From a Technocratic Process to a Citizen-based Process: "Strategizing national health in the 21st century: a handbook"

Nadège Ade

Strategizing national health has evolved a lot over the last decades. A growing number of countries are moving away from old style planning and embracing a more inclusive and participatory approach. This is exactly the focus of Strategizing National Health in the Twenty-First century- A Handbook, Nadège Ade, the facilitator of the community of practice on health systems planning & governance, presents us this new book published by the WHO.
​

The theory and practice of “planning” is a field that has grown and changed over the years following the industrial revolution. During the revolution, spatial planning was an important activity to improve the wellbeing and standards of living of populations in cities and towns. The approach taken was to put focus on the “object” of planning, that is space and infrastructure. It was believed that through careful and rational thinking, using numbers and data, all planning problems could be solved in an effective and efficient way. The work of planning was therefore performed by highly skilled technocrats, often known as “spatial planners”.

In the 1970s and onwards, there was however a paradigm shift. Planning problems started to be referred to as “wicked problems”, indicating that a careful and rational approach to planning could not provide answers to situations in complex networks. This realization led to a shift in perspective, from the “object” of planning to the “process” of planning, and more recently to the “context” of planning.  Technocrats are no longer at the center of the stage, but are within highly complex networks structures, and they plan alongside various actors involved in these processes as well.

Strategizing national health in the 21st century: a handbook falls well within this shift in perspective. It is a practical guide on how to develop national health policies, strategies and plans in a way that is more inclusive, participatory and reflective of the pluralistic nature of current age health care systems. Developed by the Department of Health Systems Governance and Financing of the World Health Organization, the handbook comes as a practical response to the perceived need for more robust, realistic, comprehensive and well balanced national plans, policies and strategies within the health sector.

Purpose of the handbook

The need for stronger national health policies, strategies and plans (NHPSP), seems to be evident, especially in light of the many challenges faced by the public health field in low and middle income countries.  Indeed, despite the good progress that has been achieved in the overall health status of populations, it has been recognized that the health policies and plans of the MDG era did not fulfill their promises, largely due to design deficiencies and implementation failures.

The growing mismatch between the performance of health care systems and the rising expectations of societies has also been recognized.  The severity of the Ebola crisis in West Africa is evidence of this.  There is a need for stronger health systems foundations and consequently, a need for stronger NHPSP. This handbook takes on this challenge by providing practical guidance on how to go about developing such robust plans in pluralist and complex health systems.

Stronger national health plans, implies plans that are comprehensive enough to encompass not just the “public health sector” but the entire “mixed, public-private” health system.  These plans are also go beyond an emphasis on the provision of “health care” services to include the broad public health agenda. We are talking disaster preparedness, risk management, international health regulations, and actions on the social determinants of health. I will also add to this list, “actions on the foundational elements of any health care system” including an independent health financing system, a well-trained (& regulated) human resource system, an adequate medical procurement and supply system based on country epidemiological profile and demand etc.

To develop such plans, a radical shift in the process of planning is advocated. A shift from the more or less “technocratic” and “command & control” process that is (or was) usually left in the hands of some specialists in the department of planning of ministries of health, to a more dynamic and open process, focused on policy dialogues and communication with all relevant stakeholders within (and out of) the system including politicians, policy-makers, citizens, health care providers and other governmental sectors.

At the publication launch of the handbook during the Fourth Global Symposium on Health Systems Research in Vancouver, I had the opportunity to meet Dheepa Rajan, one of the editors and authors of the handbook, and a health systems expert at the WHO-Department of Health Systems Governance and Financing. She espoused her views about the added value of this work:

"We realized that there was a huge gap in the body of literature when it comes to practical guidance on how to put together a national health strategy. We also saw this as a key role for WHO to play to give countries normative guidance in this area. We very consciously gave the title “strategizing national health in the 21st century”, by that we wanted to say this is the new age, the post MDG, it’s the SDG era, we are thinking more inter-sectorally, we are thinking more systemically and we are being more participatory and inclusive which means we are thinking beyond the health sector and the public sector. A lot of what we say in the handbook is nothing that anyone will contest in theory, but in practice it is very difficult to implement and it happens very rarely. What we espouse in this handbook is to say, we need to really reach out to other sectors, to 

other constituencies-civil society organizations, the private sector, especially in pluralistic health systems. We need to manage diverging views and we should not be afraid of conflicts of interests. These are all issues that need at least to be laid bare and made explicit so that they can be discussed. But then practically, how do we go about it? That’s what we hope to help countries with, in this guide by linking it to the specificities of the planning process”

The scope of the handbook is therefore the provision of practical guidance on how to develop stronger and comprehensive NHPSP through building on innovative realities of national planning at country level (examples of Thailand, Tunisia, Senegal etc.) and through emphasizing the importance of policy dialogues.

Structure of the handbook

The handbook is structured around the health policy and planning process, with each chapter of the handbook relating to each stage of this process.  As can be seen from the diagram below, the process is depicted as spiral as opposed to a linear or cyclical one, as it has often been represented.  An attempt to emphasize how complex and challenging the process actually is in practice?  This however begs the question of how related or linked these different stages are to each other in practical terms. Is there a rational flow from one stage to the next or are the different stages intertwined and meshed up all along the process? Both scenarios maybe?

As advocated in the handbook, the dynamic planning process kicks off with population consultations to assess population health needs and expectations (Chapter 2). Here, a case is made for including citizens’ voices in the planning process through various innovative approaches such as national health assemblies or citizen juries. This is followed by a situational analysis of the health sector (Chapter 3) to take stock of the system’s strengths, weaknesses, opportunities and threats for an informed decision making. Priority setting is then conducted, to make the critical choices that have to be made in determining the strategic direction of the plan (Chapter 4). These priorities have to be turned into medium term plans and interventions, thus the strategic planning phase (Chapter 5) and in turn transformed into concrete actionable short-term plans- operational planning (Chapter 6). The cost implications of these plans have to be estimated through various scenario analysis, to consider the extent to which the policy objectives and strategic directions are feasible and affordable (Chapter 7). Budgeting for health then follows (Chapter 8), and the process ends with Monitoring, Evaluation & Review of the NHPSPs through a single country-led platform for tracking progress and obtaining quality data for decision making and accountability (Chapter 9).

The handbook additionally includes four independent chapters on issues which are considered cross-cutting to the entire process. These are law and regulation, decentralization, inter-sectoral (whole-of-government) planning & planning within the context of fragile states.  

What next?

Strategizing national health in the 21st century: a handbook, seems to be an important knowledge contribution that comes at an opportune time, where much work and resources need to be put on the processes of developing the governance tools and instruments (in this case NHPSPs) that will drive and steer country health system towards a set vision. It is envisaged that many countries will make use of this wealth of documented knowledge and experience to develop robust health policies, strategies and plans. To support such endeavors, the community of practice on Health Systems Planning and Governance, will be preparing blogs and possibly webinars on the chapters of the handbook, so be sure to stay tuned.

What more? Strategizing national health in the 21st century: a handbook should not be taken as a prescriptive book, neither should it be viewed as a blueprint. As Dheepa Rajan states “There is no one way that is right for every country”. That notwithstanding, the handbook showcases innovative country examples of participatory national planning at a level of good detail, to enable other countries to get inspired by what has been done elsewhere and potentially draw parallels with their own contexts to see which planning approaches might or might not work.

---

The full chapters of this handbook can be downloaded on the WHO’s official website

If you would be interested in capacity building webinars on some of the chapters of this handbook, (given by the authors), please register here.  Specify the chapters which would interest you the most.