Policy Sciences, 5 (1974), pp. 343-361

9 Elsevier ScientificPublishing Company, Amsterdam--Printed in Scotland

The Transfer of Planning Theories to Health Planning Practice D A V I D E. BERRY College of Human Development, Pennsylvania State University, State College, Pennsylvania 16801, USA

ABSTRACT Improvement is required in the theoretical bases of health planning in order for needed advances to occur in health planning practice. Four major planning strategies are utilized in other public policy sectors: the rational, the incremental, the mixed scanning and the radical strategies. All four strategies are potentially useful in health planning and their impact is suggested in a health planning situation.

The mid-1960's in the United States, especially during the 89th Congress, were characterized by the enactment of significant health legislation; Medicare and Medicaid ushered in new directions in the financing of health care services and provided the beginnings of a renewed interest in national health insurance. During this same period a greater interest was shown in health planning than previously in this country. Several major pieces of legislation emphasized health planning; section 202 of PL 89-4 ("Appalachian Regional Act of 1965") provided for the planning and operation of multi-county comprehensive health demonstrations as one means of achieving the primary goals of economic growth and developments for the Appalachian Region. PL 89-239 "Heart Disease, Cancer, and Stroke Amendments of 1965" popularly known as the Regional Medical Program was particularly concerned with the application of medical technology and actively involved health professionals and others in the achievement of its goals. The Model Cities Program (PL 89-745 Demonstration Cities and Metropolitan Development Act) was concerned with comprehensive demonstration efforts to develop means of improving the quality of life in slums and blighted areas of many cities. The first year of the Model Cities program in each community is devoted solely to planning of social programs including health. The most inclusive and potentially the most significant health planning legislation enacted by the 89th Congress was PL 89-749 "The Comprehensive Health Planning and 343

Public Health Service Amendments of 1966." The mandate for health planning is expressed in the Declaration of Purpose of the Act: The Congress declares that the fulfillment of our national purpose depends on promoting and assuring the highest level of health attainable for every person, in an environment which contributes positively to healthful individual and family living; that attainment of this goal depends on effectivepartnership, involving close intergovernmental collaboration, official and voluntary efforts and participation of individuals and organizations... (and) marshalling all health resources to assure comprehensive health services of high quality for every person...1 The Act encompasses comprehensive planning for personal and environmental health services, health manpower, and health facilities on state and local levels. The Act abolished many of the former categorical grants in favor of a more generic funding approach. Provision was also made for the preparation of health planners and demonstrations. President Nixon early in 1973 expressed displeasure with the effectiveness and efficiency of certain health programs enacted during the mid-1960's. The Regional Medical Programs and Model Cities Programs were eliminated in his proposed budget and many other health programs were greatly reduced or phased out. Comprehensive Health Planning survived the close scrutiny given to federal health efforts and actually received increased funds sufficient to support the development of additional area wide health planning agencies at the local level (multi-county). Comprehensive health planners are reluctant to interpret this as long-term support or endorsement by the Executive Branch, the Congress or the American public. While the immediate future of Comprehensive Health Planning looks favorable, its ability to survive will be determined by the consumer, elected officials and professional leaders' perceptions and judgement of the impact of Comprehensive Health Planning. The last ten years have brought increased recognition of the importance of effective planning in the health field. While the future of a particular effort is difficult to predict, health planning has become established as an important function for the beneficial use of scarce resources in the health industry of the United States.

Advancement of Health Planning Practice and Health Planning Theories The new popularity of health planning and its endorsement by society as a viable tool for improving health services and health is accompanied by high expectations. The health industry in the United States has a limited tradition of broad-based areawide health planning. Health planning theories that can be applied as tools for use by practitioners have been generated very slowly. Too frequently experience with health planning has been limited to internal planning within an agency, facilities planning or loosely organized health and welfare agencies. The limited experience of the health industry with planning is explained by the historical dependence upon the market for the allocation and distribution of health. resources. Increasing federal participation in programs of facility construction, manpower training and the purchase of care (Medicare and Medicaid) have produced a growing concern for planning and efforts to adapt the market for better use of 344

scarce health resources. If health planning is to be a viable force in the health industry, immediate and significant advances are required in both the theories and practice of health planning. An examination of the experience and theories generated in other public policy sectors may suggest some possible tools that can be transferred to health planning. Planning is a recognized tool used daily by public administrators, business administrators, city planners, economists, and others. These practitioners have used planning for problems of internal management, inter-organizational relationships, community decision-making and societal policies. Early theoretical leaders such as Gulick and Urwick acknowledged planning as a basic ingredient in their conceptual scheme of administration which they expressed in the convenient acronym POSDCORB.2 Theorists and practitioners of city planning historically have emphasized the centrality of planning and have included it in their professional title. This title has remained even though agreement as to the mission of city planning has shifted from an emphasis solely on land use planning to the current interest in strategies for attacking social issues. Although planning has become accepted as a critical tool in most public policy sectors many basic issues remain unresolved.

Basic Characteristics and Expectations of General Planning Theories A review of planning literature quickly reveals that there is not a general consensus on planning theories. Too frequently a planning theorist highlights the inadequacies of other theories and proceeds to present his theory as the "one best way." A more productive direction would be to channel additional empirical studies and theoretical efforts into an examination of the rationalities of existing theories and the determination of the conditions under which a particular strategy has utility. In attempting to make sense out of general planning theory, Friedman's distinction between normative and positive theory seems useful) Positive theory seeks to be descriptive about what is and also seeks to make predictions about the future. Normative theory deals with values and questions of what ought to be. Most of the work which appears in planning literature, with the exception of a number of studies in economics is normative. Many significant contributions have come from normative theory; however, too frequently in the absence of positive theory, normative theories neglect significant variables in the planning environment. A definite need exists for improved normative health planning theories. Yehezkel Dror in the first issue of Poficy Studies Journal suggests several kinds of expectations of normative theory: (1) Capacity to handle value issues in a way which distinguishes between fundamental value choice and instrumental consideration of intermediate goals: In respect to fundamental value choice, clarification of choice dimensions is needed, such as: consistency, trade-offs, time evaluation, and risk propensities ("lottery values").., social mechanisms for determining choice between irreducible value mixes must be redesigned and even nova-designed (i.e. designed anew)... (2) Adjustment of paradigms, methods, methodologies and techniques to the needs of policy-improvements. This involves, for instance, changes in the standards of validity and reliability: in respect to policy, preferization in the sense of arriving at solutions better than would otherwise be the case is the main goal 4 345

Planning Theory No agreed upon scheme of classification for planning theories exists. Planners might indeed learn from biology and the progress that resulted from Darwin's classification of the members of the animal kingdom. As Lowi has expressed: There is more to the urge for classification than the desire for complexity. Finding different manifestations or types of a given phenomenon is the beginning of orderly control and prediction9 Taxonomy before ontogeny or phylogeny. Moreover to find the basis for classification reveals the hidden meaning and significance of the phenomenon, suggesting what the important hypotheses ought to be concerned with.5 In order to develop a tentative scheme for use in health planning, an initial division will be made between major strategies and complementary or secondary strategies. This paper will seek to develop in more depth the major strategies. As in any classification scheme some detail and precision is lost by the emphasis upon common features rather than subtle differences. The alternative strategies of planning represent basically different definitions of planning and philosophical positions on how planning should occur9 Agreement on a definition of planning is only reached at the most general level as expressed in the definition offered by Friedman: "Guidance of change within a social system. ''6 Further refinement of this definition produces clearly distinct approaches. Four positions characterize the major planning strategies present in the literature: the rational strategy, the incremental strategy, the mixed-scanning strategy, and the radical strategy. This paper will review these four major strategies and discuss their implications for health planning9

Basic Features of the Rational, Incremental, Mixed-Scanning and Radical Strategies The Rational Strategy The rational strategy is possibly the most familiar strategy found in planning literature. The strategy appears to be identical with or at least very similar to the "pure rational model," root model, and the master plan. The rational model assumes the position of the logical positivist and offers minimal assistance in dealing with values. The necessity for problem definition and the establishment of relevant goals and objectives are acknowledged but considered to occur outside the context of the rational strategy9 The strategy thus emphasizes means-end analysis and maximization of the preferred alternative. No claim is made that the rational strategy is a "positive theory"; indeed, its normative nature has resulted in its identification primarily as an ideal. The basic features of the rational strategy have been succinctly described by Meyerson and Banfield: 9 a. The decision-maker considers all of the alternatives (courses of action) open t o him, i.e., he considers what courses of action are possible within the conditions of the situation and the light of the end which he seeks to attain; b. he identifies and evaluates all of the consequences which would follow from the adoption of each alternative; i.e., he predicts how the total situation would be changed by the course of action he might adopt; c. he selects the alternative the probable consequences of which would be preferable in terms of his most valued ends. 7 346

The rational strategy emphasizes a comprehensive approach to problem solving and the maximization of goals. The orientation is frequently long-range and the strategy is assumed to take place in an atmosphere with stable and widely accepted values. Rational as the dominant adjective in the rational strategy implies that other strategies are non-rational. The question of what is rationality and more specifically what is health planning rationality is dealt with in detail elsewhere.S Rationality is not a concept characterized by one value such as efficiency but is characterized by multiple dimensions whose emphases vary by the planning situation. Close examination of the rational strategy suggests that its rationalities are primarily technical and economic. The rational strategy is often manifested in methodological tools such as epidemiology, the systems approach, PERT, PPBS, and cost-benefit and effectiveness studies. The model is particularly naive politically as will be discussed in detail later. Unfortunately since it is not linked to descriptive theory and suggests an unachievable ideal, it has been dismissed by many planners, especially younger planners. Health planning must become more sophisticated and successful in its attempt to incorporate technical rationality (the knowledge and beliefs of cause and effect) and economic rationality (the optimal utilization of scarce resources). Successful use of the rational strategy- has been identified primarily with policy problems that are physical in nature, such as hospital locations and with middle level management problems such as clinic waiting lines. Adaptations of the rational model must be found in order to more systematically attack the task of health planning. Techniques must be explored that will allow for the systematic tracking of value assumptions through problem definition, data analysis, and policy decisions. Many tools of this nature exist and have not become standard equipment of the health planner. The health planner must find ways of adapting the rational strategy in order to capture the rich tradition of public health and the sciences of epidemiology and bio-statistics. The policy sciences, especially economics, political science and sociology, must be focused upon the critical decisions of organization, financing, regulation, and delivery of health services. The existing tools of the health and social sciences have only been partially utilized in health planning endeavors. A great need exists to find new combinations and new tools to aid in the assessment of community health levels, data analysis, the determination of technically feasible policies, and the evaluation of health planning endeavors. Two examples reinforce the potential contributions of rational tools. Sanders in a classic article that many health planners seem to have missed, raised the question of how to determine the level of health of a community. The usual assumption of many programs has been that base line morbidity data can be collected and the impact of an intervention program will be reflected in a decrease in morbidity. Sanders attacks this assumption by two observations: first, good medical care usually results in the uncovering of additional medical problems and is thus reflected in the statistics by an increased morbidity and second, as people continue to live longer there will be an increase of chronic disease and a high level of morbidity in a community may reflect this phenomenon. Sanders suggests the need for alternative measures such as "productive man years."9 347

Possibly the most difficult area for incorporating the rational strategy is in a systematic approach to the value element in poficies. The close relationship of facts and values does not prohibit the use of systematic approaches to arriving at values. Stickle has demonstrated an interesting acknowledgement of values and has systematically applied different assumptions to the same data.10 He observes that an examination of mortality data for the United States leads to the conclusion that the leading causes of death are heart diseases, cancer and stroke. Such a conclusion was drawn by Congress and resulted in PL 89-239 "The Heart Disease, Cancer and Stroke Amendments of 1965." He also makes explicit the reality that all people must die of something. Fixing the priority for disease intervention on the causes of death from which most people die, results in a value judgment that the elderly are the most important group in society. Stickle suggests that instead of looking only at the absolute number of deaths from all causes, we need also to look at age distribution of deaths. This added ingredient brings forth additional values that can be analytically assessed, lost years of life and future income sacrificed. The death of a male infant represents an average loss of 67 years of life, including his entire reproductive period, and over 50 years of economic productivity; the death of a man at age 60 on the average represents a sacrifice of only 16 years of life and even fewer years of economic productivity.11 Stickle further suggests the need to examine the consequences associated with death of the head of a household during the middle years of life. Accidents, for example claim substantially more life years and more personal income during the age interval 20 to 49 than either of the three major killers.12 Where then should scarce resources be directed for intervention and research activities ? to heart disease ? cancer? stroke programs ? accident programs ? or intervention programs to reduce infant mortality ? Stickle forces health workers and other policy makers to confront the difficult question of "What Priority Human Life ?" This analytical approach to value questions utilizes many of the tools common to cost-benefit analysis and illustrates a useful adaptation of the rational strategy which aids in determining value assumptions in all phases of planning and allows for Dror's suggestion of a prescriptive methodology in which " . . . preferization in the sense of arriving at solutions better than otherwise would be the case is the main goal."x3 In summary, the rational strategy in its narrowest, purest sense has been dismissed by many as the tool of analysts who are concerned primarily with means-end quantification and wish to avoid value questions or the economic and political constraints of compromise and scarce resources. The results from the rational model have too frequently been master plans that have collected dust or helpful insights for low level problems of institutional management. The tendency to dismiss the rational strategy as a useful tool in health planning fails to acknowledge the potential of adapting the strategy rather than hiding behind its inadequacies as an intellectual excuse for low level sub-optimization and non-systematic planning.

The Incremental Strategy Incrementalism is a significant descriptive and normative strategy which has emerged as an approach that is primarily a response to the inadequacies of the rational model. 348

The rational strategy has been challenged by many, but the most extensive criticisms have come from Lindblom. 14, 15, 16 He claims that man has limited problem solving ability. Furthermore he argues that the rational model is inadequate because of its failure to take into account the planning system in which decisions are made. Lindblom argues that decision-making must occur with inadequate information and that the costliness of data collection and analysis prohibits the extensive analysis recommended by the comprehensive model. He also criticizes the rational model for its tendency to be static. Lindblom is especially concerned with the close inter-relationship of facts and values and argues that " . . . one chooses among values and among policies at one and the same time. ''17 According to Lindblom, analysis is constrained by scarce resources and includes examination of only a few policies which differ slightly from previous policies. Original assumptions and problem definitions are usually not re-examined. Remedial action, according to Lindblom follows analysis rather than movement toward goal achievement. Problems are constantly redefined and attacked through time. (It is important to realize that Lindblom bases his case on the classical, " p u r e " version of the rational model rather than adaptations of the rational model.) Explanation of why planning occurs as it does comes from Lindblom's description of the policy-making system of the United States. In this country policy-making takes place within a highly pluralistic environment dominated by interdependent interest groups. These interest groups operate in an open system which accepts the necessity of compromise for the production of policies. This explanation of the decisionmaking environment sharply differs with the traditional view of the rational model which assumes a single decision-maker, rather than a highly complex process involving many actors and characterized by "partisan mutual adjustment." One major study that seems to re-affirm Lindblom's thesis is Wildavsky's study, The Politics" of the Budgetary Process.XS A central thrust of the study is the observation that this year's budget is the best predictor of next year's budget, in that policies tend to differ in only a minor way from one year to the next. Nixon's budgetary action represents an exception to this pattern. T h e process of incrementalism is not only suggested as a description of how policymaking occurs but also a normative strategy. Braybrooke and Lindblom argue: Psychologically and sociologically speaking, decision-makers can sometimes bring themselves to make changes easily and quickly only because the changes are incremental and are not fraught with a great risk of error or political conflict. In a society, for example, that is a rapidly changing society, one can argue that it can change as fast as it does only because it avoids big controversies over big change J9 Theorists and practitioners disagree on the merits of incrementalism as a normative strategy9 Strong opponents include Dror who considers incrementalism to be: an ideological reinforcement of pro-inertia and anti-innovation forces present in all human organizations... If it is accepted uncritically, it can be very dangerous since it offers a "scientific" rationalization for inertia and conservatism, can easily prove itself through self-fulfilling prophecy and can thus block essential improvements.20 9

Other problems with the strategy include its emphasis upon the present rather than the future. The impact of the so called "small changes" on future generations may 349 25

be much more profound than is generally acknowledged. Lindblom suggests that incrementalism is used because the costs of comprehensive analysis are prohibitive yet, this model tends to ignore the possibility that situations arise in which the costs of analyses are not as great as the costs of error. A real danger exists that "muddling through" will become so sub-optimal that it becomes only an emotional form of ad hoc opportunism. The desirable features of the incremental strategy also deserve mention. In an environment characterized by a high degree of uncertainty associated with technical possibilities or value choice, incrementalism can become a useful exploratory tool. In such situations a problem may be recognized but the analytical tools of the rational model would not offer assistance since goals and objective were not explicit. Incrementalism acknowledges the closeness of facts and values and through a process of checks and balances which are highly consistent with democracy, it seeks to arrive at a consensus on a policy. Many problems seem to require a period of incubation and the clarification that results from the reactions of those who may potentially be affected by the policy. Using incrementalism as a tool in this manner would not need to result in the danger Arnold suggests of "reliance upon an unseen hand."Zl Instead this evolutionary process may be more useful than the rational tools or the best guesses of "experts" in determining the kinds of data needed for analysis and important values to be consideredin problem definition. An example of how incrementalism might be applied will help clarify its potential utility. Present patterns of organizing and delivering health care services are receiving considerable re-examination at this time in many communities. An incremental strategy would suggest caution and slow movement away from present problems rather than a major shift to Health Maintenance Organizations especially if based on the Kaiser pre-paid version group practice model. The "Kaiser Model" has become a highly popular organizational form to many health planners, administrators and students.Z2 The appeal is at this time based in part on data, in part on hopeful ideology, and in part on incentives for efficiency and the maintenance of health rather than care for the sick. The impact of pre-paid group practice has not been widespread and the successes are not clearly understood. In addition to these reasons for caution many communities have not evolved organizational patterns for medical care that go much beyond in-patient acute care and solo practice. Physicians and other providers thus become rather cautious when they are pushed to jump from present organizational patterns to an organizational form in which physicians are salaried; are expected to work in groups; are asked to link into a system of screening, health education, hospitals, extended care facilities, out-patient services, and home health services; are asked to consider the costs of their recommendations; are asked to be responsible for the health as well as the illness of patients; and are asked to justify their actions and accept priorities established by a board highly influenced by consumers. The planner who attempts to force a community to accept a pre-paid group practice model can anticipate resistance in many communities. The health planner would be well advised to first observe the many changes that are occurring in the organization and financing of health services throughout this country. These include: the hiring of full time physicians in emergency rooms; the development of group practices 350

which go beyond the sharing of secretaries and office space and include interdependencies based upon technical skills and the sharing of work loads; broader third party payment for services rendered outside the hospital thus increasing ambulatory care; and a greater emphasis upon comprehensive pre-payment arrangements. Planners must acknowledge that in most communities these changes are remedial rather than toward an "organizational panacea" such as the "Kaiser model." As planners work toward goal oriented strategies, incremental strategies may be useful in dealing with immediate problems and for providing useful information for the determination of desirable and acceptable future directions. In summary, the incremental model tends to emphasize the political rationality of a pluralistic society and a short run rationality of marginal efficiency. The model describes how planning and policy-making frequently occur. The model is also suggested as a desirable direction for planning. Implicit dangers would seem to be eminent if this were the principle strategy used in planning because of the tendency toward sub-optimization. Incrementalism is a helpful tool for clarification of issues and values associated with alternative intervention schemes. In some circumstances incrementalism can become a useful tool to help overcome some of the unrealistic features of the rational model.

The Mixed-Scanning Strategy Mixed-scanning, the strategy suggested by Etzioni, may upon initial observation appear to be only a combination of certain desirable features of the rational and incremental strategies. Further study of Etzioni's model reveals that mixed-scanning deserves its claim as a third major approach to planning.23 Etzioni suggests that Lindblom's description of how planning occurs is only partially accurate, and maintains that mixed-scanning is descriptive of the way in which decisions are made and a normative ideal. The mixed-scanning strategy distinguishes between fundamental and incremental decisions. According to Etzioni: Fundamental decisions are made by exploring the main alternatives the actor sees in view of his conception of his goals, but, unlike what rationalism would indicate, details and specifications are omitted so that an overview is feasible... Incremental decisions are made but within the context set by fundamental decisions and fundamental reviews.24 Etzioni further elaborates that while incremental decisions may be used to work out fundamental decisions, they also may be used to alert and prepare for the necessity of making a fundamental decision. These uses of incrementalism differ from those originally described by Lindblom. The owner of several newspapers in small communities once described how he quickly assessed a community. The process seems to share elementary features with mixed-scanning. The newspaper owner initially wanted to determine a rough guess of the economic viability of a community. This could be done by driving through the community looking at the houses, office buildings and stores. Chain store groceries and department stores were important indicators. Which ones were located in the community and what was the size of the stores ? If a community, on a quick glance appeared economically viable, he would investigate in a more systematic fashion other 351

important factors before deciding if he wished to begin a newspaper in that community. Scanning has traditionally been used to a limited degree in public health, although the implications for health planning have probably been given minimal consideration. The sanitarian drives through the community and makes an assessment from his car of randomly assigned houses. Certain features can be determined in this manner and further in-depth investigation can be completed if so indicated. Weekly morbidity and mortality reports produced by the Communicable Disease Center in Atlanta illustrate another application of the concept of mixed-scanning in the health field. A sudden change in deaths or morbidity associated with a disease would signal to health officials the importance of further investigation. In order to determine the degree of scanning that should be initially undertaken in data analysis, the mixed-scanning strategy suggests three guidelines. First, a consideration of the cost that would result from the missing data; second, a determination of the costs of additional scanning; and third, the time required for further scanning. Further in-depth investigation of certain data and alternatives follow the initial scanning. The sudden appearance of a few cases of diptheria among children may suggest the need to examine the school records in order to assess the immunization status of students. An executive director of a Comprehensive Health Planning Agency may observe a poorer attendance record by committee members on one of the committees than on others. This signal would suggest the need to carefully examine the characteristics of the members, the task under pursuit, the meeting time and other factors. An in-depth consideration of selected data and possibilities for intervention may be applied at more than one level and the same procedure may be used again as the strategist begins an in-depth pursuit. Etzioni recommends that the amount of time and scarce resources that are devoted to in-depth analyses and scanning change over time. The relationship of values to analyses is handled differently by the rational, incremental and mixed-scanning strategies. The rational strategy offers minimal help in this matter and usually assumes that values are constant and developed before the rational strategy is applied. The incremental strategy assumes that values are very closely linked to facts and that interest groups will carry out analyses and affect their well being and that a good decision is one in which there is a consensus. The mixedscanning strategy does not accept the assumption that the establishment of goals is as difficult as suggested by the other two strategies. Etzioni observes that many programs do specify values and goals and rank them if only on an ordinal scale and informally. The determination of a good policy in the mixed-scanning strategy is based upon the extent to which the major goal was achieved. Following class discussion of the rational strategy, the incremental strategy and the mixed-scanning strategy, an undergraduate student in health planning and administration at Pennsylvania State University made an initial transfer of the models to his special interest, motorcycle racing. There are three approaches to planning that I can most effectivelydescribe by comparing to the operation and updating of a race vehicle. The rationalist approach is a lot like designing the vehicle, coming out with an untested prototype that is likely to have a lot of imperfections that need to be worked out so that the vehicle will be super-efficient. 352

The incrementalist approach compares with the attitude the designer would use toward the end of the racing season to get just a little more speed or cornering stability to keep up with or stay ahead of the competition; nothing drastic, just a little more of that needed efficiency to keep out of hot water with the sponsor. After the first season of racing, changes will be made that are like the mixed-scanning approach. More power is needed as during the season, but consideration is also made concerning what this extra power is going to do to the handling characteristics of the machine, not like during the season, when the only concern was the primary one. An over-view is put to use in addition to the consideration given to the specific point of interest. 25 This description highlights some of the distinct features of each of the three models. The rational strategy seeks to consider all possible alternatives and produces a design. Even for purely physical problems such as the design of a motorcycle for racing the results may be less than satisfactory. For health and other human service problems the results have often been unsatisfactory. Incrementalism would leave data analysis to the interest groups affected. This assumes that interest groups realize the implications of policies, are equipped to perform the necessary analysis and have a voice that will be heard. The resolution of differences through consensus is highly consistent with the democratic process but also produces solutions at the lowest common denominator. The mixed-scanning strategy emphasizes the scanning of a large number of possibilities as a part of analysis as well as in the selection of alternatives for action. The intent of the strategy is to avoid missing any major piece of data or course of action yet not to consider all alternatives nor the in-depth assessment suggested by the rational strategy.

The Radical Strategy Another phenomenon that characterizes some behavior associated with improving health care and prescriptions for needed changes is the radical strategy. Radicalism may be looked at in at least two ways. The first is as defined by Theodorson and Theodorson in Modern Dictionary of Sociology: A nonconformist approach to social and political problems characterized by extreme dissatisfaction with the status quo and a call to change society as quickly as possible and by vigorous means. The extreme leftist and the extreme rightist would be considered radicals. Both desire to make fundamental changes in society and its leadership although they would each change different things. 26 Radicalism based on the Theodorson and Theodorson definition is a relative term. Several examples of non-traditional approaches would seem to be appropriately labeled as radical left. The publications of Health-PAC (Health Policy Advisory Center) and the proposals of the Medical Committee for H u m a n Rights represent non-traditional intellectual attacks and proposals for the health system. Groups such as the Young Lords in New York have taken radical action in several instances. On one occasion The Young Lords seized a tuberculosis X-ray unit in one section of New York City where it was under-utilized and moved it to another section of the community where they felt the need was greater. Another community group in New York was angered at the death of a Puerto Rican woman from a therapeutic abortion in which the physician had not taken into account the woman's previous history of rheumatic heart disease. The angered citizens demanded the resignation of the physician 353

in attendance and the opportunity to attend physicians' review committees.27 Less dramatic yet non-traditional views of relevance to health planning may also be found in the literature. Ginzberg has questioned our national emphasis on better medical care as the key to improved health. Admittedly people with inadequate incomes suffer from inadequate medical care, but improved nutrition and housing might contribute more to their health and longevity than easier access to physicians and hospitals. Many citizens would surely benefit from more and better medical care. But socio-economicfactors and the limitations of current scientific knowledge present real bounds to the promise of medical services for improved health.28 Nationally, Congress has recently challenged President Nixon's constitutional authority for his action involving the impounding of funds. His action would generally be considered extreme right since non-traditional means have been used to achieve his ends. The President's action in health matters also seems appropriately described as radical. It has included: discontinuation of many traditional programs and their rapid dismantelling; the shifting of categorical health funds into general revenue sharing and the refusal to spend certain appropriated health funds. The use of radicalism as a relative term may be useful in describing how a community perceives the rational, incremental and mixed-scanning strategies. Another dimension to the radical strategy focuses upon a developing ideology. A general summary of this ideology and its implications for planning have recently been described by Garbow and Heskin.29 Garbow and Heskin attack the structure as well as the goals of traditional planning, especially the rational model. They contend that the rational model contributes to planning problems by supporting the tendency toward centralization, resistance to change and elitism. They propose a model of radical planning which emphasizes decentralization, an ecological ethic and utilizes the tool of evolutionary social experimentation. Basic to evolutionary experimentation is a synthesis of consciousness and action. Etzioni acknowledges the inadequacies and dysfunctions of our society's present planning system but criticizes the resistance of counter culture planning to deal with gradations which may be highly significant.30 Two of Etzioni's observations seem of special interest: first, is the question of how will the multiple decentralized communities relate to each other? He suggests that the 225 kibbutzims in Israel and Yugoslavia have encountered difficult problems when each seeks to do his own thing. Second, Etzioni observes: 9 there is a great deal of "skewed" pluralism in this country, (U.S.A.), in which many of the decisions and plans are made by "local" elites, which are more partisan, exploitative, and change-resistant than any national ones and which often are in conflict, rather than in harmony with each other.., progress in the "present" society is often found in the national, not local, political arena (for instance, it is here the defense budget could be cut in half with endless ramifications for thousands of localities and all citizens)...31 Health planning students' reactions to the radical strategy range from those who label it as non-professional to those who do not desire to be planners if they cannot utilize the strategy. The radical strategy is the least standardized of the four health planning strategies, yet seems to have established itself as an emerging strategy worthy of further consideration9 354

General Planning Theories and Health Planning Practice The four major planning theories assume distinct philosophical positions on crucial issues in planning. The probable impact of these positions on planning behavior becomes somewhat clearer when they are examined in the context of planning practice. The planning practice situation which will be used is a local comprehensive health planning agency. The illustration is selected only as an example and thus is not intended to present an over-view of comprehensive health planning or to suggest that the theories are limited in their application to settings of this nature. Four functions of CHP "B" agencies were described in the early studies of these agencies by the Organization for Technical and Social Innovation (OSTI Reports).32 The nature of these functions has changed since the early survey and the list is not all inclusive of the functions of the "B" agencies. For purposes of illustration, the functions described in the OSTI report are highly useful for differentiating and summarizing the major features of the strategies. Within this framework, the four major strategies would have identifiable effects upon a Comprehensive Health Planning Agency. These are discussed in the text that follows and are summarized in Table 1. Plan Development Comprehensive Health Planning emphasized planning as a process during the early years of development. Minimal attention was given to the development of documents or plans, indeed some health planners interpreted the creation of a written product to be the antithesis of planning. All now involved in health planning efforts recognize that Federal guidelines are demanding a plan and that such plans must give attention to personal health services, health facilities, health manpower and environmental health services, the areas specified in the Comprehensive Health Planning Act. For purposes of this discussion plan development will focus on the plan as a product and the process dimension of planning will be discussed under other categories, particularly Community Relations. The rational strategy would require that initially a maximum amount of time and resource be devoted to plan development. The plan would be oriented to long-range goals, at least five to ten years and possibly twenty-five years. The plan would be comprehensive to the extent feasible. The impact of general social planning upon health would be considered. Due consideration would, for example, be given to the over-lap of the criminal justice field in drug problems and the mental health of the community. Land use planners and health planners would seek to find the best site for future health facilities and consider the impact of transportation patterns upon accessibility to care. Multi-colored maps would probably be used to graphically present data; cost-benefit analysis would be used to justify why decisions reached were the most efficient choices. This description of the impact of the rational strategy on plan development represents its thrust when carried to its logical extreme. The possibility of numerous adaptations of the rational strategy exists and would be reflected in the Plan Development. 355

L/I

1. Analysis would focus on major alternatives to the

Radical

2. Non-traditional means of goal achievement suggested 3. Moderate time in planningaction oriented

status quo

1. Project judged if moves to general goal 2. Projects may suggest additional analysis 3. Moderate time

I. Extensive analysis and fairly comprehensive consideration of alternatives 2. General framework with goals and objectives specified--some detail 3. Moderate time

Mixed-Scanning

I. Projects judged on potential impact on status quo and relevance for immediate action 2, Minimum time

I. Seek to involve multiple interest of community and emphasis on consensus building 2, Maximum time

1. Project compared to previous attacks on problem 2. Consensus used as criterion of good policy 3, Maximum time

1, Marginal analysis 2. Specification of ways to move away from problems 3. Minimum time

Incremental

1, Seek to develop commitment to rapid major changes 2. Maximum time

1. Seek to keep public informed of fundamental decision and changes in direction 2. Maximum time

1. Seek to achieve involvement of technical experts and stabilize values 2. Moderate time

1. Project judged on extent fit master plan 2. Emphasis on maximizing means-end achievement 3. Minimal time

1. Comprehensive analysis including factors other than health services that affect health 2. Master plan 3. Maximum time

Community Relation

Rational

Review and Comment

Plan Development

Strategy

Time Requirements and Nature of Activities Fund raising

1. Difficult 2. Maximum time

l, Relatively easy 2. Moderate time

1. Easy 2, Minimal time

1, Difficult 2, Maximum time

Impact of Planning Strategies on the Time Requirements and Nature of Select Activities of CHP " B " Agencies

TABLE 1

Given the assumption of the required development of plans, the incremental strategy would be reflected in a document which requires minimal time to develop. The document would be characterized by limited attention to analysis and the specification of short-range action to move away from problems in the four areas specified in the Comprehensive Health Planning Law. A plan of this nature will probably characterize many of the first documents developed by Comprehensive Health Planning Agencies. The incremental strategy would probably also characterize certain dimensions of the plans of more developed agencies, especially as new areas are investigated. The incremental approach would tend to give minimal attention to inter-relationships within the health system and to the impact of general social planning upon health planning. Plans developed through use of the mixed-scanning strategy would require a moderate amount of time although this would vary through time with the depth of analysis and the number of alternatives considered. Goals would be specified for each of the areas required by the Comprehensive Health Planning Act and although there would be additional details, these would not be as specific as the rational strategy. Plan Development would be more associated with the dynamic nature of the incremental strategy than the tendency toward a static approach that characterizes the rational strategy. Plan Development associated with the radical strategy would be concerned with major sweeping changes in the approach to the four areas specified in the law: personal services, health facilities, health manpower, and environmental health services. To predict the exact substantive proposals associated with these four areas is impossible; that which might be considered a major shift in the approach to these four areas would vary in each community. In some communities the proposals might emphasize HMOs, salaried physicians, universal insurance schemes, and the elimination of fee for service. The means of achieving the radical strategy may also be non-conventional. The definition of acceptable and non-acceptable tactics is not universal and varies in communities. Time required for Plan Development would probably be moderate. Review and Comment

In fulfillment of Federal Guidelines, CHP agencies have performed a Review and Comment function on community requests for federal health funds. This function was performed not as an official agency of government, but as a voluntary community organization. A significant change in direction is occurring in some parts of the United States as health agencies become quasi-governmental and the Review and Comment function shifts to a mechanism for achieving regulation and control. The links between Review and Comment and planning remain unsettled. A possible dysfunctional impact upon planning has been suggested by Farag, Director of Comprehensive Health Planning of Region III, HEW. Our review and comment functions have been so expanded that, I fear we can be expending so much of our efforts in monitoring and tinkering with the periphery of the system, i.e., how many beds are here or there, that we may be missing the critical element of their u s e . . , or their cost, or the quality of service delivered at the bedside.33 357

Projects reviewed by local Comprehensive Health Planning agencies utilizing a rational approach would be judged by the extent to which they fit into a grand scheme --the Comprehensive Health Plan. As suggested by Bolan, the rational plan would " , . . . eliminate debate on goals and on general means so that debate could focus on relatively narrow grounds of particular means."34 Minimal time would probably be required for the Review and Comment function since it would be a simple comparison of a proposal to the plan. Comprehensive Health Planning Agencies that utilize the incremental strategy would judge proposals based upon past efforts to deal with a problem area and the limited approach described in the health plan. A project would be viewed as another attempt to tackle a community ill. The major criterion for judging a project by the board of a Comprehensive Health Planning Agency would be the degree to which a community consensus could be reached that the activity represented a desirable endeavor. The process of gaining consensus frequently would require maximum time even for modest projects. The Review and Comment functions associated with the mixed-scanning strategy would be directed to determining if specific proposals would move toward general goal achievement as specified in the health plan. The Review and Comment function would also frequently result in the further application of mixed-scanning to reconsider goals and future directions. Proposals for activity in areas not previously considered by the council would stimulate the council to make fundamental decisions in order to have a framework for judging specific efforts. A moderate amount of time would be required for the Review and Comment function when the strategy used is mixed-, scanning. Proposals exposed to the radical strategy for Review and Comment would be judged for their orientation to immediate action and potential impact on the status quo. The orientation of the radical strategy to the present and its sense of urgency would suggest that a minimum amount of time would be required for the Review and Comment function.

CommunityRelations The original OSTI report described a category of activity as "fostering better relations with other related health agencies." Undoubtedly this function is performed by most CHP agencies. A somewhat broader category of activity that would include this function is Community Relations. This would seem to convey a CHP agency's interaction with health providers and others within the community including governmental officials, members of human service agencies, minority groups, businessmen and others. The rational strategy seeks to plan in a technically sophisticated manner and to achieve this, an environment with rather stable values is required. Council and committee members would be selected based on their ability to contribute to these requirements. Community debate and discussion would be encouraged in relation to all aspects of the general planning document. Following approval of this document community reaction and debate would be discouraged except as linked to specific means. A moderate amount of time would be required for Community Relations. 358

The incremental strategy places primary emphasis upon consensus building and structuring systems that will assure that the multiple interests of a community are represented. The council and committees of the Comprehensive Health Planning Agency would be very concerned that membership is based upon a fair representation of the community. The agency would seek to achieve wide support for and participation in its activities. A maximum amount of time would be required for Community Relations. Attempts would be made to develop a council and committee that deal with planning as a dynamic process when the mixed-scanning strategy is used. A systematic effort would be required to keep the public aware of fundamental decisions that must be made and the alternative intervention schemes that might be used to achieve desired ends. Periodically fundamental directions and current goals would be assessed as would alternatives. A maximum amount of time would be required for active involvement of the community in planning based on the mixed-scanning strategy. The radical strategy would probably be characterized by an attempt to develop a council and committees that would be committed to rapid major social changes. Conflict would probably characterize the relationship of the CHP effort to traditional mainstream health agencies. The radical strategy would require a maximum amount of time to be devoted to Community Relations.

Fund Raising Federal grants for health funds generally require local matching funds and the OSTI Reports described fund raising as a common function among CHP "B" agencies. At present a tendency exists among most agencies to decrease this function. The ease or difficulties associated with fund raising probably would reflect an indication of community acceptance of a planning strategy. The many projects of a rational plan would be phased through time. Master plans, however, have generally not been well accepted at the "grass roots" level and fund raising associated with the rational strategy would be difficult and require a maximum amount of time. In contrast with the rational strategy, using the incremental strategy, would produce projects agreed upon by most of the community and fund raising would require a minimal amount of time. Projects associated with the mixed-scanning strategy would probably require a moderate amount of time. Projects produced by use of the radical strategy would represent a considerable shift in current directions for a community and fund raising would require a maximum amount of time.

Conclusion Four major strategies of planning have been described: the rational strategy, the incremental strategy, the mixed-scanning strategy and the radical strategy. Some possible impacts of using these general planning theories as tools in health planning have been surveyed. No attempt has been made to suggest that a particular strategy is the desirable strategy or "the one best way." Planners choose strategies or mixes of strategies. To be effective the choices must be deliberately and consciously linked to the planning environment. Key variables in the planning environment include: 359

the decision-making mechanisms, the degree of autonomy of the planning system, the kinds of inter-actions between planners, consumers, and providers of services, and the available and acceptable mechanisms for administrative control of the action that follows planning. Other important considerations focus on the specific problem under consideration and include: the technological feasibility of having an impact on a problem, the nature of the goals and objectives pursued, the stability of values regarding goals and objectives, techniques of calculation that have applicability, and the economic feasibility of available alternatives. In an attempt to transfer existing planning theories to health planning, identification of "situationally oriented strategies" may be a step that cannot be skipped if the theoretical foundations of health planning are to become relevant and health planning is to become a viable force.

REFERENCES 1 Public Law 89-749, Comprehensive Health Planning and Public Service Amendments of 1966. 89th Congress, S 3008, November 3, 1966, p. 1. 2 Gulick, Luther and L. Urwick, The Papers on the Science of Admhffstration, New York: Columbia University Press, 1937. 3 Friedman, Milton, "The Methodology of Positive Economics" in Essays in Positive Economics. The University of Chicago Press, 1953, pp. 3-16. 4 Dror, Yehezkel, "The Challenge of Policy Studies," Policies Studies Journal (Autumn 1972), p. 4. 5 Lowi, Theodore J., "Four Systems of Policy, Politics and Choice" Public Administration Review (July/August 1972), p. 299. 6 Friedman, John, "A Conceptual Model for Analysis of Planning Behavior," Administrative Science Quarterly (Summer 1967), pp. 225-252. 7 Meyerson, Martin and Edward C. Banfield, Politics, Planning and the Public Interest. London: Collier, Macmillan Limited, 1955, pp. 314-315. 8 Berry, David E., "Health Planning Rationality," Policy Sciences (March, 1973), pp. 13-19. 9 Sanders, Barkev S., "Measuring Community Health Levels," American Journal of Public Health (July 1964), pp. 1063-1070. 10 Stickle, Gabriel, "What Priority Human Life," American Journal of Public Health (November, 1965), pp. 1692-1698. 11 Ibid., p. 1693. 12 Ibid., p. 1697. 13 Dror, op. cit., p. 4. 14 Lindblom, Charles E., "The Science of Muddling Through," Public Administration Review (Spring 1959), pp. 79-88. 15 Braybrooke, David and Charles E. Lindblom, A Strategy of Decision: Policy Evaluation As A SocialProcess, New York: Free Press of Glencoe, 1963. 16 Lindblom, Charles E., The Policy-Alaking Process, Englewood Cliffs, New Jersey" Prentice Hall, 1968. 17 Lindblom, "The Science of Muddling Through," op. cit., p. 82. 18 Wildavsky, Aaron, The Politics of the Budgetary Process, Boston: Little Brown, 1964. 19 Lindblom, Charles E., "Context for Change and Strategy: A Reply," Public Administration Review (September, 1964), p. 157. 20 Dror, Yehezkel, "Muddling Through--'Science' or Inertia?" Public Administration Review (September, 1964), p. 155. 21 Arnold, Mary F., "Philosophical Dilemmas in Health Planning," pp. 208-225 in Administering Health Systems: Issues and Perspectives, edited by Mary F. Arnold, L. Vaughn Blankenship, and John M. Hess, Chicago: Aldine-Atherton, 1971. 360

22 Saward, Ernest W. and Merwyn R. Greenlick, "Health Policy and the HMO," The Milbank Memorial Fund Quarterly, Vol. L: 2 (April, 1972, Part I), pp. 177-210. 23 Etzioni, Amitai, "Mixed Scanning: A 'Third' Approach to Decision Making," Public Administration Review (December, 1967), pp. 385-392. 24 Ibid., pp. 389-390. 25 The quote is from a student exam written by Robert King, Fall 1972. 26 Theodorson, George A. and Achilles G. Theodorson, Modern Dictionary of Sociology, New York: Crowell Company, 1969, p. 330. 27 Ehrertreich, Barbara, "Bronx Community Wants Control," Health PAC Bulletin, Health Policy Advisory Center (September, 1970), pp. 12-16. 28 Ginzberg, Eli, "Facts and Fancies About Medical Care," American Journal of Public Health (May 1969), p. 786. 29 Garbow, Stephen and Allan Heskin, "Foundations for a Radical Concept of Planning," Journal of the American Institute of Planners (March 1973), pp. 106-114. 30 Etzioni, Amitai, "Commentary," (March 1973) Journal of the American Institute of Planners, p. 107, on: Stephen Grabow and Allan Heskin, "Foundation for a Radical Concept of Planning," March 1973 Journal of the American Institute of Planners, pp. 106114. 31 Ibid., p. 107. 32 Organization for Social and Technical Innovation, "Phase One Report on Comprehensive Health Planning (a) and (b) Agencies," Executive Summary, October 1971, and "Final Report: Phase II Analysis (April 1972). 33 Farag, Erik, "State of CHP in Region III," (unpublished), May 19, 1972, p. 16. 34 Bolan, Richard S., "Emerging Views of Planning," Journal of the American Institute of Planners (July 1967), pp. 234.

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