|Medicine - Epidemiology (ECHO - NOHA - Network on Humanitarian Assistance) (European Commission Humanitarian Office, 1994, 120 p.)|
|Chapter 1: Epidemiology and biostatistics|
|Section 1 - Presentation and summarising of data|
|Section 2 - Measures of disease frequency and association|
|Section 3 - Planning and conducting an investigation|
|Chapter 2: Health Care Planning|
|Section 1 - Priorities and objectives in the context of planning|
|Section 2 - Obstacles to planning|
|Section 3 - Different stages of the planning process|
|Section 4 - Economic evaluation of health care programmes|
|Chapter 3: Health and development|
|Section 1 - Overview and general aspects|
|Section 2 - Operational aspects|
A - The preconditions
* political will or impetus
* legal framework / health care policy
* consult and inform the socio-professional groups concerned, with a view to:
> at the very least, harmonising their opinions (over and above
the various sectoral viewpoints)
> if possible, motivating them
> at best, getting them to work together
* administrative capacity
* initial census of "problem sectors"
In many countries (including our own), any form of general planning is doomed from the outset... owing to lack of political will or impetus.
When the political will is there, getting the relevant socio-professional groups involved can sometimes pose an insurmountable obstacle, inasmuch as institutional interests tend to prevail over considerations of public health.
In some cases (as in certain Third World countries) it is the administrative capacity which is lacking.
B - Identifying needs/problems
Remark - Different authors do not always use the same terms in the same way.Pineault and Daveluy for instance, interpret the term "health problem" as meaning a "problem such as it is perceived by the population", as opposed to need.
Identifying needs and problems hinges on the COLLECTION and ANALYSIS of data.
a) approach based on indicators (Cf. "Community diagnostics")
- socio-demographic indicators:mortality rate, birth rate, age
- health indicators:prevalence, incidence, attributable risk, etc.
- takeup of health care services
Often the data is too sketchy to justify this indicator-based approach, in which case one must use:
b) a survey-based approach
c) a dead-reckoning approach (scientific literature)
d) a comparative approach (i.e. compare two neighbouring areas one of which is better known)
e) a consensus-seeking approach
- key informers
- Delphi method
- nominal group
- community forum
- community's impressions
f) inventory of health care resources and their use
Surprisingly often, one ends up with a surfeit of data, in which case the big mistake can be to think they all have to be used. No planner can process everything.He must be able to pick out the relevant data.
This raises, among other things, the question of the quality of the data available.
- are sometimes designed, presented and processed in such a bureaucratic manner that the health officer in charge of recording them will tend to enter any old figure rather than leave a particular column blank (he knows that no-one will bother to check falsified figures, whereas he will get into trouble if all the columns are not completed!)
- even when they are "reliable", still only represent the diagnosed sickness ratio (section 1 of the figure below).
The Diagnosable sickness ratio represents a broader measure (section 2) : diagnosis errors and forgetting to record all of the cases account for the difference. Sometimes, however, Diagnosed sickness can tend to overstate a particular problem (too many fevers in tropical regions for example, are labelled "malaria").
Actual sickness is even broader: it requires in effect that those who are ill realise they are ill, think to contact the health service for treatment and are actually able to do so (notion of geographical, cultural and financial accessibility of health services).
Finally too, one cannot overlook the fact that the current trend towards training peripheral, auxiliary staff in Third World health services on the basis of "specific problems to be solved" (often using decision trees) is not conducive to data collection based on "cases of clearly defined pathologies". One needs to be quite clear however, what it is one wants: to place data collection in the service of basic practitioners or vice versa... There is no reason why we should not have a data collection systembased on "specific problems to be solved", although it may mean entrusting the in-depth analysis of the prevalence and incidence of particular pathologies to more selective epidemiological studies.
C - Establishing priorities
1) To begin with, one requires a precise definition of the health problem concerned, which must be clearly delimited. Thus for example, rather than "combatting malaria" , the problem will be defined as "combatting infant mortality due to malaria" or as "combatting sickness in pregnant women due to malaria".This makes it possible to plan and organise the different stages more effectively.
2) The golden rule is as follows:
Any given health problem constitutes a "priority" from the point of view of planning health care measures, if it is important and if it is vulnerable.
The importance of any given problem depends on the weighting assigned to the following three components:
- its importance / urgency for the community in question
This urgency can be due to a correct appraisal of the situation by the public at large or can be the "distorted" result of inadequate treatment of a particular issue by the media.In this latter instance, health care planners can make this very area of better public information, one of their goals.
- its intrinsic seriousness (as measured by the specific sickness
ratio and death rate)
- its frequency (as measured by prevalence and incidence)
To disregard the public perception of the problem is to lay oneself open to a technocratic concept of planning, of the sort practised by the promoters of so-called "selective" primary health care (cf. details of this debate elsewhere). On the other hand, focusing too exclusively on people's requirements - as in the case of Western liberal medicine -leads to a medical profession which merely responds to demand without considering the needs, and without reorganising its offerings in the light of those needs; in other words, without establishing priorities.
The vulnerability of any given problem can be broken down into a number of elements :
- its technical vulnerability:is there an effective method (preventive or curative) of combatting this problem?
- The degree of certainty, in medicine, concerning the validity of any given method of prevention or treatment, hinges, in descending order of reliability, on:
- the randomised controlled trial
- case-control study
- the studies prior to/after or with/without the given programme
- experts' opinion
- personal experience, etc.
- its operational vulnerability (= practical vulnerability, in the field), sometimes referred to as feasibility, which in turn depends :
- on the operational possibilities (infrastructures, personnel, climatic conditions, means of transport, etc.)
- on the costs, in terms of : costs for the individuals / for a third party who foots the bill immediate / recurrent costs absolute / relative costs (cost-effectiveness, cost-benefit)
- what result am I getting and at what cost ?
- what am I saving in another sector of the health service if I plan such and such an activity (e.g. curative health care costs saved by a prevention programme) ?
- what will I have to forgo if I devote my resources to such and such an activity (notion of opportunity cost) ?
The relative costs study (using the notions of cost-effectiveness and in some cases, cost-benefit) throws up Several choices and thus paves the way for options in planning.
- on the acceptability of the activities envisaged (legal, political, cultural, ethical acceptability).
3) How do we select priority problems ?
One could start by subjecting all of the problems listed in point 4.2. to the following test :
Please note - that what we are dealing with here are priority measures and not exclusive measures. That is to say, a problem which is deemed to be "unimportant" and "non-vulnerable" should not necessarily be excluded from any health care measure.It is just that since it is not a priority, it can only warrant a small share of the available resources.If one were to exclude the vast majority of "minor complaints" from health care measures however, one would end up with a technocratic and indeed inhuman health service, which would rapidly alienate those it purported to serve.
Even if he follows the steps outlined above, the planner will still find himself faced with a daunting list of priorities. How can we grade these priorities further?
D - Establishing objectives
1) Defining possible alternative forms of action
No planning process is complete without examining alternative solutions for each chosen objective
This is done by :
- basing oneself on the data contained in scientific literature
(compared with the practical feasibility)
- and/or using the same techniques as those used to select problems (4.2.)
2) Defining the target group, at whom the project is aimed
The entire population? A particular age group? A particular high-risk group? Etc.
3) Defining the general objectives
Example : to reduce the incidence of tetanus by x% within such and such a time-limit the number of deaths due to tetanus by z% within such and such a time-limit or, more specifically, umbilical tetanus, or tetanus in children, or adults, etc.
4) Defining the operational objectives
vaccinate --% of the target population with 3 injections
inform --% of the overall population
train --% of midwives
retrain --% of auxiliary staff
ensure that --% of sufferers contact the health service.
E - Determining the activities
The idea at this stage is to determine the type and number of specific activities which need to be undertaken: e.g. number of vaccines, method of conveyance, the freezer chain, information medium, etc.
This stage is more than just an administrative one. Not just because success on the ground depends on the practical organisation, but mainly because this stage requires us to answer two important questions:
1 ) Preventive or curative measures ?
- primary prevention: any measure aimed at reducing the incidence
of illness in the community
- secondary prevention: any measure aimed at reducing the prevalence of illness in the community
- tertiary prevention: any measure aimed at mitigating the consequences of illness in the community (in terms of permanent disability, loss of independence, etc.)
Early detection of illnesses (via screening or case research) generally comes under secondary prevention (the illness is already present but at a preclinical stage: detecting it with a view to treatment thus reduces the prevalence).Detection comes under primary prevention when it concerns a particular risk factor or a precursory stage of the illness (the illness has not yet developed: detection has the effect of reducing its incidence).
In short, a preventive measure is only justified if one can answer "yes" to the following five questions :
1_ Is the illness sufficiently frequent and serious to warrant early intervention (= is it a priority)?
2_ Does the illness have a sufficiently long preclinical phase to allow early intervention?
3_ Is there a valid, reliable test for identifying the illness at the preclinical phase?
4_ Is there some form of intervention (treatment) which is more useful or more effective when it is applied following detection than when it is applied following a diagnosis formed under the usual circumstances?
5_ Is the community at large well-disposed towards screening and does it accept the relevant modes of application?
2) Vertical or horizontal strategy?
The choice of intervention strategy is of cardinal importance: it determines the type of medicine that will eventually be offered to the population concerned.
The first type of strategy involves organising a vertical action programme : from the Department of Health right down to grassroots level (be it a New York district, a station in the Tanzanian bush or a village in the Bolivian Altiplano), the planners organise everything (staff, vehicles, equipment, pay, managerial structure, information flows, etc.) in the form of an independent, self-sufficient channel, separate from the rest of the health service. The thinking behind this vertical planning is as follows: given a particular health problem, what service needs to be organised in order to deploy the methods/ activities provided to combat it?
The second type of strategy involves incorporating health care and programmes into existing services (or services which may be set up or revised on this occasion).Rather than introducing some new activity (i.e. the programme) from the top down, one endeavours to reorganise the existing services in order that they may take on the activities envisaged by the planners. The thinking behind this horizontal format is as follows: given a particular health service, how can we organise it so as to incorporate the solution of priority problems into the existing range of activities, which require a comprehensive, integrated and consistent approach to health care?
Each of the two strategies has its pros and cons.
Opting for one or other has fundamental repercussions on the overall functioning of a country's health service. The vertical approach tends to overlook this latter aspect: the "priorities" are taken care of by the vertical programmes and there is a danger that those in charge will regard the actual functioning of the permanent health services as being outside their province. Yet it is to these permanent services that the community turns on a daily basis for all its problems, "priority" or otherwise.
In the Third World, the debate is even keener. Organising primary health care involves integrating care at a peripheral level; the attitudes of the major aid and intervention agencies (who often advocate selective primary health care) encourages countries to adopt a series of vertical programmes.
"Selective" primary health care classes as "priorities" those problems where the sickness ratio/ death rate is high and where effective prevention or treatment can be readily implemented. The opinion of the communities themselves is unimportant. Non-priority problems are discounted. In practice, this leads to the selection, depending on the location, of fewer than ten or so priority measures, most of which are geared towards pregnant mothers and young children.
At the end of the day, it is a question of opting for the type of health care one prefers. For proponents of vertical planning, the key question is: "Which illnesses ought to be combatted first?" whereas the horizontal structure hinges on the question of "What type of medicine should we offer the population?" (Cf. D. Grodos et X. de Bune, Les Soins de santrimaires sctifs: un pi pour les politiques de santu Tiers Monde, Soc Sc Med, Vol. 26, N_9, pp 879-889, 1988).
F - Deploying and co-ordinating resources
The focus shifts here to the management of the actual programme.