The American Public Health Association believes that effective health planning is essential to meeting the health care needs of the American people. Such health planning needs to be comprehensive, providing for the effective coordination and integration of environmental, social, and physical health planning. The health system, rather than emphasizing regulation and control of health services, must embody creative processes that lead to positive change and innovation in the delivery of health services. The Association believes that effective and innovative health planning is more likely to occur in a decentralized system that builds from the bottom up and that places maximum responsibility on the community: citizens, health providers, and local and area wide health planning agencies. The Association calls for the support and participation by local, state, and federal governments and voluntary associations in community health planning.
While environmental and personal health services planning are naturally related and interdependent, the following "Principles of Comprehensive Health Planning of Personal Health Services" are intended to focus on the roles and responsibilities of the various groups, institutions, and agencies involved in health planning endeavors related primarily to personal health services.
1.0 Definitions
1.1 Comprehensive health planning should include a federal, state, and local partnership to promote and assure the right to the highest level of health attainable for every person, in an environment which contributes positively to healthful individual and group living.The planning process seeks to establish short range plans and long range goals through a comprehensive consideration of needs, resources, and solutions.
Commentary
Comprehensive health planning is an on-going, representative, community process coordinated by a formalized community health planning organization. The comprehensive health planning process involves a broad base of consumers, providers, local government officials, and planning specialists to: (1) identify, evaluate, and assess current and future health needs, goals, resources, inadequacies, causal factors, and alternative courses of action; (2) establish priorities; and (3) promote the implementation of its recommendations. The health planning organization is accountable to the people through open and democratic decision-making procedures involving a majority of consumers.
The comprehensive health planning process assumes that each community health problem must have multiple causes, multiple consequences, and multiple solutions, and seeks, in so far as is practical, to give adequate attention to all of the primary ones in arriving at both short and long term solutions.
1.2 Personal health services include all those services rendered to individuals which enable them to maintain, develop, or restore their physical and mental well-being; these include, among others, such "enabling" services as community health education, outreach and social services.
Commentary
Personal physical and mental health services include all modalities of care: ambulatory, emergency, home health, acute in-patient, long-term care, and convalescent services. Access to these services must be available to the patient from a central access point responsible for the totality of his care and capable of offering or arranging for, then following-up on and maintaining liaison with, all elements of the services rendered to the patient.
Personal health services are provided in a variety of settings: the common denominator of these services is, however, the location of the patient in a progressive comprehensive care system which is accessible to him at all times. In this comprehensive care setting, be it a free-standing ambulatory care service, a group practice, a private physician's office, or an institutionally based service, the patient should be free to choose among options for his care. That is, a full range of personal health services as defined must be offered and explained to the patient; and within that range, he must be able to choose among a totality of services that suit his needs ranging from crisis-oriented to drop-in, nonemergent services.
1.3 Consumers of health services are those persons whose occupations are other than administration of health activities, provision of health services, or education and training in health subjects; and who have no direct fiduciary interest in health facilities, health organizations, the financing of health care, or the rendering of health services.
Commentary
While everyone will be a user of health services several times in his life, and will in various ways be a provider of personal health services for the purpose of comprehensive health planning, a distinction is made between the average person seeking services and those who are in some direct way responsible for the delivery of health services. Consumer involvement in health planning and decision-making is essential to the understanding of health conditions and the solutions of health problems. Similarly, while everyone has either a direct or indirect financial interest in health facilities or services, a distinction is made between those who are immediate financial beneficiaries and those whose interest is more indirect.
2.0 Structures for Planning
2.1 The three levels of planning (local, state, and national) should operate as an integrated system of planning.
Commentary
The planning capability being developed at community and state levels through comprehensive health planning needs to be expanded and linked to include local, regional, and national levels in order to assure a more systematic input from each level into other levels of decision-making.
2.2 The responsibility for stimulating, guiding, and maintaining a community's comprehensive health planning process should be clearly assigned to a single agency for a given area, and all areas should be served by such an agency.
Commentary
While unduplicated responsibility is essential, consideration must also be given to assure that the responsibilities assigned are rational and manageable. Territorial size should be such that participatory arrangements are possible, with special emphasis to fixing boundaries as much as possible according to a local sense of community. Areawide agencies should foster the development of sub-area planning groups as part of their organizational structure.
2.3 The State Comprehensive Health Planning Agency should support personal health services planning at the community level by supporting the development of local and areawide agencies, providing leadership for health planning concerns in the state, and advising and influencing state level decision-making for responsiveness to community needs.
2.4 The local and regional comprehensive health planning agencies should secure for themselves input into any statewide planning for personal health services.
2.5 The key to developing delivery systems of personal health services which meet peoples' comprehensive health needs is effective planning and joint consumer-provider decision-making at the local, state, and national levels.
Commentary
Personal health services have their impact on people and on the health of people at the point of delivery. Regardless of changes made in the financing and regulation of health care, it is essential that affected consumers and their local health care institutions in the community—hospitals, group practices, mental health centers, health departments and others—respond constructively and assume a common responsibility for the development of programs and arrangements to meet the comprehensive health needs of people.
Decisions relating to the development and implementation of financing mechanisms, regulations and program incentives are generally made at state and national levels. These decisions result in a downward flow of priorities, directions, and initiatives which directly affect the manner in which services are provided. Consumer involvement is, therefore, appropriate at all levels of health planning and decision-making. At the institution and agency level, consumers must be included in governing bodies as well as in the organizations' planning processes. At the community and state level, the opportunity for consumer involvement in planning exists in comprehensive health planning agencies. At the federal level, mechanisms for consumer involvement in planning require development.
2.6 The principal leadership of an areawide comprehensive health planning agency should be vested in local consumers.
Commentary
To be an effective instrument of the community an areawide comprehensive health planning agency or its viable equivalent should be directed by local citizens and be an effective partnership among consumers, health professionals, provider interests, and public officials. A variety of organizational alternatives are available for assuring the existence of a partnership with consumer leadership, and the choice should be reflective of the area's own characteristics. Agencies need to be aware of the responsibility for the education of all partners so that they can work together.
2.7 Appropriate consumer involvement includes representation of the interests of all social, economic, and ethnic groups in the community of interest.
Commentary
It is essential in the planning of personal health services that there be a mix of consumers, representative of all segments of the community, to assure the development of services responsive to community needs and not just to the convenience or needs of a select group of consumers or providers.
2.8 In arriving at program decisions affecting the delivery of personal health services, health care providers, agencies, and institutions must provide regularized mechanisms for meaningful participation in planning and decision-making by consumers and health professionals.
Commentary
There is a strong need for the governing bodies of health care institutions and agencies to arrive at decisions through a process that blends the best advice of affected consumers, health professionals, other health workers, administrators, other related experts, payment agencies, and public authorities.
While in given circumstances, one alternative approach or structure may be more appropriate than others, the effectiveness of consumer participation is mainly dependent upon the institution's sensitivity to needs for consumer influences in corporate decision-making and on the willingness of those in authority to heed consumer voices.
No formulae for "meaningful participation" can be enunciated, but care should be taken to assure that consumer participants are able to represent some community of interests, and that honest dialogue among all participants in the institution's planning process is encouraged by those responsible for the institution's management and governance.
2.9 Local, regional, and state health planning agencies should assure the availability of an appeals system to the decisions made by them.
Commentary
Appeals systems are essential because of the possibility of errors in health planning. They require an open system to which the public has access and which in turn publicizes its activities and decisions. It also requires written procedures which clearly identify all the steps to be taken in filing an appeal. 2.10 Each health provider institution or agency must have a continuous, effective, long-range corporate planning process as an indispensable part of its management process.
Commentary
Long-range planning by an institution is not an episodic undertaking, active only at points in time when a new building or program is being considered. Corporate planning is a never-ending part of the management process, requiring the commitment of major time and effort by governing boards, professional staffs, and administrators. The planning process must emphasize developing the bases upon which effective decisions will be made by those responsible for the institution's direction. A sound process demands a solid base of information about the institution, its environment, its community, its programs, its clients, and its resources. Corporate planning should focus not only on new programs but also on the overall purposes and goals of the institution as they relate to community needs, as well as on continuous evaluation of the effectiveness of the institution's ongoing programs. Finally, inherent in the corporate planning process should be working mechanisms for joint planning with other agencies with whom responsibilities are shared.
2.11 Each health provider institution or agency must have a written institutional or corporate plan which describes the mission, priorities, goals, and programs of the institution for the present and the long-range future.
Commentary
The long-range plan of the institution should be considered a public document, regularly communicated to the community and to the institutions and agencies whose service programs, regulatory functions, or financial responsibilities are affected. The plan should be under constant review and evaluation through the institution's internal planning process as well as in cooperation with other institutions and agencies with whom responsibilities are shared.
3.0 Principles of Planning
3.1 Personal health services in the community should be planned and implemented within the framework of the community's comprehensive health planning process.
Commentary
An effective personal health services delivery system depends on participation by the provider agencies in the community's comprehensive health planning process, in which all program decisions are openly made in the interest of solving identified community health problems and filling community health needs according to systematically agreed upon priorities. Any provider institution that fails to plan in this framework weakens the community's planning process and calls into question the integrity of the provider institutions—no matter how laudable the institution's motives may be.
3.2 The principal mission of the community's comprehensive health planning process related to personal health services is to promote positive change in the local delivery system when possible improvements can be identified, and to promote stabilization and continuity when services have been found to be desirable and effective.
Commentary
In community health planning, the main focus should be on stimulating the development of changed and new programs to fill community needs. While review of proposed programs by the areawide planning agency is a necessary function to help secure support for needed programs and to discourage poorly planned programs, it is far more important for the comprehensive health planning process to foster the development of imaginative plans which will help meet people's needs. The planning process is pointless if it is not focused principally on developing action programs that improve the delivery of personal health services in terms of community health goals and priorities. Action programs in health services delivery should be planned within a framework which considers judicious allocations of scarce human, technological, and mental resources. Innovation and experimentation should be encouraged with orderly evaluatory mechanisms involving the comprehensive health planning process.
3.3 The community's comprehensive health planning process should result in the establishment of clearly enunciated priorities, criteria, guidelines, and responsibilities for the allocation of resources and the development of programs which will achieve positive change in the community's personal health service system.
Commentary
Priority, reflecting community consensus, should encompass both the concept of importance and the concept of sequence. It is vital not only to decide what has the greatest significance as an unmet community health need, but also to arrive at reasoned judgments about what ought to be done in what order. It is quite legitimate to seize opportunities created by the availability of resources, so long as development remains consistent with overall community goals.
3.4 The community's comprehensive health planning process should require full consideration of alternative courses of action and should promote practical experimentation and innovation in delivery systems, uses of manpower and technology, and financing patterns.
3.5 The community's comprehensive health planning process should emphasize filling gaps in needed programming, and should prohibit obsolescence or wasteful duplication of services and facilities.
Commentary
The processes of defining needs, of determining the degree of which specified unmet needs should be filled in an economy of scarcity, and of deciding when duplicative service programs are against the public interest, are judgmental rather than scientific, and should be treated as such.
3.6 The community's comprehensive health planning process should promote and be responsive to sound institutional and areawide judgments regarding the relationship between costs (both direct and indirect) and benefits (both short-term and long-term) of any proposed and existing course of action.
Commentary
There can be no formulae for establishing a "right" balance between costs and benefits when human development, suffering, and life itself may be at stake, and when consumers' demands are to be considered. It is nevertheless essential that judgment processes regarding the personal health services system should, at all times, consider whether the expenditures for a particular program are justifiable in terms of measurable gains in community health. This applies equally if the purpose is setting priorities or implementing programs.
3.7 In designing, planning, and evaluating community personal health services, the health planning agency should apply the criteria of accessibility, comprehensiveness, availability, effectiveness, efficiency, adaptability, public acceptance, accountability and continuity of care to determine if the services in fact are in the public interest.
Commentary
While it may not be possible to meet all of the above criteria, which should be a mix of nationally accepted standards and local judgment, every personal health program should demonstrate that it has attempted to meet the above criteria to the best of its ability.
3.8 The areawide comprehensive health planning agency should utilize and develop where necessary an adequate base of data and information about the characteristics of the community population, their health resources and utilization patterns, attitudes and behavior patterns, and general and special health problems, so that it can assist consumer groups and health care providers, institutions, and agencies in their activities related to the planning of personal health services.
Commentary
While there appears to be no limit to the amounts of data that would aid effective planning, a growing body of experience exists in many communities regarding which data are crucial—and regarding the techniques and systems for gathering and analyzing those data. This body of experience must be shared among communities in order to diminish the wasteful rediscovery of known techniques.
3.9 The community's comprehensive health planning process should include a component of the routine evaluation of existing and proposed personal health services resources.
Commentary
The components of a community's personal health service system must be periodically evaluated as to their relevance, completeness, and consistency with community priorities.
3.10 The planning of health provider institutions and agencies must focus on the comprehensive health service needs of defined target populations or geographic service areas.
Commentary
The impact on community health of any program of health services will be maximized if planning is focused on the total health needs of a target population. No institution can aspire to meet the complete health needs of an unlimited population—at best, a program can do no more than meet selected needs of a particular group of people. Planning must, therefore, define not only what will be provided for whom, but also how the program will relate to other programs (within or outside the institution) that meet the same or other aspects of the health needs of the same target population. Similarly, provider institutions should clearly delineate how those elements of a comprehensive service which they cannot provide will be provided for elsewhere. When more than one provider institution is planning programs to provide aspects of comprehensive health services to a given population, early interagency communication and operational coordination are required if the goal of comprehensiveness is to be met. This applies equally to public and private providers, and to all sectors of the personal health services system, including preventive, acute, long-term, and rehabilitative services in physical, mental, and public health.
3.11 In identifying health service needs, health providers, agencies, and institutions have a responsibility for advocating appropriate actions which will get at the causes of health status breakdowns.
Commentary
Many accidents, illnesses, and diseases are preventable through corrective actions taken in the home, work place, highway, general environment, etc. Health service providers, with the information available to them, should identify particular health problems in the community induced by environmental conditions, and should encourage corrective actions.
3.12 In making and implementing program decisions, health provider institutions and agencies must apply broadly accepted standards of quality, efficiency, community priorities, and consumer acceptability in the establishment and operation of programs.
3.13 In making and implementing program decisions, health provider institutions and agencies must communicate and coordinate regularly and early with the community and the other institutions whose programs and plans have impact on all or part of the same target population or geographic service area.
3.14 Provider institutions and agencies should plan openly and arrive at program decisions in the context of public debate and review.
Commentary
Openness is an assurance of responsiveness and accountability to the people served. Secretiveness in planning is antithetical to the kind of careful weighing of alternatives, consideration of facts, and probing of community needs that good decision-making requires. The understandable desire to keep preliminary discussions confidential frequently can lead to plans that are wastefully duplicative or competitive among agencies that should be acting in concert.
3.15 The community's personal health services providers, institutions, and agencies should take full part in the local and areawide comprehensive health planning agency's activities, and should look to the agency as a resource in their own planning processes.
Commentary
Few health provider institutions have developed strength in their internal corporate planning activities—at the same time, no community planning process can flourish if it is alien and adversary to the community's health institutions. The hospitals, health departments, and other health provider institutions should cooperate in the local and areawide comprehensive health planning process by releasing personnel for board, committee, and task force assignments, by furnishing data and cooperating in the development of information systems, and by subscribing to agreed upon programs of funding for the planning agency.
3.16 The areawide comprehensive health planning agency should advise and assist health care providers, institutions, agencies, groups of providers, professional organizations, and consumer groups in their planning and decision-making related to personal health services.
Commentary
Provider agencies need help in developing their corporate planning processes, in obtaining data needed for planning, in communicating with consumers, and in relating to other provider institutions and to regulatory and payment agencies. The planning agency should furnish guidance and assistance to the provider agencies in these matters and in the development of plans and programs.
3.17 Groups of consumers of many kinds are concerned with securing for themselves and their loved ones better services to fill specific needs. The planning agency should aid them in their planning by providing information and data, by mediating communications with provider agencies, and by offering practical planning assistance.
3.18 The areawide comprehensive health planning agency should advise and assist responsible regulatory, approval, financing, and payment agencies at community, state, and national levels that affect the personal health services delivery system.
3.19 Programs that regulate, accredit, or finance any aspect of the personal health services system should incorporate effective corporate planning, should be publicly accountable, and should support and be sensitive to the community's comprehensive health planning process.
3.20 Regulatory and financing agencies should develop effective planning processes to guide their decision-making.
3.21 Communications regarding impending decisions in the planning, regulation, approval, or financing of personal health services programs should be open and multilateral.
Commentary
Federal, state, and local governmental and voluntary bodies which fund, plan, or administer personal health related programs should, to the fullest extent possible, provide for formal inter-program coordination or joint management in order to promote comprehensiveness of programming, planning, budgeting, and services. Personal health or community health needs do not recognize artificial administrative or legislative boundaries.
It is an indispensable role of the areawide community health planning agency to serve as a broker for communications to the community regarding developments which would have impact on the community's personal health services system. Regulatory and payment agencies should not only seek recommendations on specific projects from the planning agencies, but they should also view the planning agency as a resource in their relationship with provider institutions and the community.
3.22 Statutes, regulations, and contracts should specify that before a significant change in a personal health services program can be made, endorsed, or underwritten, the project should be submitted for appropriate review by the areawide comprehensive health planning agency and be responsive to its standards and criteria.
Commentary
All public and private agencies, whether consumer-directed, provider-oriented, or professional, that have responsibility to regulate, approve, or finance any aspect of the local community's personal health services system, should reach their decisions regarding licensure, sanctions, incentives, limitations, accreditation, and financial support in the context of the areawide comprehensive health planning process as reflected by the planning agency. When appropriate, the review and comment of the planning agency should be sought. Community health programming is undermined when institutions are rewarded after flouting the community's comprehensive health planning process. While the regulatory, approval, and payment agencies should not relinquish their responsibility to assure that their programs are sound, it is essential that their program decisions be sensitive to the priorities, guidelines, and planning processes of the local community.
4.0 Financing for Planning
4.1 The amounts needed to operate an areawide comprehensive health planning agency are substantial, and must be reasonably assured if the agency is expected to function effectively.
Commentary
National, state, and regional sources of health planning funds should assure that these are distributed equitably, using criteria of population to be served and economic need. While the budget of an areawide comprehensive health planning agency would never be more than a miniscule fraction of the total health expenditures in an area, few, if any, agencies to date have enjoyed either the quantity of resources or the security of income to permit fully effective functioning. The actual amounts needed will obviously vary as the characteristics of areas vary—and also as the ability of the planning agency to rely on other organizations to perform aspects of the comprehensive health planning job will be considerably different from community to community. The planning agency should have adequate resources to furnish substantial planning assistance to health, providers and consumer groups, to provide planning, communications, data and information services, staffing for committees and task forces, help to community organizations, consumer education, and project review, at least.
4.2 The areawide comprehensive health planning agency should receive its basic financial support from multiple sources, reflecting the commitment of multiple interests to the community's comprehensive health planning process.
Commentary
The proportions of the agency's total support that come from various public and private interest sectors should remain reasonable. The mix will vary from community to community and area to area, depending on many factors. It is essential that no agency become so dependent on a few financial supporters so as to hinder its ability to function independently and judge objectively. To the extent feasible, the financial role of the federal and state governments, in supporting areawide comprehensive health planning agencies, should be viewed as a subsidizing force, using public dollars to encourage the community to support its own planning process, as opposed to finding local dollars to match the government's support of a "mandated" activity.
