Describe health planning and management with reference to India.

Planning Cycle and the Indian Machinery

• The planning cycle has six stages, and presenting it as a cycle rather than a list is the point:
• 1. Analysis of the situation — demography, morbidity and mortality, existing services and their utilisation, resources available, and the social and economic context
• 2. Establishment of objectives and priorities
• 3. Assessment of resources — manpower, money, materials and time
• 4. Fixing priorities and selecting the strategy
• 5. Writing the programme and implementing it
• 6. Monitoring and evaluation, which feeds back into the next situation analysis
• The priority-setting stage is where planning actually happens, and the criteria should be given — the magnitude of the problem (how many people affected); its severity (mortality, disability and economic loss); the vulnerability of the problem to intervention, meaning whether anything effective exists; the cost and cost-effectiveness; community concern, which determines whether people will cooperate; and feasibility, including political and administrative acceptability
• The vulnerability criterion is the one most often forgotten and the most important — a very large and severe problem for which NO effective intervention exists is a poor priority for a health programme, however distressing
• Community concern also deserves weight, since a technically correct priority that the community does not share will not be implemented
• The objectives must be SMART — specific, measurable, achievable, relevant and time-bound
• The distinction between goal, objective and target should be made — a goal is a broad, long-term aspiration; an objective is specific and measurable; a target is the quantified level to be reached by a stated date
• The planning machinery in INDIA:
• At the centre — the ministry of health and family welfare, with its Department of Health and Family Welfare, Department of Health Research, and Department of AYUSH (now a separate Ministry)
• The directorate general of health services, headed by the DGHS, which is the principal technical adviser
• The central council of health and family welfare, chaired by the Union Health Minister with state ministers as members, which provides the forum for centre-state coordination
• NITI AAYOG, which replaced the planning commission in 2015
• The change from Planning Commission to NITI Aayog is significant and should be explained — the Planning Commission allocated funds to states through five-year plans; NITI Aayog is an advisory and think-tank body without allocative power, reflecting a shift from central planning to cooperative federalism, with greater state discretion over spending
• At the state level — the State Ministry of Health, the State Health Directorate, and the State Health and Family Welfare Society
• Health is a state subject under the Indian Constitution, with certain matters in the concurrent list including population control, family planning, medical education, prevention of communicable disease across states, food and drug adulteration
• The consequence of health being a state subject is important — the Centre can fund, advise and set norms but cannot direct, which is why national programmes are "centrally sponsored" and implemented by states, and why performance varies so widely between them
• At the district level — the Chief Medical and Health Officer or District Health Officer, and the district health society
• The district is regarded as the operational unit of health planning and management in India, being large enough to command specialist services and small enough for the manager to know the ground
• Panchayati RAJ institutions at zilla parishad, panchayat samiti and gram panchayat levels, which give local elected bodies a role in health under the 73rd and 74th Constitutional Amendments

Management Methods and Their Limits

• The management functions, remembered as posdcorb — planning, organising, staffing, directing, coordinating, reporting and budgeting
• The management techniques relevant to health, with what each is for:
• PERT (Programme Evaluation and Review Technique) and CPM (Critical Path Method) — for scheduling a project of many interdependent activities
• The critical path is the longest sequence of dependent activities, and it determines the minimum time in which the project can be completed
• Its practical use is that delay in an activity ON the critical path delays the whole project, while delay in one off it may not matter at all — so management attention should be concentrated on the critical path
• Network analysis, the GANTT chart and the milestone chart for displaying schedules
• Cost-benefit, cost-effectiveness and cost-utility analysis, considered with health economics
• Systems analysis, input-output analysis, and operations research
• Work sampling and time studies, which are useful for finding where a worker’s time actually goes, and frequently reveal that a large share is spent on records and travel rather than on patients
• Management by objectives, in which manager and subordinate agree objectives jointly, which produces better commitment than objectives imposed
• Decision-making and decision trees; and SWOT analysis
• Planning for health manpower — estimating requirement, production, deployment and retention
• The binding constraint in India is not production but distribution and retention — India produces a very large number of doctors, but they concentrate in urban areas and in the private sector, so shortage and surplus coexist
• Hence the useful measures are those affecting where people work rather than how many are trained — rural service incentives and bonds; admission preference for rural candidates, who are more likely to return; housing, schooling and security; professional support and continuing education; career progression; and training mid-level providers who are more likely to stay
• Selecting students from rural areas is among the best-evidenced measures internationally, since origin predicts eventual practice location better than any incentive offered later
• The health planning experience of India, assessed:
• Successes — an extensive infrastructure created from almost nothing; large-scale programme delivery; smallpox and polio eradication; substantial gains in life expectancy and mortality; and the National Health Mission’s decentralised planning
• Weaknesses:
• Plans made with inadequate or unreliable data
• Top-down planning with limited involvement of those who implement it
• Chronic under-funding relative to the plans made
• Poor intersectoral coordination
• Emphasis on physical targets rather than health outcomes
• Weak monitoring and almost no use of evaluation to change the next plan
• Unspent funds coexisting with unmet needs, reflecting weak absorptive capacity
• The unspent-funds problem is a genuinely instructive one — it shows that money alone does not produce services where the capacity to plan, procure, recruit and spend is missing, which is an argument for investing in management capacity and not only in budgets
• The most important single point about the planning cycle — the loop from evaluation back to situation analysis is what makes it a cycle, and it is the step most often omitted
• A plan that is written, implemented and never evaluated cannot improve, and the next plan will repeat its errors