body Long-Term Planning Body Involvement Planning Body Image Planning Process Image TABLE V. C r i t e r i a f o r Resource A l l o c a t i o n -10 to+10 -10 to+10 -10to+10 -10 to+10 -10 to+10 -10 to+10 -10 to+10 -lOto + 10 -10to+10 -10 to+10 -10 to+10 -10 to+10 -10to+10 -10 to+10 SOURCE: H. Blum, Planning f o r Health. Human Sciences Press, 1974, pp. 238-9.. 97 The c o n c e p t o f " w e i g h t i n g " h e a l t h p r o b l e m s has been d i s c u s s e d e a r l i e r ( e . g . t h e S e r i o u s n e s s o f I l l n e s s S c a l e ) . B lum c a l c u l a t e s f o r e a c h c r i t e r i o n a " s i g n i f i c a n c e " l e v e l by m u l t i p l y i n g t h e r a t i n g and w e i g h t i n g . An o v e r a l l " a v e r a g e d s i g n i f i c a n c e " l e v e l f o r e a c h h e a l t h p r o b l e m i s t h e n o b t a i n e d by c o m b i n i n g t h e s c o r e s f o r e a c h c r i t e r i o n , and a p r i o r i z e d l i s t i n g of h e a l t h p r o b l e m s r e s u l t s . These c a l c u l a t i o n s a r e r a t h e r a r b i t r a r y , as a r e t h e w e i g h t i n g s Blum s u g g e s t s . However , t h e c r i t e r i a a r e w o r t h y of n o t e , and Blum i n d i s c u s s i n g t h i s r a n k i n g p r o c e s s makes a number o f v a l i d p o i n t s . He n o t e s t h a t v a l u e s , and t h e r e f o r e g o a l s may be i n c o n f l i c t o r c o m p e t i t i o n w i t h e a c h o t h e r . P r e p a r a t i o n of c r i t e r i a l i s t s s h o u l d be done by a w i d e l y r e p r e s e n t a t i v e g r o u p , s e n s i t i v e t o community c o n c e r n s . H i g h e s t and l o w e s t p r i o r i t y r a n k i n g s a r e g e n e r a l l y e a s i l y d e c i d e d ; m i d d l e p r i o r i t y i t e m s r e q u i r e more s t u d y . B lum a l s o g i v e s examp les of how a p r i o r i z e d r a n k i n g of h e a l t h p r o b l e m s m i g h t be u s e d : t o i n d i c a t e w h i c h i t e m s i n e a c h c a t e g o r y a r e t o be i m p l e m e n t e d f i r s t ; t o i n d i c a t e w h i c h i t e m s i n each c a t e g o r y a r e t o r e c e i v e no f u r t h e r c o n s i d e r a t i o n ; t o i n d i c a t e w h i c h i t e m s i n e a c h c a t e g o r y a r e t o r e c e i v e t h e m a j o r s h a r e of r e s o u r c e s ; t o i n d i c a t e w h e t h e r t h e a c t i v i t i e s c a l l e d f o r by t h e h i g h p r i o r i t y i t e m s i n e a c h c a t e g o r y a r e t o be f i r m l y e s t a b l i s h e d b e f o r e o t h e r s a r e t o be embarked u p o n ; t o i n d i c a t e , w h i c h among t h e h i g h r a n k i n g i t e m s i n a l l t he c a t e g o r i e s , a r e t o ge t the go a h e a d , on what t i m e t a b l e , and w i t h what p r o p o r t i o n of t h e r e s o u r c e s . Blum d i s c u s s e s t h e d i f f i c u l t i e s i n d e s i g n a t i n g m i n i m a l , i n t e r m e d i a t e , and o p t i m a l l e v e l s f o r v a r i o u s a c t i v i t i e s . I n t u i t i v e l y , t h e u n d e r l y i n g g u i d e l i n e s s h o u l d be t o f u n d t o a l l m i n i m a l l e v e l s b e f o r e any i n t e r m e d i a t e , and s i m i l a r l y t o a l l i n t e r m e d i a t e l e v e l s b e f o r e o p t i m a l . But t h e argument i s a d v a n c e d by Blum t h a t t h i s r a n k i n g s y s t e m g i v e s no i n d i c a t i o n w h e t h e r 98 minimal l eve l s should be s a t i s f i e d completely before resources can be a l l o c a t e d to the next higher l e v e l . In p a r t i c u l a r , the s i t u a t i o n of threshold l e v e l s of f inancing i s c i t e d , where the t o t a l amount of funding i s required on an a l l -or -none ba s i s , e . g . c a p i t a l c o n s t r u c t i o n . The conceptual d i f f i c u l t y Blum encounters hinges on an inadequate d e f i n i t i o n of minimal l e v e l . If "minimal" i s taken to mean a basic l e v e l , which i t i s genera l ly agreed should be maintained, then indeed l o g i c a l l y , a l l a c t i v i t i e s should be funded to minimal l e v e l s . That dec i s i on as to minimum must already have taken into account factors such as marginal gains r e l a t i v e to other s ec tor s , f e a s i b i l i t y , and threshold l e v e l s . A d i f f e r e n t perspect ive on Blum's l i s t i n g i s poss ib le through cons iderat ion of H a l l , Land, Parker, and Webb's ( 1975 ) three major c r i t e r i a for determining whether an issue assumes p r i o r i t y s ta tus : l eg i t imacy , f e a s i b i l i t y , support . The authors takes a government per spec t ive , but th i s i s cons i s tent with the perspective of t h i s t h e s i s . Legit imacy , as H a l l et a l discuss the concept, r e l a te s to the proper ro le and sphere of government a c t i o n . There are var ious l eve l s of l eg i t imacy , ranging from issues almost u n i v e r s a l l y recognized as government r e s p o n s i b i l i t y ( e . g . wars) , to issues i n which government normally has l i t t l e involvement. The question of leg i t imacy becomes e s p e c i a l l y important at times of p o l i c y (or program) i n i t i a t i o n and te rminat ion . F e a s i b i l i t y depends upon t h e o r e t i c a l and t e c h n i c a l developments, i . e . the " s t a t e - o f - t h e - a r t " . Equal ly important, but often overlooked, are factors r e l a t i n g to resource a v a i l a b i l i t y ( f i n a n c i a l , manpower, e t c . ) ; l i k e l i h o o d of c o l l a b o r a t i o n or cooperation with key groups or i n d i v i d u a l s ; and admini s t ra t ive f e a s i b i l i t y . As with l eg i t imacy , issues w i l l be 99 c o n s i d e r e d a t v a r i o u s l e v e l s o f f e a s i b i l i t y . U s u a l l y p l a n s a r e t h e o r e t i c a l l y f e a s i b l e , bu t t h e c o s t s of a c h i e v i n g t h e d e s i r e d r e s u l t s have t o be e s t i m a t e d . S u p p o r t , w h i c h H a l l e t a l i n t e r p r e t i n p o l i t i c a l t e rms of p u b l i c o p i n i o n , can be c o n s i d e r e d " d i f f u s e " o r " s p e c i f i c " . The g e n e r a l p u b l i c mood t o w a r d s government i s r e f l e c t e d i n d i f f u s e s u p p o r t . S p e c i a l i n t e r e s t g r o u p s , and g r o u p s w i t h s p e c i a l r e s o u r c e s p r o v i d e s p e c i f i c s u p p o r t . The d e g r e e and t y p e of s u p p o r t a r e i m p o r t a n t t o government d e p e n d i n g on t h e t y p e o f i s s u e under c o n s i d e r a t i o n . Most of t h e l e n g t h y l i s t i n g of c r i t e r i a by Blum c o r r e s p o n d s t o one of t h e t h r e e ma jo r c r i t e r i a d e f i n e d by H a l l e t a l . F o r e x a m p l e , t h e c r i t e r i a " t e c h n o l o g y f e a s i b l e " and " t e c h n o l o g i c a l f e a s i b i l i t y " a r e f a c t o r s o f f e a s i b i l i t y . S i m i l a r l y , " p u b l i c c o n c e r n " and " p u b l i c d i s s a t i s f a c t i o n " a r e f a c t o r s of s u p p o r t . The m a j o r c o n c e p t u a l m o d i f i c a t i o n s t o t h e m a j o r c r i t e r i a as p r o p o s e d by H a l l e t a l r e l a t e t o l e g i t i m a c y f a c t o r s . B l u m ' s l i s t i n g i m p l i e s t h a t p r i n c i p l e s , a p a r t f r om t h e q u e s t i o n of t h e p r o p e r r o l e o f government v i s - a - v i s o t h e r s e c t o r s of s o c i e t y ( e . g . t h e i n d i v i d u a l o r f a m i l y ) d e t e r m i n e t h e T i g h t n e s s o r a p p r o p r i a t e n e s s of an i s s u e i n e s t i m a t i n g t h a t i s s u e ' s o v e r a l l p r i o r i t y . F o r e x a m p l e , Blum l i s t s " e q u i t y " as a n i m p o r t a n t c r i t e r i o n . In o t h e r w o r d s , when d e t e r m i n i n g t h e r e l a t i v e i m p o r t a n c e o f a h e a l t h p r o b l e m , r e f e r e n c e w i l l be made t o c e r t a i n g e n e r a l p r i n c i p l e s w h i c h i n some way " l e g i t i m i z e " t h e p r o b l e m ( o r p r o p o s e d s o l u t i o n ) , and t h i s e x t e n d s beyond s i m p l y l e g i s l a t i v e o r l e g a l s a n c t i o n . The c r i t e r i a of l e g i t i m a c y , f e a s i b i l i t y , and s u p p o r t c a n a l s o be v i e w e d i n the c o n t e x t o f t h e p l a n n i n g m a t r i x d i s c s s e d e a r l i e r i n t h i s t h e s i s ( s e e F i g u r e 4 . ) L e g i t i m a c y c r i t e r i a r e f l e c t w h e t h e r a h e a l t h p r o b l e m o r i s s u e a t 100 one planning l e v e l can draw upon p r i n c i p l e s or gu ide l ines at a higher planning l e v e l as j u s t i f i c a t i o n . F e a s i b i l i t y and support c r i t e r i a r e f l e c t the ease of movement of an issue at any given planning l e v e l , from a r a t i o n a l planning mode to an incremental planning mode. Support c r i t e r i a are p a r t i c u l a r l y important at the i d e o l o g i c a l and p o l i c y planning l e v e l s . Conceptual ly , the higher the p r i o r i t y of a hea l th problem or issue according to the c r i t e r i a of l eg i t imacy , f e a s i b i l i t y , and support, the eas ier (and f a s te r ) the movement of the issue to lower l eve l s i n the planning matrix and eventual implementat ion/service d e l i v e r y . The p r o v i n c i a l government has recognized, perhaps more on the bas is of p r a c t i c a l experience than conceptual f o re s i gh t , the usefulness of examining issues i n a systematic f a sh ion , to include c e r t a i n key c r i t e r i a . The standard format for a Cabinet Submission includes s p e c i f i c sect ions on f i n a n c i a l i m p l i c a t i o n s , l e g i s l a t i v e i m p l i c a t i o n s , munic ipal and reg iona l i m p l i c a t i o n s , p o l i t i c a l i m p l i c a t i o n s , and f e d e r a l - p r o v i n c i a l i m p l i c a t i o n s . The s i m i l a r i t y of these c r i t e r i a to the l eg i t imacy , f e a s i b i l i t y , and support c r i t e r i a i s worth n o t i n g . It i s a lso of i n t e r e s t that the e f for t s of the United States to e s t a b l i s h na t iona l gu ide l ines for t h e i r hea l th care system, pursuant to P u b l i c Law 93-641 ( Nat iona l Heal th Planning and Resources Development A c t , 1974 ) use a number of c r i t e r i a for "goa l " s e l e c t i o n that correspond to l e g i t i m a c y , f e a s i b i l i t y , and support c r i t e r i a . Legitimacy c r i t e r i a include relevance to s tatuatory mis s ion , whether the goal addresses an important h e a l t h i s sue , consis tency with other p o l i c y statements i n law or r e g u l a t i o n . F e a s i b i l i t y c r i t e r i a inc lude s u s c e p t i b i l i t y to achievement through program ac t ion and p o t e n t i a l usefulness to Heal th System Agencies . Support c r i t e r i a 101 include whether the goal i s ready to be adopted as a na t iona l statement ( United S ta tes , Department of Hea l th , Education and Welfare 1977a ) . I I I . F . Previous B . C . Health Plans Before concluding t h i s chapter on hea l th p lanning , i t i s useful to b r i e f l y review previous B . C . hea l th plans of a scope s i m i l a r to the proposed P r o v i n c i a l Heal th P l a n . B r i t i s h Columbia attempted a comprehensive plan for i t s hea l th care system i n the E l l i o t and Hamilton Reports of the e a r l y 1950's. The E l l i o t Report ( 1952 ) , "Survey of Health Services and F a c i l i t i e s i n B . C . " , was i n i t i a t e d o r i g i n a l l y to meet condi t ions for obtaining federa l Nat iona l Heal th Grants . But the mandate was soon broadened to include cons idera t ion of major p o l i c y . The report descr ibed federa l government hea l th services i n the province , p r o v i n c i a l and l o c a l pub l i c hea l th and mental s e r v i c e s , h o s p i t a l f a c i l i t i e s , and other h e a l t h services (WCB, VON, Red Cross , medical insurance p lans , e t c . ) and made 41 major recommendations to improve B . C . ' s hea l th care system. The Hamilton Report ("A Hospi ta l P lan and Profes s iona l Educat ional Programme for the Province of B r i t i s h Columbia") was also ca r r i ed out to meet condit ions of f edera l funding ( Hamilton and Associates 1950 ) . Its focus was on est imating h o s p i t a l bed requirements for the province , and how to best meet these requirements; but i t a lso attempted to estimate hea l th manpower requirements ( i n c l u d i n g phys ic i ans , pro fes s iona l nurses, h o s p i t a l admin i s t ra tor s , t e chn ic i ans , and s o c i a l workers) and the educat ional programs necessary to supply the needed hea l th manpower. It i s i n t e r e s t i n g to note that t h i s report some t h i r t y years ago stressed the same approach taken by the Hosp i t a l Role Study undertaken more recent ly by the 102 B . C . M i n i s t r y of Health ( 1981 ) . The Hamilton Report suggested four l e v e l s of h o s p i t a l : community c l i n i c and hea l th centre ; community h o s p i t a l ; reg iona l h o s p i t a l ; and teaching or base h o s p i t a l ; and stated that the functions performed by each acute general h o s p i t a l are determined by factors such as l o c a t i o n , s ize of community to be served, r e l a t i v e distance between h o s p i t a l s , and a v a i l a b i l i t y of doctors . The E l l i o t and Hamilton Reports were e s s e n t i a l l y a r a t i o n a l comprehensive planning mode approach. An inventory of hea l th resources was prepared; a l i s t of hea l th needs was es tab l i shed by "experts" and r e l i a n c e on accepted standards; and recommendations were made to bridge the gap between e x i s t i n g resources and perceived needs. However, there was l i t t l e mention of hea l th status outcomes expected from increas ing se rv ice s , nor was there a t t e n t i o n to problems of resource a l l o c a t i o n except i n the h o s p i t a l s ec tor . This was to be expected given the context of these repor t s , i . e . proposed federa l cos t- shar ing for h o s p i t a l c o n s t r u c t i o n . No explanation i s given i n the reports for the ranking of h o s p i t a l p ro j ec t s , and there was l i t t l e e x p l i c i t d i scus s ion i n the report of the gu ide l ines used to a r r i v e at the recommendations. The next comprehensive study of B . C . ' s hea l th care system was Health  Secur i ty for B r i t i s h Columbians, completed i n l a t e 1973, and known commonly as the Foulkes Report a f ter i t s author. This report began by s ta t ing the basis of i t s approach to improving the hea l th care system: (1) a W.H.O. d e f i n i t i o n of h e a l t h , (2) consumerism, (3) systems approach to hea l th care , (4) equal access based on needs, 103 (5) r e g i o n a l i z a t i o n of s e r v i c e s f o r p u b l i c p a r t i c i p a t i o n and r a t i o n a l i -z a t i o n o f s e r v i c e s , (6) a government r o l e i n h e a l t h p l a n n i n g , f i n a n c i n g , m o n i t o r i n g , r e s e a r c h , and e d u c a t i o n , (7) i n c r e a s e d p u b l i c r e g u l a t i o n of p r o f e s s i o n s , (8) modern management t h e o r y and t e c h n i q u e s . The F o u l k e s R e p o r t t h e n d e s c r i b e d t h e e x i s t i n g h e a l t h c a r e s y s t e m o f t h e p r o v i n c e , and p r o p o s e d a number of c h a n g e s : r e o r g a n i z a t i o n of t h e M i n i s t r y of H e a l t h ; d e c e n t r a l i z e d f u n d i n g ; Community Human R e s o u r c e and H e a l t h C e n t r e s ; C o u n c i l s t o i n t e r f a c e w i t h o t h e r government m i n i s t r i e s , t h e p u b l i c , and h e a l t h p r o f e s s i o n a l s / w o r k e r s ; e s t a b l i s h m e n t of 7-9 r e g i o n s f o r h e a l t h p l a n n i n g , a d o p t i o n o f PPBS and p e r s o n n e l d e p a r t m e n t e x p a n s i o n . More s p e c i f i c c o n c e r n s were a l s o a d d r e s s e d by t h e r e p o r t , and t h e s c o p e of i t s r ecommendat ions i s i m p r e s s i v e . The r e p o r t a d d r e s s e d h e a l t h manpower i s s u e s , t e a c h i n g h o s p i t a l s , emergency s e r v i c e s , r e h a b i l i t a t i o n , o c c u p a t i o n a l h e a l t h , e n v i r o n m e n t a l h e a l t h , p r e v e n t i v e m e d i c i n e , m e n t a l h e a l t h , a l c o h o l , n a t i v e p e o p l e s , t he a g e d , c h i l d r e n ' s d e n t a l n e e d s , h o u s i n g and h e a l t h , e t c . Many o f t h e p o i n t s o r i s s u e s r a i s e d i n the r e p o r t a r e s t i l l a p p l i c a b l e i n B . C . and i n t h i s s e n s e t h e R e p o r t s e r v e s as a u s e f u l r e f e r e n c e f o r h e a l t h p l a n n e r s . H o w e v e r , i n the c o n t e x t of deve lopment of t h e P r o v i n c i a l H e a l t h P l a n , i t i s u s e f u l t o f o c u s no t so much on t h e c o n t e n t as t h e p l a n n i n g a p p r o a c h a d o p t e d i n t h e F o u l k e s R e p o r t , and an a n a l y s i s of p o s s i b l e r e a s o n s i t was n e v e r o f f i c i a l l y a d o p t e d as government p o l i c y . As d e s c r i b e d a b o v e , t h e F o u l k e s R e p o r t l a i d t h e b a s i s of i t s r e p o r t and r e c o m m e n d a t i o n s on a "New P h i l o s o p h y of H e a l t h S e c u r i t y f o r B r i t i s h C o l u m b i a n s " . The use of t h e t e r m " p h i l o s o p h y " i s o v e r s t a t e m e n t ; t h e 104 c o n c e p t s a r e more a t the l e v e l of v a l u e s and g e n e r a l p r i n c i p l e s r a t h e r t h a n p h i l o s o p h y . There i s e x p l i c i t r e c o g n i t i o n t h a t s u c h g e n e r a l p r i n c i p l e s p r e c e d e , and s e r v e t o g u i d e , h e a l t h p l a n n i n g . However , i n s u f f i c i e n t a t t e n t i o n was g i v e n t o t h e s e g e n e r a l p r i n c i p l e s i n t h e F o u l k e s R e p o r t i n two i m p o r t a n t r e s p e c t s : t he g e n e r a l p r i n c i p l e s s t a t e d were n o t s u f f i c i e n t l y c o m p r e h e n s i v e and t h e p r o c e s s t o d e r i v e o r d e v e l o p s u c h g e n e r a l p r i n c i p l e s was n e g l e c t e d . The gaps i n the g e n e r a l p r i n c i p l e s , as s t a t e d i n t h e F o u l k e s R e p o r t c a n be s e e n on c o m p a r i n g them w i t h t h e g e n e r a l p r i n c i p l e s used as i l l u s t r a t i v e examp les i n t h i s t h e s i s ( s e e S e c t i o n V . A . ) The l a c k o f a t t e n t i o n t o t h e p r o c e s s of d e v e l o p i n g s u c h p r i n c i p l e s i s t h e more s e r i o u s s h o r t f a l l . The g e n e r a l p r i n c i p l e s p r o p o s e d i n the F o u l k e s R e p o r t a r e j u s t i f i e d by t h e a u t h o r as a r e f l e c t i o n of t h e s t a t e d p h i l o s o p h y of t h e New D e m o c r a t i c P a r t y , who had j u s t been e l e c t e d t o p r o v i n c i a l g o v e r n m e n t . T h e r e i s no i n d i c a t i o n t h a t o t h e r g r o u p s , i . e . p r o f e s s i o n a l a s s o c i a t i o n s , o t h e r l e v e l s of g o v e r n m e n t , u n i o n s , e t c . had been c o n s u l t e d i n e i t h e r e s t a b l i s h i n g o r r a t i f y i n g t h e s e g e n e r a l p r i n c i p l e s . C l e a r l y , any a p p e a l t o l e g i t i m i z e p r o p o s e d changes on t h e b a s i s of t h e s e p r i n c i p l e s w o u l d c a r r y l e s s w e i g h t . A n o t i c e a b l e f e a t u r e of t he F o u l k e s R e p o r t i s t h e amount of d e t a i l p r o v i d e d . T h e r e a r e f o r many a r e a s d e t a i l e d " b l u e p r i n t s " of what i s t o be done o r c h a n g e d , e g . new u n i f o r m s f o r ambu lance c r e w s . I n e f f e c t , t h e F o u l k e s R e p o r t a t t e m p t e d t o p l a n f o r t h e e n t i r e h e a l t h c a r e s y s t e m f r o m t h e p o l i c y p l a n n i n g l e v e l t o t h e p rogram d e l i v e r y l e v e l . I n d o i n g s o , i t t o o k a r a t i o n a l p l a n n i n g mode a p p r o a c h , i g n o r i n g the i m p o r t a n c e o f f e a s i b i l i t y and s u p p o r t c r i t e r i a . The F o u l k e s R e p o r t d e l i b e r a t e l y s e t ou t t o c r e a t e a new s y s t e m , and i n p l a n n i n g s u c h a s y s t e m p r o p o s e d s i g n i f i c a n t changes w h i c h w o u l d a d v e r s e l y a f f e c t i n f l u e n t i a l and i m p o r t a n t g r o u p s i n t h e 105 e x i s t i n g h e a l t h c a r e s y s t e m . F o r e x a m p l e , t he r e p o r t recommended p u t t i n g p h y s i c i a n s on s a l a r y r a t h e r t h a n f e e - f o r - s e r v i c e , i n t h e f a c e of a l o n g h i s t o r y of m e d i c a l a s s o c i a t i o n o p p o s i t i o n i n t h i s p r o v i n c e f o r any s u c h move. The r e p o r t recommended w h o l e s a l e changes i n s e n i o r management o f t h e t h e n f o u r d e p a r t m e n t s d e a l i n g w i t h h e a l t h , t h e r e b y a n t a g o n i z i n g the e x i s t i n g c i v i l s e r v i c e . The r e p o r t t o o k an o b l i q u e s w i p e a t v o l u n t a r y a s s o c i a t i o n s , s t r o n g l y i m p l y i n g t h a t t h e y w o u l d be i n t e g r a t e d i n t o t h e p u b l i c s y s t e m . The r e p o r t d e t a i l e d a r e g i o n a l s t r u c t u r e f o r t h e p r o v i n c e , w h i c h n e c e s s a r i l y w o u l d a f f e c t the autonomy of h o s p i t a l s and o t h e r i n s t i t u t i o n s . Many o t h e r e x a m p l e s c o u l d be c i t e d , bu t t h e p a t t e r n s h o u l d be e v i d e n t . I n a t t e m p t i n g t o p r o v e i t s c a s e , t h e F o u l k e s R e p o r t o f t e n had t o concede t h a t i t s d a t a base was i n a d e q u a t e . T h i s may have been a c c e p t a b l e i n a l e s s a n t a g o n i s t i c c l i m a t e , b u t was u n a c c e p t a b l e g i v e n the scope of t h e changes p r o p o s e d i n t h e r e p o r t . O p e r a t i o n a l i z i n g t h e recommendat ions of t h e F o u l k e s R e p o r t r e q u i r e d e x t r a o r d i n a r y c o o p e r a t i o n f r o m a l l t h e components of t h e h e a l t h c a r e s y s t e m , g i v e n t h a t a l a r g e segment was no t (and s t i l l i s n o t ) i n t h e d i r e c t c o n t r o l o f t he g o v e r n m e n t . Such c o o p e r a t i o n and s u p p o r t was v e r y u n l i k e l y g i v e n t h e p l a n n i n g a p p r o a c h a d o p t e d . The outcome of t h e F o u l k e s R e p o r t ( i . e . b a s i c a l l y " s h e l v e d " ) s u p p o r t s t h e more l i m i t e d s c o p e of t h e P r o v i n c i a l H e a l t h P l a n , and s u g g e s t s t h a t g r e a t e r a t t e n t i o n must be g i v e n t o b u i l d i n g c o n s e n s u s as t o t h e g e n e r a l p r i n c i p l e s w h i c h a r e t o g u i d e t h e P r o v i n c i a l H e a l t h P l a n . As w e l l , t h e r e must be i n c o r p o r a t i o n of w i d e l y r e p r e s e n t a t i v e v i e w p o i n t s and e x p e r t i s e i n t h e deve lopment phase of s u c h a p l a n . L a s t l y , a d a t a base i n s u p p o r t of p l a n n i n g must be d e v e l o p e d as an i n t e g r a l p a r t of t h e d e v e l o p m e n t of t h e P r o v i n c i a l H e a l t h P l a n . 106 Chapter IV. PROPOSED SCOPE OF A PROVINCIAL HEALTH PLAN: B . C . The review of general planning i n Chapter I I i s app l icab le to the planning for the P r o v i n c i a l Heal th Plan i n both the s e l e c t i o n of the type of items to be included i n the p l a n , and the approach suggested to develop the content i t s e l f . Therefore , the fo l lowing chapters w i l l draw heav i ly upon the t h e o r e t i c a l framework e s t a b l i s h e d , e s p e c i a l l y the concept of a matrix of planning modes and l e v e l s . Although the r a t iona le for a P r o v i n c i a l Health Plan was discussed i n general terms i n Chapter I, the s p e c i f i c nature and scope of the P r o v i n c i a l Health Plan and how i n fact i t would improve the funct ioning of the hea l th care system has not been d e t a i l e d . This chapter addresses the scope, form and a p p l i c a b i l i t y of the P r o v i n c i a l Heal th P l a n . R ight ly or wrongly, "p lans" are often considered inherent ly d e s i r a b l e . The connotations of comprehensiveness, r a t i o n a l i t y , coord ina t ion , i n t e g r a t i o n , e f fec t ivenes s , and e f f i c i e n c y may obscure the fact that planning must be d i rec ted to s p e c i f i c outcomes, and that there are both good plans and bad p lans . A frequent major f a i l i n g of plans i s that important assumptions, l i m i t a t i o n s , and intended scope of the plan are l e f t unstated. This chapter d e t a i l s the impl i ca t ions of the planning l e v e l s e l e c t e d ; the r a t iona le for adopting a government (and w i t h i n government, a M i n i s t r y of Health) planning per spec t ive ; and the boundaries and l i m i t a t i o n s of the P r o v i n c i a l Health Plan proposed i n t h i s t h e s i s . I V . A . Planning Levels It should be emphasized that planning takes place at d i f f e r e n t l eve l s 107 (see Figure 4 . ) , and i t i s not a question of determining the "best" l e v e l to p l a n , but rather c l a r i f y i n g the most appropriate l e v e l for the s p e c i f i c outcome intended. The wide range and type of issues discussed i n Chapter I , Rationale for a P r o v i n c i a l Heal th P lan , point towards the " p o l i c y planning" l e v e l as the primary focus of the P r o v i n c i a l Health P l a n . R e c a l l that t h i s was discussed e a r l i e r as " s e l e c t i o n of broad i d e o l o g i c a l goals , determination of p r i o r i t i e s on i d e o l o g i c a l grounds, cons idera t ion of the 'general w i l l ' , development of d e f i n i t i o n s , categories and c l a s se s , development of l e g i s l a -t i o n and r e g u l a t i o n s , and development of standing plans" ( C r i c h t o n 1981, p . 279 ) . It i s i n t e r e s t i n g to compare th i s approach to Dror ' s ( 1971 ) three l eve l s of p o l i c y : metapol icy , megapolicy, and s p e c i f i c p o l i c y . Metapolicy i s concerned with p o l i c y about pol icymaking. Megapolicies are a set of master gu ide l ines to more s p e c i f i c p o l i c i e s . The P r o v i n c i a l Heal th Plan can therefore be considered as megapolicy, while the development of the framework for the plan can be considered metapol icy . This thes i s suggests that development of l e g i s l a t i o n and r e g u l a t i o n s , although d e f i n i t e l y inf luenced by p o l i c y p lanning , i n fact i s more appropr ia te ly considered at the l e v e l of adminis t ra t ive p lanning . In other words, l e g i s l a t i o n i s but one of many mechanisms by which p o l i c y i s o p e r a t i o n a l i z e d . The other c h a r a c t e r i s t i c a c t i v i t i e s of the p o l i c y planning l e v e l are app l i cab le as gu ide l ines to what must be considered by the P r o v i n c i a l Heal th P l a n . Thus, there must be a s e l e c t i o n of i d e o l o g i c a l goals and cons idera t ion of the 'general w i l l ' . In other words, the P r o v i n c i a l Heal th Plan must incorporate statements of values and general p r i n c i p l e s of a f a i r l y high order of a b s t r a c t i o n , although not at the l e v e l 108 of p h i l o s o p h y , a p p l i c a b l e t o t h e h e a l t h c a r e s y s t e m . M o r e o v e r , t h e p r o c e s s o f d e v e l o p m e n t of s u c h s t a t e m e n t s must i n c l u d e i n p u t s by i n d i v i d u a l s and g r o u p s i n a manner a c c e p t a b l e t o w e s t e r n l i b e r a l d e m o c r a t i c p r i n c i p l e s . F o l l o w i n g f r o m t h e s e l e c t i o n of t he p o l i c y p l a n n i n g l e v e l , t h e r e comes the need f o r d e f i n i t i o n s and c a t e g o r i z a t i o n s . T h i s depends i n p a r t on t h e g e n e r a l p r i n c i p l e s s e l e c t e d . F o r e x a m p l e , c o n c e r n s o r p r i n c i p l e s r e l a t i n g t o r e g i o n a l e q u i t y of h e a l t h s e r v i c e s w i l l r e s u l t i n d i f f e r e n t c a t e g o r i z a t i o n s t h a n c o n c e r n s o r p r i n c i p l e s r e l a t i n g t o s o c i o e c o n o m i c e q u i t y of h e a l t h s e r v i c e s . The d e f i n i t i o n s and c a t e g o r i z a t i o n s depend i n p a r t a l s o on t h e n a t u r e of t h e h e a l t h c a r e s y s t e m i t s e l f : t h e e x i s t i n g o r g a n i z a t i o n of s e r v i c e s , t h e p a t t e r n s and c a u s e s of i l l - h e a l t h , e t c . The P r o v i n c i a l H e a l t h P l a n must t h e r e f o r e have a f ramework w h i c h c a t e g o r i z e s components of t h e h e a l t h c a r e s y s t e m i n a way w h i c h i s c o n s i s t e n t w i t h g e n e r a l p r i n c i p l e s , and y e t w h i c h r e c o g n i z e s t h e c a t e g o r i z a t i o n s i n h e r e n t i n t h e h e a l t h c a r e s y s t e m . P e r h a p s o f g r e a t e s t i m p o r t a n c e a t t h e p o l i c y p l a n n i n g l e v e l , and c e r t a i n l y t h e c h a r a c t e r i s t i c w h i c h a p p e a l s most s t r o n g l y t o s e n i o r managers and d e c i s i o n - m a k e r s , i s t h e f o c u s on d e t e r m i n a t i o n of p r i o r i t i e s . T h i s i s i n t r i n s i c t o p l a n n i n g ; w h a t e v e r l e v e l of p l a n n i n g i s s e l e c t e d , p r i o r i t i e s w i l l have t o be d e t e r m i n e d . The p o l i c y p l a n n i n g l e v e l i s u n i q u e i n t h a t i t must s e r v e as t h e i n t e r f a c e between the p h i l o s o p h i c a l l e v e l , where p r i o r i t i e s a r e r e l a t i v e l y u n i m p o r t a n t ; and t h e a d m i n i s t r a t i v e l e v e l , where p r i o r i t i e s a r e e s s e n t i a l . A t a d m i n i s t r a t i v e and l o w e r l e v e l s of p l a n n i n g , d e t e r m i n a t i o n of p r i o r i t i e s i s amenable t o t r a d i t i o n a l " r a t i o n a l " a p p r o a c h e s t o e v a l u a t i o n ( c o s t - b e n e f i t , c o s t - e f f e c t i v e n e s s , e t c . ) A t t h e p o l i c y p l a n n i n g l e v e l , d e t e r m i n a t i o n of p r i o r i t i e s i s much more s u b j e c t to 109 p o l i t i c a l ( i . e . i d e o l o g i c a l ) cons idera t ions , and there i s a tremendous d i f f i c u l t y i n o p e r a t i o n a l i z i n g general p r i n c i p l e s into "ob jec t ive s " which are understandable and useful to managers at the admini s t ra t ive l e v e l . C r i c h t o n ' s f i n a l c h a r a c t e r i s t i c of p o l i c y p lanning , development of standing p lans , provides an e x p l i c i t i n d i c a t i o n that the P r o v i n c i a l Heal th Plan i s appropr ia te ly considered at the p o l i c y planning l e v e l , and also sheds some i n s i g h t in to how the P r o v i n c i a l Health Plan i s l i k e l y to be of usefulness . Standing plans , whether by design or de fau l t , are r e l a t i v e l y comprehensive and a ready reference when time or circumstances preclude developing a new plan to meet a p a r t i c u l a r s i t u a t i o n . The timeframe i s genera l ly longer s ince the standing p l an , even i f r e g u l a r l y updated, i s meant to be app l i cab le over a period of t ime. Se lec t ion of the p o l i c y planning l e v e l i m p l i c i t l y de l imi t s the scope of the P r o v i n c i a l Heal th Plan by s ta t ing i n ef fect i t does not deal p r i m a r i l y with other planning l e v e l s . Thus, i t does not deal with "b luepr in t p lanning" as envis ioned by MacStravic ( 1978 ) : "The outcome of the needs-determination process should be a b luepr in t of the hea l th system and i t s performance. This b luepr in t describes the number, type, o r g a n i z a t i o n , and l o c a t i o n of hea l th resources required to respond to the popula t ion ' s expected behaviour" ( p . 26 ) . Such a plan i s app l icab le at a lower planning l e v e l . The P r o v i n c i a l Heal th Plan w i l l not address planning at the l e v e l of abs t rac t ion and scope of , for example, G i l ' s ( 1970 ) formulat ion of s o c i e t a l functions as resource development, a l l o c a t i o n of s t a tu s , a l l o c a t i o n of r i g h t s / p r e r o g a t i v e s , and l inkages of the l a t t e r two a c t i v i t i e s . This i s not to suggest that analyses , such as G i l ' s , are not a use fu l and necessary part of the understanding of the o v e r a l l planning 110 p r o c e s s . The i m p o r t a n c e of a l l o c a t i o n of s t a t u s and r i g h t s t o t h e d e f i n i t i o n s and c a t e g o r i z a t i o n s d e t e r m i n i n g p r i o r i t i e s i s o b v i o u s . However , t h e p l a n n i n g l e v e l s e l e c t e d ( i n t h i s c a s e , p o l i c y p l a n n i n g ) p r e c l u d e s t h i s l e v e l of a n a l y s i s . A d h e r e n c e t o a p a r t i c u l a r p l a n n i n g l e v e l f o r t h e P r o v i n c i a l H e a l t h P l a n may a p p e a r a r t i f i c i a l and u n n e c e s s a r y . Why do we n o t t a k e a b r o a d e r v i e w o f p l a n n i n g and c o n s i d e r s i m u l t a n e o u s l y d i f f e r e n t p l a n n i n g l e v e l s ? As t h i s t h e s i s i l l u s t r a t e s , a l a r g e t a s k r e m a i n s even when we p r i m a r i l y d i s c u s s one p l a n n i n g l e v e l . More i m p o r t a n t l y , d i f f e r e n t l e v e l s of p l a n n i n g a r e u n d e r t a k e n and u n d e r s t o o d by d i f f e r e n t l e v e l s of management. M i x i n g l e v e l s may r e s u l t i n an i r r e l e v a n t p l a n f r o m t h e v i e w p o i n t of t h e g r o u p s / l e v e l of p e o p l e t h a t t h e P r o v i n c i a l H e a l t h P l a n i s i n t e n d e d t o s e r v e . R e c o g n i t i o n of t he p l a n n i n g l e v e l s h o u l d p r e v e n t , o r a t l e a s t m i t i g a t e , N j u m p i n g i n a p p r o p r i a t e l y f r o m one p l a n n i n g l e v e l t o a n o t h e r . F o r c i r c u m -s c r i b e d p r o b l e m s o r i s s u e s , i t may be n e c e s s a r y and d e s i r a b l e t o p l a n how an i s s u e c a n be d e v e l o p e d f r o m the p h i l o s o p h i c l e v e l t o t h e a c t u a l s e r v i c e p r o v i s i o n . However , t h e b r e a d t h of t h e P r o v i n c i a l H e a l t h P l a n makes s u c h an a p p r o a c h u n f e a s i b l e . A d i s t i n c t i o n s h o u l d be made b e t w e e n f l i p p i n g back and f o r t h i n a p p r o p r i a t e l y be tween p l a n n i n g l e v e l s , and an a p p r e c i a t i o n t h a t o t h e r p l a n n i n g l e v e l s , n o t a b l y t h e two a d j a c e n t ( h i g h e r and l o w e r l e v e l s ) , e x i s t and must be c o n s i d e r e d . I l l IV.B. Government ( M i n i s t r y of Health ) Perspective Culyer ( 1978 ) discusses the public i n t e r e s t ( = government ) involvement i n health care, i n terms of four f a c t o r s : (1) communicable disease,(2) f i n a n c i a l burden, (3) geographical d i s t r i b u t i o n , (4) health status. Communicable disease i s the c l a s s i c example where the s o c i a l benefit i s greater than i n d i v i d u a l benefit because of s p i l l over e f f e c t s . The l a t t e r three factors are "public i n t e r e s t " because the public or community at large i s presumed to adhere to values about equity, (extending to income d i s t r i b u t i o n and in-kind d i s t r i b u t i o n ) , geographic d i s t r i b u t i o n , and p r i o r i t i e s of health "needs" based on status. This i s an expression of a government r o l e that extends beyond what Lowi ( 1964 ) has termed " d i s t r i b u t i o n a l " a c t i v i t i e s , into areas of "regulative" and " r e d i s t r i b u t i v e " a c t i v i t i e s , p a r t l y because market forces are seen as inoperative or at least i n e f f e c t i v e i n coordinating and integrating the health care system. Evans and Williamson ( 1978 ) provide, from an economist's perspective, c r i t e r i a f o r government inte r v e n t i o n : (1) reduction of f i n a n c i a l r i s k , (2) t r a n s f e r of wealth, (3) impact on l e v e l or patterns of u t i l i z a t i o n , (4) improved r e l a t i v e economic e f f i c i e n c y of health services to meet needs. In Canada, one of the major factors i n government involvement i n health care has been the d i v i s i o n of r e s p o n s i b i l i t i e s between federal and p r o v i n c i a l governments. C o n s t i t u t i o n a l l y , provinces have j u r i s d i c t i o n over "health". H i s t o r i c a l l y however, that p r o v i n c i a l r e s p o n s i b i l i t y was not re l a t e d to revenue generating authority to fund health care costs. Beginning i n 1948, the federal government entered into a series of Cost-sharing agreements with the provinces, which had the federal government funding approximately 50% of medical and h o s p i t a l costs. Since the 112 p r o v i n c i a l government was i n ef fect spending "50 cent" d o l l a r s for h e a l t h care , there was perhaps i n i t i a l l y le s s incent ive to concern i t s e l f with d e t a i l s of how e f f e c t i v e l y the hea l th care system was opera t ing . The cont inuing r i s e i n hea l th care costs did cause concern and led to var ious e f for t s to contain costs ( e . g . Canada 1970 ) . From the f edera l per spec t ive , cos t- shar ing was too open-ended and a formula of b loc grants to the provinces was negotiated in s t ead . As these monies were t rans ferred to the provinces ' general revenue, there was increased incent ive for each province to contain i t s hea l th care cos t s . P r o v i n c i a l governments i n i t i a l l y content to c o n t r o l costs by attempting to c o n t r o l o v e r a l l hea l th care expenditures , found that despite projected budgets and c e i l i n g s on expenditures , hea l th care costs continued to r i s e . Faced with dec i s ions whether to cover budget d e f i c i t s and over-runs , or to c u r t a i l h igh p r o f i l e hea l th services and programs, p r o v i n c i a l governments have tended to avoid the p o l i t i c a l l y unpopular step of c u r t a i l i n g programs. However, given the current economic reces s ion and drop i n government revenues i n B r i t i s h Columbia, containment of hea l th care costs becomes i n c r e a s i n g l y a major i s s u e . The p r o v i n c i a l government continues to take steps to ensure the most e f f e c t i v e use of the resources i t does a l l oca te for hea l th care ; i n other words, rather than delegat ing the a l l o c a t i o n of hea l th services e n t i r e l y to providers ( e . g . hosp i t a l s ), the p r o v i n c i a l government tends to a greater r o l e i n determining p r i o r i t i e s and se t t ing g u i d e l i n e s . A quick overview of the hea l th insurance system operating i n B . C . i l l u s t r a t e s the degree of p r o v i n c i a l government involvement i n hea l th care funding. A l l res idents of the province ( a f t e r 3 months ) who are landed immigrants or c i t i z e n s have t h e i r h o s p i t a l expenses covered by taxat ion 113 revenue, except for a nominal d a i l y charge to the p a t i e n t . Af ter approximately a three month wait ing p e r i o d , a l l landed immigrants and c i t i z e n s can subscribe to the Medica l Services P l a n . Rates are , as of January 1982, $138/year for a s ing le person and $345/year for a family of three or more. This insurance covers phys ic i an serv ices ( i n c l u d i n g lab work ) and a l i m i t e d number of services for other groups ( c h i r o p r a c t o r s , phys io therap i s t s , osteopaths, e t c . ) . Pharmacare covers drug costs for senior c i t i z e n s ( over age 65 ) and a l s o , i n instances where an i n d i v i d u a l ( or f ami ly ) r eg i s te red with the Medical Service Plan spends over $100/year on p r e s c r i p t i o n drugs, 80% of any a d d i t i o n a l co s t s . The Long Term Care Program provides personal ca re , intermediate care , and extended care beds at a nominal d a i l y charge for e l i g i b l e p a t i e n t s . Home support and Home Care ( i . e . home nurs ing serv ices ) are also covered. Even the hea l th care costs which are borne p r i v a t e l y are e l i g i b l e for an income tax deduction, further reducing the net out-of-pocket pr iva te expenditure. The existence of such a comprehensive hea l th insurance system, government funded, means that almost a l l of the hea l th care costs of operat ing the hea l th care system are channelled through government, notably the M i n i s t r y of Health and to a much les ser extent the M i n i s t r y of Human Resources. An often overlooked aspect of t h i s system however i s that the M i n i s t r y i s u sua l ly a t h i r d party payer. Although the Medica l Services Commission pays physic ians d i r e c t l y , i t does t h i s for phys ic i an-pa t i ent t r ansac t ions . The r e l a t i o n s h i p i s even more i n d i r e c t with h o s p i t a l s , where the M i n i s t r y funds h o s p i t a l s , who i n turn negotiate with and pay t h e i r s t a f f . There i s every i n d i c a t i o n that the government i s attempting to 114 change the s ty l e of p ro fe s s iona l cont ro l from what Johnson ( 1972 ) terms " c o l l e g i a t e " to "media t ion" , i . e . towards greater government r e g u l a t i o n and standards. The r a t i o n a l e for th i s i s i n many ways s i m i l a r to points r a i s e d by the Castonguay Commission, i . e . " to r econc i l e the pub l i c i n t e r e s t with the incontes table advantage of a c e r t a i n autonomy of the profess ions with regard to p u b l i c a u t h o r i t y " ( Quebec 1970, p. 9 ) . A d d i t i o n a l l y , c a p i t a l and equipment costs are funded p r i m a r i l y through government, although unl ike operating cos t s , i n a shared fashion amongst d i f f e rent l eve l s of government. O r d i n a r i l y , c a p i t a l costs are d iv ided 50% to the reg iona l h o s p i t a l d i s t r i c t and 50% to the M i n i s t r y of Hea l th . For f a c i l i t i e s or equipment that can be considered as r e f e r r a l centres , the M i n i s t r y of Health pays a higher p ropor t ion , up to 100% for c a p i t a l that cons t i tutes a p r o v i n c i a l resource . Because of the comprehensive hea l th insurance system, the government has access to a wealth of information r e l a t i n g to prov i s ion of hea l th s e r v i c e s , e . g . Medical Services Plan b i l l i n g data provides information on number and types of services provided by physic ians to p a t i e n t s , grouped according to age/sex. Further information i s ava i l ab le from the V i t a l S t a t i s t i c s branch of the M i n i s t r y , which by statute must gather and pub l i sh c e r t a i n hea l th status in format ion . Information not found w i t h i n the M i n i s t r y of Health ( and the data sources are numerous ) can often be r e l a t i v e l y e a s i l y accessed from other government departments. For example, populat ion pro jec t ions by age/sex breakdown are prepared by the Centra l S t a t i s t i c s Bureau, a branch of the M i n i s t r y of Industry and Small Business Development. The l e v e l of planning expert i se and experience i n the M i n i s t r y of 115 Health should permit cons idera t ion of a wide range of hea l th i s s u e s . Planning resources ava i l ab l e w i t h i n the M i n i s t r y of Health include a d i v i s i o n devoted to p o l i c y and p lanning . Other d i v i s i o n s wi th in the M i n i s t r y also have planning and research s t a f f , although genera l ly with a more narrow per spec t ive . The increases i n M i n i s t r y of Health budget were noted e a r l i e r , as were the factors leading to continued expansion. These t rans la te in to increased pressure on the M i n i s t r y to conta in co s t s , and develop more e f f ec t ive p lanning . The s e l e c t i o n of a government per spect ive , and i n p a r t i c u l a r a M i n i s t r y of Health per spec t ive , i s seen as a reasonable choice , given the p u b l i c i n t e r e s t aspects , degree of government funding involvement, information and data a v a i l a b i l i t y , and wi l l ingnes s ( under some pressure ) to devote resources to undertake the p lanning . Indeed, the types of problems which Shigan ( 1979 ) l i s t s for the hea l th care system are very much ju s t those problems which the M i n i s t r y of Health i s expected to address and i n f a c t , i s best prepared ( r e l a t i v e to any other organiza t ion or i n s t i t u t i o n ) to address: -Long-term forecas t ing of hea l th , environmental and resource demand ind ice s - Reorganizat ion of the hea l th care system - Se l ec t ion of new d i r e c t i o n s for research - Es t imat ion of hea l th status i n d i c e s , environmental parameters, and resource demands and u t i l i z a t i o n - Contro l of costs of medical services - E f f i c i e n t s a t i s f a c t i o n of emergency and non-emergency demands - Short-term forecas t ing of h e a l t h , environmental , and resource demand 116 i n d i c e s . H a v i n g s t a t e d a g o v e r n m e n t a l , and s p e c i f i c a l l y a M i n i s t r y of H e a l t h , p l a n n i n g p e r s p e c t i v e f o r t h e P r o v i n c i a l H e a l t h P l a n g i v e s some g u i d e l i n e s a s t o t h e scope o f s u c h a p l a n . A d o p t i n g a M i n i s t r y of H e a l t h p e r s p e c t i v e i s n o t synonymous w i t h f o r m u l a t i o n of a M i n i s t r y o f H e a l t h p l a n . C e r t a i n f u n c t i o n s w i t h i n t h e h e a l t h c a r e s y s t e m a r e d i r e c t government r e s p o n s i b i l i -t i e s ; o t h e r f u n c t i o n s a r e f unded by g o v e r n m e n t , but o p e r a t i o n a l l y c o n t r o l l e d by n o n - g o v e r n m e n t a l b o d i e s . There a r e s t i l l o t h e r e l e m e n t s of t h e h e a l t h c a r e s y s t e m a f f e c t e d by t h e M i n i s t r y o f H e a l t h o n l y i n d i r e c t l y i n t h e b r o a d s e n s e t h a t t h e M i n i s t r y i n f l u e n c e s a l l m a j o r components of t h e s y s t e m . The P r o v i n c i a l H e a l t h P l a n , and t h e o b j e c t i v e s c o n t a i n e d t h e r e i n , w i l l t h u s be most d i r e c t l y a p p l i c a b l e t o t h o s e h e a l t h s e r v i c e s p r o v i d e d by t h e M i n i s t r y o f H e a l t h and o t h e r p r o v i n c i a l a g e n c i e s o r m i n i s t r i e s . To t h e e x t e n t t h a t o t h e r p r o v i d e r s of h e a l t h s e r v i c e s , and consumers of h e a l t h s e r v i c e s , a c c e p t t h e P r o v i n c i a l H e a l t h P l a n , i t i s a p p l i c a b l e as a p l a n n i n g document f o r t h e h e a l t h c a r e s y s t e m . Of c o u r s e , t he government t h r o u g h i t s f i s c a l and l e g i s l a t i v e a u t h o r i t y c a n s t r o n g l y i n f l u e n c e t h e a d o p t i o n and a p p l i c a t i o n o f t h e P r o v i n c i a l H e a l t h P l a n , e v e n i n a r e a s no t d i r e c t l y under a M i n i s t r y l i n e r e s p o n s i b i l i t y . S i n c e , as w i l l be e l a b o r a t e d i n l a t e r s e c t i o n s of t h i s t h e s i s , t h e r e w i l l be e x p l i c i t o p p o r t u n i t y f o r v a r i o u s i n t e r e s t e d g r o u p s t o p r o v i d e i n p u t t o t h e d e v e l o p m e n t of t h e P r o v i n c i a l H e a l t h P l a n , and s i n c e t h e r e i s r e c o g n i t i o n and e x t e n s i v e r e l i a n c e on b o t h " e x p e r t " o p i n i o n and community i n p u t , t h e P r o v i n c i a l H e a l t h P l a n w i l l h o p e f u l l y be b r o a d l y a c c e p t e d as t h e g e n e r a l d i r e c t i o n and p o l i c i e s f o r t h e e n t i r e B . C . h e a l t h c a r e s y s t e m . I m p l e m e n t a t i o n of t h e p l a n may r e q u i r e s e p a r a t e p l a n s by 117 var ious actors w i t h i n the hea l th care system. There may wel l be a M i n i s t r y of Health p l a n , which given i t s resources and r e s p o n s i b i l i t i e s , d e t a i l s s p e c i f i c M i n i s t r y goals and ob ject ives wi th in the context of the P r o v i n c i a l Health P l a n . S i m i l a r l y profes s iona l groups or as soc ia t ions and i n d i v i d u a l f a c i l i t i e s may develop t h e i r O ~ T I plans and ob ject ives wi th in the environment of the P r o v i n c i a l Heal th P l a n . To better understand the impl ica t ions of a M i n i s t r y of Health perspect ive requires some assumptions as to the r o l e of the M i n i s t r y , and i n p a r t i c u l a r , i t s ro le v i s a v i s other l eve l s of government, e . g . municipal or other r eg iona l s t r u c t u r e s . I V . C . Reg iona l i za t ion and the P r o v i n c i a l Health Plan Reg iona l i za t ion i s not a new concept. A U.S . P u b l i c Health Service report some four decades ago, proposed a b luepr in t of an integrated na t iona l h o s p i t a l system ( Shonick 1976 ) . This was subdivided in to h o s p i t a l serv ice areas composed of base h o s p i t a l s , d i s t r i c t h o s p i t a l s , small r u r a l h o s p i t a l s , and hea l th centres for i s o l a t e d areas . The base hosp i t a l s are what we might term today t e r t i a r y r e f e r r a l centres . In England, the 1974 reorganiza t ion created 15 reg iona l hea l th a u t h o r i t i e s , with smaller subdiv i s ions of "area hea l th a u t h o r i t i e s " . The Castonguay Report recommended CLSC's for d e l i v e r y of l o c a l s e r v i c e s , supported by a h i e r a r c h i c a l s t ructure of r e g i o n a l , s p e c i a l i s t and u n i v e r s i t y c e n t r e s / h o s p i t a l s . D i s t r i c t Health Counci ls have been i n existence now i n Ontario for many years . Foulkes recommended a reg iona l s t ructure for B . C . i n 1973, with community human resource and hea l th centres and a r e g i o n a l hea l th d i s t r i c t board. 118 Despite the f a m i l i a r i t y of the r e g i o n a l i z a t i o n concept, B . C . has only a rudimentary reg iona l system for hea l th planning purposes ( eg. Regional H o s p i t a l D i s t r i c t s ) , and i t i s worthwhile s t a r t i n g from basic explanations of r e g i o n a l i z a t i o n . There are many d e f i n i t i o n s i n the l i t e r a t u r e for r e g i o n a l i z a t i o n . For example, i t has been described as a "scheme for the n a t i o n a l / geographic development of hea l th care resources i n an organized and h i e r a r c h i c a l arrangement, so that the maximum amount poss ib le i s done at the lowest service l e v e l and services of progres s ive ly greater l eve l s of i n t e n s i t y are provided according to the needs of the i n d i v i d u a l p a t i e n t s " ( Rhode I s l and , Department of Health 1977 ) . Despite the wide v a r i e t y of d e f i n i t i o n s , genera l ly two basic concepts ( over and above genera l ly app l i cab le hea l th planning p r i n c i p l e s ) are s t re s sed : (1) resource a l l o c a t i o n or service d e l i v e r y based on geographical areas (2) h i e r a r c h i c a l arrangement of service d e l i v e r y , ranging from primary to secondary, to t e r t i a r y l eve l s of care , f u n c t i o n a l l y l inked i n a coordinated manner. These two concepts imply a p r e s c r i p t i v e d i s t r i b u t i o n of hea l th manpower and f a c i l t i e s and also consumer usage pat terns . This l a t t e r aspect i s often overlooked, i . e . i t does l i t t l e good to locate manpower or f a c i l i t i e s at the geographica l ly optimal loca t ions i f pat ients refuse to make use of them. A long l i s t of advantages i s c i t e d i n support of r e g i o n a l i z a t o n , but ana lys i s ind ica te s that these can be subsumed under three major headings: (1) increased e f f e c t i v e n e s s / e f f i c i e n c y , and therefore cost containment 119 (2) improved access to hea l th s e r v i c e s , i n c l u d i n g a more personal nature of service (3) increased community p a r t i c i p a t i o n There are d i f f e r i n g approaches i n def in ing a r e g i o n . An A u s t r a l i a n report s ta tes : " A reg ion i s a geographical area that i s economically and s o c i a l l y de f ined . A region should show a considerable l e v e l of independence such that wi th in region t i e s are stronger than between reg ion t i e s . " ( A u s t r a l i a , Hospi ta l s and Health Services Commission 1974 ) . It c l a s s i f i e d three d i f f e ren t approaches to determination of reg ions : (1) e c o l o g i c a l -based on usage patterns of services wi th in an area ; (2) op t imiza t ion -areas determined on a t h e o r e t i c a l basis and pre sc r ibed ; (3) admini s t ra t ive -adoption of a r b i t r a r y boundaries of already e x i s t i n g ( or proposed ) admini s t ra t ive reg ions . There i s some overlap i n these d e f i n i t i o n s and an e c l e c t i c approach would seem more reasonable than r i g i d adherence to any s ing le method. On t h i s ba s i s , a number of factors are commonly used i n determination of reg ions : (1) geography - e . g . na tura l geographic b a r r i e r s , (2) t ranspor ta t ion and communication l i n e s - e x i s t i n g and future roads , r a i l , a i r , e t c . The actua l t r a v e l time involved i s c r u c i a l . One c r i t e r i a that has been proposed i s that there be a maximum of 2-3 hours from centre to periphery of the r eg ion , (3) populat ion - present and projected t o t a l , and the d i s t r i b u t i o n among urban and r u r a l areas . For example, i t i s suggested that there be a minimum of 100,000 populat ion to cons t i tu te a r eg ion , and that 850,000 to 1 m i l l i o n populat ion i s needed to j u s t i f y a f u l l range of hea l th serv ices with 120 severa l major centre s . (4) s o c i a l and economic pat terns , (5) e x i s t i n g f a c i l i t i e s , s e r v i c e s , and u t i l i z a t i o n pat terns . The i n t e r - r e g i o n a l flow can be used to quantify the s e l f - s u f f i c i e n c y of a r e g i o n . (6) e x i s t i n g government and adminis t ra t ive s t ruc ture s , boundaries, e t c . (7) f i n a n c i a l systems and mechanisms of funding. These factors are not independent of each other . Geography w i l l a f f ec t t r a n s p o r t a t i o n , which i n turn a f fects s o c i a l and economic pat terns , and so on. It has been suggested, from cons iderat ion of such f a c t o r s , each reg ion should have a " c r i t i c a l mass" a l lowing appropriate community involvement, a sophi s t i ca ted l e v e l of integrated hea l th care services l o g i c a l l y t i e d i n t o c e n t r a l s e r v i c e s , and an e f f ec t ive management and admini s t ra t ive o rgan iza t iona l group for the r e g i o n . R e g i o n a l i z a t i o n allows for varying degrees of autonomy for the region r e l a t i v e to c e n t r a l a u t h o r i t y . For a n a l y t i c purposes, three degrees of autonomy are described ( Martins 1975 ) : (1) complete autonomy (2) r e l a t i v e autonomy (3) c lose superv i s ion Complete autonomy describes a " s tate w i t h i n a s tate" s i t u a t i o n . The region would have a high degree of s e l f - s u f f i c i e n c y and l e g a l a u t h o r i t y . The r e l a t i v e autonomy model tends to leave areas of d i s c r e t i o n i n a p p l i c a t i o n of bas ic p r i n c i p l e s decided at the c e n t r a l l e v e l . Close  superv i s ion impl ies branch o f f i ce s of cent ra l author i ty rather than reg iona l 121 admin i s t ra t ions . The pure forms are seldom seen i n p r a c t i c e ; u sua l ly a mixture of each type for var ious a t t r ibu te s are found i n any p a r t i c u l a r r eg ion , e s p e c i a l l y as re la ted to executive power, f inanc ing sources , r egu la t ion of services and o v e r a l l standards. The current s i t u a t i o n i n B . C . regarding r e g i o n a l i z a t i o n has been the subject of much study. Ex i s t ing j u r i s d i c t i o n a l boundaries for hea l th services are not coterminous. Thus, the reg iona l h o s p i t a l d i s t r i c t s ( corresponding to the reg iona l d i s t r i c t s ) are not exact ly the same as the p u b l i c hea l th unit d i s t r i c t s . Mental hea l th services r e l y on s t i l l another set of boundaries . The d i s t r i c t s contr ibute to c a p i t a l f inancing for h o s p i t a l bu i ld ings and equipment, but operating expenses are negotiated d i r e c t l y between the M i n i s t r y of Health and i n d i v i d u a l i n s t i t u t i o n s . Present ly , i n the hea l th care system i n B . C . , there i s not a delegat ion of au thor i ty or r e s p o n s i b i l i t y to reg iona l a u t h o r i t i e s . Indeed, most reg iona l a u t h o r i t i e s present ly lack the s t a f f and t e c h n i c a l resources to undertake such r e s p o n s i b i l i t i e s . For d i scus s ion purposes, boundaries for r e g i o n a l i z a t i o n of hea l th services i n B .C . have been proposed, r e s u l t i n g i n seven regions with populations ranging from 200,000 to 800,000: (1) The North (2) Centra l I n t e r i o r (3) Okanagan/Kootenays (4) Lower Mainland (5) Vancouver (6) Vancouver Is land and Coast (7) C a p i t a l Regional D i s t r i c t 122 This thes i s suggests the most e f f ec t ive approach to r e g i o n a l i z a t i o n i s a " r e l a t i v e autonomy" model. Reference can be made to Ontar io ' s ( 19 74 ) e f for t s i n r e g i o n a l i z a t i o n , which appears to follows th i s model. A number of complementary functions were proposed for the p r o v i n c i a l , i e . c e n t r a l , and reg iona l l e v e l s . Thus, at the p r o v i n c i a l l e v e l : (1) D e l i n e a t i o n of boundaries and updating (2) Overa l l planning and guidance for the prov i s ion of hea l th serv ices - s e t t i n g p o l i c i e s , s tandards. (3) Prov i s ion of s p e c i a l i z e d consul t ing s e r v i c e s . (4) C o l l e c t i o n and ana lys i s of data for e v a l u a t i o n . (5) Maintenance of f i n a n c i a l c o n t r o l . (6) Necessary cent ra l reorganiza t ion to accommodate a reg iona l system. And at the reg iona l l e v e l , these functions were proposed: (1) Develop goal s , recognizing the hea l th needs and concerns of the c i t i z e n s wi th in the r e g i o n . (2) Develop plans for the p r o v i s i o n of resources , programs, and f a c i l i t i e s . (3) Coordinate hea l th services programs and the resources of manpower, f a c i l i t i e s , and f inances for the r e g i o n . (4) In c o l l a b o r a t i o n with the Prov ince , evaluate the ef fect of region programs. (5) Exerc i se f i n a n c i a l author i ty commensurate with assigned r e s p o n s i b i l i t i e s . The P r o v i n c i a l Heal th Plan should therefore accommodate the sharing of planning r e s p o n s i b i l i t i e s between c e n t r a l and reg iona l planning a u t h o r i t i e s . 123 In p a r t i c u l a r , o v e r a l l p o l i c i e s and standards would be c e n t r a l l y determined, but the reg iona l or community-specific a p p l i c a t i o n of such standards would be r e g i o n a l l y determined. I V . D . Boundaries of Health The scope of the P r o v i n c i a l Heal th Plan must also address the quest ion of boundaries of " h e a l t h " . What i s the subject matter of the plan? There are c e r t a i n areas genera l ly agreed to be part of the hea l th care system ( e . g . hosp i t a l s ) . However, other marginal areas are often considered part of the economic, wel fare , and education systems rather than part of the hea l th care system. E s p e c i a l l y d i f f i c u l t i s the d i s t i n c t i o n between h e a l t h care and s o c i a l welfare p o l i c y . Cr ichton ( 1982 ) has observed that hea l th p o l i c y i n Canada has been used as an instrument of key s o c i a l p o l i c y , not ju s t d i rec ted to hea l th care . The d i s t i n c t i o n between hea l th planning and hea l th care planning attempts to resolve semantica l ly the question of boundaries ( Know 1979 ) . Health planning i s described as operating "through modifying any or a l l of the determinants of h e a l t h , i n c l u d i n g the p h y s i c a l and s o c i a l environments and patterns of i n d i v i d u a l and group behaviour, as w e l l as through the personal hea l th se rv ice s " ( p . 30 ) . Health care p lanning , on the other hand, "focuses on the l a t t e r ( personal hea l th services ) , attempting to se lect volumes and conf igurat ions of f a c i l i t i e s , personnel , t echnolog ie s , equipment, and services which w i l l best meet the needs of defined populations w i t h i n the l i m i t s imposed by resources and a c c e p t a b i l i t y " ( P . 30 ) . Blum ( 1974 ) argues that s o c i a l and environmental factors are the 124 larges t determinants of hea l th and therefore should be considered i n any study of the hea l th care system: "As mult i faceted as our d e f i n i t i o n of hea l th has become, i n d i c a t o r s d i rec ted only to hea l th (our system of concern) are not enough and must be matched by ba t ter ie s of ind ica tor s useful i n the nonhealth sectors of our soc ie ty (the environment around our hea l th system)" ( p . 166 ) . I d e a l l y , the P r o v i n c i a l Health Plan would concern i t s e l f with hea l th  p lanning , and i t i s not d i f f i c u l t to f ind support for th i s approach. The In terna t iona l I n s t i t u t e for Appl ied Systems Ana lys i s (IASSA) s tates ( Shigan 1979 ) : "To answer questions of medical resource demand and a l l o c a t i o n , i t i s necessary not only to estimate populat ion change but also to forecast the dynamics of the hea l th of the popu la t ion . This problem i s a lso complicated by the strong dependence of the hea l th care system on socio-economic, environmental , and other external sys tems . . . We see that both the HCS and external systems may be d iv ided in to subsystems and that the connections between subsystems and t h e i r parameters may be d i r e c t or i n d i r e c t , continuous or d i s c r e t e , strong or weak, changeable over time or constant" ( p . 3 ) . I t i s worth mentioning an e f for t to model a system incorporat ing var ious s ec tor s , the Vancouver Regional Simulat ion Model, which inc luded aspects such as p o p u l a t i o n , t r a n s p o r t a t i o n , land use, p o l l u t i o n , ecology, e t c . ( Quebec 1972 ) . MEDICS also out l ined a broad p ic ture of hea l th care w i t h i n a wider government system, inc lud ing education and pub l i c works ( Quebec 1972 ) . McKeown ( 1975 ) concluded that s ince the 18th Century, " in f luences responsible for the modern improvement i n hea l th were mainly behavioural (the change i n reproduct ive p rac t i ce which led to the dec l ine of i n f a n t i c i d e and r e s t r i c t e d the growth of populat ion) and environmental (comprising two changes, an improvement i n food supplies and removal of hazards from the 125 p h y s i c a l environment. ) " ( P« 71 ) . This conclus ion i s s t i l l v a l i d , and modern man's hea l th i s l a r g e l y dependent on behavioural and environmental f ac tor s - not the medical care system. Thus hea l th planning should encompass more than the t r a d i t i o n a l hea l th care system with i t s medical o r i e n t a t i o n . One of the best known statements/reports advocating a hea l th planning rather than a hea l th care planning approach i s Lalonde's (1974) New  Perspectives on the Health of Canadians, a report which has perhaps generated more a t t ent ion outside Canada than at home. There i s a c l e a r demonstration that i f p o t e n t i a l years of l i f e l o s t i s used as a c r i t e r i o n , the major hea l th problems i n Canada are re l a ted to l i f e s t y l e and environmental f a c t o r s . The arguments presented for taking a hea l th planning perspect ive are very f o r c e f u l . There i s a r a t i o n a l , l o g i c a l basis for taking such a comprehensive approach. Unfortunate ly , the disadvantages inherent i n such a planning mode are app l i cab le also i n taking a hea l th planning approach. Belanger et a l ( 1974 ) s t a t e : "our current s o c i a l organiza t ion packages our concerns in to d i s c re te bureaucrat ic departments. It seems u n l i k e l y that t h i s can change s i g n i f i c a n t l y w i t h i n the near fu ture . Consequently, models of hea l th care systems must n e c e s s a r i l y mimic t h e i r parent systems i n being d e l i m i t e d , i f rather a r b i t r a r i l y so" ( p . 407 ) . Close r e l a t i o n s h i p s across sectors cannot be assumed. Shonick ( 1976 ) cautions that reductions of expenditures i n the hea l th care system w i l l not nece s sa r i ly lead to increased resources being set aside to improve non-health care system determinants of hea l th s ta tus . S i m i l a r l y , the Resource A l l o c a t i o n Working Party (RAWP) made a conscious dec i s ion to take a r e s t r i c t i v e d e f i n i t i o n of 126 h e a l t h : "We recognize the important inf luences of other f a c t o r s , e . g . hous ing , environmental hea l th f a c i l i t i e s , working cond i t ions , e t c . Except i n the sense that they a l l have an impact on the morbidity of popula t ions , we cannot take them into account. They are the province of other s o c i a l programmes and the extent to which they react with the hea l th care programme i s not an i ssue with which we are equipped to dea l " ( Great B r i t a i n , Department of Health and S o c i a l Services 1976, p. 11 ) . Because the hea l th care system i s exceedingly complex and rooted i n the medical model, e f for t s to i n s t i t u t e r a d i c a l change w i l l encounter s t i f f r e s i s t a n c e . For example, the "Black Report" i n Great B r i t a i n reviewed the per s i s tent socioeconomic c lass i n e q u a l i t i e s i n hea l th status and use of hea l th s e r v i c e s , and recommended a wider s trategy encompassing more progress ive taxat ion measures ( e . g . increase of c h i l d tax allowance and increased housing benef i t s ) and more educat ional oppor tun i t i e s . However, the government has given the report a " f ro s ty r e c e p t i o n " , and i n fact made only a l i m i t e d number of copies of the report ava i l ab le ( Gray 1982 ) . The i n e r t i a of e x i s t i n g i n s t i t u t i o n s and organizat ions precludes taking a s t r i c t hea l th planning approach as the basis for the P r o v i n c i a l Heal th P l a n . However, i t i f were simply a quest ion of maintaining the status quo, with only marginal changes, there would be l i t t l e purpose i n developing the P r o v i n c i a l Heal th P l a n . What i s required i s a r ecogn i t ion and i n c o r p o r a t i o n of e x i s t i n g o rgan iza t iona l patterns and hea l th care resources into a planning framework which s t i l l permits the i n j e c t i o n of "exper t i se " and r a t i o n a l p lanning . This suggests that ne i ther a hea l th planning nor a hea l th care planning approach i s adequate i n de f in ing the boundaries of "hea l th " for the purposes 127 of t h e P r o v i n c i a l H e a l t h P l a n . I n s t e a d , t h i s t h e s i s a d o p t s what m i g h t be te rmed a m o d i f i e d h e a l t h c a r e p l a n n i n g a p p r o a c h . T h i s a p p r o a c h i n c l u d e s , bu t i s n o t l i m i t e d t o , a r e a s t r a d i t i o n a l l y c o n s i d e r e d i n h e a l t h c a r e p l a n n i n g , i n c l u d i n g a r e a s c l e a r l y under t h e j u r i s d i c t i o n of t h e M i n i s t r y of H e a l t h . I t encompasses t h e r e f o r e a r e a s of r e s p o n s i b i l i t y mandated by s p e c i f i c l e g i s l a t i o n f a l l i n g u n d e r t h e M i n i s t r y of H e a l t h . T h e r e a r e c u r r e n t l y about 40 s p e c i f i c A c t s a d m i n i s t e r e d by t h e M i n i s t r y o f H e a l t h . A d o z e n of t h e s e r e l a t e t o h e a l t h p r o f e s s i o n a l g r o u p s , d e f i n i n g s e l f - r e g u l a t o r y r i g h t s and r e s p o n s i b i l i t i e s , n o t a b l y p r e v e n t i n g n o n - q u a l i f i e d p r a c t i t i o n e r s f r o m t h e s p e c i f i c p r o f e s s i o n s : C h i r o p r a c t e r s A c t , D e n t a l T e c h n i c i a n s A c t , D e n t i s t s A c t , M e d i c a l P r a c t i t i o n e r s A c t , N u r s e s ( P r a c t i c a l ) A c t , N u r s e s ( P s y c h i a t r i c ) A c t , N u r s e s ( R e g i s t e r e d ) A c t , O p t o m e t r i s t s A c t , P h a r m a c i s t s A c t , P h y s i o t h e r a p i s t s A c t , P o d i a t r i s t s A c t , and P s y c h o l o g i s t s A c t . A number of t he a c t s u n d e r t h e M i n i s t r y of H e a l t h a r e v e r y s p e c i f i c i n s c o p e , and t h e r e f o r e of l e s s i n t e r e s t i n d i s c u s s i o n o f b o u n d a r i e s f o r t h e P r o v i n c i a l H e a l t h P l a n , e . g . H a i r d r e s s e r ' s A c t . A f u r t h e r g r o u p of a c t s r e l a t e t o " v i t a l " e v e n t s , b u t a g a i n i s of l e s s i n t e r e s t f rom t h e p e r s p e c t i v e o f b o u n d a r i e s s i n c e t h e f u n c t i o n s a r e o f an a d m i n i s t r a t i v e and r e c o r d - k e e p i n g n a t u r e : M a r r i a g e A c t , Name A c t , V i t a l S t a t i s t i c s A c t , W i l l s A c t . T h e r e a r e a number of m a j o r a c t s u n d e r t h e M i n i s t r y of H e a l t h ' s a d m i n i s t r a t i o n w h i c h do d e f i n e the s c o p e , and t h u s i n a s e n s e t h e b o u n d a r i e s f r o m a l e g i s l a t i v e s t a n d p o i n t , of t h e M i n i s t r y . The M i n i s t r y of H e a l t h A c t s t a t e s t h a t " t h e M i n i s t r y , under t h e m i n i s t e r ' s d i r e c t i o n , s h a l l have c h a r g e o f a l l m a t t e r s r e l a t i n g t o p u b l i c h e a l t h and government h e a l t h i n s u r a n c e p r o g r a m s . " The g o v e r n m e n t ' s t r a d i t i o n a l p u b l i c h e a l t h p r o t e c t i o n r o l e i s 128 found more s p e c i f i c a l l y i n the Pub l i c T o i l e t A c t , Tuberculos i s I n s t i t u t i o n A c t , Venereal Disease A c t , and the Health A c t . The emphasis, r e f l e c t i n g h i s t o r i c a l development, i s on measures to prevent and contain communicable d i seases . The Mental Heal th Act authorizes the r e s t r a i n t and custody of persons su f fer ing from mental i l l n e s s ; th i s again has overtones of p u b l i c p r o t e c t i o n . The government's involvement with h o s p i t a l and medical insurance i s d e t a i l e d i n the H o s p i t a l Insurance A c t , the Medical Service A c t , and the Medical Service P lan A c t . The extent of hea l th insurance and impl i ca t ions a r i s i n g from th i s have been discussed i n Sect ion I V . B . Government involvement i n h o s p i t a l cons t ruct ion i s de t a i l ed i n the H o s p i t a l D i s t r i c t A c t . Within th i s l e g i s l a t i v e framework, the M i n i s t r y of Hea l th ' s r e s p o n s i b i l i t i e s are r e f l e c t e d i n i t s o rgan iza t iona l s t r u c t u r e . Reporting to the Deputy M i n i s t e r are four major areas, three of which are "program" areas , with the fourth encompassing support functions app l i cab le M i n i s t r y - w i d e . These four areas, and the corresponding func t iona l a c t i v i t i e s , as noted i n the 1981 Annual Report, are shown below ( B r i t i s h Columbia, M i n i s t r y of Health 1981 ) : Management Operat ions : L e g i s l a t i o n , P lanning , P o l i c y Formulat ion, Research and E v a l u a t i o n , Financing and Budgets. I n s t i t u t i o n a l Se rv i ce s : Emergency Health Services ( p r i m a r i l y the ambulance serv ice ) , H o s p i t a l Programs ( funding of operat ional budgets, c a p i t a l c o n s t r u c t i o n , purchase of equipment ) , Home Care and Long Term Care ( i n c l u d i n g home support services and r e s i d e n t i a l care ) . Community Care Serv ice s : Mental Heal th Serv ices , Forensic P s y c h i a t r i c Serv ices , A lcoho l and Drug Serv ice s , Medica l Services Plan ( the medical 129 i n s u r a n c e s y s t e m ) . P r e v e n t i v e S e r v i c e s : P u b l i c H e a l t h I n s p e c t i o n , P u b l i c H e a l t h N u r s i n g , Speech and H e a r i n g S e r v i c e s , D e n t a l H e a l t h S e r v i c e s , H e a l t h P r o m o t i o n and N u t r i t i o n , O c c u p a t i o n a l H e a l t h , V e n e r e a l D i s e a s e C o n t r o l , T u b e r c u l o s i s c o n t r o l , P r o v i n c i a l L a b o r a t o r y . A r e a s w h i c h i n t e r f a c e w i t h o t h e r s e c t o r s of s o c i e t y , c o r r e s p o n d i n g t o s o - c a l l e d " i n t e r f a c e " i s s u e s w i t h o t h e r government m i n i s t r i e s c a n be c a t e g o r i z e d a c c o r d i n g t o t h e M i n i s t r y i n q u e s t i o n . M a j o r a r e a s of i n t e r f a c e a r e w i t h t h e M i n i s t r y o f Human R e s o u r c e s , A t t o r n e y G e n e r a l , t h e M i n i s t r y o f E d u c a t i o n ( and b e c a u s e B . C . has a s e p a r a t e M i n i s t r y f o r U n i v e r s i t i e s ) , t h e M i n i s t r y o f U n i v e r s i t i e s , S c i e n c e , and C o m m u n i c a t i o n s , and t h e M i n i s t r y o f t h e E n v i r o n m e n t . Examp les of i n t e r f a c e i s s u e s , where t h e b o u n d a r i e s of t h e P r o v i n c i a l H e a l t h P l a n may be " f u z z y " a r e shown b e l o w . M i n i s t r y o f Human R e s o u r c e s ; C h i l d r e n S e r v i c e s , i n c l u d i n g C h i l d A b u s e ; Long Term C a r e ; P h a r m a c a r e ; " S o c i a l " p r o b l e m s ; H a n d i c a p p e d and R e h a b i l i t a t i o n S e r v i c e s . A t t o r n e y G e n e r a l : S e a t b e l t u s a g e ; A l c o h o l A b u s e , i n c l u d i n g w h i l e d r i v i n g a c a r ; F o r e n s i c p s y c h i a t r i c p r o b l e m s ; B e h a v i o u r d i s o r d e r s ; D rug A b u s e , i n c l u d i n g h e r o i n . M i n i s t r y o f E d u c a t i o n : H e a l t h manpower e d u c a t i o n ; C l i n i c a l p l a c e m e n t s of i n t e r n s . M i n i s t r y o f t h e E n v i r o n m e n t : P e s t i c i d e s ; P o l l u t i o n . There i s no q u e s t i o n t h a t t h e s e i s s u e s and f a c t o r s i m p a c t on " h e a l t h " , and t h e r e f o r e must be c o n s i d e r e d i n a m o d i f i e d h e a l t h c a r e p l a n n i n g a p p r o a c h . F o r t h e p u r p o s e s of t h e P r o v i n c i a l H e a l t h P l a n , t h e s e a r e a s r e q u i r e s p e c i a l a t t e n t i o n . On ly t h o s e a s p e c t s of t h e i n t e r f a c e i s s u e s w h i c h 130 are considered wi th in the t r a d i t i o n a l hea l th care system ( and the boundaries for such cons idera t ion are renegotiated constant ly ) w i l l be formal ly included i n the process of ob jec t ive s e t t i n g , p o l i c y , s tandards , p r i o r i t y determination e t c . of the P r o v i n c i a l Health P l a n . The boundaries on " h e a l t h " suggested by th i s paper for the purposes of the P r o v i n c i a l Health Plan can be u se fu l ly compared to the framework developed by de Miguel ( 1975 ) for the study of n a t i o n a l hea l th systems. He proposes four sub-systems, with " f ac to r s " or components i n each subsystem: (1) I n d i v i d u a l - Health s tatus , Bio-medical f ac tor s , Psycholog ica l f a c t o r s ; (2) I n s t i t u t i o n s - Health Serv ices , Health Organizat ions , Health Planning; (3) Society - S o c i o c u l t u r a l p a t t e r n s , P o l i t i c a l S t ruc ture , Economic Development, Demographic S t ruc ture ; (4) Larger Systems - Environment. The sub-systems range from the micro to the macro, and together provide a comprehensive p i c ture of the hea l th system. The P r o v i n c i a l Heal th Plan focuses on the " I n d i v i d u a l " subsystem, and the " I n s i t u t i o n a l " subystem, with l e s ser a t t e n t i o n to the Society sub-system. 131 Chapter V . PROPOSED FRAMEWORK FOR A PROVINCIAL HEALTH PLAN: B . C . Chapters I to IV have provided the background for an approach or framework for development a P r o v i n c i a l Health P lan . The out l ine of the proposed framework i s diagrammed below: COMMUNITY INPUT VALUES ABOUT THE* HEALTH CARE SYSTEM CENTRAL PLANNING [LONG TERM OBJECTIVES CENTRAL PLANNING BASELINE REGIONAL PLANNING OBJECTIVES SHORT TERM OBJECTIVES Figure 21. Outline of the Proposed Framework for a P r o v i n c i a l Health Plan The P r o v i n c i a l Health Plan focuses on the p o l i c y planning l e v e l , which corresponds to ob jec t ive s e t t i n g . Hence the endpoint , or outcome, of the development process cons i s t s of Short Term Objectives ( STO' s ) . Because the P r o v i n c i a l Heal th Plan i s a "standing p l a n " , Long Term Objectives (LTO's) are also i n c l u d e d . Indeed, as suggested by the sequentia l nature of the development, e s t a b l i s h i n g LTO's f a c i l i t a t e s development of STO's . This concept i s common to most planning approaches. The t r a n s l a t i o n of LTO's to STO's - those opera t iona l ob ject ives which are to receive current funding -requires a resource a l l o c a t i o n process . This thes i s proposes using the concept of Basel ine Object ives to make th i s a more manageable undertaking. Because the p o l i c y planning l e v e l takes i t s reference from the ideology planning l e v e l , Values or general p r i n c i p l e s concerning the h e a l t h 132 care system and soc ie ty i n genera l , are a major determinant of the ob jec t ives for the P r o v i n c i a l Heal th P l a n . Thus, Values are shown as an i n i t i a l input to the development process . The basic skeleton of t h i s process also assumes that a reg iona l hea l th care planning system has evolved i n B r i t i s h Columbia. The d i v i s i o n of planning r e s p o n s i b i l i t y between c e n t r a l and reg iona l planning author i ty i s an i n t e g r a l part of the developmental o u t l i n e . Community input i s considered by r e g i o n a l planners as part of the process of determining STO's . The P r o v i n c i a l Heal th Plan w i l l therefore contain statements of Values , Long Term Objec t ive s , Basel ine Objec t ives , Short Term Objec t ives , and also a consis tent methodology for ensuring community input i s taken in to account. Fol lowing sect ions of th i s chapter discuss i n greater d e t a i l the development and a p p l i c a t i o n of each of these components necessary to the P r o v i n c i a l Health P l a n . It i s of i n t e r e s t to compare the framework for development of the P r o v i n c i a l Heal th Plan with the many-stage developmental process descr ibed for Health Systems Plans i n the United States , shown i n the fo l lowing f i g u r e 22. PLAN DEVELOPMENT PROCESS 0 PREPARATION • POLICIES t ORGANIZATION • SCHEDULE/WORK PLAN 0 ASSESSMENT • FRAMEWORK FOR PLANNING • INDICATORS 6 DATA GATHERING • REFERENCE PROJECTION (FORECAST) 0 "GOALS AND OBJECTIVES 9 GOALS AND PRIORITIES • OBJECTIVES AND PRIORITIES LONG-RANGE ACTIONS/RESOURCE REQUIREMENTS • LONG-RANGE ACTION PROPOSALS 9 CONSTRAINTS 0 ALTERNATIVE COMBINATIONS 0 SELECTED LONG-RANGE ACTIONS/RESOURCE REQUIREMENTS 0 HEALTH SYSTEM PLAN 0 DRAFT HSP 0 REVISED HSP 0 ANNUAL IMPLEMENTATION 0 SHORT-RANGE ACTION PROPOSALS 0 COMBINATIONS OF ACTIONS 0 SELECTED SHORT-RANGE ACTIONS 0 PUBLISHED AIP 133 FIGURE 22. Development Process f o r Health Systems Plans SOURCE: United States, Department of Health, Education and Welfare. A Course on a Systems Approach to Health Plan Development Leader's Guide. 1979, p. I-I3 < 134 The stages are "a c y c l i c a l process of expressing community values and long-range a p p l i c a t i o n s for hea l th status and hea l th system performances; p r o j e c t i n g and eva luat ing the c a p a b i l i t i e s of current hea l th serv ices to address them; and designing and choosing among act ions that w i l l c lose the gap between pro jected and des ired l e v e l s of community hea l th and hea l th sytem performance" ( United S ta te s , Department of Hea l th , Educat ion and Welfare 1979a, p. 1 - 1 3 ) . The P r o v i n c i a l Hea l th P l a n i s of more modest scope, focusing p r i m a r i l y upon the expression of community values i n terms of hea l th status and hea l th system ob jec t ive s . V . A . Va lues , as app l ied to the Hea l th Care System The planning matr ix , F igure 4 . , summarizes the concept that planning ob jec t ives stem from higher order general p r i n c i p l e s or va lues . Most planning approaches incorporate t h i s concept i m p l i c i t l y or ( less often ) e x p l i c i t l y . For example, Cantley ( 1981 ) re fers to "general idea l s about q u a l i t y of l i f e and s o c i e t y , and the r o l e of h e a l t h " as an input to strategy formulat ion i n hea l th care , ( see F igure 23. ) As Abel-Smith ( 1976 ) observed: "Value premises must u n d e r l i e any choice of p r i o r i t i e s whether or not these premises are formal ized i n a hea l th status i n d e x . . . S u c h choices should r e f l e c t the values of a p a r t i c u l a r s o c i e t y . I d e a l l y each community should be enabled to p a r t i c i p a t e i n the choice of i t s own p r i o r i t i e s " ( Chapter 8 ) . 0 1 3 5 P r e s e n t o n d f o r e c o s t e n v i r o n m e n t : E c o n o m i c ( R e v e n u e 8 C o p i t a l B u d g e t s ) - , D e m o g r p p h i c ; M o r b i d i t y ; T e c h n o l o g i c a l ( M e d i c o l Science); O t h e r s o c i o l o n d p o l i t i c a l t r e n d s o u t s i d e t h e a u t h o r i t y ' s c o n t r o l P r e s e n t |^| p e r f o r m a n c e P r e s e n t r e s o u r c e s o n d c o p o b i i i t i e s C u r r e n t p o l i c i e s N o t i o n a l g u i d e - l i n e s ; p u b l i c e x p e c t a t i o n s , G e n e r a l i d e a l s o b o u t q u a l i t y o f l i f e o n d s o c i e t y , a n d t h e r o l e o f h e a l t h M e a s u r o b l e , s c h e d u l e d t o r g e t s f o r s p e c i f i c l e c t o r s o f o c f i v i t y , b y g e o g r a p h i c a l o r e o Forecast future performance C o m p a r i s o n : t o i d e n t i f y i n f e a s i b i l i t y o r u n o c c e p t o b i l i t y o n c u r r e n t p l o n s , r e s o u r c e s , a s s u m p t i o n s F u t u r e r e s o u r c e s o n d c a p a b i l i t i e s P l o n s f o r e x p a n d i n g , c o n t r a c t i n g , r e d e p l o y i n g , m o d i f y i n g r e s o u r c e s FIGURE 23. Gap A n a l y s i s Appl ied to Strategy Formulat ion i n Heal th Care SOURCE: M . F . Cant ley , S t ra teg ic Contro l f o r a United Kingdom Regional Heal th A u t h o r i t y : A Conceptual Framework. Behavioural  Sc ience, 1981, V o l . 26, p . 7. 136 The f i r s t step i n development of o b j e c t i v e s f o r the P r o v i n c i a l Health Plan i s c o n s i d e r a t i o n of the values which are to serve as the b a s i s f o r the h e a l t h care system i n B r i t i s h Columbia. Major inputs f o r the establishment of values are shown below: POLIT ICAL + SOCIAL IDEOLOGIES GOVERNMENT VALUES ABOUT THE HEALTH CARE SYSTEM GROUP IDEOLOGIES VALUES ABOUT THE HEALTH CARE SYSTEM DATA BASE FIGURE 24. Determination of Values P o l i t i c a l and s o c i a l i d e o l o g i e s , and t h e i r t r a n s l a t i o n i n t o value statements a p p l i c a b l e to the h e a l t h care system and c o n s i s t e n t with current government and M i n i s t r y of Health v a l u e s , are discussed i n S e c t i o n V.A.I. Group i d e o l o g i e s , and a proposed mechanism to f o r m a l i z e such input f o r the purposes of the development of the P r o v i n c i a l Health P l a n , are discussed i n Se c t i o n V.A.2. The Data Base i s discussed i n S e c t i o n V.B.I., i n the context of development of Long Term O b j e c t i v e s . 137 V . A . I . P o l i t i c a l and S o c i a l Ideologies V . A . 1 . 1 . An Overview Roemer ( 1977 ) has d i scussed , i n h i s review of i n t e r n a t i o n a l hea l th care systems, the determinants of a hea l th care system as being h i s t o r i c a l events , economic l e v e l s , and c u l t u r a l inf luences as w e l l as p o l i t i c a l p o l i c i e s . However, s ince the factors amenable to planning are wi th in the p o l i t i c a l ( and s o c i a l ) sphere, i t i s useful to f i r s t present a b r i e f overview of p o l i t i c a l and s o c i a l i d e o l o g i e s . Marchak ( 1975 ) defines ideologies as "screens through which one perceives the s o c i a l wor ld . Their elements are assumptions, b e l i e f s , explanat ions , va lues , and o r i e n t a t i o n s " ( p . 1 ) . Geertz ( 1964 ) adds: "Whatever e l se ideo log ies may b e . . . t h e y are most d i s t i n c t i v e l y maps of problematic s o c i a l r e a l i t y and matrixes for the c rea t ion of c o l l e c t i v e conscience" ( p . 64 ) . He further suggests that ideolog ies are a r e su l t of s o c i e t a l s t r a i n , permit t ing mechanisms for r e l i e f of that s t r a i n through catharcism, morale sustainment, group s o l i d a r i t y , and advocacy. C h r i s t i a n and Campbell ( 1974 ) d iscuss two expressions of ideology . The f i r s t i s found i n an abstract p r i n c i p l e or set of p r i n c i p l e s ; the second i s found i n the ac tua l operations of i n s t i t u t i o n s . These two expressions may not c o i n c i d e . For example, statements of Canadian ideology have s tressed equa l i ty of condi t ion s ince World War I I . Yet, Badgley and Charles ( 1978 ) present epidemiologic evidence that th i s i s not i n fact the case i n Canadian s o c i e t y . The major p o l i t i c a l ideo log ies i n Canada are ( democratic ) s o c i a l i s m , conservatism, and l i b e r a l i s m . Warham ( 1974 ) notes that s o c i a l i s m , i n 138 whatever form impl ies a commitment to " e q u a l i t y " . Moreover, on reviewing the var ious forms of s o c i a l i s m , she concludes that i n democratic s o c i a l i s m , equa l i ty of cond i t ion i s considered the "end" , and equa l i ty of opportunity i s seen only as one of several means to that end. The aims of democratic soc i a l i sm w i l l therefore be more equitable d i s t r i b u t i o n of p o l i t i c a l and economic power ( e . g . na t iona l income ) using t axa t ion , extension of the government sector through s o c i a l s e r v i c e s , and other forms of r e d i s t r i b u t i o n . Conservatism has elements of soc i a l i sm and l i b e r a l i s m . Horowitz ( 1970 ) describes i t as s t re s s ing " p r e s c r i p t i o n , a u t h o r i t y , order and hierarchy i n an organic s o c i e t y " . Thus, there i s s imultaneously an i m p l i c a t i o n of c o l l e c t i v i s t o r i e n t a t i o n ( as i n soc i a l i sm ), and a lso a minimal r o l e for government ( as i n l i b e r a l i s m ) . The conservative w i l l downplay innova t ion , seeking instead to accept only those changes that are unavoidable i n a changing s o c i e t y . In a conservat ive ly ordered s o c i e t y , the rules and laws w i l l tend to maintain the e x i s t i n g s t a tus . Given the dominant nature of the l i b e r a l ideology i n Canada, i t i s discussed here i n greater d e t a i l . It i s important not to equate p o l i t i c a l party l abe l s with ideo logy . Marchak ( 1975 ) cautions that the L i b e r a l Party i n Canada i s not synonymous with the l i b e r a l ideology , which has i t s roots elsewhere, and i t s strongest expression i n other countr ie s , notably the United S ta tes . The l i b e r a l ideology rests on the ph i lo sophic p o s i t i o n that the i n d i v i d u a l i s more important than soc i e ty . Weber traces t h i s back to Protestant i sm, which emphasized i n d i v i d u a l r e s p o n s i b i l i t y for s i n and redemption. L i b e r a l i s m focuses not on equa l i ty of c o n d i t i o n , but rather claims the r i gh t of i n d i v i d u a l s to seek t h e i r own happiness , i . e . equa l i ty 139 of opportuni ty . Warham ( 1974 ) s t a te s : "Whereas the ega l i t a r i an i sm of s o c i a l i s m i s based on the notions of c o l l e c t i v i t y , and of e q u a l i t i e s of cond i t ion as conducive to the freedom of i n d i v i d u a l s to p a r t i c i p a t e more f u l l y as equal ly valued members of the c o l l e c t i v i t y , l i b e r a l i s m sees s o c i e t i e s as composed e s s e n t i a l l y of i n d i v i d u a l s i n competit ion with each other" ( pp. 36 - 37 ) . Government i n t e r v e n t i o n i s j u s t i f i e d only to promote the capaci ty of i n d i v i d u a l s to work towards t h e i r aims - not to supply or provide the aims themselves. The U .S . Economic Opportunit ies Act c l e a r l y demonstrated th i s a t t i t u d e : "to integrate the poor in to the opportunity s t ructure of American L i f e . " In Canada, Pearson explained l i b e r a l i s m : "(the problem) i s posed i n the necess i ty of preserving the independence and s e l f - r e l i a n c e of the i n d i v i d u a l , d r i v i n g home the r e a l i z a t i o n that he stands above the s ta te , which i s the essence of l i b e r a l i s m , with the o b l i g a t i o n , i n the complicated organiza t ion of soc iety which we have today, of the state to protect the i n d i v i d u a l when pro tec t ion i s r e q u i r e d . " ( Marchak 1975, p. 35 ) . The ro le of government i s thus very d i f f e r e n t l y viewed i n democratic soc i a l i sm and l i b e r a l i s m . In the l a t t e r , s o c i a l s e r v i c e s , rather than being government instruments of f i r s t r e sor t , are instruments of l a s t r e s o r t , to be discarded as soon as p o s s i b l e . Horowitz ( 1970 ) , on analyzing l i b e r a l i s m i n Canada, concludes that i n Eng l i sh Canada, l i b e r a l i s m , although dominant, has had and continues to have l eg i t imate streams of toryism and s o c i a l i s m . H i s t o r i c a l factors help to exp la in L i p s e t ' s ( 1963 ) f indings that Canada has much greater tendency to a s c r i p t i o n and e l i t i s m than the United States , accepting hierarchy and s o c i a l s t r a t i f i c a t i o n as we l l as the power of the state to develop and 140 c o n t r o l the economy to a much greater degree. Marchak. ( 1975 ) a lso notes that l i b e r a l i s m i n Canada, although dominant, i s not the only i d e o l o g i c stream: "the dominant ideology of the country i s l i b e r a l i n the u t i l i t a r i a n t r a d i t i o n . Its humanitarian conscience i s expressed i n the chal lenging welfare state ideo log ies of the NDP and the ph i l an throp ic endeavour supported by L i b e r a l s and Conservat ives" ( p . 12 ) . Cr ichton ( 1980 ) , i n comparing a number of western nations ( i n c l u d i n g Canada ) , observes that s o c i a l ideologies have stemmed from p o l i t i c a l i d e o l o g i e s . This close r e l a t i o n s h i p i s seen i n the three models of s o c i a l ideology w i t h i n western democracies, described by Titmuss ( 1974 ) : (1) r e s i d u a l wel fare , (2) i n d u s t r i a l achievement, (3) i n s t i t u t i o n a l r e d i s t r i b u t i o n . The r e s i d u a l welfare model can be traced to England's poorhouse. An i n d i v i d u a l ' s needs should be met by himself ( or f ami ly ) and the market, according to th i s model. Only i f these f a i l should s o c i a l welfare i n s t i t u t i o n s in tervene . Titmuss exp la ined : "It i s the case for minimum government, c e n t r a l and l o c a l , maximum l i b e r a t i o n from state i n t e r v e n t i o n , a r e s i d u a l r o l e for ( pre ferab ly ) a voluntary s o c i a l p o l i c y , and maximum permission ( or freedom ) for the i n d i v i d u a l to act according to h i s own conscience and to spend h i s own money as he wishes i n the pr ivate market without l e t or in ter ference from o f f i c i a l s or bureaucrats ( who cannot know best )" ( p . 33 ) . The i n d u s t r i a l achievement model views s o c i a l welfare i n s t i t u t i o n s as s i g n f i c i a n t adjuncts to the economy. The determination of needed serv ices 141 i s very much i n f l u e n c e d by the e f f e c t on p r o d u c t i v i t y and work performance. The i n s t i t u t i o n a l r e d i s t r i b u t i o n model places s o c i a l welfare i n t e g r a l l y w i t h i n s o c i e t y . Services are d i s t r i b u t e d on the basis of "need", and based on a p r i n c i p l e of s o c i a l e q u a l i t y . Titmuss c i t e d the United States as an example of a r e s i d u a l welfare model, West Germany as an example of an i n d u s t r i a l achievement model, and Great B r i t a i n as an example of an i n s t i t u t i o n a l r e d i s t r i b u t i o n model. A more recent a n a l y s i s of the values of h e a l t h p o l i c y " e l i t e s " i n the United S t a t e s , the United Kingdom, and West Germany suggests that these models of s o c i a l ideology are s t i l l a p p l i c a b l e , and lead to d i s t i n c t h e a l t h care i d e o l o g i e s i n each country. For example, h e a l t h insurance i s viewed as a r i g h t of c i t i z e n s h i p i n Great B r i t a i n , whereas i n West Germany, i t i s l i n k e d to employment and p r o d u c t i v i t y , ( e.g. through employment-related c o n t r i b u t i o n s ( Lockhart 1981 ). C r i c h t o n ( 1980 ), i n the context of r e h a b i l i t a t i o n s e r v i c e s , has analyzed the progress from r e s i d u a l w e l f a r e , to i n d u s t r i a l achievement, to i n s t i t u t i o n a l r e d i s t r i b u t i o n models, moving most r e c e n t l y to the "human r i g h t s " model. The l a s t model goes beyond d i s t r i b u t i o n of s e r v i c e s on the b a s i s of need, and advocates reverse d i s c r i m i n a t i o n i n some i n s t a n c e s . A h i s t o r i c a l p e r s p e c t i v e i s u s e f u l i n understanding the changes of p o l i t i c a l and s o c i a l i d e o l o g i e s i n Canada. The Beveridge Report i n Great B r i t a i n , and the Burns Report i n the United S t a t e s , r e f l e c t e d a preoccupation i n the western world w i t h e q u a l i t y of c o n d i t i o n . This also found expression i n Canada, e.g. the Marsh-Heagarty r e p o r t . The emphasis on e q u a l i t y of c o n d i t i o n held sway through the 1960's as values were t r a n s l a t e d i n t o s t r u c t u r e s and processes. Since the 1970's, the Canadian 142 ideology i n the area of s o c i a l services appears to have cycled away from an emphasis on equa l i ty of c o n d i t i o n . Cr ichton ( 1982 ) notes that Canada, having developed na t iona l hea l th insurance and a s o c i a l s ecur i ty scheme, seems to have returned to the idea of equa l i ty of opportuni ty . However, th i s c y c l i n g has not seen a complete r e v e r s a l . Rather, a bas ic f loor or minimum l e v e l of s o c i a l s e c u r i t y , used i n a broad sense, i s incorporated in to th i s ideology of equa l i ty of opportuni ty . P o l i t i c a l and s o c i a l ideo log ies provide the broad gu ide l ines for the value statements of the P r o v i n c i a l Heal th P lan . Within our democratic system of government, p o l i t i c a l and s o c i a l d i r ec t ions are decided at the b a l l o t box. In B r i t i s h Columbia, the S o c i a l Credi t government presents i t s e l f as f r e e - e n t e r p r i s e , and therefore tends to l i b e r a l i s m . The oppos i t ion par ty , the New Democratic Party (NDP) presents i t s e l f as democratic s o c i a l i s t . It i s worth noting the l e v e l of NDP support . In government only once ( 1972-75 ) , the NDP won 39% of the popular vote i n 1975, and 46% of the vote i n 1979. Although the p o l i t i c a l and s o c i a l ideologies are defined i n general terms by the choice of p o l i t i c a l par ty , there has not been, up to t h i s p o i n t , e x p l i c i t cons idera t ion of how p o l i t i c a l and s o i c a l ideo log ies ought to be appl ied to the hea l th care system. A d e s c r i p t i o n of the e x i s t i n g hea l th care system does not adequately r e f l e c t the a p p l i c a t i o n of p o l i t i c a l and s o c i a l i d e o l o g i e s , s ince group pressures , budgetary c o n s t r a i n t s , p o l i t i c a l cons idera t ions , e t c . , a l l play ro les i n determining the hea l th care system's current s tructures and processes. It i s useful for government to have a c lear statement of i t s va lues , as appl ied to the hea l th care system, so that whatever compromises and accommodations are made, p o l i c i e s 143 consi s tent ( or at leas t not e n t i r e l y incons i s tent ) with i t s s tated values can eventua l ly r e s u l t . On reviewing a number of p r o v i n c i a l , n a t i o n a l , and i n t e r n a t i o n a l statements of p r i n c i p l e s , i m p l i c i t l y or e x p l i c i t l y s ta ted , which should guide the hea l th care system, i t i s apparent that the statements show some v a r i a t i o n ( as might be expected from the range of p o l i t i c a l , s o c i a l and other ideologies which ex i s t ) but f a l l w i t h i n four d i s t ingu i shab le areas ( Beveridge 1942; Canada 1964, 1969; Foulkes 1973; Lalonde 1974; World Health Organizat ion 1977, 1978, 1979 ) : (1) D e f i n i t i o n of h e a l t h , and re l a ted to t h i s , r e s p o n s i b i l i t y of the h e a l t h care system (2) S o c i a l Ju s t i ce (3) Role of Government, I n d i v i d u a l s , and Profess ions (4) Ef fect iveness and e f f i c i e n c y . For example, according to United States l e g i s l a t i o n , Health Systems Plans are to improve the hea l th of r e s i d e n t s ; to increase the a c c e s s i b i l i t y , a c c e p t a b i l i t y , c o n t i n u i t y and q u a l i t y of the hea l th services provided; and to contain hea l th care cos t s , i n part by preventing unnecessary serv ices ( United States , Department of Hea l th , Education and Welfare 1979a ) . The "hea l th " of res idents f a l l s under D e f i n i t i o n of h e a l t h . A c c e s s i b i l i t y and a c c e p t a b i l i t y f a l l under S o c i a l J u s t i c e . Cont inui ty and q u a l i t y r e f l e c t Ef fect iveness and e f f i c i e n c y , as do r e s t r a i n i n g costs and prevention of d u p l i c a t i o n of s e r v i c e s . For each of the four areas, a range of value statements i s p o s s i b l e , associated with the range of p o l i t i c a l and s o c i a l ideo log ies that are l i k e l y to ex i s t i n a p a r t i c u l a r j u r i s d i c t i o n . For the purposes of the P r o v i n c i a l 144 Heal th Plan i n B . C . , the re levant range of p o l i t i c a l and s o c i a l ideo log ie s has been o u t l i n e d . It remains therefore to apply these ideolog ies i n a hea l th care system context . V . A . I . 2 . P o l i t i c a l and s o c i a l ideo log ie s app l ied to the HCS The fo l lowing matrix provides a convenient format for d i s c u s s i o n : Area of Concern Ideology L i b e r a l i s m Soc ia l i sm Conservatism D e f i n i t i o n of Health S o c i a l Ju s t i ce Role of Government, I n d i v i d u a l s , Profess ions E f f e c t i v e n e s s / E f f i c i e n c y FIGURE 25. A p p l i c a t i o n of P o l i t i c a l / S o c i a l Ideologies The issues or questions addressed by the above matrix should encompass what Fuchs ( 1974 ) has l i s t e d as the "choices we must make" i n hea l th-care p o l i c y . He includes i n h i s l i s t i n g as the most "bas ic " l e v e l of choice "hea l th or other goa l s " . However, as discussed i n Sec t ion V . D . 2 . , t h i s choice i s more appropr ia te ly considered at another planning l e v e l . The p o l i c y planning l e v e l , and the P r o v i n c i a l Health Plan do not consider the r e l a t i v e worth of " h e a l t h " , " j u s t i c e " , "beauty" , "knowledge", e t c . The other choices i n Fuch's l i s t i n g are relevant and summarized below: (1) medical care or other hea l th programs? (2) phys ic ians or other medical care providers? (3) how much e q u a l i t y , and how to achieve i t ? 145 (4) today or tomorrow? (5) your l i f e or mine? (6) the jungle or the zoo? A choice must be made between medical care or other hea l th programs, where medical care re fers to the t r a d i t i o n a l hea l th care system with a medical model ( p h y s i c i a n s , h o s p i t a l s , e t c . ) as compared to other hea l th programs such as p o l l u t i o n c o n t r o l and accident prevent ion . Within a medical model, there may be a l t e r n a t i v e methods of providing se rv ice s , e . g . s u b s t i t u t i n g nurse p r a c t i t i o n e r s for phys i c i ans , so that choices must be made whether phys ic ians or other medical care providers or other methods of serv ice d e l i v e r y are to be used. How much e q u a l i t y , and how to achieve i t , cons t i tu te major choices for any s o c i e t y . The d i s t r i b u t i o n of goods and services to i n d i v i d u a l members of s o c i e t y , and whether hea l th care serv ices are to be treated i n the same way as other goods and se rv ice s , i s a matter of s o c i a l cho ice . Today or tomorrow refers to a choice between what economists term "consumption" and " investment" , and ra i se s the quest ion of how much should be spent i n provid ing for future problems, at the expense of care for present problems. Your l i f e or mine refers to a cen t ra l i ssue i n making choices — who decides what choices are to be made? Di f ferent groups have d i f f e r e n t i n t e r e s t s and p r i o r i t i e s ; how are these to be reconci led? F i n a l l y , the jungle or the zoo i s a v i v i d metaphor descr ib ing the balance between i n d i v i d u a l and s o c i e t a l r e s p o n s i b i l i t y for h e a l t h , and to what extent soc ie ty can impose r e s t r a i n t s on i n d i v i d u a l act ions to improve e i t h e r that i n d i v i d u a l ' s hea l th or the hea l th of o thers . These d i f f i c u l t choices r e c a l l what Cr ichton ( 1981 ) has termed the 146 fundamental issues of hea l th p o l i c y . She reviews the importance of de f in ing " h e a l t h " , and whether hea l th p o l i c y i s to be considered synonymous with p o l i c i e s about medical care and s e r v i c e s ; or whether a broader d e f i n i t i o n , i n c l u d i n g s o c i a l and economic i s sues , i s to be adopted. The basic issue then ar i se s whether h e a l t h , however def ined , i s regarded as a "means" ( e . g . to na t iona l s o l i d a r i t y or economic development ) , or as an "end" i n i t s e l f . If hea l th i s considered the l a t t e r , issues of hea l th promotion versus l i f e preservat ion require p o l i c y d e c i s i o n s . In other words, should the qua l i ty of l i f e take p r i o r i t y over the prolongat ion of l i f e ? Should acute l i f e - s a v i n g medica l ly or iented services take precedence over prevention and promotion? In order to address these quest ions , one must face issues of s o c i a l r e c i p r o c i t i e s i n modern , re l a t ive ly a f f luent s o c i e t i e s and consider the r i g h t s and p r i v i l e g e s of i n d i v i d u a l s and hea l th care providers i n the face of the a l l o c a t i o n of scarce hea l th care resources . P o l i t i c a l and s o c i a l i d e o l o g i e s , as appl ied to the hea l th care system, should also address those c h a r a c t e r i s t i c s which define and d i f f e r e n t i a t e types of hea l th care systems: economic support , manpower, f a c i l i t i e s , d e l i v e r y pa t terns , preventive s e rv i ce s , r e g u l a t i o n , and admini s t ra t ion and planning ( Roemer 1977 ) . The fo l lowing d i scus s ion sys temat ica l ly considers each of the four areas of concern shown i n the matrix ( F igure 25. ) , and the a p p l i c a t i o n of d i f f e r e n t p o l i t i c a l and s o c i a l i d e o l o g i e s . I l l u s t r a t i v e value statements are included to suggest some sense of the form such statements could take i n the P r o v i n c i a l Health P l a n , and also to a l low demonstration of the a p p l i c a t i o n of value statements i n l a t e r stages of development towards Short Term Object ives for the P r o v i n c i a l Heal th P l a n . 147 D e f i n i t i o n o f H e a l t h and R e s p o n s i b i l i t y o f t h e H e a l t h Ca re Sys tem The c h o i c e of a b r o a d o r n a r r o w d e f i n i t i o n of " h e a l t h " f o r p l a n n i n g p u r p o s e s , and s p e c i f i c i n c l u s i o n s o r e x c l u s i o n s , i s v e r y much a v a l u e - l a d e n d e c i s i o n . B o u n d a r i e s of " h e a l t h " f o r t h e P r o v i n c i a l H e a l t h P l a n a r e p r o p o s e d i n S e c t i o n I V . D . of t h i s t h e s i s . I t s h o u l d be e v i d e n t t h a t t h e a u t h o r ' s p e r s o n a l v a l u e s y s t e m p r e d i s p o s e s towards t h a t p a r t i c u l a r d e f i n i t i o n . There c a n n o t be v a l u e - f r e e p l a n n i n g , and t h e p l a n n i n g f o r t h e P r o v i n c i a l H e a l t h P l a n i s no e x c e p t i o n . However , by c o n s c i o u s l y a d d r e s s i n g t h e i s s u e o f D e f i n i t i o n o f H e a l t h , and e x a m i n i n g a l t e r n a t i v e d e f i n i t i o n s , t h i s t h e s i s i n v i t e s d i f f e r i n g a p p r o a c h e s ( w h i c h v a r i a t i o n may i n t u r n l e a d to m o d i f i c a t i o n s i n t h e f o r m and d e v e l o p m e n t a l o u t l i n e f o r t h e P r o v i n c i a l H e a l t h P l a n ) . L i b e r a l i s m t e n d s t o a f a i r l y r e s t r i c t i v e d e f i n i t i o n of " h e a l t h " f o r p l a n n i n g p u r p o s e s . T h i s s tems n o t f r o m a p a r t i c u l a r v a l u e a b o u t " h e a l t h " i n h e r e n t i n t h e l i b e r a l i d e o l o g y , bu t r a t h e r f rom i t s e m p h a s i s upon t h e i n d i v i d u a l and t h e c o m p e t i t i v e m a r k e t t o d e a l w i t h s o c i a l and e c o n o m i c p r o b l e m s . There i s no need to d e f i n e h e a l t h i n a b r o a d manner i f i n p r a c t i c e , o n l y a n a r r o w s e t of " h e a l t h " p r o b l e m s a r e deemed t o r e q u i r e f o r m a l p l a n n i n g and e v a l u a t i o n . F o r e x a m p l e , w h e t h e r l i f e s t y l e p r o b l e m s c o n s t i t u t e " h e a l t h " p r o b l e m s c e a s e s t o be a ma jo r i s s u e f o r p l a n n i n g p u r p o s e s i f o n e ' s v a l u e s s t r e s s i n d i v i d u a l r e s p o n s i b i l i t y f o r p e r s o n a l a c t i o n s ( o r i n a c t i o n s ) . A l i b e r a l d e f i n i t i o n of h e a l t h w o u l d t h e r e f o r e encompass o n l y t h o s e a r e a s t r a d i t i o n a l l y c o n s i d e r e d " p u b l i c h e a l t h " , a c c e p t i n g ( p e r h a p s r e l u c t a n t l y f o r p l a n n i n g p u r p o s e s ) a l s o t h o s e a r e a s w h i c h t r a d i t i o n a l l y have been c o n s i d e r e d as f a l l i n g w i t h i n t h e h e a l t h c a r e s y s t e m , e . g . p h y s i c i a n s , h o s p i t a l s , and emergency s e r v i c e s . W i t h o u t n e c e s s a r i l y 148 implying government p r o v i s i o n , the emphasis i s on personal care and the medical model p r o v i d i n g such care. The re i s l i t t l e a t t e n t i o n to the concept of "community h e a l t h " . Conservatism takes a s i m i l a r l y r e s t r i c t i v e d e f i n i t i o n of h e a l t h , although f o r d i f f e r e n t reasons. The e x i s t i n g s o c i a l order of the h e a l t h care system s t i l l r e f l e c t s to a large degree the medical model of " h e a l t h " . To the extent that the conservative ideology attempts to preserve the e x i s t i n g order, the more r e s t r i c t i v e d e f i n i t i o n i s favoured. There i s a greater a t t e n t i o n to the c o l l e c t i v i t y and the " s o c i a l good" which would be r e f l e c t e d i n more emphasis on occupational h e a l t h , the workers i n s o c i e t y being viewed as an important component of the s o c i a l f a b r i c . A l s o , d i s r u p t i o n s to the s o c i a l order seen i n f a m i l y breakups or d i s i n t e g r a t i o n of s o c i a l networks may be viewed more s e r i o u s l y i n conservatism. In other words, " s o c i a l h e a l t h " may be a more l e g i t i m a t e concept i n a c o n s e r v a t i v e , r a t h e r than a l i b e r a l , s o c i e t y . S o c i a l i s m tends to a f a i r l y broad d e f i n i t i o n of " h e a l t h " . As i n conservatism, there i s greater a t t e n t i o n to the c o l l e c t i v e good and community or s o c i a l h e a l t h . Thus, f o r example, environmental h e a l t h may be given greater emphasis. As w e l l , s o c i a l problems, such as deviant behaviour, have tended to be categorized as "he a l t h " problems. In the dominant l i b e r a l s o c i e t y , being s i c k seems to be more acceptable than being bad. I t i s unclear whether the same d e f i n i t i o n s would be made i n a dominant s o c i a l i s t s o c i e t y . The broader d e f i n i t i o n of " h e a l t h " a l s o stems from s o c i a l i s t values supporting c e n t r a l i z e d " r a t i o n a l " planning and government i n t e r v e n t i o n . The d e f i n i t i o n of "he a l t h " f or planning purposes would, i n s o c i a l i s m , t h e r e f o r e i n c l u d e preventive h e a l t h s e r v i c e s and l i f e s t y l e 149 problems,(and pos s ib ly a lso housing, income, and education to the extent they affect hea l th s t a t u s ) ; family c o u n s e l l i n g , s o c i a l and psycholog ica l problems; services to the handicapped and r e h a b i l i t a t i o n ; long term care p a t i e n t s ; and so on. I l l u s t r a t i v e value statements which would be considered under D e f i n i t i o n of Health are l i s t e d : 1) Health i s a s tate of complete p h y s i c a l , mental and s o c i a l wel l -being and not merely the absence of disease or i n f i r m i t y . Fol lowing from t h i s W.H.O. d e f i n i t i o n , r e s p o n s i b i l i t y for hea l th re s t s not only with the hea l th care system, but also other sectors of soc ie ty such as s o c i a l s e r v i c e s , the educat ional system, and the economic system. 2) The Health Care System has major r e s p o n s i b i l i t i e s i n areas of p u b l i c hea l th and primary and s p e c i a l i z e d care for d iagnos i s , treatment, and r e h a b i l i t a t i o n from disease , i n c l u d i n g the fo l lowing areas : medicine, surgery, o b s t e t r i c s , gynaecology, p a e d i a t r i c s , p sych ia t ry , d e n t i s t r y , e t c . Primary care should include at l e a s t : education concerning p r e v a i l i n g hea l th problems and the methods of i d e n t i f y i n g , preventing and c o n t r o l l i n g them, promotion of food supply and proper n u t r i t i o n and adequate supply of safe water and basic s a n i t a t i o n , maternal and c h i l d hea l th care inc lud ing family p lanning , immunization against the major i n f e c t i o u s diesease , prevent ion and c o n t r o l of l o c a l l y endemic disease , appropriate treatment to common disease and i n j u r i e s , promotion of mental hea l th and prov i s ion of e s s e n t i a l drugs. 3) The Health Care System also has major r e s p o n s i b i l i t y i n the areas of hea l th care re search . 4) The Health Care System shares r e s p o n s i b i l i t y with other sectors i n areas such as environmental p r o t e c t i o n , preventive hea l th measures, hea l th 150 promotion/education and l i f e s t y l e changes, housing and income maintenance. 5) The B . C . Health Care system i s dedicated to maintaining and improving the hea l th of B . C . r e s i d e n t s ; f i r s t l y through maintaining and improving serv ices i n i t s major areas of r e s p o n s i b i l i t y , and secondly by working with other sectors i n areas of shared r e s p o n s i b i l i t i e s . In order to accomplish these purposes, the B . C . Health Care System should be responsive to demographic, s o c i a l , economic, and techno log ica l changes. S o c i a l Ju s t i ce F le tcher ( 1976 ) notes that j u s t i c e has t r a d i t i o n a l l y been considered as commutative, l e g a l , and d i s t r i b u t i v e . Commutative j u s t i c e re fers to one-to-one or one-to-group r e l a t i o n s h i p s . Legal j u s t i c e refers to the ob l iga t ions of the i n d i v i d u a l to the s t a t e . D i s t r i b u t i v e j u s t i c e concerns what soc iety or the s tate owes to the i n d i v i d u a l . This d i s cus s ion uses s o c i a l j u s t i c e p r i m a r i l y i n the l a s t sense. The standard conceptions of s o c i a l j u s t i c e , w h i c h f ind expression i n p o l i t i c a l and s o c i a l i d e o l o g i e s , are : to each according to h i s merit ( e f fo r t or achievement); to each according to h i s s o c i e t a l c o n t r i b u t i o n ; to each according to h i s c o n t r i b u t i o n i n s a t i s f y i n g whatever i s f r e e l y desired by others i n the open market; to each according to h i s needs; and s i m i l a r treatment for s i m i l a r cases ( Veatch 1976 ) . Expressed i n a p o l i t i c a l context , l i b e r a l i s m stresses equa l i ty of opportuni ty , and i n the hea l th care system, access to hea l th care s e r v i c e s . Whether these hea l th care services i n fact lead to bet ter "hea l th " i s perhaps of l e s ser importance than the access to those i n s e r v i c e s . A 151 f u r t h e r d i s p l a c e m e n t o c c u r s where e q u i t a b l e a c c e s s i s p r o p o s e d t o s u b s t i t u t f o r e q u a l a c c e s s . D i f f e r e n c e s i n a c c e s s a r e a c c e p t e d u n d e r c e r t a i n c o n d i t i o n s , o f t e n c o u c h e d i n te rms o f E f f e c t i v e n e s s / e f f i c i e n c y a r g u m e n t s . F o r e x a m p l e , a c c e s s t o Emergency S e r v i c e s i n r u r a l a r e a s may be l e s s t h a n V a n c o u v e r and V i c t o r i a , bu t t h i s i s j u s t i f i e d on the b a s i s t h a t u r b a n a r e a s have s u f f i c i e n t vo lume of c a l l s t o p r o v i d e 24 h o u r s e r v i c e . L i b e r a l i s m , w i t h o u t n e c e s s a r i l y c o n c e d i n g t h a t t h e government need be d i r e c t l y r e s p o n s i b l e f o r an e q u i t a b l e d i s t r i b u t i o n of h e a l t h c a r e r e s o u r c e s does n o n e t h e l e s s t e n d t o e m p h a s i z e the a v a i l a b i l i t y and a c c e s s t o r e s o u r c e s s u c h as h o s p i t a l s and p h y s i c i a n s . T h i s c a n be measured e i t h e r i n g e o g r a p h i d i s t a n c e o r t r a v e l l i n g t i m e . Whether t h e r e s o u r c e s a r e u t i l i z e d i s a f u r t h e r i n d i c a t o r of a c c e s s , b u t t h e i m p o r t a n t f e a t u r e f rom a l i b e r a l p e r s p e c t i v e i s t h a t p a t i e n t s s h a l l have t h e c h o i c e t o o b t a i n s e r v i c e s . C u l t u r a l o r e c o n o m i c d i s i n c e n t i v e s t o o b t a i n s e r v i c e s a r e no t of m a j o r c o n c e r n . C o n d i t i o n a l d i f f e r e n c e s i n a c c e s s a r e more w i d e s p r e a d and a c c e p t a b l e i n l i b e r a l i s m . F o r e x a m p l e , t h o s e who c a n a f f o r d b e t t e r h e a l t h c a r e s e r v i c e s ( o r f a s t e r s e r v i c e s ) s h o u l d be a b l e t o o b t a i n t h o s e s e r v i c e s . U s e r c h a r g e s , e x t r a b i l l i n g , and i n d i v i d u a l r e s p o n s i b i l i t y f o r m e d i c a l and h o s p i t a l i n s u r a n c e premiums a r e a l l c o n s i s t e n t w i t h l i b e r a l i s m . The d e v e l o p m e n t o f s o p h i s t i c a t e d h i g h t e c h n o l o g y m e d i c a l s e r v i c e s f o l l o w s a l s o f r o m t h e f r e e - m a r k e t e n t r e p r e n e u r i a l a t t i t u d e s of t h e l i b e r a l i d e o l o g y . S o c i a l i s m s t r e s s e s e q u a l i t y of c o n d i t i o n , and i n a h e a l t h c o n t e x t , e q u a l i t y of h e a l t h s t a t u s , ( u s u a l l y d i s p l a c e d t o e q u i t a b l e h e a l t h s t a t u s , r e c o g n i z i n g t h a t no two p e o p l e w i l l e v e r have t h e same g e n e t i c e n d o w m e n t s ) . S o c i a l i s m t h u s p l a c e s g r e a t e r e m p h a s i s on i n d i c a t o r s of h e a l t h s t a t u s and 152 the e f f e c t i v n e s s / u t i l i z a t i o n of hea l th care resources i n improving h e a l t h s t a tus . Demonstration of a v a i l a b i l i t y of services w i l l be i n s u f f i c i e n t assurance of equitable resource d i s t r i b u t i o n . Instead, those areas of greatest "need" , according to hea l th s ta tus , would receive more resources . Insofar as non-medical services can improve or af fect hea l th s ta tus , they too w i l l be considered important. For example, aids to d a i l y l i v i n g , long term care/home care s e r v i c e s , voca t iona l r e h a b i l i t a t i o n would be considered a "hea l th " r e s p o n s i b i l i t y . With i t s emphasis on e q u a l i t y , soc i a l i sm tends to accept fewer q u a l i f i c a t i o n s to equal access . Health care becomes a " r i g h t " ; e x t r a - b i l l i n g , user charges, i n d i v i d u a l insurance premiums, would be opposed as d i s c r i m i n a t o r y . Because of the"greatest good for the greatest number"approach inherent i n an e g a l i t a r i a n view of s o c i e t y , soc i a l i sm would favour general improvement of bas ic hea l th services over more expensive h igh technology s e r v i c e s . The e g a l i t a r i a n viewpoint would lead also to greater emphasis on the hea l th of workers. Health serv ices planning would revolve around economic aspects of access to medical care , and secondar i ly , the planning for the required manpower and f a c i l i t i e s i n the face of economic cons t ra int s ( Roemer 1977 ) . E q u a l i t y ( or equity ) of e i t h e r access or hea l th status impl ies comparisons and therefore c a t e g o r i z a t i o n s . The number and type of categories r e f l e c t value systems and ideology . Specifying categories such as c h i l d r e n ' s h e a l t h , nat ive h e a l t h , g e r i a t r i c h e a l t h , and r u r a l h e a l t h , stem from values about these groups. ( Indeed, not only p o l i t i c a l and s o c i a l , but a lso c u l t u r a l values may play an important r o l e , although t h i s i s beyond the scope of th i s d i scus s ion ) . I l l u s t r a t i v e value statements w i t h i n the area of S o c i a l Jus t i ce are as fo l lows : 153 1) B .C . res idents should have equitable access to hea l th s e r v i c e , regardless of age, sex, ethnic background, p o l i t i c a l b e l i e f s , economic or s o c i a l c o n d i t i o n s . 2) Because of the unique geographic c h a r a c t e r i s t i c s of B . C . , spec i a l e f for t s should be made to ensure equitable access to hea l th services i n remote areas, p a r t i c u l a r l y emergency hea l th care and primary hea l th care . Because of the d i v e r s i t y of c u l t u r a l backgrounds i n the province , s p e c i a l e f for t s should be made to ensure equitable access to hea l th services by minor i ty groups. 3) Because there remain income d i s p a r i t i e s which may prevent equitable access to hea l th s e r v i c e s , hea l th insurance that i s comprehensive and un iver sa l should be an i n t e g r a l component of the Health Care System. 4) P r i o r i t y should be given i n p rov i s ion of hea l th services to those who are i n greatest need, i n p a r t i c u l a r : indigenous peoples, the handicapped, low income groups, refugee/immigrant groups, and the e l d e r l y . 5) The optimal hea l th of the members of soc iety i s des i rab le not only because th i s enables more productive l i v e s , but also because of humanitarian concern. Role of Government, I n d i v i d u a l s , Professions The values with respect to ro le of government, i n d i v i d u a l s , and profess ions are best understood i f they are thought of as the ro le s of government r e l a t i v e to i n d i v i d u a l s , ro l e s of government r e l a t i v e to profes s ions , and the ro les of professions r e l a t i v e to the i n d i v i d u a l p a t i e n t / c l i e n t s . L i b e r a l i s m stresses i n d i v i d u a l r e s p o n s i b i l i t y for hea l th and hea l th 154 s e r v i c e s , with minimal government p lanning , r egu la t ions , standards, or d i r e c t p r o v i s i o n of s e r v i c e s . Government i n t e r v e n t i o n , such as i t i s , involves educating people so that they are better able to make informed d e c i s i o n s . Areas considered to be of "pub l i c i n t e r e s t " and thus which j u s t i f y government i n t e r v e n t i o n i n c l u d e : publ ic hea l th measures ( water, sewage, communicable diseases , e t c . ) , and because i t has been a government r e s p o n s i b i l i t y i n B . C . for many years , bas ic medical and h o s p i t a l insurance . A d d i t i o n a l s e rv i ce s , such as drug cos t s , are the r e s p o n s i b i l i t y of i n d i v i d u a l s or t h e i r pr iva te insurance p l a n . Family and community support ( as i n voluntary assoc ia t ions or ph i l an throp ic groups ) are expected to provide necessary ass i s tance for hea l th s e r v i c e s . Loca l community, and r e g i o n a l , d i r e c t i o n and p a r t i c i p a t i o n are important parts of the hea l th care system i n l i b e r a l i s m . This r e s u l t s often i n a m u l t i p l i c i t y of groups and a p l u r a l i s t i c approach to coordinat ing s e r v i c e s . The p r a c t i c a l a p p l i c a t i o n of the l i b e r a l approach to the hea l th care sytem may be more d i f f i c u l t than proponents care to admit. As Roemer ( 1977 ) notes , " there hardly remains a country with a hea l th care sytem i n which free e n t e r p r i s e , once common, i s the predominant mode of operat ion" ( p . 14 ) . According to Roemer, the nearest example i s the United States c a . 1940. Conservatism supports the i n d i v i d u a l w i t h i n s o c i e t y . There may w e l l be f a i r l y extensive government involvement i n the hea l th care system, but only where e x i s t i n g support networks ( such as family ) are not opera t ing . Soc ia l i sm opts for a wider r o l e for government, as compared to l i b e r a l i s m . Government would be eva lua t ing , moni tor ing , and se t t ing standards and regula t ions for the hea l th care system. A wider range of serv ices would be included under the government medical and h o s p i t a l 155 insurance schemes, and these would be funded i n t o t a l from general t axa t ion revenue. More government i n t e r v e n t i o n i n i n d i v i d u a l behaviour would be consis tent with s o c i a l i s m , e . g . increased taxes on a l coho l or c i g a r e t t e s , mandatory use of seat b e l t s . Value statements concerning governmental-professional ro le s also flow from i d e o l o g i e s . L i b e r a l i s m assumes that hea l th occupat ional groups, to the extent that the p u b l i c requires p r o t e c t i o n , should be granted s e l f -r e g u l a t i o n , which genera l ly involves l i c e n s u r e . This includes aspects of q u a l i f i c a t i o n s and approval of educational programs, fees, s e l f - d i s c i p l i n e by a peer group, number and d i s t r i b u t i o n of p r a c t i t i o n e r s , e t c . Phys ic ians i n a l i b e r a l system would be paid on a f e e - f o r - s e r v i c e ba s i s . However, where p o s s i b l e , hea l th occupat ional groups should not have a monopoly on p r o v i s i o n of services so that a competit ive market system can f u n c t i o n . Enthoven's ( 1980 ) proposed "Consumer Choice Heal th Plan" i s an often c i t e d example of a l i b e r a l approach. He advocates a system of f a i r economic competit ion among a l t e r n a t i v e f inanc ing and d e l i v e r y systems, rewarding providers for bet ter care at lower cos t s . Fixed d o l l a r subsidies would be provided to i n d i v i d u a l s ( or f ami l i e s ) who could then choose amongst competing p lans . Conservatism would tend to preserve the ex i s t ing system, where pro fe s s iona l groups ( wi th in the medical model ) have wel l -de f ined h i e r a r c h i c a l ro le s i n the hea l th care system. Attempts by occupat ional groups to use government to s h i f t these ro le s would be r e s i s t e d . Soc ia l i sm extends government i n t e r v e n t i o n to the hea l th occupat ions . Areas of p ro fe s s iona l s e l f - r e g u l a t i o n under l i b e r a l i s m become areas of government regu la t ion and standards under s o c i a l i s m . S a l a r i e d , ra ther than 156 f e e - f o r - s e r v i c e p r a c t i t i o n e r s w o u l d be the g e n e r a l r u l e . Fewer s p e c i a l i s t s w o u l d be u t i l i z e d , w i t h d e s i r e d d i s t r i b u t i o n s of manpower a c h i e v e d by more c o e r c i v e means t h a n i n l i b e r a l i s m . D i s c i p l i n e by t h e p e e r g roup i s l e s s i m p o r t a n t s i n c e t h e a d m i n i s t r a t i v e s t r u c t u r e has b u i l t i n c o n t r o l s . The g o v e r n m e n t ' s r o l e r e l a t i v e t o o r g a n i z a t i o n s and i n s t i t u t i o n s can be c o n s i d e r e d a s u b s e t of t h e g o v e r n m e n t - p r o f e s s i o n r e l a t i o n s h i p , e x c e p t t h a t i n s t e a d of i n d i v i d u a l p r a c t i t i o n e r s , a c o l l e c t i v e " p r o f e s s i o n a l " ( e . g . a h o s p i t a l ) i s i n v o l v e d . L i b e r a l i s m t e n d s t o a m i n i m a l r o l e f o r g o v e r n m e n t , l i m i t i n g i n v o l v e m e n t t o s e t t i n g b a s i c r e g u l a t i o n s o r c r i t e r i a . S o c i a l i s m w o u l d l o o k t o d i r e c t government c o n t r o l of i n s t i t u t i o n s and a g e n c i e s r e c e i v i n g f u n d s f r o m g o v e r n m e n t . The n o t a b l e e x c e p t i o n i n p r a c t i c e seems t h e m a n u f a c t u r e and d i s t r i b u t i o n of d r u g s w h i c h e v e n i n d e m o c r a t i c s o c i a l i s t c o u n t r i e s r e m a i n s i n t h e p r i v a t e s e c t o r . The r e l a t i o n s h i p b e t w e e n p r o f e s s i o n a l s and t h e i n d i v i d u a l a r e a l s o of i m p o r t a n c e t o t h e P r o v i n c i a l H e a l t h P l a n , and t h i s i s d i s c u s s e d i n S e c t i o n V . A . 2 . A l t h o u g h i t has been n o t e d under e a c h i d e o l o g y , i t i s w o r t h r e p e a t i n g t h a t one o f t h e f u n d a m e n t a l d i f f e r e n c e s between h e a l t h c a r e s y s t e m s i s t h e method of f i n a n c i n g . T h i s r a n g e s f r o m p e r s o n a l p a y m e n t , c h a r i t y , payment by i n d u s t r y , v o l u n t a r y i n s u r a n c e , s o c i a l i n s u r a n c e , t o g e n e r a l t a x a t i o n r e v e n u e f u n d i n g . I t i s of i n t e r e s t t o n o t e t h a t i n C a n a d a , and most o t h e r c o u n t r i e s , t h e t r e n d has been t o w a r d s i n c r e a s i n g r e g u l a t i o n by g o v e r n m e n t , e i t h e r t h r o u g h r e g u l a t i o n of " p u r c h a s e s " ( i . e r e q u i r i n g p r i o r a p p r o v a l f o r government f u n d e d s e r v i c e s , s c r u t i n i z i n g s e r v i c e s p r o v i d e d , and n e g o t i a t i n g f e e s t o be p a i d ) o r r e g u l a t i o n of " s u p p l y " , i . e . l i m i t i n g t h e number of f a c i l i t i e s , 157 equipment or manpower, ( Roemer 1977 ) . I l l u s t r a t i v e value statements concerning the Role of Government, I n d i v i d u a l s , Professions are as fo l lows : 1) The p r o v i n c i a l government and therefore the M i n i s t r y of Health has the o v e r a l l r e s p o n s i b i l i t y for B . C . ' s Health Care System, except for s p e c i f i e d areas of federa l r e s p o n s i b i l i t y , such as nat ive h e a l t h , immigrat ion, and i n t e r n a t i o n a l hea l th commitments. 2) The government has a r e s p o n s i b i l i t y to deal with hea l th problems that i n d i v i d u a l s are incapable of handling themselves. This inc ludes areas of what has been t r a d i t i o n a l l y termed pub l i c hea l th , i . e . sewage, i n f e c t i o u s diseases , water supply, food i n s p e c t i o n , in spec t ion of p u b l i c ea t ing establ i shments , maternal and c h i l d h e a l t h , v i t a l s t a t i s t i c s , and mental h e a l t h . Because research for the most part benef i ts the general community, government should provide funding for hea l th care research. 3) The government should take a leadership r o l e i n the o v e r a l l planning and coord inat ion of the Health Care System i n the prov ince . This e n t a i l s c l ea r statements of goals and p r i o r i t i e s , and fo l lowing from t h i s , standards and g u i d e l i n e s . Government must monitor hea l th needs and hea l th resources i n the province to ensure prov i s ion of hea l th services that meet p r o v i n c i a l standards and also adhere to the general p r i n c i p l e s l i s t e d under S o c i a l Ju s t i ce and E f f e c t i v e / E f f i c i e n t Management. 4) Although not nece s s a r i ly involved with the ac tua l p r o v i s i o n of hea l th s e rv i ce s , government should ensure a w e l l - t r a i n e d admini s t ra t ive i n f r a s t r u c t u r e i n support of the Health Care System i n the prov ince . 5) Government should be responsive to community and i n d i v i d u a l concerns; i n d i v i d u a l s and communities have a r e s p o n s i b i l i t y to be well- informed and 158 provide input to government p lanning . 6) The government should take a leadership ro le i n encouraging i n t e r -s e c t o r a l cooperation i n areas of shared r e s p o n s i b i l i t y for hea l th i s s u e s . 7) Communities have a r e s p o n s i b i l i t y to encourage the hea l th of i n d i v i d u a l s . Reg iona l i za t ion i s one mechanism for encouraging and strengthening such community r e s p o n s i b i l i t y . There i s a continuing r o l e for voluntary a c t i v i t i e s and a l l things being equal , i n d i v i d u a l and voluntary act ions are preferable to government i n t e r v e n t i o n s . 8) Indiv idual s should have freedom of choice i n determining hea l th s e rv i ce p rov ider s . Government should provide funding for adequate p r o v i s i o n of bas ic hea l th s e r v i c e s , but i n d i v i d u a l s should have the opportunity to seek a d d i t i o n a l or a l t e r n a t i v e services at t h e i r own cos t s , so as not to s t i f l e i n c e n t i v e , opportuni ty , and i n d i v i d u a l r e s p o n s i b i l i t y . 9) The i n d i v i d u a l has the r e s p o n s i b i l i t y to make use of ava i l ab l e s e r v i c e s , fo l low prescr ibed treatment and r e h a b i l i t a t i o n p lans , and adopt healthy l i f e s t y l e habi t s and preventive measures which depend on i n d i v i d u a l i n i t i a t i v e s . The i n d i v i d u a l must ensure adequate insurance coverage for out-of-province s e r v i c e s . O v e r a l l , i n d i v i d u a l s are p r i m a r i l y responsible for t h e i r own h e a l t h . 10) Profess ions must maintain adequate standards of care and e t h i c a l p r a c t i c e . There must be a c c o u n t a b i l i t y to the p u b l i c and the i n d i v i d u a l pat ients they s e r v i c e . 11) The profes s ion has the r e s p o n s i b i l i t y to provide the pub l i c with s u f f i c i e n t informat ion so that the pub l i c can make a reasoned dec i s ion as to a l t e r n a t i v e forms of hea l th s e r v i c e s . 159 E f f e c t i v e n e s s / E f f i c i e n c y In one sense, values i n support of e f fec t ive and e f f i c i e n t operat ion of the hea l th care system are not dependent on p o l i t i c a l and s o c i a l i d e o l o g i e s . It would be d i f f i c u l t to argue i n support of i n e f f e c t i v e or i n e f f i c i e n t operat ions . However, i t i s worth noting that value systems and ideo log ies determine the c r i t e r i a for " e f fec t ivenes s " ( e . g . short term cost containment v s . longer term savings ) . I l l u s t r a t i v e value statements are shown below: 1) Containment of hea l th care costs i s a high p r i o r i t y and steps should be taken towards t h i s end without compromise of p rov i s ion of hea l th s e r v i c e s . For example, r e g i o n a l i z a t i o n can lead to coordinat ion and i n t e g r a t i o n of services and greater e f f i c i e n c i e s . Appropriate use of hea l th manpower and technology i n a t i e r e d r e f e r r a l system makes most e f f i c i e n t use of our hea l th care resources . Emphasis on preventive and environmental measures, such as screening programmes, can often re su l t i n cost savings . 2) E f f i c i e n t operat ion of the Health Care System requires c l e a r , measurable ob jec t ives and ongoing eva luat ion inc lud ing maintenance of accurate records and a c c o u n t a b i l i t y for funding ( e s p e c i a l l y by government and government-funded agencies and organizat ions ) . 3) Health care research i s necessary for the most e f f i c i e n t operat ion of the Health Care System when viewed i n the longer term. Such research would include bas ic research , problem-oriented research, and hea l th care management re search . Value statements i n the areas of D e f i n i t i o n of Hea l th ; Soc ia l J u s t i c e ; Role of Government, I n d i v i d u a l s , Pro fes s ions ; and E f f e c t i v e n e s s / e f f i c i e n c y are a necessary, but often neglected step i n the determination of ob ject ives 160 for the hea l th care system. It i s useful a lso to have some general sense of the r e l a t i v e importance of these areas ( and even of the value statements wi th in each area ) s ince the p r a c t i c a l a p p l i c a t i o n of value statments may show some inherent c o n f l i c t s . For example, values i n support of equal or equitable access to hea l th services may run counter to values i n support of e f f i c i e n t d e l i v e r y of those s e r v i c e s . Placement and s ize of hosp i ta l s i s one commonly c i t e d example. S i m i l a r l y , values i n support of i n d i v i d u a l and community p a r t i c i p a t i o n i n hea l th planning may re su l t i n delays and adminis t ra t ive c o s t s . It seems u n l i k e l y that precise weightings of the r e l a t i v e importance of value statements can be made u n t i l s p e c i f i c s i tua t ions and ob ject ives are examined. However, i t would be poss ib le and des i rab le to review the e n t i r e set of value statements, once formulated, i n a ranking ( e . g . pa ired comparison ) e x e r c i s e . Viewing the set of values i n t h i s way may also a s s i s t i n the preparat ion of a summary statement of values - a "goal statement" - which r e f l e c t s the government's p o l i t i c a l and s o c i a l ideo log ies as app l i cab le to the hea l th care system. For example, the Report of the Ontario Heal th Planning Task Force summarized i t s g o a l : "The bas ic ob jec t ive of Ontar io ' s hea l th services p lan i s to provide and maintain for res idents of the province a state of p h y s i c a l , mental , and s o c i a l w e l l - b e i n g , i n c l u d i n g the prevention or treatment of disease or i n f i r m i t y , to the extent poss ib le given the resources that are a v a i l a b l e " ( Ontario 1974, p. 6 ) . Another example i s found i n the stated goal of the Health System Plan as "the Health Systems Agency's statement of des i red achievements for improvement i n the hea l th status of area res idents and i n the hea l th systems serving that popula t ion . The purpose of the HSP i s to promote at the l o c a l l e v e l comprehensive hea l th systems which w i l l improve 161 l eve l s of hea l th s tatus ,assure a h e a l t h f u l environment, and provide for the a v a i l a b i l i t y and a c c e s s i b i l i t y of high q u a l i t y hea l th services i n a manner which fosters c o n t i n u i t y of care at a reasonable costs for a l l res idents of the a r e a . " ( United S ta tes , Department of Heal th , Education and Welfare 1979a ) . V . A . 2 . Group Ideologies The p o l i t i c a l and s o c i a l ideo log ies of the government, as appl ied to the hea l th care system, are the major determinants of the value statements for the P r o v i n c i a l Heal th P l a n . There are other inputs to the determination of value statements, i n c l u d i n g group va lues . Some plans ignore or downplay the importance of such input s . However, i t would seem more r e a l i s t i c , and u l t imate ly more e f f e c t i v e , to an t i c ipa te that c e r t a i n groups are important to the implementation of hea l th p o l i c i e s and therefore , group values or ideolog ies should be considered at an ear ly stage i n the development of ob jec t ives for the P r o v i n c i a l Health P l a n . There are many mechanism whereby groups make t h e i r viewpoints and in te re s t s known to the B . C . government. For example, vo luntary and profes s iona l associat ions send b r i e f s or reports to the M i n i s t r y of Hea l th . Their executive meet with M i n i s t r y s t a f f and the M i n i s t e r to express concerns and request funding support. Groups use the media to make pub l i c var ious hea l th problems i n hopes of generating wider support and pressures on government. More formalized mechanisms are p o s s i b l e . For example, Health Systems Agencies i n the United States have employed problem or need surveys sent to consumer and provider groups, community meetings, and meetings with l o c a l hea l th agencies and o f f i c i a l s to ga in some sense of community and group values ( C a s t e r l i n e 1977 ) . Murphy 162 ( 1975 ) has developed and used a community hea l th o r i e n t a t i o n scale to assess a t t i tudes towards primary prevent ion , cont inu i ty of care , epidemiologic approaches to hea l th care , consumer involvment, e t c . Af ter a large study i n v o l v i n g over 600 hea l th profess ionals and admini s t ra tor s , Murphy concluded that the scale seems "reasonably v a l i d and r e l i a b l e for assessing o r i e n t a t i o n to community hea l th on a group bas i s " ( p. 1295 ) . Other poss ib le mechanisms that have been used or proposed inc lude Royal Commissions, advisory c o u n c i l s , conferences, p o l l s , surveys, Delphi or other group techniques , b r i e f s or wr i t ten submissions and r e p o r t s . In order to b u i l d some measure of consensus amongst a broad range of groups, over the spectrum of hea l th p o l i c y i s sues , one of the more formal mechanisms i s i n d i c a t e d . This thes i s proposes a conference format to provide a forum for d i scuss ion of values and d e f i n i t i o n of group i d e o l o g i e s . Numerous advantages accrue from using a conference. The associated p u b l i c i t y and p a r t i c i p a t i o n of a c ro s s - sec t ion of groups would lend importance and a sense for both p a r t i c i p a n t s and the community at large that basic gu ide l ines for the hea l th care system were being s e r i o u s l y and comprehensively addressed. Groups would therefore be more w i l l i n g to commit the time and resources i n preparat ion for the conference, and government would be more i n c l i n e d to heed the outcomes. By having var ious groups p a r t i c i p a t i n g , each group's i n t e r e s t s w i l l be represented. Thus, i t i s more d i f f i c u l t for any one group to advance Its own i n t e r e s t s at the expense of other groups. Government i s spared the r o l e of a r b i t r a t i n g between competing or c o n f l i c t i n g i n t e r e s t s , The conference, separate from the usual ongoing mechanisms of group pressures-, can more e a s i l y adopt the perspect ive of values and general p r i n c i p l e s , rather than deal ing with s p e c i f i c adminis t ra t ive and program 163 i s sue s . The personal contacts and networks r e s u l t i n g from the conference would help ensure the commitment of important sectors of the hea l th care system. The key questions are then f i r s t l y , which groups are to be considered and what weighting should be attached to t h e i r value pos i t ions i n formulat ing value statements for the P r o v i n c i a l Heal th P l a n ; and secondly, what work must be done i n preparat ion for the conference. These questions are discussed i n Sections V . A . 2 . 1 . and V . A « . 2 . 2 . r e s p e c t i v e l y . V . A . 2 . 1 S e l e c t i o n of Groups, t h e i r r e l a t i v e inf luence For hea l th planning purposes, Blum ( 1974 ) l i s t s t h i r t e e n i n t e r e s t group ca tegor ie s : p o l i t i c a l i n t e r e s t , t e c h n i c a l i n t e r e s t , government agencies i n the subject area , voluntary agencies, other government and voluntary agencies i n the same g e o p o l i t i c a l area , p lanners , s p e c i a l i n t e r e s t groups ( e . g . labour ) , consumers, spec ia l needs groups, s p e c i f i c a l l y vested groups, experts , operat ive and policy-making persons. Other ca tegor iza t ions have also been used i n descr ib ing re levant i n t e r e s t groups w i t h i n the hea l th care system. A l f o r d ( 1972 ) c l a s s i f i e s in te re s t s according to p l u r a l i s t ( market ) , bureaucrat ic ( planning ) and i n s t i t u t i o n a l ( c l a s s ) and Schmitter ( 1977 ) uses categories of p l u r a l i s t , c o r p o r a t i s t , s y n d i c a l i s t . Perhaps the s i m p l i s t typology i s that of providers ( hea l th occupat ional groups and i n s t i t u t i o n s ) ; consumers and t h e i r advocacy groups; planners and  bureaucrats ( government, u n i v e r s i t y , independent ) ; and p o l i t i c a l  o f f i c i a l s , at var ious l e v e l s of government. Within each of these broad ca tegor ie s , i n d i v i d u a l groups w i l l have in te re s t s and values s p e c i f i c to t h e i r group. However, there are some common c h a r a c t e r i s t i c s of the broader 164 group. For example, the hea l th care provider ideology for the most part cons i s t s of "arguments about the r i g h t to c la im the pro fe s s iona l prerograt ive of having freedom to c o n t r o l one's own work i n re turn for g i v i n g services to the community" ( Cr i chton 1982, p. 219 ) . And hea l th service consumers, at l eas t middle-c lass consumers, have been "anxious to r e t a i n and develop t h e i r p r i v i l e g e s i n get t ing access when they want i t and to the pro fe s s iona l providers of t h e i r choice" ( C r i c h t o n 1982, p . 223 ) . Examples of groups and organizat ions i n B .C . are l i s t e d below: Provider Groups 1. Pro fe s s iona l a s soc ia t ions ( and t h e i r l i c e n s i n g bodies ) , e . g . B . C . Medica l As soc i a t ion ( College of Physicians and Surgeons ) , B . C . Nurses Union ( Registered Nurses As soc i a t ion of B .C . ) . 2. Non-licensed hea l th occupat ional a s soc i a t ions , e . g . B. C . Government Employees Union, Hosp i t a l Employees Union, Dispensing Optic ians As soc i a t ion of B . C . 3. H o s p i t a l s , i n d i v i d u a l l y and c o l l e c t i v e l y through B . C . Health A s s o c i a t i o n , Heal th Labour Relat ions A s s o c i a t i o n . 4. Long Term Care F a c i l i t i e s As soc ia t ion Consumer Groups 1. Disease groups, d i r e c t serv ice and advocacy/funding a s soc i a t ions ; e . g . C . N . I . B . , B . C . Heart Foundation, B . C . Lung A s s o c i a t i o n . 2. General hea l th and s o c i a l serv ice a s soc i a t ions , e . g . United Way 3. Pr ivate groups paying providers on behalf of consumers, e . g . C. U . & . C . , M . S . A . 165 Planners and Bureaucrats 1. Government, e . g . M i n i s t r y of Health s t a f f , Greater Vancouver Regional H o s p i t a l D i s t r i c t Staff 2 . U n i v e r s i t i e s , e . g . U . B . C . Health Services Planning Facul ty 3. Independent, e . g . var ious pr ivate consul t ing f irms P o l i t i c a l o f f i c i a l s 1. Federal 2. P r o v i n c i a l 3. Regional and Munic ipa l A comprehensive l i s t i n g of groups with some i n t e r e s t i n the hea l th care system would be quite lengthy. What then are the c h a r a c t e r i s t i c s of such groups which provide some guidance as to t h e i r r e l a t i v e inf luence? Blum ( 1974 ) suggests a number of areas for cons idera t ion : evidence of i n t e r e s t i n hea l th i s sues , pos i t ions genera l ly taken on such i s sues , access to resources , l e v e l and extent of c i t i z e n p a r t i c i p a t i o n , a b i l i t y to get voter turnout , i n t e g r i t y , alignments and o b l i g a t i o n s , o rgan iza t iona l capac i ty , i d e n t i f i e d l eader s , general gatekeepers, hea l th issue gatekeepers. Ecks te in ( 1960 ) a l so notes that a group's e f fect iveness i n pressuring government depends upon group c h a r a c t e r i s t i c s , such as p h y s i c a l resources , s i z e , o rgan iza t iona l cohesiveness, p o l i t i c a l s k i l l s , and nature of the group ob jec t ives ( i . e . s e l f - i n t e r e s t versus s o c i a l "good" ) . However, he makes the a d d i t i o n a l point that a group's e f fect iveness i s dependent on factors external to the group, i n c l u d i n g a c t i v i t e s of government and the governmental decision-making s t r u c t u r e . For example, governmental a c t i v i t i e s and p o l i c i e s may require the t e c h n i c a l s k i l l s , support , and cooperation of c e r t a i n groups. 166 The fo l lowing l i s t i n g of re levant c h a r a c t e r i s t i c s of groups i n c o r p o r -ates the c h a r a c t e r i s t i c s d i scussed , using as an example, phys ic ians i n B . C . C h a r a c t e r i s t i c 1) Numbers and d i r e c t costs to the hea l th care system. 2) Resources a v a i l a b l e Physic ians 6000 physic ians i n B . C . , earning about $600 m i l l i o n (1982) B . C . M . A . s t a f f ( Executive D i r e c t o r , computer programmer, economist, pub l i c r e l a t i o n s o f f i c e r , e t c . ) ; B . C . Medical Journal + s t a f f ; College of Physicians and Surgeons s t a f f ( R e g i s t r a r , Deputy Reg i s t rar e t c . ) ; access to other medical a s soc ia t ions ( e . g . C .M.A. ) ; voluntary services of members; some $2 m i l l i o n i n annual dues. 3) Pro fe s s iona l Image and Physicians are the "model" for the r o l e i n the hea l th care system hea l th care p r o f e s s i o n a l . Years of t r a i n i n g , s k i l l s and techniques , the l i f e / d e a t h aspect of the work, media p o r t r a y a l s , e t c . lead to a very high status image of the p h y s i c i a n . Control of much of the d iagnost ic and therapeutic resources of the hea l th care system i s vested i n the p h y s i c i a n . 167 C h a r a c t e r i s t i c Physicians i n B . C . 4) Primary contact versus General P r a c t i t i o n e r s are the entry r e f e r r a l . point into the hea l th care sytem for the majori ty of people. S p e c i a l i s t s u s u a l l y require r e f e r r a l from a General P r a c t i t i o n e r . 5) L e g i s l a t i v e author i ty Physicians operate under the Medical P r a c t i t i o n e r s A c t , which allows them almost unl imited scope i n diagnosing and t rea t ing p a t i e n t s . Moreover, i t gives l e g i s l a t i v e sanct ion to prevent other groups from undertaking the " p r a c t i c e of medic ine" . 6) S o l i d a r i t y and Despite p u b l i c i t y recent ly of cohesiveness of the group d i f f e r e n t fact ions i n the pro fe s s ion , i t remains wel l organized (e .g there are reg iona l s t ruc tures , numerous committees). The common educa t iona l , income, and s o c i a l l eve l s of physic ians are major f a c t o r s . 7) Linkages to the Physicians have t r a d i t i o n a l l y been "power" s t ructure and i n f l u e n t i a l wi th in the hea l th care decis ion-makers . system. A d d i t i o n a l l y , t h e i r s o c i a l contacts give them access to the " e l i t e s " and decision-makers. 168 8) Government organiza t ion Since physic ians rece ive payments from the Medical Services P l a n , there i s frequent government-physician contact at t h i s l e v e l . Various other M i n i s t r y of Health s t ruc ture s , e . g . the Pro fe s s iona l Advisory Committee, are set up to f a c i l i t a t e phys i c i an input to the M i n i s t r y . V . A . 2 . 2 . Conference preparat ion This thes i s proposes that p rov ider , consumer, planning and p o l i t i c a l groups and organizat ions are to be included i n a conference on h e a l t h p o l i c i e s for B . C . What preparat ion i s required? Davidoff and Reiner ( 1973 ) suggest ass igning exchange pr ices to severa l goa l s , posing a l t e r n a t i v e s , analyzing r a m i f i c a t i o n s , and disseminating informat ion to a s s i s t e f f e c t i v e bargaining between proponents of opposing va lues , and rendering value meanings e x p l i c i t to provide common grounds for a p p r a i s a l . Such a process would be undertaken at the conference. This i s not to suggest that the values and general p r i n c i p l e s that are to guide the P r o v i n c i a l Heal th Plan can be simply a compilat ion of value statements from var ious groups at such a conference. There may be u n r e a l i s t i c , i n c o n s i s t e n t , and even i n c o r r e c t statements. The M i n i s t r y of Health must be s e n s i t i v e to the expression of values r e f l e c t i n g group i d e o l o g i e s , without lo s ing s ight of i t s r e s p o n s i b i l i t y to coordinate and plan for the e n t i r e hea l th care system. Depending on the consensus developed amongst p a r t i c i p a n t s at such a conference, edi ted drafts can again be d i s t r i b u t e d , perhaps to a s t i l l wider 169 c i r c l e , f o r comments and r a t i f i c a t i o n . I n a d e m o c r a t i c s o c i e t y , i t i s u n l i k e l y t h a t t o t a l c o n s e n s u s c a n e v e r be a c h i e v e d . T h i s t h e s i s s u g g e s t s , h o w e v e r , t h a t B r i t i s h C o l u m b i a i s s u f f i c i e n t l y w i t h i n t h e m a i n s t r e a m o f w e s t e r n l i b e r a l democracy t h a t t h e r e w i l l be a h i g h d e g r e e of ag reement as t o v a l u e s and g e n e r a l p r i n c i p l e s , i f n o t i n t h e i r a p p l i c a t i o n . The c o n f e r e n c e r e q u i r e s a c o n s i d e r a b l e amount of b a c k g r o u n d p r e p a r a t i o n . Under t h e a s s u m p t i o n t h a t i t i s e a s i e r f o r p a r t i c i p a n t s t o c h o o s e among g e n e r a l p r i n c i p l e s t h a n i t i s t o g e n e r a t e s u c h p r i n c i p l e s de  n o v o , i t w o u l d be d e s i r a b l e t o have a number o f mode ls o r s e t s of g e n e r a l p r i n c i p l e s t o i n i t i a t e d i s c u s s i o n . The government v a l u e s , r e f l e c t i n g i t s p o l i t i c a l and s o c i a l i d e o l o g i e s a p p l i e d t o h e a l t h , c o u l d be one s u c h s e t o f v a l u e s t a t e m e n t s s t i m u l a t i n g r e s p o n s e s f r o m t h e p a r t i c i p a n t g r o u p s . The a d m i n i s t r a t i v e d i f f i c u l t y of c o o r d i n a t i n g a l a r g e number of h e a l t h r e l a t e d g r o u p s f o r a two t o t h r e e day c o n f e n c e i s i t s e l f f o r m i d a b l e . S u f f i c i e n t l e a d t i m e w o u l d be r e q u i r e d t o p e r m i t t h e v a r i o u s g r o u p s t o p r e p a r e t h e i r p o s i t i o n s and b a c k g r o u n d m a t e r i a l . T h i s t h e s i s cannot d i s c u s s t h e d e t a i l e d p l a n n i n g and c o o r d i n a t i o n of s u c h a c o n f e r e n c e . The t a s k m e r i t s a t a s k g r o u p d e d i c a t e d t o t h i s p r o j e c t , w i t h a t a r g e t d a t e a t l e a s t one y e a r f rom i n i t i a t i o n . A number of g e n e r a l g u i d e l i n e s s h o u l d be k e p t i n m i n d . The f ramework f o r t h e c o n f e r e n c e must be made c l e a r b e f o r e h a n d t o a l l p a r t i c i p a n t s . I t s h o u l d be s e e n as an o p p o r t u n i t y f o r v a r i o u s g r o u p s and a s s o c i a t i o n s t o p r o v i d e i n p u t t o t h e government ( and s p e c i f i c a l l y t h e M i n i s t r y o f H e a l t h ) i n d e t e r m i n a t i o n of t h e v a l u e s t a t e m e n t s w h i c h w i l l g u i d e t h e h e a l t h c a r e s y s t e m o f t h i s p r o v i n c e f o r t h e f o r s e e a b l e f u t u r e . However , s p e c i f i c p r o b l e m s o r s t r a t e g i e s c a n n o t be r e s o l v e d o r d e b a t e d i n 170 s u c h a f o r u m , s i n c e t h i s w o u l d i n v o l v e p a r t i c i p a n t s b e i n g overwhe lmed w i t h d e t a i l ( a l t h o u g h p r a c t i c a l e x a m p l e s w i l l , no d o u b t , be c i t e d i n d i s c u s s i n g v a l u e s and g e n e r a l p r i n c i p l e s ) . F u r t h e r , s t a t i n g t h e l i m i t a t i o n s o f t h e c o n f e r e n c e w i l l p r e v e n t u n r e a l i s t i c e x p e c t a t i o n s . F o r e x a m p l e , t h e r e l a t i v e i m p o r t a n c e o f " h e a l t h " t o o t h e r s e c t o r s o f s o c i e t y c a n n o t be u s e f u l l y d e b a t e d as t h o s e o t h e r s e c t o r s w i l l n o t be r e p r e s e n t e d a t t h e c o n f e r e n c e . A c c o r d i n g l y , t h e q u e s t i o n o f t h e o v e r a l l f u n d i n g f o r " h e a l t h c a r e " v e r s u s o t h e r s e c t o r s c a n n o t be a n s w e r e d by t h e C o n f e r e n c e . V . A . 3 . A p p l i c a t i o n o f V a l u e s t a t e m e n t s C a u t i o n must be o b s e r v e d i n a t t e m p t i n g t o a p p l y v a l u e s t a t e m e n t s d i r e c t l y t o p r o g r a m a d m i n i s t r a t i o n o r d e l i v e r y o f s e r v i c e s . The p l a n n i n g a p p r o a c h e s o u t l i n e d i n C h a p t e r I I o f t h i s t h e s i s have s t r e s s e d t h a t t h e o v e r a l l p u r p o s e and d i r e c t i o n s o f t h e p l a n n i n g must be c l e a r l y d e f i n e d ( w h i c h i s t a n t a m o u n t t o d e f i n i n g v a l u e s t a t e m e n t s ) . H o w e v e r , t h e p l a n n i n g m a t r i x s u g g e s t s t h a t c o n s i d e r a b l e a t t e n t i o n must be g i v e n t o c o n s i s t e n c y i n d e s c e n d i n g f r o m one p l a n n i n g l e v e l t o t h e n e x t , t h r o u g h v a r i o u s p l a n n i n g modes . S k i p p i n g l e v e l s and modes i n v i t e s r e s i s t a n c e t o i m p l e m e n t a t i o n o f p o l i c i e s and o b j e c t i v e s . T h u s , t h e p r i m a r y a p p l i c a t i o n o f v a l u e s t a t e m e n t s , f r o m t h e v i e w p o i n t o f d e v e l o p i n g t h e P r o v i n c i a l H e a l t h P l a n , i s i n p r o v i d i n g a c l e a r r e f e r e n c e f o r t h e p o l i c y p l a n n i n g l e v e l , and s p e c i f i c a l l y t h e d e v e l o p m e n t o f o b j e c t i v e s f o r t h e h e a l t h c a r e s y s t e m . The v a l u e s t a t e m e n t s w i l l be a m a j o r i n p u t t o t h e d e t e r m i n a t i o n o f t h e l e g i t i m a c y o f a p a r t i c u l a r h e a l t h p r o b l e m o r i s s u e . The d e g r e e o f c o n s e n s u s as t o v a l u e s t a t e m e n t s w i l l be a r e f l e c t i o n o f t h e l e v e l o f s u p p o r t . A d d i t i o n a l l y , a c l e a r s t a t e m e n t o f v a l u e s w i l l f a c i l i t a t e and i m p r o v e 171 c o m m u n i c a t i o n among t h o s e i n t h e h e a l t h c a r e s y s t e m , t h e " p u b l i c " , t h e m e d i a , e t c . T h e s e w i l l be a measure o f c o n s i s t e n c y o f t h e v a l u e s t a t e m e n t s , b u t a l s o a f o c u s and i n c r e a s e d a w a r e n e s s o f t h e i m p o r t a n c e o f o n g o i n g r e v i e w o f some v e r y b a s i c f a c e t s o f o u r s o c i e t y . V . B . L o n g Term O b j e c t i v e s V a l u e s t a t e m e n t s a b o u t t h e h e a l t h c a r e s y s t e m a r e one o f t h e i n p u t s t o t h e d e v e l o p m e n t o f L o n g Term O b j e c t i v e s ( L T O ' s ) f o r t h e P r o v i n c i a l H e a l t h P l a n . : VALUES LONG r ABOUT THE TERM HEALTH CARE y OBJECTIVES SYSTEM DATA BASE FIGURE 2 6 . D e t e r m i n a t i o n o f L o n g Term O b j e c t i v e s The o t h e r m a j o r i n p u t i s a d a t a b a s e d e s c r i b i n g t h e p r e s e n t h e a l t h c a r e s y s t e m , and p r o j e c t i o n s o f what t h e h e a l t h c a r e s y s t e m may be l i k e i n t h e f u t u r e . The f o r m and c o n t e n t o f t h e d a t a b a s e a r e d i s c u s s e d i n V . B . I . The p r o c e s s o f d e v e l o p i n g L T O ' s f r o m v a l u e s t a t e m e n t s and t h e d a t a b a s e i s t h e n p r e s e n t e d i n S e c t i o n V . B . 2 . The f o r m and a p p l i c a t i o n o f L T O ' s r e s u l t i n g f r o m t h e d e v e l o p m e n t a l p r o c e s s a r e d i s c u s s e d i n S e c t i o n V . B . 3 . V . B . I . D a t a B a s e The d a t a b a s e f o r t h e P r o v i n c i a l H e a l t h P l a n c a n n o t s a t i s f a c t o r i l y be s e t up by t h e a c c u m u l a t i o n o f w h a t e v e r d a t a i s ( o r c a n be ) c o l l e c t e d a b o u t t h e h e a l t h c a r e s y s t e m . Few w o u l d e v e n s u g g e s t t h i s a p p r o a c h , and most p l a n n e r s i n t h i s f i e l d a r e c o n t e n t w i t h a more l i m i t e d l i s t i n g . F o r 172 example, Reinke ( 1972 ) sees a need for the fo l lowing data : demographic in format ion , ep idemiolog ica l data on the frequency and d i s t r i b u t i o n of major hea l th problems, economic data , u t i l i z a t i o n of f a c i l i t i e s and f u n c t i o n a l patterns of work of personnel , adminis t ra t ive data on manpower and f a c i l i t i e s , demand for s e r v i c e . Know ( 1979 ) suggests s i m i l a r data requirements: populat ion d i s t r i b u t i o n by age/sex, s o c i a l c h a r a c t e r i s t i c s , s o c i a l geography, morbidi ty ( i n c l u d i n g reg iona l d i s t r i b u t i o n ) , resources , and volumes of s e r v i c e s . There i s no c l ea r cut demarcation between obta ining s o c i a l c h a r a c t e r i s t i c s to a s s i s t i n planning and embarking on a socioeconomic p o r t r a i t of an a rea . For example, the Arcadiana Health Planning Counci l ( 1974 ) notes the fo l lowing number of r e g i o n a l c h a r a c t e r i s t i c s : h i s t o r i c a l development of the area, d e s c r i p t i o n of land area , populat ion d e n s i t y , major transport a r t e r i e s , temperature, populat ion ( by age and ethnic background ) , unemployment, income l e v e l s , educat ion, e t c . These fac tors could a l l be l i n k e d to the hea l th care system i n some way, but should t h i s be part of the data base for the P r o v i n c i a l Health Plan? What data should be included? The data base for the p r o v i n c i a l plan i s shaped by i t s intended a p p l i c a t i o n s . Thus, i t s d e s c r i p t i o n of the hea l th care system should be r e a d i l y app l i cab le to p o l i c y planning and object ive s e t t i n g . In p a r t i c u l a r , data on s p e c i f i c aspects of the hea l th care system, deemed important because of values re l a ted to that system, would be i n c l u d e d . The data base should al low monitoring and eva luat ion of whether the goals and ob ject ives of the hea l th care system are being achieved . And f i n a l l y , the data base must be such that pro jec t ions of the state of the hea l th care system can be made, 173 g i v e n c e r t a i n a s s u m p t i o n s . Note i n p a r t i c u l a r t h a t t h e d e g r e e of d e t a i l r e q u i r e d f o r a d m i n i s t r a t i v e o r p rogram p l a n n i n g i s no t n e c e s s a r y f o r t h e P r o v i n c i a l H e a l t h P l a n . The d e s c r i p t i o n of t h e h e a l t h c a r e s y s t e m f o l l o w s f rom t h e c o n c e p t u a l i z a t i o n bf t h e s y s t e m i n t o i t s c o m p o n e n t s : h e a l t h s t a t u s , r e s o u r c e s , r e q u i r e m e n t s f o r h e a l t h s e r v i c e s , and t h e p r o c e s s of r e s o u r c e a l l o c a t i o n . These components have been d i s c u s s e d a t l e n g t h i n C h a p t e r I I I , w h i c h p o i n t e d ou t some of t he m e t h o d o l o g i c a l p r o b l e m s i n m e a s u r i n g o r r e p r e s e n t i n g c e r t a i n a s p e c t s of t he " r e a l " w o r l d t h r o u g h u s i n g v a r i o u s I n d i c a t o r s . The i n f o r m a t i o n t o be conveyed a b o u t t h e h e a l t h c a r e s y s t e m components w i l l r e m a i n f a i r l y c o n s t a n t . However , t h e a c t u a l d a t a e l e m e n t s u s e d t o measure o r d e s c r i b e t h e components w i l l change as b e t t e r i n s t r u m e n t s , t e c h n i q u e s , and u n d e r s t a n d i n g of t h e s y s t e m a r e d e v e l o p e d . I n d e e d , t h i s u p d a t i n g and improvement s h o u l d be an i n t e g r a l p a r t of t h e deve lopment o f t he d a t a base f o r t h e P r o v i n c i a l H e a l t h P l a n . The d e g r e e o f d e t a i l r q u i r e d about t h e components w i l l v a r y a c c o r d i n g t o t h e p e r c e i v e d i m p o r t a n c e of a r e a s of c o n c e r n w i t h i n t h e h e a l t h c a r e s y s t e m . F o r example i n B . C . , t h e r e w i l l be a r e l a t i v e l y l a r g e amount of d a t a c o n c e r n i n g p h y s i c i a n s as compared t o s a y , o s t e o p a t h s . The i n f o r m a t i o n o f use f o r p o l i c y p l a n n i n g and o b j e c t i v e s e t t i n g i s l i s t e d b e l o w , u n d e r t h e r e l e v a n t h e a l t h c a r e s y s t e m component : H e a l t h S t a t u s - p o p u l a t i o n , by a g e / s e x / e t h n i c / s o c i o e c o n o m i c b a c k g r o u n d - m o r t a l i t y , m o r b i d i t y , d i s a b i l i t y / d y s f u n c t i o n - " w e l l - b e i n g " , b o t h i n d i v i d u a l and community 174 Health Resources 0 - a c t u a l phys i ca l resources : manpower, f a c i l i t i e s , equipment serving spec i f i ed populations - h e a l t h services x se t t ing x c h a r a c t e r i s t i c s ( see Sect ion I I I . B . ) serving s p e c i f i e d populations Requirements for Health Services - "need" and "demand" expressed e i ther as resources or services Resource A l l o c a t i o n - the e f fect iveness of meeting the requirements with ava i l ab l e resources . The above l i s t e d information flows from c h a r a c t e r i s t i c s i n t r i n s i c to the hea l th care system, and i s r e l a t i v e l y independent of values about the system. The opinions and judgements of "experts" are necessary i n a number of these areas, e s p e c i a l l y i n assessing "need" . A d d i t i o n a l in format ion , i n the form of p a r t i c u l a r ca tegor iza t ions and presentat ion of hea l th care system component information ar i ses from values and general p r i n c i p l e s about the hea l th care system. Thus, i t i s important to understand that the two major inputs to development of LTO's — value statements and data base — are not independent f a c t o r s ; the data base i s shaped to a large degree by the expression of va lues . This r e l a t i o n s h i p i s not an obvious one. Culyer ( 1978 ) draws a t t e n t i o n to the values and assumptions which are needed to o p e r a t i o n a l i z e the concept of hea l th status i n d i c a t o r s , noting that often these assumptions are not c l e a r l y s t a ted . Another example i s found i n the 175 biases of determining " e f f i c i e n t " programs. Blum ( 1974 ) notes that a v a i l a b l e data often tends to be i n areas where goal achievements can be q u a n t i f i e d , and that "other outputs which are d i f f i c u l t to measure may e i t h e r look poorly j u s t i f i e d or go unmeasured and remain le s s known and be seen as less deserving of further a l l o c a t i o n s " ( p. 209 ) . In other words, values about " e f f i c i e n c y " determine the type of data deemed acceptable for planning and resource a l l o c a t i o n d e c i s i o n s . Data elements under each of the hea l th care system components i s found i n Sect ion V . B . 2 . , which explains the process of determining L T O ' s . The data base describes the present hea l th care system by i n d i c a t i n g l eve l s of c e r t a i n data elements, e . g . infant m o r t a l i t y . Long Term Objectives descr ibe a des ired state of the hea l th care system by spec i fy ing l eve l s ( u sua l ly d i f f e ren t than present l e v e l s ) of these same data elements for some future p o i n t . It i s useful at th i s point to re fe r b r i e f l y to the r e l a t i v e importance and usefulness of hea l th status ( or "outcome" ) data, as compared to h e a l t h resources and resource a l l o c a t i o n ( or " input " and "process" ) da ta . One viewpoint i s that " i f the ul t imate concern o f , the populat ion based planner i s improved hea l th s ta tus , then he should be able to measure that Improvement with system-wide, general hea l th status i n d i c a t o r s at some point i n time" ( C a s t e r l i n e 1977, p. 33 ) . In counterpoint , those supporting r e l i ance on input and process i n d i c a t o r s maintain that planning within the hea l th care system, d i c t a ted by ex i s t ing adminis t ra t ive s t ructures and i n s t i t u t i o n s , cannot r e l y on outcomes which may be, to a large extent , determined by factors outside the hea l th care system. It i s argued that the more immediate i n d i c a t o r s needed to a l low p o l i c y i n t e r v e n t i o n cannot wait 17 6 for outcomes. There are often conceptual problems i n r e l a t i n g data gathered and the "outcome" which was r e a l l y to be measured. Moreover, c e r t a i n "process" c h a r a c t e r i s t i c s may be important because of general p r i n c i p l e s or values which d i c t a t e that "how" a re su l t i s achieved i s i n i t s e l f of some importance. Himatsingani ( 1973 ) , while recogniz ing the need for research in to outcome-based measures and funct iona l r e l a t i o n s h i p s between changes i n ef fect iveness and the p r o v i s i o n of s e r v i c e s , s t a te s : "It w i l l be worthwhile developing a planning framework based on input rather than outputs and t h i s framework should be improved and re f ined as and when more informat ion i s a c q u i r e d . " Although w r i t i n g i n the context of evaluating the q u a l i t y of medical care , Donabedian ( 1972 ) came to s i m i l a r conc lus ions . Thus, while he accepts outcomes as the ul t imate v a l i d a t o r s of medical care , he points out numerous l i m i t a t i o n s ( e s s e n t i a l l y s i m i l a r to the points noted already and concludes, "another approach i s to examine the process of care i t s e l f " ( p . 169 ) . Dever ( 1980 ) notes that process eva luat ion allows continuous monitoring ( and thus program operat ion and c o n t r o l ) , serving as ear ly i n d i c a t o r s of outcome. It would seem there fore , that although hea l th status data should l o g i c a l l y be the major determinant of hea l th p lanning , because of cons t ra in t s on data a v a i l a b i l i t y and timeframe required for the p lanning , hea l th resource and resource a l l o c a t i o n data may i n fact be used more o f ten , e s p e c i a l l y when hea l th status data i s inadequate or the r e l a t i o n s h i p between hea l th status and hea l th resources or resource a l l o c a t i o n i s poorly understood. Such a compromise should not be viewed as j u s t i f i c a t i o n for excessive r e l i a n c e on input and process i n d i c a t o r s . Continuing e f for t s to c l a r i f y r e l a t i o n s h i p s of inputs/processes to outputs and outcomes are needed 177 t o c o u n t e r a c t the t e n d e n c y t o s u b s t i t u t e h e a l t h c a r e f o r " h e a l t h " as t h e o v e r a l l g o a l of p l a n n i n g . As t h i s t h e s i s does not s e t ou t t o e s t a b l i s h v a l u e s , t h e d e f i n i t i v e s t a t e m e n t as t o i n f o r m a t i o n r e q u i r e m e n t s c a n n o t y e t be g i v e n . However , u s i n g t h e v a l u e s t a t e m e n t s c i t e d e a r l i e r as i l l u s t r a t i v e e x a m p l e s , t h e a p p r o a c h t o s e t t i n g i n f o r m a t i o n r e q u i r e m e n t s can be d e m o n s t r a t e d . R e c a l l t h a t t h e i l l u s t r a t i v e v a l u e s t a t e m e n t s r e l a t e d t o f o u r a r e a s : (1) D e f i n i t i o n of h e a l t h ; ( 2 ) S o c i a l j u s t i c e ; ( 3 ) R o l e of g o v e r n m e n t s , p r o f e s s i o n s and i n d i v i d u a l s ; ( 4 ) E f f i c i e n t management. The v a l u e s as t o what c o n s t i t u t e s " h e a l t h " a r e d i s c u s s e d i n S e c t i o n I V . D . w h i c h d e l i m i t e d b o u n d a r i e s f o r t h e P r o v i n c i a l H e a l t h P l a n , and i t was s u g g e s t e d t h a t a m o d i f i e d h e a l t h c a r e p l a n n i n g a p p r o a c h be t a k e n . Based on t h i s , i n f o r m a t i o n f r o m n o n - h e a l t h s e c t o r s w i l l be s o u g h t o n l y t o t h e e x t e n t t h e r e a r e q u a n t i f i a b l e i m p a c t s on t h e h e a l t h c a r e s y s t e m . F o r e x a m p l e , c u t b a c k s t o e d u c a t i o n b u d g e t s w i l l a f f e c t p r o d u c t i o n o f h e a l t h manpower and t h u s s u c h i n f o r m a t i o n i s r e q u i r e d . Poo r e c o n o m i c c o n d i t i o n s may a l s o c a u s e i n c r e a s e d unemployment , w h i c h as a s t r e s s o r may be r e l a t e d t o v a r i o u s h e a l t h p r o b l e m s . However , a t t h i s p o i n t i n t i m e , g i v e n l i m i t e d p l a n n i n g r e s o u r c e s and c a p a b i l i t i e s , i t i s i n a p p r o p r i a t e t o a t t e m p t an o v e r l y c o m p r e h e n s i v e d a t a base t h a t w o u l d n e c e s s a r i l y i n c l u d e i t e m s , s u c h as l e v e l s o f emp loyment , w h i c h have no t t r a d i t i o n a l l y been i n c l u d e d w i t h i n t h e h e a l t h c a r e s y s t e m , n o r w h i c h have been shown to d i r e c t l y c a u s a l l y i m p a c t on h e a l t h s t a t u s o r s e r v i c e s . W i t h g r e a t e r s o p h i s t i c a t i o n i n p l a n n i n g , w h i c h h o p e f u l l y w i l l r e s u l t f r o m s t e p s s u c h as d e v e l o p i n g a P r o v i n c i a l H e a l t h P l a n , non h e a l t h c a r e s y s t e m f a c t o r s c a n be added t o t h e d a t a b a s e . V a l u e s as t o s o c i a l j u s t i c e a r e a ma jo r f a c t o r i n t h e d e t e r m i n a t i o n o f 178 information to be inc luded i n the Data Base. Resource a l l o c a t i o n , to the extent that p r i n c i p l e s of s o c i a l j u s t i c e are to be cons idered , requires information by various c a t e g o r i z a t i o n s : geographic r eg ion , age/sex/ethnic groupings, socioeconomic l e v e l s , e t c . Comparisons across such groupings al low p o l i c y statements and hence LTO's i n support of p r i n c i p l e s such as equal or equitable access to hea l th s e r v i c e s . There should probably be s u f f i c i e n t information to provide an awareness of the r e l a t i v e c o n t r i b u t i o n of resources to " h e a l t h " by the hea l th care system, as compared with other s ec tor s . Culyer ( 1978 ) expresses th i s concept wi th in an economists framework: "a s o c i a l l y re levant not ion of need must therefore at once be both r e l a t i v e and marginal - r e l a t i v e to the other good things which must be s a c r i f i c e d and marginal i n that the more we succeed i n meeting need i n one f i e l d , the le s s urgent (again r e l a t i v e to other needs or demands) fur ther degrees of success become" ( p . 49 ) . Values as to the ro les of government, profess ions , and i n d i v i d u a l s imply information on community viewpoints and p r i o r i t i e s . Su l tz ( 1973 ) , i n d i scuss ing community hea l th information p r o f i l e s s t a ted : "the p r o f i l i n g process begins with consul ta t ions with representat ives of community groups who are committed to the necess i ty of having information on which to base planning d e c i s i o n s . . . T h i s i n i t i a l involvement of those who are involved i n subsequent decis ions creates an atmosphere conducive to the acceptance of the end product and contr ibutes a great deal to i t s p o t e n t i a l for e f f e c t i n g change" ( p . 7 ) . He went on to review community hea l th p r o f i l e s (which are analagous to the proposed Data Base for the P r o v i n c i a l Health Plan) for four planning pro jects and concluded that nothing construct ive happened unless the community power s t ructure was a lso involved i n the planning process . 179 Values as to the ro le of government, and i n p a r t i c u l a r the M i n i s t r y of Hea l th , demand information which allows both a cen t ra l planning c a p a b i l i t y , and an ongoing c a p a b i l i t y to set standards, monitor adherence to these standards, and generate construct ive p o l i c i e s to maintain and improve l eve l s of service i n accordance with these standards. The r o l e of government would be s i m i l a r to " a l l o c a t i v e guidance" and "problem c o n t r o l " planning modes, as described by Blum ( 1974 ) . Problem c o n t r o l i s the i d e n t i f i c a t i o n of " s i g n i f i c a n t departures from current hea l th and hea l th care goa l s " (p . 161), whereas a l l o c a t i v e guidance maintains a "continuous overview of the h e a l t h of the community under study so that i t s current status can be compared with those of other places and with that of i t s own past" ( p. 163 ) . Values regarding e f f i c i e n t management require c e r t a i n informat ion and also impose cons t ra int s on the data and information system. Povey ( 1973 ) s t a te s : "To a r r i v e at r a t i o n a l eva luat ion c r i t e r i a of hea l th care a c t i v i t i e s one must define and measure t h e i r cont r ibu t ion to h e a l t h s ta tus " ( p . 104 ) . But c l e a r l y the costs associated with data c o l l e c t i o n , processing and ana lys i s may not be j u s t i f i e d by the usefulness of a " r a t i o n a l " e v a l u a t i o n . Data, e s p e c i a l l y hea l th status informat ion , useful for the determination of o b j e c t i v e s , consis tent with the conceptua l i za t ion of the hea l th care system and with whatever value statements are adopted, may be i n s u f f i c i e n t for monitoring and evaluat ing whether ob ject ives are being adequately addressed. Although s t r i c t l y speaking, the intermediate steps ( sub-object ives ) are p r i m a r i l y considered at the next lower planning l e v e l , i t may be necessary to use these sub-objective ca tegor iza t ions ( most 180 probably data on resources or serv ices ) to provide an ongoing monitoring of the success i n moving towards the ob ject ives of the P r o v i n c i a l Health P l a n . This a d d i t i o n a l information i s then inc luded i n the data base. For example, monitoring progress towards a reduct ion i n in fant mor ta l i ty may require data on number of home v i s i t s and the proport ion of mothers who attend antenata l c l i n i c s . This l inkage between var ious planning l eve l s i s a recurr ing theme demonstrated wel l i n the d i scuss ion on data base. Although appl icab le to the p o l i c y planning l e v e l p r i m a r i l y , the data base i s very much inf luenced by values ( ideology planning l e v e l ) and may draw upon intermediate s t ra teg ie s and sub-object ives towards stated ob ject ives ( adminis t ra t ive and program planning l e v e l s ) . To be use fu l for ob ject ive se t t ing ( which nece s sa r i ly involves a future state of the hea l th care system ), the data base should enable pro jec t ions of what the hea l th care system may be l i k e , g iven c e r t a i n assumptions such as t echno log ica l trends and populat ion growth. The determination of Long Term Object ives may be s i g n i f i c a n t l y af fected by such p r o j e c t i o n s . For example, pro ject ions about new medical technology may change the prognosis of c e r t a i n hea l th problems, and the Long Term Objectives must incorporate assumptions as to a v a i l a b i l i t y of such technology and corresponding ef fect on morb id i ty . The methodology for future pro jec t ions are not included within the framework of the P r o v i n c i a l Health P l a n , but i t i s of i n t e r e s t to touch b r i e f l y on the approaches a v a i l a b l e . Ackoff ( 1970 ) discussed using four pro ject ions for p lanning : reference p r o j e c t i o n , modified reference p r o j e c t i o n , wishful p r o j e c t i o n , and planning p r o j e c t i o n . The reference pro jec t ion re fers to cont inuat ion of the 181 e x i s t i n g s i t u a t i o n . The modified reference p ro j ec t ion postulates changes i n e x i s t i n g trends . The normative or wishful p r o j e c t i o n expresses the preferred outcomes. The planning p r o j e c t i o n estimates how far towards the goals a p lan could a c t u a l l y be e f f ec ted . MacStravic ( 1978 ) reviews various methodologies: status quo forecas t , trend e x t r a p o l a t i o n , trend c o r r e l a t i o n , m u l t i v a r i a t e a n a l y s i s , group process . Other authors have d i f f e r e n t l a b e l l i n g for s i m i l a r techniques . Blum ( 1974 ) c l a s s i f i e d p ro j ec t ive methods as: per s i s t ence , t r a j e c t o r y , c y c l e , a s s o c i a t i o n , a n a l y s i s , c o r r e l a t i o n , s imula t ion , best guess. Abt ( 1970 ) described e x t r a p o l a t i v e , specu la t ive , a n a l y t i c , and judgemental techniques . Of the var ious pos s ib le pro jec t ions that can be used, one i n p a r t i c u l a r i s f a i r l y basic to the determination of o b j e c t i v e s : the fu ture , given cont inuat ion of the current c o n d i t i o n s . Such a status quo or reference p r o j e c t i o n should be included as part of the data base. A d d i t i o n a l pro jec t ions can be used depending on the importance of an issue and ava i l ab l e forecas t ing resources ( s t a f f , computer t ime, data , e t c . ) . D e f i c i e n c i e s i n obtaining the desired information for the data base should be expected, given that most of the ava i l ab le data i s not c o l l e c t e d for planning purposes. Sultz ( 1973 ) considers the usefulness of data according to the usefulness of the information over t ime, whether i t i s v a l i d and comparable to other data , and whether the format Is e a s i l y understandable. King and Ross ( 1981 ) s tress the a v a i l a b i l i t y of data , l e v e l of ana lys i s for which the data i s r e q u i r e d , and the d e s i r a b i l i t y of s tra ightforward c a l c u l a t i o n s and manipulations of data to produce i n d i c a t o r s . Dever ( 1980 ) provides c r i t e r i a i n assessing data : importance 182 of program to be measured, v a l i d i t y , uniqueness, accuracy, t i m e l i n e s s , c o n f i d e n t i a l i t y , cos t s , completeness. Chambers et a l ( 1980 ) descr ibe hea l th data according to four subject areas : mor ta l i ty /morb id i ty data , s o c i a l i n d i c a t o r s , manpower and hea l th f a c i l i t i e s , u t i l i z a t i o n rates under treatment. ,Very broadly speaking, the f i r s t two subject areas correspond to output i n d i c a t o r s ; the l a t t e r two are input and process i n d i c a t o r s . The advantages and disadvantages of each type of data are tabulated by Chambers et a l . For example, m o r t a l i t y data i s u sua l ly r e a d i l y a v a i l a b l e , f a i r l y wel l -def ined and understood by hea l th pro fe s s iona l s , and can be mathematically manipulated. On the other hand, mor ta l i ty data depends on accuracy of repor t ing with the usual d i f f i c u l t i e s i n e s t a b l i s h i n g correc t cause of death, e t c . On reviewing t h e i r t a b u l a t i o n , there are t rade-of f s for every data type i n each subject a rea . Usual ly the a v a i l a b i l i t y of data i s inver se ly re la ted to the usefulness of the data as a v a l i d i n d i c a t o r . Bearing i n mind these caveats , c u r r e n t l y ava i l ab le data sources for B r i t i s h Columbia are l i s t e d below, according to data element. The required data may or may not be published as part of a regular r e p o r t . If data i s unava i l ab le , estimates of the B .C . experience can be made from nat iona l or i n t e r n a t i o n a l rates and r a t i o s . Data Element Source Populat ion S t a t i s t i c s Canada M o r t a l i t y Centra l S t a t i s t i c s Bureau V i t a l S t a t i s t i c s Morbid i ty Hosp i ta l U t i l i z a t i o n (Hospi ta l Programs + I n d i v i d u a l h o s p i t a l s ) ; s p e c i a l r e p o r t s ; 183 D a t a E l e m e n t S o u r c e D y s f u n c t i o n Manpower H e a l t h f a c i l i t i e s E q u i p m e n t S e r v i c e s and programmes M e a s u r e s o f r e s o u r c e a l l o c a t i o n and s y s t e m e f f e c t i v e n e s s M e d i c a l S e r v i c e s P l a n H e a l t h S u r v e i l l a n c e R e g i s t r y R e c o r d s o f R e p o r t a b l e D i s e a s e s Canada H e a l t h S u r v e y W o r k e r ' s C o m p e n s a t i o n B o a r d S c h o o l s H e a l t h Manpower R e s e a r c h U n i t P r o f e s s i o n a l a s s o c i a t i o n s o r l i c e n s i n g body ; MSP, CU&C, MSA. H o s p i t a l P r o g r a m s B.C. H e a l t h A s s o c i a t i o n Community C a r e F a c i l i t i e s A s s o c i a t i o n H o s p i t a l P r o g r a m s I n d i v i d u a l h o s p i t a l s M i n i s t r y o f H e a l t h N e w s p a p e r s and o t h e r m e d i a S p e c i f i c r e v i e w s o r s t u d i e s V . B . 2 . P r o c e s s o f D e t e r m i n i n g L o n g Term O b j e c t i v e s A l t h o u g h t h e k e y i n p u t s t o d e t e r m i n a t i o n o f L T O ' s have been p r e s e n t e d , i t i s r a t h e r u n s a t i s f y i n g t o s u g g e s t s i m p l y t h a t t h e M i n i s t r y o f H e a l t h s t u d y t h e D a t a B a s e and V a l u e s t a t e m e n t s and somehow a r r i v e a t L o n g Term O b j e c t i v e s . Some g u i d e l i n e o r a f ramework i s e s s e n t i a l . W i t h u n l i m i t e d r e s o u r c e s , h e a l t h needs c o u l d be c o n s i d e r e d synonymous w i t h t h e o b j e c t i v e s 184 of the hea l th care system. However, because the resources s t i p u l a t e d to match hea l th needs would exceed the ava i l ab le resources soc iety has ( or i s w i l l i n g ) to set aside for the hea l th care system, some form of resource a l l o c a t i o n must take p l ace . LTO's are thus a f i r s t approximation i n that the sum of resources required to meet a l l LTO's i s less than required to meet a l l hea l th needs, but s t i l l i n excess of cur rent ly ava i l ab le resources . Since the determination of LTO's i s a form of resource a l l o c a t i o n , a process s i m i l a r to that described i n Sect ion I I I . E . 3 . can be used as a framework. Thus determination of these Long Term Objectives w i l l be based on factors of l e g i t i m a c y , f e a s i b i l i t y , and support . As noted i n Sect ion I I I . E . 3 . , t h e weighting and r a t i n g scale proposed by Blum (1974) i s somewhat a r b i t r a r y , and thus quant i t a t ive ana lys i s and p r i o r i z i n g based on such a scale are nece s s a r i ly suspect . Indeed, Blum s t a te s : "It remains to be s tressed that use of c r i t e r i a , weights and ra t ings cannot subs t i tu te for judgement, even though t h e i r use helps inform those who do the judg ing . Rather than provid ing a s i m p l i s t i c guide to se t t ing p r i o r i t i e s , the main u t i l i t y of c rea t ing and using a r a t i n g scheme i s to guide planning body members to cons idera t ion of what may be, for them, novel value systems; such cons iderat ions would then lead to a f u l l view of the complexit ies i n v o l v e d . " ( p . 246 ) . In t h i s v e i n , a c h e c k l i s t of factors (non-weighted) adapted from Blum's l i s t i n g , but wi th in the general paradigm of l eg i t imacy , f e a s i b i l i t y , and support c r i t e r i a as out l ined by H a l l et a l ( 1975 ) , i s suggested below: Legit imacy (1) L e g i s l a t i o n 185 (2) E x i s t i n g p o l i c y , procedures, r u l e s , goals , p lans , e t c . (3) Values : 1) D e f i n i t i o n of Health and R e s p o n s i b i l i t y of the Health Care System - s ever i ty of c o n d i t i o n : symptoms, d y s f u n c t i o n / d i s a b i l i t y , prognosis ( s e l f - l i m i t e d to l i f e - t h r e a t e n i n g ) - urgency of c o n d i t i o n ; r e v e r s i b i l i t y - prevalence ; incidence - l i f e - y e a r s l o s t - environmental concerns; r i s k f a c t o r s . 2) S o c i a l Ju s t i ce - e q u i t y , f a i r shares, e t c . - s p e c i a l groups; a t - r i s k groups 3) Role of Government, I n d i v i d u a l s , Professions - threat to S o c i e t y ; impact on other people - environmental impact - p r o d u c t i v i t y l o s s ; employment - downstream costs - community involvement: p a r t i c i p a t i o n , c o n t r o l / r e s p o n s i b i l i t y , education - coord ina t ion of government sec tors , and with non-government - new s c i e n t i f i c knowledge 4) E f f e c t i v e / e f f i c i e n t Management - secondary, s ide-e f f ec t s - outcome ef fect iveness ( c r i t i c a l path ana lys i s ) - c o s t - b e n e f i t ; e f f i c i e n c y - resource consumption 186 - f l e x i b i l i t y opt ion ( v s . future committed ) F e a s i b i l i t y (1) T h e o r e t i c a l l y t e c h n i c a l l y f e a s i b l e . ( Or research with a high p r o b a b i l i t y of success ) . (2) Prac t i cab le a p p l i c a t i o n of technology: s k i l l e d manpower, adminis t ra t ive i n f r a s t r u c t u r e , support f a c i l i t i e s , e t c . (3) Manpower a v a i l a b i l i t y . Support (1) The number of problems/issue addressed by a " s o l u t i o n " ( also termed leverage ; a s soc i a t ion ) . (2) Time frame, with longer so lut ions having le s s p r i o r i t y . (3) Pub l i c concern, d i s s a t i s f a c t i o n : numbers, i n t e n s i t y , l i k e l i h o o d of change. (4) P o l i t i c a l support; impact on government image. (5) Bureaucrat ic support . (6) Support of s p e c i a l i n t e r e s t groups. Each of these l i s t e d factors i s discussed i n more d e t a i l below, i n d i c a t i n g the d i r e c t i o n of impact on the p r i o r i t y ra t ing of an i s s u e . L e g i s l a t i o n i s not immutable, but e x i s t i n g l e g i s l a t i o n has great force i n cons idera t ion of an i s sue ' s p r i o r i t y . Health services that are to be provided by s tatute almost i n v a r i a b l y are funded without much s c r u t i n y , e . g . maintenance of v i t a l s t a t i s t i c s and publ ic hea l th i n s p e c t i o n . Conversely, services or r e s p o n s i b i l i t i e s that require new l e g i s l a t i o n or r ev i s ions to e x i s t i n g l e g i s l a t i o n are more d i f f i c u l t to in t roduce . 187 To t h e e x t e n t t h a t a h e a l t h i s s u e i s c o n s i s t e n t w i t h e x i s t i n g p o l i c y , p r o c e d u r e s , p l a n s and p r i o r i t i e s , i t w i l l be g i v e n h i g h e r p r i o r i t y . The l e n g t h o f t i m e an e x i s t i n g p o l i c y has been i n p l a c e , and w h e t h e r o r n o t t h e c u r r e n t a d m i n i s t r a t i o n was i n v o l v e d i n s e t t i n g up t h a t p o l i c y , w i l l a f f e c t the d e g r e e t o w h i c h c o n s i s t e n c y i s r e q u i r e d . A l s o , i f e x i s t i n g p o l i c y h a s b e e n c h a l l e n g e d by t h e c o u r t s o r t h e Ombudsman o r government i t s e l f , t h e n i t may p l a y a r e l a t i v e l y m i n o r r o l e i n d e t e r m i n i n g w h e t h e r a p a r t i c u l a r i s s u e i s g i v e n a h i g h e r p r i o r i t y . V a l u e s c o n c e r n i n g " h e a l t h " w i l l d e t e r m i n e an i s s u e ' s p r i o r i t y . I n t h e a r e a s of h e a l t h s t a t u s , t h o s e c o n d i t i o n s t h a t a r e l i f e - t h r e a t e n i n g o r u r g e n t a r e l i k e l y to be g i v e n h i g h e r p r i o r i t y , e . g . o p e n - h e a r t s u r g e r y . The g r e a t e r t h e p r e v a l e n c e o r i n c i d e n c e of a c o n d i t i o n , the g r e a t e r t h e p r i o r i t y . F o r e x a m p l e , c a r d i o v a s c u l a r d i s e a s e and c a n c e r a r e m a j o r c a u s e s of m o r t a l i t y ; a r t h r i t i s i s a ma jo r c a u s e o f d i s a b i l i t y . L i f e - y e a r s l o s t w i l l be i m p o r t a n t i f y o u n g e r l i v e s a r e c o n s i d e r e d more v a l u a b l e t h a n o l d e r l i v e s . The g r e a t e r t h e e n v i r o n m e n t a l r i s k , c l e a r l y t h e h i g h e r the p r i o r i t y t o a d d r e s s a p a r t i c u l a r h e a l t h p r o b l e m , a l t h o u g h t h e d e g r e e of u r g e n c y w i l l v a r y as to v a l u e s about government i n t e r v e n t i o n and r e g u l a t i o n . The c l e a r e r and more d i r e c t t h e c o n n e c t i o n be tween a r i s k f a c t o r , e i t h e r b e h a v i o u r a l o r e n v i r o n m e n t a l , t h e h i g h e r t h e p r i o r i t y g i v e n t o t h a t r i s k i.. f a c t o r . F o r e x a m p l e , c i g a r e t t e smok ing has been shown t o be a m a j o r f a c t o r i n many h e a l t h p r o b l e m s , n o t a b l y l u n g c a n c e r . D e p e n d i n g on v a l u e s i n t h e a r e a of s o c i a l j u s t i c e , i s s u e s t h a t i n v o l v e e q u i t a b l e a c c e s s , t r e a t m e n t , o r c o n d i t i o n s w i l l be o f h i g h e r p r i o r i t y . F o r e x a m p l e , t h e d i s p a r i t y be tween N a t i v e I n d i a n i n f a n t m o r t a l i t y and t h a t of the g e n e r a l p o p u l a t i o n may be g i v e n more a t t e n t i o n . R e l a t e d t o s o c i a l 188 j u s t i c e , i s s u e s o r p r o b l e m s t h a t a f f e c t s p e c i f i c g r o u p s may be g i v e n p r i o r i t y b e c a u s e o f c e r t a i n v a l u e s t h a t h o l d t h e s e g r o u p s as more i m p o r t a n t , e . g . c h i l d r e n , w o r k e r s , t h e e l d e r l y . I s s u e s i n v o l v i n g p u b l i c p r o t e c t i o n o r a t h r e a t t o t h e p u b l i c w e l f a r e a r e g i v e n h i g h p r i o r i t y , e . g . e p i d e m i c s . S i m i l a r l y , i s s u e s t h a t may a f f e c t p e o p l e o t h e r t h a n t h e p a t i e n t / c l i e n t i n q u e s t i o n w i l l be g i v e n p r i o r i t y . F o r e x a m p l e , m e n t a l l y i l l p a t i e n t s , e s p e c i a l l y t h o s e t h a t have o r may engage i n v i o l e n t b e h a v i o u r a r e g i v e n p r i o r i t y a t t e n t i o n . The f a c t o r o f e n v i r o n m e n t a l i m p a c t on h e a l t h i s n o t e d e a r l i e r ; h o w e v e r , t h e more g e n e r a l e c o l o g i c a l c o n c e r n s o f p r e s e r v i n g t h e n a t u r a l e n v i r o n m e n t may a l s o be i n v o k e d i n a s s e s s i n g an i s s u e ' s p r i o r i t y . I s s u e s t h a t a f f e c t p r o d u c t i v i t y and employment ( w h i c h may o r may n o t be r e l a t e d t o h e a l t h s t a t u s ) may be g i v e n p r i o r i t y , e . g . a l c o h o l i s m a f f e c t i n g w o r k e r p r o d u c t i v i t y t h r o u g h a b s e n t e e i s m o r j o b - r e l a t e d a c c i d e n t s may be g i v e n p r i o r i t y . The downst ream c o s t s o f an i s s u e , e i t h e r t h e c o s t s o f a s e r v i c e ( e . g . o p e r a t i n g c o s t s o f c a p i t a l c o n s t r u c t i o n ) o r t h e c o s t s f r o m n e g l e c t i n g h e a l t h p r o b l e m s , a l s o i s a f a c t o r t o be c o n s i d e r e d . C l e a r l y , t h e h i g h e r t h e c o s t s , t h e h i g h e r t h e p r i o r i t y . I f communi ty p a r t i c i p a t i o n i s c o n s i d e r e d i m p o r t a n t , t h e d e g r e e o f communi ty c o n c e r n and o p p o r t u n i t y f o r t h e community t o become i n v o l v e d w i t h an i s s u e may e n h a n c e i t s i m p o r t a n c e . I t may be i m p o r t a n t f r o m a p o l i t i c a l v i e w p o i n t , t o be s e e n as c o o p e r a t i n g w i t h o t h e r g r o u p s o r g o v e r n m e n t s . I s s u e s t h a t a l l o w t h i s m u t u a l a s s i s t a n c e may be c o n s i d e r e d h i g h e r p r i o r i t y . I s s u e s t h a t g e n e r a t e new s c i e n t i f i c k n o w l e d g e may be g i v e n h i g h e r 189 p r i o r i t y , e . g . i n t r o d u c t i o n of d i g i t a l imaging to B . C . The t o t a l resource consumption or costs of an issue i s a major determinant of p r i o r i t y . In genera l , the higher the cos t s , regardless of cos t -e f fec t iveness over the longer term, the lower the p r i o r i t y . This i s not to say that the cos t -e f fect iveness and the cos t-benef i t r a t i o of serv ices are not also determining factors i n an i s sue ' s p r i o r i t y . The degree to which an issue forces commitments and reduces options and f l e x i b i l i t y w i l l a l so determine i t s p r i o r i t y . F e a s i b i l i t y fac tors are f a i r l y s tra ightforward i n assesing an i s s u e ' s p r i o r i t y . I f a serv ice or programme has been prev ious ly shown to work s u c c e s s f u l l y , the p r i o r i t y w i l l be h i g h e r . If i t can be done within current resources , then so much the b e t t e r . As hea l th services are labour i n t e n s i v e , a v a i l a b i l i t y of manpower ( both the actua l numbers and the s p e c i f i c s k i l l s ) i s of p a r t i c u l a r importance. Levels of services or hea l th status achieved i n other j u r i s d i c t i o n s can be considered also as a demonstration of the t e c h n i c a l f e a s i b i l i t y of achieving those l e v e l s . For example, i n t e r n a t i o n a l comparisons of infant m o r t a l i t y , as shown below for 1972, may inf luence determination of LTO's i n t h i s area ( Maxwell 1975 ) : Country Infant M o r t a l i t y per 1000 l i v e b i r t h s A u s t r a l i a 16.7 Canada 17.1 United States 18.5 England/Wales 17.3 Sweden 10.8 Norway 11.8 Netherlands 11.7 190 France 16.0 USSR 24.7 Japan 11.7 TABLE VI International Comparison of Infant M o r t a l i t y , 1972 SOURCE: R. Maxwell, H e a l t h c a r e The Growing Dilemma. McKlnsev & Co., 1975. Support i n the most general sense i s the pub l i c concern for an i s sue , measured by the number of people and i n t e n s i t y of f e e l i n g . Issues with a longer time frame w i l l genera l ly have less impact, and thus less p r i o r i t y . Solut ions that address s imultaneously a v a r i e t y of d i f f e r e n t issues tend to be viewed as higher p r i o r i t y . For example, b u i l d i n g a long term care f a c i l i t y i n a community w i l l be seen not only as he lp ing the e l d e r l y , but also as f ree ing acute care beds for the general popula t ion , provid ing employment during the cons t ruct ion and operat ion of the f a c i l i t y , and encouraging community p a r t i c i p a t i o n through the voluntary board of the f a c i l i t y . S p e c i f i c support i s a l so a factor i n assess ing p r i o r i t y . The Impact on the p o l i t i c a l image of the government, or whether an issue has the support of the bureaucracy or c e r t a i n s p e c i a l i n t e r e s t groups, may determine i t s p r i o r i t y . The impact of some of the factors l i s t e d above has been couched i n tenta t ive terms simply because they rest i n large part on a c lear statement of va lue s . Although these factors ( and others which may be added ) are q u a l i t a t i v e , i t would useful to have a sense of r e l a t i v e weight ing. Formal techniques could be used ( ranking , paired comparisons, ra t ings ) or i t may be jus t a matter of dea l ing with s u f f i c i e n t s p e c i f i c issues to generate some patterns of r e l a t i v e importance. 191 V . B . 3 . Form and A p p l i c a t i o n of Long Term Objectives The inputs to determination of LTO's have been presented; the process of s e l e c t i n g c e r t a i n l e v e l s for these L T O ' s , and a q u a l i t a t i v e order ing of the LTO's has been d i scussed . The general concept of ob ject ives for the P r o v i n c i a l Heal th Plan i s r e a l l y an expression of a des ired state of the hea l th care system at a c e r t a i n point i n t ime. Some hea l th plans state LTO's with ten or twenty year time frames. For purposes of the P r o v i n c i a l Health P l a n , th i s time per iod i s too lengthy. Since the operat ional outcome of the P r o v i n c i a l Heal th Plan are Short Term Object ives , with a one year time h o r i z o n , i t i s more appropriate to consider LTO's to have a three to f i v e year time h o r i z o n . This co inc ides with the p o l i t i c a l time h o r i z o n , allows a reasonable but not excessive lead time for c a p i t a l planning purposes, and most important ly , i s wi th in the l i m i t s of present forecas t ing c a p a b i l i t y . There has been a tendency to equate LTO's with p o l i c y planning and STO's with admini s t ra t ive p lanning . More accura te ly , "ob jec t ive s " are considered at the p o l i c y planning l e v e l ; " s t r a t e g i e s " at the admini s t ra t ive l e v e l . There can be both short term and long term o b j e c t i v e s . In other words, STO's do not speci fy "how" LTO's are to be achieved . Long Term Objectives describe a des ired state of the hea l th care system i n three to f i v e years t ime; short term ob ject ives describe a des ired s tate of the hea l th care system i n one year ' s t ime. LTO's and STO's are expressed i n the same dimensions. For example, a LTO may be an infant mor ta l i ty of 9.0/1000. The corresponding STO may be 10.0/1000; i t would not be expressed i n terms of some intermediate ob jec t ive such as increas ing the proport ion of women attending antenatal c l a s s e s . As the data base, and i t s ca tegor iza t ion of elements, i s d e s c r i p t i v e of the hea l th care system, both LTO's and STO's 192 w i l l , for the most part adhere to a s i m i l a r framework. V . B . 3 . 1 . Form of Long Term Object ives In a d d i t i o n to fo l lowing the general framework ou t l ined for the data base, LTO's should a l so adhere to c h a r a c t e r i s t i c s suggested for " o b j e c t i v e s " . The United States Department of Hea l th , Educat ion and Welfare ( 1976b ) l i s t s a number of these: goals and ob ject ives should be v i s i b l e and measurable ; an ob jec t ive should spec i fy the dimension i n which changes are to occur , i t s measure or i n d i c a t o r , the time per iod i n which the change i s to occur , and i t s d i r e c t i o n or magnitude. The M i n i s t r y of Heal th i n B . C . a l so s tresses the importance of measurable ob ject ives i n i t s d e f i n i t i o n of a long term ob jec t ive : "an e x p l i c i t statement of in tent that describes a des i red r e s u l t . In the Hea l th context such an ob jec t ive should address a hea l th problem to be solved and/or an improvement to be made i n the we l l -be ing of the popula t ion . While complete measurement of the long term ob jec t ive i s not always f ea s ib l e i t should be stated i n terms that provide some means for asess ing achievement" ( B r i t i s h Columbia, M i n i s t r y of Heal th 1981a, p. 3 ) . Weiss et a l ( 1975 ) provide some a d d i t i o n a l gu ide l ines for ensuring that goals can be evaluated, not ing i n p a r t i c u l a r the importance of cons ider ing unant ic ipa ted outcomes, s p e c i f i c program goals and eva luat ion c r i t e r i a or i n d i c a t o r s , the i n c l u s i o n of d o l l a r costs i n a l l assessments, and the usefulness of mul t ip l e i n d i c a t o r s for expressing o b j e c t i v e s . Thus, o b j e c t i v e s , i n a d d i t i o n to meeting the c r i t e r i a of l eg i t imacy , f e a s i b i l i t y , and support, should d i sp l ay the c h a r a c t e r i s t i c s of good " i n d i c a t o r s " : measurable ( e i t h e r q u a n t i t a t i v e , or a q u a l i t a t i v e yes/no ) , accurate r e f l e c t i o n of the under ly ing concept ( s ing ly or i n combination ) , 193 e t c . The time hor izon i s determined by the s p e c i f i c a t i o n of Long Term Objective or Short Term Ob jec t ive , although i t may be useful also to estimate when c e r t a i n prescr ibed l eve l s or ob ject ives can be reached. These c h a r a c t e r i s t i c s of ob ject ives do not seem complicated but the p r a c t i c a l adherence i s more d i f f i c u l t . O n e of the major problems i s the d i f f e ren t usages of the term "Long Term Objec t ives " by planners . For example, the M i n i s t r y of Health ( B . C . ) Long Term Objectives for 1979 were: (1) To promote programs of a preventive nature as w e l l as other a l t e r n a t i v e s i n order to contain r i s i n g costs of hea l th care and provide an optimum s ta te of h e a l t h . (2) To fos ter a responsive organiza t ion of the M i n i s t r y of Health which f a c i l i t a t e s e f f e c t i v e communication, cooperat ion, and coord inat ion and achieves a planning and eva luat ion c a p a b i l i t y supported by an integrated hea l th information system. (3) To provide an e f f e c t i v e d e l i v e r y system throughout the province which provides equi table access to preventive and treatment programs. (4) To implement a province-wide P u b l i c Education program d i rec ted at the Publ ic deal ing with t h e i r : a) f i n a n c i a l r e s p o n s i b i l i t y and u t i l i z a t i o n of s e r v i c e s , b) l i f e s t y l e and a t t i t u d e s , c) per sona l , f ami ly , and community involvement. (5) To i d e n t i f y and reduce environmental hazards to hea l th i n cooperation with other m i n i s t r i e s and agencies . I t i s c l ea r that these "ob jec t ive s " do not correspond to the d e f i n i t i o n of ob ject ives used by th i s t h e s i s , and proposed for the P r o v i n c i a l Health P l a n . In f a c t , the above statements seem c lo ser to value statements than o b j e c t i v e s . Although the framework and form of the LTO's have already been discussed i n the context of the data base for the P r o v i n c i a l Heal th P lan , i t i s useful to demonstrate now i n greater d e t a i l what the LTO's of the P r o v i n c i a l Heal th Plan might look l i k e . The ca tegor i za t ion of LTO's according to hea l th care system component i s l i s t e d below. It i s of i n t e r e s t to note the general s i m i l a r i t y to the "goa l " areas for which the United States i s e s t a b l i s h i n g na t iona l g u i d e l i n e s : hea l th s t a tus , hea l th promotion/prevention, hea l th care s e rv i ce s , hea l th data systems, hea l th 194 innova t ion , and hea l th f inancing ( United States , Department of H e a l t h , Education and Welfare 1977 ) . Health Status Long Term Objectives I . M o r t a l i t y 1) O v e r a l l mor ta l i ty and l i f e expectancy 2) M o r t a l i t y , by In te rna t iona l C l a s s i f i c a t i o n of Disease ( ICD ) grouping 3) M o r t a l i t y , by age/sex grouping 4) M o r t a l i t y and l i f e expectancy, by spec i a l groupings ( Nat ives , s o c i o -economic , geographic reg ions , e t c . ) 5) P o t e n t i a l Years of L i f e Lost by ICD grouping . I I . Morb id i ty 1) Incidence and Prevalence of Risk Factors ( and r i s k p ro tec t ion f a c t o r s , such as immunization ) , i n c l u d i n g those i n the environmental and p u b l i c hea l th areas 2) Incidence and Prevalence by ICD grouping 3) Incidence and Prevalence by ICD grouping,by age/sex grouping 4) Incidence and Prevalence by ICD grouping, by spec i a l groupings ( Nat ives , socio-economic, geographic reg ions , e t c . ) I I I . D y s f u n c t i o n / d i s a b i l i t y 1) Dysfunction by s e v e r i t y 2) Dysfunction by ICD grouping 3) Dysfunction by age/sex grouping 4) Dysfunction by s p e c i a l groupings ( N a t i v e s , socioeconomic, geographic reg ions , e t c . ) 195 IV. Health Status Index 1) Infant m o r t a l i t y 2) Other ind ice s that may be adopted Health Resource Long Term Objectives I . Health Manpower Groupings. For each group, there i s s p e c i f i c a t i o n of ac tua l numbers, f u l l - t i m e equivalent numbers, p r a c t i t i o n e r s per populat ion r a t i o s , services per populat ion r a t i o s , hea l th care expenditures for the group, and some measure of a c c e s s i b i l i t y . 1) Phys ic i ans ; 2) Nurses; 3) Other manpower groups as l i s t e d i n Sect ion I I I . B . , Table I I I . I I . Health F a c i l i t i e s . For each group, there i s s p e c i f i c a t i o n of number of beds, bed per populat ion r a t i o s , bed-days per populat ion r a t i o s , age and condi t ion of f a c i l i t y , a c c r e d i t a t i o n of f a c i l i t y , occupancy and length of stay ( by diagnosis ) , and hea l th care expenditures. 1) Acute Care 2) Long Term Care ( Per sona l , Intermediate, Extended Care ) 3) Others ( R e h a b i l i t a t i o n , e t c . ) I I I . Equipment. For each category, there i s s p e c i f i c a t i o n of numbers, number per populat ion r a t i o s , capaci ty u t i l i z e d , annual serv ices or procedures, and hea l th care expenditures . 1) Imaging: CT scanners, Nuclear Med, U l t r a Sound, PET; 2) Spec i a l i zed Lab Serv ice s ; 3) Spec ia l i zed d iagnost ic or therapeutic equipment, e . g . cardiac 19 6 c a t h e t e r i z a t i o n and d i a l y s i s . IV. Health Serv ice s . For each s e r v i c e , and se t t ing i n which the serv ice i s performed, there i s s p e c i f i c a t i o n of c h a r a c t e r i s t i c s of a v a i l a b i l i t y , a c c e s s i b i l i t y , a c c e p t a b i l i t y , q u a l i t y , c o n t i n u i t y , and cos t . ( See Sect ion I I I . B . and Figure 18. ) V . Finances 1) T o t a l hea l th care costs 2) Health care costs by major service or program area 3) Per capi ta hea l th care cos t s , o v e r a l l and by major serv ice or program area . Resource A l l o c a t i o n Long Term Objectives 1) Assessment of coord inat ion and i n t e g r a t i o n of the hea l th care system 2) Information system operat ion 3) Congruence LTO's and values 4) Discrepancy hea l th needs and resources 5) Discrepancy between LTO's and hea l th needs 6) Pub l i c s a t i s f a c t i o n 7) Health care provider s a t i s f a c t i o n 8) Cr i ses and formal complaints In order to convey some sense of the quant i ta t ive nature of the L T O ' s , the Canadian averages for mor ta l i ty by age/sex grouping ( a hea l th s tatus LTO ) , for physic ians per populat ion ( a hea l th resource LTO ) , and t o t a l 197 hea l th care costs ( another hea l th resource LTO ) are presented. Comparable B r i t i s h Columbia f igures are also g i v e n . Of course, determination of ac tua l L T O ' s , although r e l y i n g on the Canadian averages w i l l take i n t o account many other factors and also would be considerably more d e t a i l e d . Age- spec i f i c m o r t a l i t y Canada B . C . (deaths/1000 popu la t ion , 1976) age 1-14 Male 0.54 0.53 Female 0.36 0.38 age 15-24 Male 1.6 1.9 Female 0.5 0.7 age 25-44 Male 1.9 1.9 Female 0.9 0.9 age 45-64 Male 11.8 10.7 Female 5.8 5.7 age 65 + Male 65.5 61.8 Female 44.6 42.6 ( Canada, Department of Nat iona l Health and Welfare 1979b ) . 198 Populat ion per phys i c i an Canada B . C . (excluding interns and r e s i d e n t s , 1981 ) General P r a c t i t i o n e r s 636 553 \ S p e c i a l i s t s 1276 1188 ( Canada, Department of Nat ional Health and Welfare 1982 ) . Health Expenditures per cap i t a Canada B . C . ( p u b l i c and p r i v a t e , 1975 ) $517 $547 ( Canada, Department of Nat iona l Health and Welfare 1979a ) . The general nature of some of the ca tegor iza t ions l i s t e d for LTO's suggest that more e f for t i s needed to opera t iona l i ze concepts in to measures which can serve as ob jec t ives for the hea l th care system. A major e f f o r t i n th i s d i r e c t i o n i s contained i n the report Operat ional Measures for Health  Systems C h a r a c t e r i s t i c s ( United States , Department of Hea l th , Education and Welfare 1979b ) . The s i x c h a r a c t e r i s t i c s of a v a i l a b i l i t y , a c c e s s i b i l i t y , a c c e p t a b i l i t y , q u a l i t y , c o n t i n u i t y , and cost are analyzed to develop mutually exc lus ive opera t iona l measures. For example, measures for a c c e s s i b i l i t y i n c l u d e : per cent of the populat ion with hea l th insurance, per cent of populat ion wi th in a s p e c i f i e d t r a v e l time to se lected serv ices ( e . g . 30 minutes to general medical services ) , wait ing time to obta in an appointment, f a c i l i t i e s with access for the handicapped, serv ice uni t s a v a i l a b l e outside normal working hours, e t c . Most of the LTO's l i s t e d are stated i n per capi ta measurement terms as 199 wel l as ac tua l numbers. Shaughnessy ( 1982 ) discusses two approaches to per cap i ta mesurement i n hea l th care : community-based and provider-based . The more t r a d i t i o n a l community-based approach s tar t s with a target populat ion ( u s u a l l y geographica l ly defined ) and determines the u t i l i z a t i o n of that target populat ion across a l l prov ider s , whether or not i n the s p e c i f i e d r e g i o n . The community-based u t i l i z a t i o n measure i s then the t o t a l u t i l i z a t i o n d iv ided by the community popula t ion . The LTO's proposed are p r i m a r i l y of th i s type. The provider-based approach spec i f i e s a group of hea l th serv ice prov ider s , and the s ize of t h e i r serv ice populat ion i s determined by a l l o c a t i n g ( to the provider group ) port ions of the populat ion from each community served. The ca lcu la ted serv ice populat ion i s then used as a basis for cost or u t i l i z a t i o n per cap i t a measures for that p a r t i c u l a r provider group. The community-based and provider-based measures are complementary, and cons idera t ion should be given to adding p rov ider -based measures i f data a v a i l a b i l i t y and planning c a p a b i l i t y a l lows . The community-based measures i n d i c a t e whether a given community i s over or under-serviced compared to average r a t e s ; while the provider-based measures i n d i c a t e provider e f f i c i e n c y r e l a t i v e to other groups, the degree of "market penetrat ion" of a p a r t i c u l a r group, and also provides information on an important factor a f f ec t ing c ros s - reg iona l community-based measures. V . B . 3 . 2 . A p p l i c a t i o n of Long Term Objectives The primary a p p l i c a t i o n of LTO's i s to a s s i s t i n determination of STO's by provid ing a longer time h o r i z o n . The three to f i v e year r o l l i n g pro jec-t i o n enables adjustment for demographic, s o c i a l , economic, and technolog ica l changes, and a lso statements of f i n a l outcome for ob ject ives r e q u i r i n g that 200 l e n g t h o f t i m e , e . g . c a p i t a l c o n s t r u c t i o n p r o j e c t s . I n c e r t a i n i n s t a n c e s , a n e v e n l o n g e r t i m e h o r i z o n , e . g . up t o t e n y e a r s , may be n e c e s s a r y t o e n a b l e t h e t h r e e t o f i v e y e a r o b j e c t i v e t o be m e a n i n g f u l l y e s t a b l i s h e d . F o r e x a m p l e , d e m o g r a p h i c changes o v e r a t e n y e a r p e r i o d ( o r l o n g e r ) w i l l i n f l u e n c e d e c i s i o n s r e g a r d i n g c o n s t r u c t i o n of l o n g t e r m c a r e f a c i l i t i e s . T h e r e a r e a l s o a number of s e c o n d a r y a p p l i c a t i o n s of L T O ' s . S i n c e t h e y a r e i n a s e n s e t h e o p e r a t i o n a l i z a t i o n of v a l u e s , t h e L T O ' s s e r v e as a f e e d b a c k and l i n k a g e t o s t a t e m e n t s of v a l u e s . The L T O ' s t e s t t h e r e l a t i v e i m p o r t a n c e o f v a l u e s , and e n c o u r a g e r e v i e w and r e a s s e s s m e n t . D i s c u s s i o n and d i a l o g u e among g o v e r n m e n t , i n t e r e s t e d g r o u p s , and t h e " p u b l i c " a r e f a c i l i t a t e d . The L T O ' s a l s o a l l o w i n t e r - s e c t o r a l c o m p a r i s o n s f o r p u r p o s e s of r e s o u r c e a l l o c a t i o n , e . g . c o m p a r i s o n o f L T O ' s i n h e a l t h w i t h L T O ' s i n e d u c a t i o n o r s o c i a l s e r v i c e s . A l t h o u g h most L T O ' s r e q u i r e some t r a n s l a t i o n i n t o s e r v i c e o r p rogram d e l i v e r y , and t h u s downward movement ( and f e e d b a c k ) t h r o u g h o t h e r p l a n n i n g l e v e l s , i n some i n s t a n c e s , L T O ' s l e a d f a i r l y d i r e c t l y t o p o l i c i e s o r changes of t h e h e a l t h c a r e s y s t e m . F o r e x a m p l e , changes t o t h e o r g a n i z a t i o n a l s t r u c t u r e o f t h e M i n i s t r y o f H e a l t h may be a d i r e c t r e s u l t of L T O ' s c o n c e r n i n g r e g i o n a l i z a t i o n . L e g i s l a t i v e changes may be made on t h e b a s i s o f L T O ' s . G r a n t e d , t h e s e , o r o t h e r c h a n g e s , t h e n g e n e r a t e v a r i o u s a d m i n i s t r a t i v e o r p r o g r a m a t i c . p l a n n i n g a c t i v i t i e s . N o n e t h e l e s s , i t i s c o n c e p t u a l l y i m p o r t a n t t o r e c o g n i z e t h a t i m p l e m e n t a t i o n o f L T O ' s i s no t l i m i t e d t o t h e i r t r a n s l a t i o n i n t o s t r a t e g i e s and e v e n t u a l s e r v i c e d e l i v e r y . V . C . B a s e l i n e O b j e c t i v e s A l t h o u g h f a i r l y i n v o l v e d , t h e d e t e r m i n a t i o n of L T O ' s d e s c r i b e d i n t h e 201 previous s e c t i o n i s s t i l l r e l a t i v e l y e a s i e r than determination of STO's. Despite some l i m i t a t i o n s on expe c t a t i o n s , LTO's s t i l l , i n g e n e r a l , a l l o w f o r some degree of non-commited w i s h f u l n e s s . They are not placed i n d i r e c t competition f o r current resources, the a l l o c a t i o n of which w i l l impact on day-to-day operations of the h e a l t h care system. Moreover, LTO's, although q u a n t i t a t i v e , a l l o w some measure of f l e x i b i l i t y , given the longer time frame, i n approaches or s t r a t e g i e s that might be adopted. However, moving from LTO's to STO's requ i r e s more s e l e c t i v e resource a l l o c a t i o n and p r i o r i z a t i o n d e c i s i o n s . To f a c i l i t a t e the task, t h i s t h e s i s proposes u s i n g the concept of Baseline O b j e c t i v e s . The ( minimally acceptable ) l e v e l f o r any p a r t i c u l a r LTO considered f o r B r i t i s h Columbia i s defined as the Baseline O b j e c t i v e . I m p l i c i t i n t h i s d e s i g n a t i o n i s the p o l i c y that any area or group of people f o r whom the measure f a l l s "below" t h i s b a s e l i n e must be considered highest p r i o r i t y i n the planning and resource a l l o c a t i o n process. "Below" i s meant to imply that increase of the measure i s d e s i r a b l e , e.g. l i f e expectancy or amount of h e a l t h resources or s e r v i c e s . C l e a r l y , c e r t a i n measures are scaled i n the opposite d i r e c t i o n , e.g. m o r t a l i t y . A l s o , there may w e l l be some measures which i n i t i a l l y improve on increase of the measure, but reach a point where f u r t h e r increase i s un d e s i r a b l e , e.g. number of physicians per po p u l a t i o n . For LTO's r e l a t e d to one area of concern, or p o s s i b l y even f o r a range of d i f f e r e n t areas, a p r o f i l e can be used to g r a p h i c a l l y d i s p l a y the r e l a t i o n of Basel i n e Objectives t o LTO's. Because LTO's would have d i f f e r e n t i n d i c a t o r s , and thus d i f f e r e n t measures, some method of s c a l i n g would have to be used, e.g. d e f i n i n g the LT0=1, and the Ba s e l i n e Objectives as some f r a c t i o n between 0 and 1. A graph s i m i l a r to the f o l l o w i n g would r e s u l t : 1 202 1.0 0.0 LTO's B a s e -l i n e O b j e c -t i v e s F o r t h e most p a r t , S T O ' s w o u l d be d e t e r m i n e d t o f a l l be tween t h e B a s e l i n e O b j e c t i v e s and t h e L T O ' s , and s u c h p r o f i l e s a l l o w p l a n n e r s to b e t t e r v i s u a l i z e t h e p r o c e s s of d e t e r m i n i n g t h e a p p r o p r i a t e l e v e l f o r t h e STO. The i n p u t s to d e t e r m i n i n g B a s e l i n e O b j e c t i v e s a r e shown b e l o w : VALUES ABOUT THE HEALTH CARE SYSTEM LONG TERM OBJECTIVES BASELINE OBJECTIVES J DATA BASE FIGURE 2 7 . D e t e r m i n a t i o n o f B a s e l i n e O b j e c t i v e s 203 The p r o c e s s i t s e l f i s e s s e n t i a l l y s i m i l a r t o t h e p r o c e s s used t o d e t e r m i n e L T O ' s , i . e . c o n s i d e r a t i o n of t h e f a c t o r s mak ing up t h e l e g i t i m a c y , f e a s i b i l i t y , and s u p p o r t c r i t e r i a . E v e r y LTO t h u s has a b a s e l i n e l e v e l . However , one c a n n o t e q u a t e t h e e x i s t i n g l e v e l w i t h t h e b a s e l i n e l e v e l ; o t h e r w i s e s i m p l e i n c r e m e n t a l i s m r e s u l t s . Nor c a n one assume t h a t t h e b a s e l i n e need a l w a y s be a c e r t a i n p r o p o r t i o n of t h e LTO, o r t h e s t a t u s q u o . Such an a s s u m p t i o n w o u l d be v a l i d o n l y i f a l l L T O ' s were c o n s i d e r e d e q u a l l y i m p o r t a n t , and i f t h e p r i o r i t y f o r a l l L T O ' s v a r i e d i n a l i n e a r f a s h i o n . I n p r a c t i c e , i t w o u l d seem t h a t t h e p r i o r i t y f o r a LTO need no t f o l l o w a l i n e a r p a t t e r n , e . g . i t may be c o n s i d e r e d c r u c i a l t o have a c e r t a i n l e v e l of a s e r v i c e , a f t e r w h i c h a d d i t i o n a l s e r v i c e s p r o v i d e f a r l e s s " r e t u r n " o r v a l u e f o r t h e r e s o u r c e s p r o v i d e d . S i n c e B a s e l i n e O b j e c t i v e s s h o u l d , by d e f i n i t i o n , a l l be r e a c h e d , t h e y must be f e a s i b l e and i n t e r n a l l y c o n s i s t e n t . F o r e x a m p l e , s h o u l d t h e B a s e l i n e O b j e c t i v e f o r i n f a n t m o r t a l i t y r e q u i r e a c e r t a i n number o f n e o n a t a l o g i s t s i n t h e p r o v i n c e , and a c e r t a i n number o f I n t e n s i v e C a r e N u r s e r y n u r s e s , t h e n i t f o l l o w s t h a t t h e B a s e l i n e O b j e c t i v e s f o r t h e s e c a t e g o r i e s of h e a l t h manpower r e s o u r c e s must be a t l e a s t t h o s e s p e c i f i e d n u m b e r s . The B a s e l i n e O b j e c t i v e s s h o u l d a l l o w some f l e x i b i l i t y f o r l o c a l c o n d i t i o n s , and t h u s may r e q u i r e some q u a l i f i c a t i o n . F o r e x a m p l e , whereas a LTO f o r p h y s i c i a n manpower may be t h e same f o r u r b a n and r u r a l a r e a s , B a s e l i n e O b j e c t i v e s f o r p h y s i c i a n manpower may s p e c i f y d i f f e r e n t l e v e l s . The a p p l i c a t i o n s of B a s e l i n e O b j e c t i v e s a r e , f i r s t l y , t o f a c i l i t a t e deve lopment o f STO 's ( w h i c h i s d i s c u s s e d a t l e n g t h i n S e c t i o n V . D . 2 . , e x p l a i n i n g t h e p r o c e s s of d e v e l o p i n g STO 's ) ; and s e c o n d l y , as an a i d t o t h e b u d g e t i n g p r o c e s s . S i n c e a l l B a s e l i n e O b j e c t i v e s , by d e f i n i t i o n , a r e 204 funded, the greater part of the resource a l l o c a t i o n w i l l be accomplished once Baseline Object ives are des ignated. It i s useful to consider the a p p l i c a t i o n of Basel ine Objectives i n the context of the budgeting system of the M i n i s t r y of Hea l th . In a modified zero-base approach, each r e s p o n s i b i l i t y or cost centre i s required to ou t l ine "packages", beginning with core items as package #1, and progres s ive ly more d i s c r e t i o n a r y items i n packages #2, #3, e t c . As w e l l , i ssue papers are prepared and ranked for program areas exceeding a designated d o l l a r amount, or for expansion of any major program area . Basel ine Objectives wi th in th i s system can be considered as the base "packages": those items which do not require futher j u s t i f i c a t i o n i n the form of issue papers. Note that use fu l a p p l i c a t i o n of Basel ine Object ives i s not l i m i t e d to the M i n i s t r y of Hea l th . Other l eve l s of government, hea l th i n s t i t u t i o n s and organzations can a lso use them i n p lanning , management, and budgeting. V . D . Short Term Objectives The des ired "end-product" of the development of the P r o v i n c i a l Heal th Plan are Short Term Objectives ( STO's ) for the hea l th care system. The inputs to the process of developing these object ives are shown below: LONG TERM OBJECTIVES COMMUNITY INPUT BASELINE OBJECTIVES SHORT TERM OBJECTIVES DATA BASE FIGURE 28. Determination of Short Term Object ives 205 The Data Base, L T O ' s , and Basel ine Objectives have been discussed i n Sections V . B . I . , V . B . 3 . , and V . C , r e s p e c t i v e l y . Community input i s an important input to the determination of STO's . The emphasis placed upon t h i s input w i l l depend upon the value statements regarding the ro le of the government and the i n d i v i d u a l , and the importance of community p a r t i c i p a -t i o n . There are a number of advantages to emphasizing community i n p u t . The a l i e n a t i o n of consumers to the i n s t i t u t i o n s and services i n the community i s reduced. Consumers are able to inf luence decis ions which d i r e c t l y af fect them. Communication i s improved and minor i ty groups have a greater opportunity to make t h e i r concerns known. Community p a r t i c i p a t i o n also re inforces the underlying p r i n c i p l e s of a democratic system. There are a l so p i t f a l l s to formal iz ing community i n p u t . Decision-making may become short-s ighted and vulnerable to l o c a l pressuring and lobby ing . Questions of representat iveness of i n d i v i d u a l s or groups claiming to speak on behalf of the community may a r i s e . The planning and implementation process may be s i g n i f i c a n t l y lengthened by i n v i t i n g community p a r t i c i p a t i o n . Community input i s obtained through a v a r i e t y of mechanisms. One mechanism o f fe r ing p a r t i c u l a r advantages Is the Delphi method. To i l l u s t r a t e i t s a p p l i c a t i o n , a small scale Delphi study was ca r r i ed out i n the Queen Char lo t te I s l ands . This i s presented i n Sec t ion V . D . I . The more general methodology and d e t a i l s of the De lph i method are provided i n the Appendix. The synthesis of the input s , inc lud ing community input , to develop STO's i s presented i n Sect ion V . D . 2 ; and the a p p l i c a t i o n of the STO's so der ived i s discussed i n Sect ion V . D . 3 . V . D . I . Obtaining Community Input: the Delphi method appl ied The Queen Char lot te Islands i n northern B .C . o f fer a number of 206 advantages as the s i t e for a Delphi study to determine r e l a t i v e importance of hea l th problems as perceived by the community. Although d iver se , the Queen Char lo t te Islands are s u f f i c i e n t l y geographical ly i s o l a t e d and have s u f f i c i e n t common concerns to be considered a d i s c r e t e " r e g i o n " . One of the major concerns of the P r o v i n c i a l Heal th Plan i s that of access to hea l th s e r v i c e s . The Charlot tes have p a r t i c u l a r c h a r a c t e r i s t i c s , such as geographical i s o l a t i o n and sparse populat ion base, which may af fect access and thus a study i n the area i s of i n t e r e s t from t h i s per spec t ive . A d e t a i l e d account of the study i s found i n a separate r e p o r t , A p p l i c a t i o n of the Delphi Method to Determine a P r i o r i t y Ranking of Health  Problems i n the Queen Char lot te Islands ( Hsu 1982 ) . The fo l lowing d i scus s ion presents aspects of the study of relevance to the development of STO's for the P r o v i n c i a l Health P l a n . The a p p l i c a t i o n of the Delphi i n the Queen Char lot te Islands fol lows the general format described by Dalkey ( 1969 ) , except that being a p o l i c y D e l p h i , a representat ive ra ther than s o l e l y an expert panel i s used. This panel i s asked to i n d i c a t e t h e i r opinion of r e l a t i v e importance of hea l th problems for the Queen Char lot te Islands and to provide comments i n support of t h e i r rankings . A coordinator c o l l e c t e d and edi ted the responses and prepared a c o n t r o l l e d feedback to the pane l , who were asked again to rank hea l th problems, taking account of the feedback provided. This generated another round of responses which the coordinator again edited and provided to the panel as feedback. In t o t a l , three rounds were used i n the s tudy. From a methodological v iewpoint , there are a number of features of the study 207 which may be used i n the a p p l i c a t i o n of the Delphi i n other communities to generate community input for determination of STO's . The major task requested of the panel was to rank hea l th problems, according to t h e i r percept ion of each problem's importance i n the Queen Char lo t te I s l ands . The d e f i n i t i o n of "importance" was purposely l e f t vague. Questions of prevalence, inc idence , urgency, s e v e r i t y , emotional overtones, amenabil i ty to treatment, populat ion subgroups a f fec ted , e t c . were not s p e c i f i c a l l y addressed. It was f e l t that the r e l a t i v e weightings of these factors may wel l d i f f e r from one i n d i v i d u a l to another. Blum ( 1974 ) has attempted a comprehensive l i s t i n g , with suggested "scores" for such f a c t o r s . This approach seemed Impract ica l i n a community s e t t i n g . As F i scher ( 1979 ) s t a te s , "people often behave i n c o n s i s t e n t l y when confronted with hea l th or s a fe ty- re l a ted wi l l ingnes s - to-pay d e c i s i o n s ; people do so because the i ssues involved are so complex that they cannot respond to them i n an informed systematic f a sh ion" ( p . 194 ) . Instead, an assumption was made that an i n d i v i d u a l takes these factors into account, perhaps i m p l i c i t l y , when asked to consider the importance of a hea l th problem. A ranking , ra ther than a r a t ing on an "importance" scale was used, s ince for resource a l l o c a t i o n purposes, the r e l a t i v e ordering i s of greater usefulness . Of course, ra t ings could be analyzed and scored to rank hea l th problems, but l i k e l y t h i s would have re su l t ed i n le s s d i s c r i m i n a t i o n amongst hea l th problems. There seems to be a tendency to consider most hea l th problems f a i r l y " important" . Of the var ious approaches to ranking , a card sort was f e l t most u s e f u l . There was a f a i r l y lengthy l i s t i n g of hea l th problems, which would have been very d i f f i c u l t for a p a r t i c i p a n t to rank by p lac ing a rank 208 order number by each hea l th problem. The card sort allows easy modi f i ca t ion of the ordering during the ranking process . Health problems are placed side by s ide for comparison ( i n essence using successive paired comparisons ) , and the p h y s i c a l p o s i t i o n i n g of the cards may re in force the sense of ordering according to importance. Each hea l th problem appeared on a 4 x 6 inch white ca rd . This gave s u f f i c i e n t space to place typed comments ( from the Panel ) on each hea l th problem/card. Thus, t h i s feedback was d i r e c t l y i n front of p a r t i c i p a n t s as they ranked the hea l th problem. A simple ana lys i s was done to average the rankings of hea l th problems: (1) cards were numbered sequent i a l ly by the p a r t i c i p a n t s according to the r e l a t i v e r ank ing , #1 being most important ; (2) for each hea l th problem, an average score was ca lcu la ted using the mean of the numbers accorded to the hea l th problem by the p a r t i c i p a n t s ; (3) the hea l th problems were ranked according to average score , the lowest score being most important. Previous Delphi s tudies have suggested the use of a prepared l i s t , or s t ructured f i r s t round, ra ther than asking the panel to generate the i n i t i a l p o l i c y choices or problems de novo. The study i n the Queen Char lot te Islands drew up an i n i t i a l l i s t of 17 hea l th problems. This was based on a number of sources : general f a m i l i a r i t y with B . C . ' s hea l th care system and problems of northern B . C . , previous studies of the Queen Char lo t te I s lands , and annual reports of the Health and Human Resources Centre i n the Queen Char lo t te I s l ands . An e f for t was made to include a c ro s s - sec t ion of hea l th problems, i . e . r e l a ted to hea l th s ta tus , hea l th resources , and the admini s t ra t ive /p lanning of hea l th services ( = process of resource a l l o c a t i o n ) . Thus, although "hea l th problem" was not e x p l i c i t l y def ined , 209 the p a r t i c i p a n t had i n the i n i t i a l l i s t a very broad range of h e a l t h problems. Since that i n i t i a l l i s t was expanded through panel suggestions, th i s placed few r e s t r i c t i o n s on what a pa r t i c ipant might of fer as a d d i t i o n a l "hea l th problems". Previous Delphi s tudies , e s p e c i a l l y p o l i c y Delphis have ind ica ted that i t i s useful to track panel subgroups. The Queen Char lot tes study requested p a r t i c i p a n t s to i n d i c a t e whether or not they were: Haida; associated ( or not ) with the DND base at Masset (one of the two main populat ion centres i n the Queen Char lot te Is lands) ;and whether or not they were hea l th p r o f e s s i o n a l s . Although the Delphi study was aimed p r i m a r i l y at ranking hea l th problems by " importance" , i t was f e l t useful to obta in at leas t a general assessment of the panel ' s percept ion of the f e a s i b i l i t y of improving a p a r t i c u l a r hea l th problem. The r a t ing scale used for f e a s i b i l i t y was e s s e n t i a l l y the same as the one proposed by Turoff ( 1975 ) , and reproduced i n the Appendix. The r e s u l t s , a f ter the f i n a l round of the D e l p h i , showed the fo l lowing "top ten" hea l th problems according to importance: 1. A lcoho l Abuse 2. Motor Vehic le Accidents 3. Drug Abuse 4. I n d u s t r i a l Accidents 5. Mental Disorders 6. Poor N u t r i t i o n 7. Inadequate Long Term Care F a c i l i t i e s / P r o g r a m s 8. Inadequate Dental Services 9. Inadequate Emergency Care 10. Lack of Programs on L i f e s t y l e and Preventive Medicine A d d i t i o n a l information about these hea l th problems, and indeed a l l the hea l th problems inc luded i n the study, was obtained i n using the D e l p h i . 210 F o r e x a m p l e , t h e r e a r e c l e a r l y two v i e w p o i n t s on whethe r t e e n a g e p r e g n a n c y amongst t h e H a i d a p o p u l a t i o n c o n s t i t u t e s a " p r o b l e m " . On t h e one h a n d , t h e r e i s a h i g h e r r a t e amongst t h e H a i d a when compared t o t h e n o n - H a i d a p o p u l a t i o n ; on t h e o t h e r h a n d , t h e e x t e n d e d f a m i l y of t h e H a i d a community s u p p o r t s the c h i l d r e n of t e e n a g e m o t h e r s . The a d v a n t a g e s c i t e d i n t h e r e v i e w o f D e l p h i m e t h o d o l o g y a r e c o n f i r m e d by the e x p e r i e n c e of t h i s s m a l l s c a l e s t u d y . A ma jo r c o n s i d e r a t i o n f o r an a r e a s u c h as t h e Queen C h a r l o t t e s i s t h e expense and u n c e r t a i n t y of t r a v e l . S i n c e t h e D e l p h i u s e d m a i l e d r e s p o n s e s , i t was p o s s i b l e t o e f f e c t i v e l y g a t h e r r e s p o n s e s f r o m a g r o u p of p e o p l e g e o g r a p h i c a l l y d i s p e r s e d , w h i l e s t i l l a l l o w i n g an exchange of i n f o r m a t i o n and i d e a s . The e d u c a t i o n a l a s p e c t o f t h e D e l p h i was n o t s t r e s s e d i n t h i s s t u d y , b u t c l e a r l y i t w o u l d be f e a s i b l e t o have l a r g e r p a n e l s and d i s s e m i n a t i o n of i n f o r m a t i o n a b o u t h e a l t h t o t h e p a r t i c i p a n t s . The l i m i t a t i o n s o f t h e D e l p h i s h o u l d a l s o be n o t e d . I t s i m p l e m e n t a t i o n does r e q u i r e p l a n n i n g and a d m i n i s t r a t i v e r e s o u r c e s . The method does n o t n e c e s s a r i l y " f o r c e " c o n s e n s u s amongst r e s p o n d e n t s ; i n d e e d , i t i s not r e a l l y meant t o be a f o r u m f o r n e g o t i a t i o n and l o b b y i n g by c o m p e t i n g g r o u p s . H e n c e , o t h e r mechanisms may have t o be used t o r e s o l v e c o n f l i c t s . The p r o d u c t i o n o f a r a n k e d l i s t of h e a l t h p r o b l e m s does n o t t r a n s l a t e i m m e d i a t e l y t o s o l u t i o n s o f r e s o u r c e a l l o c a t i o n . The community i n p u t i s j u s t one i n p u t , a l b e i t an i m p o r t a n t o n e , t o t h e d e t e r m i n a t i o n of S T O ' s . The l e n g t h of t i m e r e q u i r e d f o r t h e t h r e e rounds of t he D e l p h i s t u d y may pose p r o b l e m s . Some p a n e l members moved ou t o f t h e a r e a d u r i n g t h e c o u r s e o f t h e s t u d y . W h i l e i t i s t r u e m a i l e d q u e s t i o n n a i r e s and r e s p o n s e s c a n c o n t i n u e t o be u s e d , p a r t i c i p a n t i n t e r e s t i s l i k e l y t o d rop once out of t h e s t u d y a r e a . D u r i n g 211 the course of a lengthy study, changes i n the hea l th care system may occur which impact the ranking of hea l th problems. For example, over the durat ion of the study i n the Queen Char lo t te s , a d d i t i o n a l resources i n the form of a replacement mental hea l th worker and an a l coho l counse l lor were being a c t i v e l y sought. It i s inappropriate to extrapolate the usefulness of the Delphi study s o l e l y on the basis of the small scale study i n the Queen C h a r l o t t e s . The smal l populat ion base Is of some concern s ince a p r o v i n c i a l " reg ion" w i l l l i k e l y be much larger than the 5-6,000 populat ion of the Queen C h a r l o t t e s . A methodology that works w e l l with a small community may be inappropr ia te for a l a rger r e g i o n . The same reasoning cautions against ex t rapo la t ing from a p r i m a r i l y rura l - re source based community to areas with major urban centres . However, the experience of the Delphi method i n other app l i ca t ions ( i n c l u d i n g urban areas, although not i n the hea l th care f i e l d ) , and the r e l a t i v e l y simple procedures of the methodology s t rongly suggest that i t can be used i n d i f f e r e n t regions of the prov ince . Moreover, other mechanisms of community input can be used to complement the Delphi method. For example, informal sources include l o c a l press and media report ing of hea l th re la ted concerns, p u b l i c expressions of i n t e r e s t , statements by l o c a l governments or organizat ions and volunteer a c t i v i t y i n the hea l th care system. More formalized mechanisms include survey, community meetings and the Knowledge Network. V . D . 2 . Process of Determining Short Term Objectives The inputs for developing STO's have been discussed, and examples of each prov ided . The process of determining STO's uses these inputs i n a way 212 e s s e n t i a l l y s i m i l a r t o t h e p r o c e s s e s d e s c r i b e d e a r l i e r f o r d e t e r m i n i n g L T O ' s and B a s e l i n e O b j e c t i v e s . The p a r a d i g m f o r d e t e r m i n i n g L T O ' s , B a s e l i n e O b j e c t i v e s , and STO 's i s c o n s i d e r a t i o n of c r i t e r i a o f l e g i t i m a c y , f e a s i b i l i t y , and s u p p o r t . Once t h e L T O ' s a r e d e v e l o p e d , d e t e r m i n a t i o n of B a s e l i n e O b j e c t i v e s i s f a c i l i t a t e d b e c a u s e t h e c o m p a r i s o n o f t h e e x i s t i n g s t a t e of t h e h e a l t h c a r e s y s t e m t o L T O ' s p r o v i d e s g u i d e l i n e s . S i m i l a r l y , once B a s e l i n e O b j e c t i v e s a r e d e v e l o p e d , d e t e r m i n a t i o n of STO 's i s f a c i l i t a t e d b e c a u s e c o m p a r i s o n of t h e e x i s t i n g h e a l t h c a r e s y s t e m t o B a s e l i n e O b j e c t i v e s p r o v i d e s a d d i t i o n a l g u i d e l i n e s . F o r e x a m p l e , one m i g h t s u g g e s t t h a t t h o s e i s s u e s o r h e a l t h p r o b l e m s w h i c h a r e p r e s e n t l y w e l l above t h e B a s e l i n e O b j e c t i v e c a n be g i v e n l e s s p r e f e r e n c e , and t h u s i n t h e c o n t e x t o f r e s o u r c e a l l o c a t i o n , f e w e r r e s o u r c e s . The d e t a i l e d d e v e l o p m e n t of STO 's w o u l d f o l l o w a l i s t i n g s i m i l a r t o t h e one i n S e c t i o n V . B . 2 . B e c a u s e of t h e s h o r t e r t i m e f r a m e , more e m p h a s i s w i l l be p l a c e d on f a c t o r s u n d e r t h e f e a s i b i l i t y and s u p p o r t c r i t e r i a . A c c o r d i n g l y , more d e t a i l may be needed f r o m the d a t a base f o r t h e s e a r e a s when c o n s i d e r i n g S T O ' s , as compared t o L T O ' s . F o r e x a m p l e , b u d g e t a r y c o n s t r a i n t s and d i f f i c u l t i e s i n t r a n s f e r r i n g r e s o u r c e s f r o m e x i s t i n g i n s t i t u t i o n s and p rograms p l a y a dominant r o l e i n t h e d e v e l o p m e n t o f S T O ' s . The t o t a l r e s o u r c e s o r d o l l a r s i m m e d i a t e l y a v a i l a b l e f o r t h e h e a l t h c a r e s y s t e m i s a n o t h e r f a c t o r o f c o n s i d e r a b l y more i m p o r t a n c e i n d e v e l o p m e n t o f STO's t h a n i n d e v e l o p m e n t o f L T O ' s . D e t e r m i n a t i o n o f an a p p r o p r i a t e t o t a l amount o f r e s o u r c e s f o r t h e h e a l t h c a r e s y s t e m i s n o t a d d r e s s e d by t h e P r o v i n c i a l H e a l t h P l a n . The p l a n n i n g and d e c i s i o n - m a k i n g w h i c h d e t e r m i n e s t h e t o t a l amount f o r t h e h e a l t h c a r e s y s t e m does n o t o c c u r a t t h e p o l i c y 213 p l a n n i n g l e v e l , but a t a h i g h e r p l a n n i n g l e v e l . Such r e s o u r c e a l l o c a t i o n b e t w e e n s e c t o r s of s o c i e t y may use L T O ' s d e v e l o p e d by t h e P r o v i n c i a l H e a l t h P l a n i n a b r o a d e r p r i o r i z a t i o n and p o l i c y s e t t i n g p r o c e s s . D e t e r m i n a t i o n o f t h e r e s o u r c e s a v a i l a b l e t o a r e g i o n a l p l a n n i n g a u t h o r i t y c o u l d i n i t s e l f p r o v i d e t h e s u b j e c t o f a ma jo r r e p o r t o r t h e s i s . I t i s no t d e a l t w i t h a t l e n g t h i n t h i s t h e s i s b e c a u s e of t i m e c o n s t r a i n t s . V a r i o u s a p p r o a c h e s t o d e t e r m i n i n g r e s o u r c e a l l o c a t i o n on a r e g i o n a l , i n s t e a d o f a s e r v i c e o r p r o g r a m b a s i s , a r e p o s s i b l e . F o r e x a m p l e , t h e s t a t u s quo f o r e a c h r e g i o n c o u l d be a s s e s s e d , and p r e s e n t and f u t u r e a l l o c a t i o n s of t h e t o t a l r e s o u r c e p o o l made on t h e same p r o p o r t i o n a t e b a s i s . T h u s , e a c h r e g i o n w o u l d r e c e i v e r o u g h l y t h e same p e r c e n t a g e i n c r e a s e , d e p e n d i n g on t h e g r o w t h o f t h e t o t a l h e a l t h c a r e s y s t e m r e s o u r c e p o o l . A l t e r n a t i v e l y , c r i t e r i a f o r a l l o c a t i o n of a p r o p o r t i o n o f t h e t o t a l r e s o u r c e p o o l c a n be s t a t e d . F o r e x a m p l e , t h e RAWP u s e s s i z e of p o p u l a t i o n a d j u s t e d f o r a v a r i e t y of f a c t o r s , as t h e i r c r i t e r i a . Somewhere be tween t h e i n c r e m e n t a l change t o t h e s t a t u s quo a p p r o a c h , and t h e r e s o u r c e a l l o c a t i o n on t h e b a s i s o f " n e e d " a p p r o a c h i s a p h a s e d change t o w a r d s some t a r g e t a n d / o r i n c l u d i n g demand f a c t o r s i n t h e c r i t e r i a f o r r e s o u r c e a l l o c a t i o n . A c o n c e p t u a l l y d i f f e r e n t a p p r o a c h t o d i v i d i n g t h e t o t a l r e s o u r c e p i e i s t o have e a c h r e g i o n pu t i n r e q u e s t s f o r r e s o u r c e s , and a p p r o v e o r a d j u s t t h e i r r e q u e s t by c o n s i d e r i n g t h e r e l a t i v e m e r i t s o f t h e i r p a c k a g e s . P r e s u m a b l y , c r i t e r i a f o r mak ing s u c h c o m p a r i s o n s w o u l d have t o be d e v i s e d , and w o u l d l i k e l y be s i m i l a r t o t h o s e used f o r d e t e r m i n i n g L T O ' s . The use o f t h e c o n c e p t o f B a s e l i n e O b j e c t i v e s a l l o w s s t i l l a n o t h e r v a r i a t i o n t o r e s o u r c e a l l o c a t i o n on a r e g i o n a l b a s i s . The l e v e l of r e s o u r c e s needed i n a r e g i o n t o a c h i e v e B a s e l i n e O b j e c t i v e s s h o u l d , by 214 d e f i n i t i o n , be provided. I t remains therefore to a l l o c a t e resources remaining from the t o t a l resource pool to the regions. At le a s t i n t h i s manner, the large part of the resource a l l o c a t i o n process i s accomplished i n a r e l a t i v e l y straightforward manner. The c r i t e r i a f o r a l l o c a t i o n of remaining resources could then be based on one of the other approaches outlined above. Regardless of the approach taken to a l l o c a t i n g resources to regions, account must be taken of catchment areas and l e v e l s of service provided i n regions. For example, a t e r t i a r y r e f e r r a l h o s p i t a l i n Vancouver w i l l be serving a much larger population than just the people i n the Greater Vancouver area. I t may be reasonable to designate c e r t a i n p r o v i n c i a l resources, which would be funded or provided at c e r t a i n l e v e l s determined by ce n t r a l ( rather than regional ) planning. These r e f e r r a l services, along with c e n t r a l administrative resources, would be considered separately and deducted from the t o t a l resource pool p r i o r to regional a l l o c a t i o n s . Further adjustement of c e n t r a l of c e n t r a l administrative costs to r e f l e c t d i f f e r i n g " s e r v i c e " to various regions may also have to be done. I t i s u n l i k e l y that a system of resource a l l o c a t i o n to regions, simultaneously s a t i s f a c t o r y to everyone, could ever be devised. For example, one could conceive of c e r t a i n wealthier regions which could by voluntary donation or municipal contribution obtain health s e r v i c e s . Should these regions then have the same drawing power on M i n i s t r y of Health funding? In B r i t i s h Columbia, the organizational structure and r e s p o n s i b i l i t y of regional planning a u t h o r i t i e s have yet to be decided or d e t a i l e d . The 215 degree of r e s p o n s i b i l i t y accorded to the region w i l l be r e f l e c t e d i n the amount of d i s c r e t i o n a r y d o l l a r s a l loca ted to the r e g i