Planning and Implementation

DOI10.1177/019251218100200103
Publication Date01 Jan 1981
AuthorChrista Altenstetter,James Warner Björkman
SubjectArticles
11
PLANNING
AND
IMPLEMENTATION
A
Comparative
Perspective
on
Health
Policy
CHRISTA
ALTENSTETTER
JAMES
WARNER
BJÖRKMAN
Amidst
the
political
sloganeering
about
health
issues,
there
is
a
basic
tension
between
those
who
plan
goals
for
the
health
care
system
and
those
who
try
to
implement
them.
This
article
examines
that
tension
by
first
discussing
the
context
of
planning
and
its
application
to
health
affairs;
then
discussing
the
issue
of
implementation
and
its
problems;
and
finally
applying
these
to
the
particular
case
of
health
care
costs.
Among
the
topics
discussed
are
the
functions
of
planning
(technical
tool,
coordination
device,
symbolic
reassurance);
the
issues
of
participation
(who
gets
represented,
how,
and
at
what
levels
of
government);
and
the
features
of
implementation
(multiple
goals,
macro-
and
micro-arenas,
private
versus
public
interests).
The
current
study
provisionally
concludes
that
health
planning
has
changed
little
in
the
health
care
system
of
any
country
because
inadequate
attention
has
been
paid
to
questions
of
implementation.
INTRODUCTION
A
great
deal
of
political
sloganeering
hovers
about
contemporary
health
issues.
There
is
a
definite
political
element
in
what
is
defined
as
health
care,
since
it
can
run
the
gamut
from
&dquo;anything
goes&dquo;-where
self-care,
preventive
measures,
nutrition,
housing,
and
even
employment
are
counted-to
only
those
services
provided
by
a
physician.
Throughout
this
article
we
restrict
our
usage
of
&dquo;health
care&dquo;
to
mean
medical
care
services
(MCS)
provided
through
clinics
and
hospitals.
This
shorthand
can
be
justified
by
common
usage
but,
more
important,
because
medical
services
account
for
the
vast
bulk
of
expenditures
on
&dquo;health&dquo;
and
because
they
can
be
measured
in
terms
of
operational
data
(Gustafson
et
al.,
1975;
Kohn
and
White,
1976;
Breslow
and
Somers,
1977;
Siegmann
and
Elinson,
1977;
Frazier
and
Hiatt,
1978).
The
chronic
claims
concerning
a
health
crisis
are
at
about
the
same
level
of
emotion-generating
abstraction
as
the
cyclical
pleas
to
&dquo;reorganize
the
govern-
ment.&dquo;
Public
concern
with
health
care
may
go
through
the
&dquo;issue
cycle&dquo;
12
described
by
Downs
( 1972),
although
the
health
issue
does
not
meet
some
of
his
classic
criteria
for
a
rapid
cycle
of
attention
/
neglect.
That
is,
health
care
does
not
affect
just
a
small
group
of
the
population
(something
less
than
15%
of
the
whole),
but
is
a
concern
of everyone.
This
pervasive
concern
suggests
that
health
will
remain
a
more
salient,
persistent
issue
than
ecology,
solar
energy,
or
any
other
of
the
passing
fads.
&dquo;Social
development&dquo;
means
the
cumulative
positive
change
upwards
over
time
of
the
whole
social
system,
and
the
emergence
of
the
welfare
state
is
a
major
current
manifestation
of
such
social
development.
Flora
et
al.
(1977)
observe
that
the
basic
elements
characterizing
the
welfare
state
are,
first,
an
assumption
by
the
state
of
primary
responsibility
for
securing
and
(re)distributing
material
and
cultural
goods,
and,
second,
expanding
interventions
based
on
the
legal
entitlements
of
specific
population
groups.
They
further
observe
that
the
overall
trend
toward
social
welfare
goals
is
the
same
everywhere,
but
that the
institutional
responses
differ
as
to
how
to
deliver
the
entitled
services.
Two
basic
patterns
of
the
contemporary
welfare
state
have
emerged,
each
of
which
bears
directly
on
the
delivery
of
health
services.
One
is
the
&dquo;Scandinavian
model,&dquo;
which
emphasizes
the
direct
provision
of
services
through
direct
expenditures
for
public
consumption;
the
other
is
the
&dquo;continental
model,&dquo;
which
emphasizes
transfer
payments
to
clients
so
they
can
purchase
their
own
services
on
an
open
market
(Flora
et al.,
1977:
746).
These
contrasting
models
of
the
welfare
state
harken
back
to
a
basic
dichotomy
in
the
conceptualization
of
human
nature.
One
view
regards
people
as
ignorant
and
in
need
of
protective
care;
hence
services
are
provided
directly.
The
other
regards
people
as
intelligent
and
generally
capable
of
caring
for
themselves
if
they
have
sufficient
where-
withal ;
hence
only
money
need
be
provided
in
order
to
finance
purchases
elsewhere.
In
health
care,
the
first
view
and
the
Scandinavian
model
are
associated
with
extensive
planning;
the
second view
and
the
continental
model
lead
to
the
advocacy
of
a
free-market
approach
to
health
care
(Donabedian,
1971).
In
health
affairs,
the
upward
movement
of
social
development
within
the
context
of
the
welfare
state
has
been
empirically
reflected
in
expanded
medical
care
services.
Expansion
has
occurred
in
terms
of
ever-wider
population
coverage
and
easier
access
of
entitled
groups;
in
terms
of
higher
quality
and
greater
quantities
of
medical
services;
and
in
terms
of
increasing
percentages
of
GNP
and
of
governmental
budgets
consumed
by
health
expenditures.’-
How-
ever,
although
the
basic
range
of
social
services
in
the
welfare
state
includes
health
care
along
with
income
maintenance
and
housing
provisions,
health
care
has
always
been
subordinate
to
social
insurance
policy,
which
(usually
as
an
afterthought)
underwrites
the
costs
of
medical
expenditures.
The
only
aspect
of
health
policy
to
be
regularly
considered
is
the
entitlement
to
services
of
various
discrete
groups,
and
ultimately
the
whole
population,
on
considerations
of
equity
(Anderson
and
Bjbrkman,
1979).
Other
aspects,
like
personnel,
mix
of
services,
appropriateness,
and
quality
of
care,
have
been
ignored.
13
&dquo;Policy,&dquo;
of
course,
is
a
term
with
a
rich
variety
of
definitions
and
nuanced
elaborations.
We
continue
with
the
Laswell
and
Kaplan
(1950:
71)
usage,
where
policy
is
a
&dquo;projected
program
of
goal
values
and
practices,&dquo;
because
this
formulation
includes
both
the
initial
aims
and
supplementary
procedures.
Public
policies
are
thus
rules
for
action
which
directly
or
indirectly
affect
the
whole
population
of
a
country
and
which
usually
are
established
by
statutory
authorities.
As
the
comparative
study
of subnational
program
implementation
has
demonstrated,
public
policies
are
continuously
reinterpreted
and
modified,
simplified,
and/or
restricted
at
successive
levels
of
government
(Altenstetter and
Bj6rkman,
1978).
New
rules
for
actions
may
supercede
or
coexist
with
old
be-
havioral
parameters;
new
goals
may
emerge
from
a
change
in
value
perspectives.
In
addition,
changes
in
public
policy
at
one
level
of
government
influence
per-
formance
at
other
levels.
Policy
environment
emerges
from
the
outcomes
of
developmental
sequences
over
a
series
of
years,
and
from
the
confluence
of
particular
policies
through
time.
Planning
serves
to
control
that
environment
as
well
as
adapting
to
it.
A
basic
reason
for
planning
is
that
governments
find
it
difficult
to
mobilize
resources
in
order
to
achieve
whatever
goals
of
collective
action
they
have
specified.
Planning
is
also
a
way
to
help
overcome
the
inertia
that
exists
from
the
accumulation
of
policies-policies
concerning
both
what
is
being
done
and
what
is
not
being
done
(Lindblom,
1968;
Bachrach and
Baratz,
1963,1970).
Although
the
policy
environment
cannot
be
easily
changed
at
will,
it
is
malleable.
Also,
purposive
policy
takes
account
of
constraints
and
surrounding
conditions
in
order
to
directly
interfere
with
its
environment.
Too
often
it
is
overlooked
that
behind
public
policy
lies
a
government,
which
implies
(even
if
it
cannot
ensure)
governance;
and
governance
means
making
people
and
organizations
do
things
that
they
otherwise
would
prefer
not
to
do,
and
vice
versa
(Lowi,
1972,
1973).
Government
involves
the
exercise
of
power,
and
so
does
policy.
The
policy
process
spans
a
number
of
overlapping
phases,
of which
one
often
neglected
is
implementation.
In
planning
efforts,
the
discrete
technical
steps
that
must
be
taken
in
order
to
achieve
some
specified
goal
are
rarely
adumbrated.
Rather,
much
so-called
planning
appears
under
the
general
rubric
of
symbolic
politics
rather
than
any
realistic,
detailed
scheme
to
accomplish
certain
ends
(Edelmann,
1964).
One
reason
for
this
bias
toward
symbolism
appears
to
be the
level
of
government
at
which
planning
takes
place.
As
a
national
undertaking,
planning
has
been
couched
in
global
terms
that
are
inapplicable
at
the
local
level.
Another
reason
relates
to
the
number
and
scope
of
political
interests
and
actors
involved.
These
occur
and
multiply
at
all
levels
of
government,
from
center
through
region
to
locality;
yet
&dquo;official
planning&dquo;
has
for
the
most
part
had
a
restricted
number
of
participants.
In
separate
studies
under
way,
we
are
mapping
the
health
planning
insti-
tutions
in
each
of
five
countries -France,
the
Federal
Republic
of
Germany,
Sweden,
the
United
Kingdom,
the
United
States-and
are
examining
the
changes
that
have
occurred
since
1950.
We
are
looking
at
who
has
participated

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