Planning and change: a Cambodian public health case study

This paper questions the appropriateness of highly structured strategic planning approaches in situations of complexity and change, using the Cambodian German Health Project as a case study. Based on participant observation and organisational analysis in the Cambodian public health sector, the paper examines the rhetoric of values, objectives and strategies outlined in the original project documents and their assumptions and implications, and the responses to the changing political situation. It demonstrates the limitations of these planning processes in complex situations of high uncertainty, with little reliable information and a rapidly changing environment. Having highlighted the limitations of the strategic planning process in these circumstances, the paper recommends changes that shift the focus away from planning towards informed strategic management, that monitors the changing environment and is given freedom to respond to emerging risks and opportunities. The Cambodian German Health Project was initiated in October 1995 as a bilateral health aid project between the German government and the government of the Kingdom of Cambodia, but was disrupted by the "events of 5-6 July, 1997", as the military action is officially described. Project planning had included an intensive goal oriented planning process (ZOPP) undertaken in collaboration with counterparts from the Ministry of Health, Provincial Health Departments and other bilateral, international and non-government stakeholders. Following the military action, the project was initially suspended, then substantially re-drafted within a new framework of assistance, and eventually re-established after an interval of eight months. The paper will examine these planning processes and responses in the light of Mintzberg's (1994 The rise and fall of strategic planning. New York: Prentice-Hall) argument that strategic planning fails because of three conceptual fallacies implicit in the process: (1) The fallacy of predeterminism allows planners to assume that goals, results, appropriate activities and required inputs can confidently be predicted based on past and current experience, when the reality is that both the internal and external environments are subject to change that may not be predictable. (2) The fallacy of detachment suggests that the functions of planning and implementation are discrete management functions, and that objective, rational decisions in determining activities and inputs are sufficient to successfully achieve project goals and results. (3) The fallacy of formalisation provides an expectation that the processes of planning will "capture" the creative insight required for successful strategic development, and reach a binding consensus despite the complex interactions and relationships that characterise bilateral aid projects.     

Using health rights to improve programme design: a Papua New Guinea case study

The non-state sector is becoming increasingly influential in funding and implementing global health programmes. However, their disease-specific focus and vertical interventions have led to criticism that these programmes can be unsustainable and unable to achieve long-term goals. This paper demonstrates that health rights can inform programme design to guide the design of appropriate and sustainable aid-funded health programmes. It draws on UN General Comment 14, which clarified the right to health duties of states and their international partners, and which determined that 'core obligations' in health must become progressively available, accessible, acceptable and of good quality. A rights-based tool assessed the design of activities proposed for Papua New Guinea by a consortium of Australian non-government organisations. The tool revealed that none of the 36 indicators was addressed in full. Five of the 12 indicators pertaining to availability were addressed partially, as were three of 10 relating to accessibility and one of six concerning human rights concepts. As shown by the case study, failure to address the indicators in this tool will result in simplistic programme designs that can win political or financial support, but will fail to respect health rights or deliver a quality health service, available, accessible and acceptable to all.     

Measuring operational efficiency in a health care system: a case study from Thailand

This paper investigates the economic relationship among medical resources and efficiency of the health care system in a developing Asian country. The rapid growth in the use of limited resources and the escalating national health expenditure, raise the critical economic question of whether the use of health care resources are efficient. We estimated a four-factor production system, based on 1982-1997 annual operational data comprising five cross-sectional regions per year. The translog production function and three derived demand for factor input equations were jointly estimated using systems regression method. Results show that different types of medical care workers (doctors, nurses, pharmacists) influenced efficiency differently. The marginal products (MPs) of nurses and capital are the highest and they varied across the regions. Third, the estimates of factor substitution possibilities indicate difficult factor adjustments; these estimates differ in magnitudes and significance across regions but they similarly classify all but one (different) input pair as economic substitutes. Fourth, the regional variations in returns to scale estimates in live births tend to converge to that of the Bangkok metropolis. Finally, technical change is physician and pharmacist labor using, but capital and nursing labor saving. Policy implications of these findings touch on Article 78 of the Thailand Constitution.     

The use of programme planning and social marketing models by a state public health agency: a case study

OBJECTIVES: To investigate the use of planning models and social marketing planning principles within a state's central public health agency as a means for informing improved planning practices. METHODS: Qualitative semi-structured interviews were conducted with 30 key programme planners in selected division branches, and a quantitative survey was distributed to 63 individuals responsible for programme planning in 12 programme-related branches. RESULTS: Employees who have an appreciation of and support for structured programme planning and social marketing may be considered the 'low hanging fruit' or 'early adopters'. On the other hand, employees that do not support or understand either of the two concepts have other barriers to using social marketing when planning programmes. A framework describing the observed factors involved in programme planning on an individual, interpersonal and organizational level is presented. CONCLUSIONS: Understanding the individual and structural barriers and facilitators of structured programme planning and social marketing is critical to increase the planning capacity within public health agencies.     

Enhancing care delivery through cross-disciplinary collaboration: a case study

This exploratory research investigates the factors contributing to and detracting from collaboration across professional groups that are working within an academic medical center. Examined within the context of three recently created service lines, the study uses both objective performance data and perceptual data obtained from the physicians, nurses, and administrators. A similar set of factors emerged across all three service lines and professional groups. These factors were highly correlated with the perceived success of the collaborative efforts in producing positive outcomes in both quality and efficiency of care, patient satisfaction, and improved work environment. Findings of the study highlight the importance of shared values, trust, and personal engagement--all empirically demonstrated to be linked with the participants' perceptions of successful collaboration. The study, however, failed to find improvement in the objective performance data analyzed. In addition, individual professional groups were found to have differing views of the collaborative environment, raising important issues for the management of collaborative efforts in the hospital setting.     

A case study of the Tenwek hospital community health programme in Kenya

Tenwek mission hospital, situated in the west-central highlands of Kenya, initiated a community health programme in 1984. This paper describes the major features of the programme and assesses the impact on a number of health and family planning practices after 3 years of implementation. Comparison of the results in the programme areas with the baseline survey and with control areas show significant changes in several indicators. It is concluded that Tenwek hospital demonstrated the impact a hospital can have on health of communities by effectively moving into community-based health care.     

Practice efficiency and physician compensation: a case study

One of the major challenges facing today's health care executive is that of achieving maximum efficiency. The public also requires an efficient health care system. However, a problem occurs when the health care executive defines "efficiency" in a manner that is diametrically opposed to the public's definition. Maximum efficiency in the physician practice is defined by productivity equal to capacity. Maximum efficiency of the health care system is defined by lower health care costs. If the physician practice is achieving its goal of maximum efficiency, the market economy will likely force a failure in achieving the public's goal of a lower cost health care system! The following case study provides an opportunity to review this health care management conundrum and offers insights into a possible approach for some solution through attention to physician compensation.     

Information system needs in health promotion: a case study of the Safe Community programme using requirements engineering methods

The international Safe Community programme was used as the setting for a case study to explore the need for information system support in health promotion programmes. The 14 Safe Communities active in Sweden during 2002 were invited to participate and 13 accepted. A questionnaire on computer usage and a critical incident technique instrument were distributed. Sharing of management information, creating social capital for safety promotion, and injury data recording were found to be key areas that need to be further supported by computer-based information systems. Most respondents reported having access to a personal computer workstation with standard office software. Interest in using more advanced computer applications was low, and there was considerable need for technical user support. Areas where information systems can be used to make health promotion practice more efficient were identified, and patterns of computers usage were described.     

Creating Europe-wide health policies: a case study

Many local-level issues have direct parallels within broader transnational and global trends. Using practical examples, this article will share the learning from policy development for England within the broader European context, focusing particularly on the changing partnership dynamics and the opportunities afforded for policy development by the new communications technologies.     

Revitalizing health promotion: a case study from Serbia

The last two decades of the twentieth century were difficult ones for health promotion in Serbia. The political, economic and social upheaval resulting from the civil conflict in the former Republic of Yugoslavia put enormous pressure on the health system overall and undermined a previously strong and effective health education and promotion service. In recent years the government, supported by external donors, has refocused attention on the need for high quality public health, including preventive activities as a central goal of the health reform process. This process is reviewed through a case study of a high profile health promotion campaign recently completed within the country. The potential for Serbia to regain its position as an innovator in community-based health care as well as the obstacles to be overcome are analysed.     

Public health services in Shenzhen: a case study

As one of the fastest growing cities in Pearl River Delta of southern China, Shenzhen accommodates a higher percentage and increasing number of internal migrants, mainly coming from the inland areas. The public health issues that challenge its local government include the special population structure, high incidence of infectious diseases, high prevalence of mental problems, rising chronic disease burdens, and maternal and children's health issues, although progress has been made in the past years. The health authority of?Shenzhen has realized that provision of high quality equitable public health services to its residents, including migrants is of high priority, and should be supported by innovations in the health insurance system and establishment of community-based primary care networks. Making changes within the national-level health reform framework and learning from international experiences are necessary and important.     

Rural health care: a case study in Maine

Experience recommends a dual financial strategy--"hard" practice money and "soft" grant and contract money--as a flexible approach to rural healthcare problems.     

Inequity in health a case study

This article presents a particular case of inequity in health, that of two types of Israeli urban settlement: development towns and veteran towns.Inequity in health is demonstrated by the varying levels of resources allocated to each type of community, by the differences in health-care utilization (process), and by the diversity of external factors affecting the two categories of towns. Despite the existence of almost universal health insurance coverage in Israel, it is shown that inhabitants of less privileged development towns are more prone to inequitable health outcomes with respect to the wealthier populations living in veteran towns.This case illustrates an integrated approach to inequity in health, including the health-care system structure, utilization patterns, and the socio-demographic-economic background of different strata.     

Virus removal efficiency of Cambodian ceramic pot water purifiers

Virus removal efficiency is described for three types of silver-impregnated, ceramic water filters (CWFs) produced in Cambodia. The tests were completed using freshly scrubbed filters and de-ionized (DI) water as an evaluation of the removal efficiency of the virus in isolation with no other interacting water quality variables. Removal efficiencies between 0.21 and 0.45 log are evidenced, which is significantly lower than results obtained in testing of similar filters by other investigators utilizing surface or rain water and a less frequent cleaning regime. Other experiments generally found virus removal efficiencies greater than 1.0 log. This difference may be because of the association of viruses with suspended solids, and subsequent removal of these solids during filtration. Variability in virus removal efficiencies between pots of the same manufacturer, and observed flow rates outside the manufacturer's specifications, suggest tighter quality control and consistency may be needed during production.     

Challenges to equity in health and health care: a Zimbabwean case study

The current economic crisis in Africa has posed a serious challenge to policies of comprehensive and equitable health care. This paper examines the extent to which the Zimbabwe government has achieved the policy of "Equity in Health" it adopted at independence in 1980, that is provision of health care according to need. The paper identifies groups with the highest level of health needs in terms of both health status and economic factors which increase the risk of ill health. It describes a series of changes within the health sector in support of resource redistribution towards health needs, including a shift in the budget allocation towards preventive care, expansion of rural infrastructures, increased coverage of primary health care, introduction of free health services for those earning below Z$150 a month in 1980, increased manpower deployment in the public sector and the reorientation of medical training towards the health needs of the majority. The implementation of equity policies in health have however been challenged by several trends and features of the health care system, these becoming more pronounced in the economic stagnation period after 1983. These include the reduction in allocations to local authorities, increasing the pressure for fees, the static nominal level of the free health care limit despite inflation, the continued concentration of financial, higher cost manpower and other resources within urban, central and private sector health care and the lack of effective functioning of the referral system, with high cost central quaternary facilities being used as primary or secondary level care by nearby urban residents. While primary health care expansion has clearly been one of the success stories of Zimbabwe's health care post 1980, the paper notes plateauing coverage, with evidence of lack of coverage in more high risk, socio-economically marginal communities. Measures to address these continuing inequalities are discussed. Their implementation is seen to be dependent on increasing the capacity and organisation of the poor to more strongly influence policy and resource distribution in the health sector.