Section 2 - Obstacles to planning

Faced with these arguments, the question naturally arises of why we plan so little, particularly in Western countries.

A - Technical factor - Lack of data

In some cases, the most basic statistics, health cards, levels of coverage per service, etc. are quite simply lacking.

B - Economic factor - The illusions fostered by the affluent society

In those countries which have experienced "the affluent society", the relative abundance of resources obscured the need for planning:what was the point of planning when, to all appearances, the full range of needs could (or would eventually) be met?

Why bother about priorities when it seemed, all of the existing needs could be satisfied? Hence, with the present budgetary constraints weighing heavily on welfare expenditure, the need for a sort of "retrograde (or retrospective) planning", is perceived by those involved in the health care sector as a policy of belt-tightening and rationing.

C - Institutional factor - The interests of institutions

Because of their organised structure and lobbying power, the interests of institutions (hospitals, peripatetic or stationary preventive medicine services, etc.) and professional associations (doctors, nurses, physiotherapists, etc.) carry more weight than any analysis of the needs and level of demand of the community concerned.In the health care sphere, the latter is still largely unorganised:the "patients" or "potential beneficiaries of preventive measures" do not constitute a force capable of deploying itself on the socialfront.Those who claim to speak on their behalf (politicians, doctors, trade unions, mutual associations) are themselves suspect because governed by their own institutional mentality.

D - Cultural factor - The "culture" (or lack thereof) of the medical world

The failure to train and educate doctors and paramedics in the aspects of evaluation, self-evaluation, resource management etc. of public health is a legacy of the liberal practice of medicine in most Western countries (postulates of liberal medicine = complete freedom for the patient to choose his or her doctor, complete freedom for doctors to choose the form of treatment, and where they wish to work, complete freedom as regards setting their fees, on-the-spot payment for treatment).

In the former colonies, by contrast, the modern health service, after the pattern of the civil service and armed forces, was instituted from the outset in the form of a public service, the move towards privatisation being a recent phenomenon. Since resources were much scarcer than in the industrialised countries, receptiveness to the notion of health care planning tends to be more immediate (although not necessarily effective!). The Implications for planning :

1) Emphasis on inputs

The deep-seated reluctance to think of health care systems, medical professions or medical services in terms of results (outputs) (= effectiveness) and yield (output / cost) (= efficiency) breeds a tendency to focus purely on the inputs, whether financial, human, material or technical:"Since you force me to plan, tell me what my budget allocation is and leave me to get on with my job".

2) Tendency to operate in isolation

Each component of the health care system tends to operate in isolation, with precious little regard for the quality of the relations between the various components: GPs / specialists / hospitals / school medicine / industrial medicine / multiple preventive services / administration.

3) Too much emphasis is placed on the two-way doctor-patient relationship

Treating illnesses in the patient's own home takes precedence over promoting health in the community at large.

4) Pathological fear of any "political meddling"

The liberal practice tradition inclines one to see any voluntarist and concerted attempt to reorganise the health care system as unwarranted political interference in the "art of healing".

All of this results in various impediments to planning:

> the proliferation of fragmented views of problems
> contradictory or redundant "plans" and policies
> tendency to latch onto false problems.

Under such circumstances:

a) health planning can never be anything more than

- a sporadic activity, lurching from one crisis or fashion to the next (AIDS, home-based health care)

- a partial activity, confined to a handful of problems leading to a more balanced form of lobbying rather than the fulfilment of needs (e.g. the former "hospital planning" scheme in Belgium)

- an activity which has no impact on the way the system operates.

b) there is no sense of direction, in other words

- what are the priorities?
- how much is the health care system going to cost and what will it deliver in return?
- which areas need to be evaluated and improved?