Health planning in Pakistan: a case study

HEALTH PLANNING IN PAKISTAN:A CASE STUDY

ANDREW GREEN1*, MOHAMMED RANA2, DUNCAN ROSS1

AND COLIN THUNHURST1

1Nu�eld Institute for Health, University of Leeds, 71±75 Clarendon Rd, Leeds LS2 9PL, UK;2Department of Health, Punjab Province, Pakistan

SUMMARY

Health planning is an essential function of the state. For it to be successful, a number ofconditions need to be satis®ed. In particular it needs to be ¯exible, participative andintegrated with other decision processes. Despite some strengths, the health planningsystem in Pakistan has generally failed to provide the framework to allow such anapproach. Links between strategic and operational planning have been weak; decision-making has been very centralized; there has been a lack of functional clarity; therespective roles of bureaucrats and politicians have been unclear; and, links betweencapital and recurrent budgets and between planning and implementation have beenweak. As a result, there is a number of imbalances in the allocation of resources. Theintroduction of a revised health planning system for Pakistan is discussed. Theconstraints on such a system and an initial assessment of its success are presented.(&1997 by John Wiley & Sons, Ltd.)

Int. J. Health Plann. Mgmt 12: 187±205, 1997

No. of Figures: 6, No. of Tables: 1, No. of References: 7

KEY WORDS: Health Planning; Pla systems; Pakistan

INTRODUCTION

This article analyses recent activities in Pakistan in the development of the healthplanning system. This work formed one component of the Asian DevelopmentBank Third Health Project funded by the British Overseas DevelopmentAdministration, managed by the British Council and technically resourced bythe Nu�eld Institute for Health, University of Leeds. The planning componentof the project started in mid 1991 and ended in April 1996.

The objective of the component was to establish a sustainable strategichealth planning capability within the Federal Ministry of Health and theProvincial Departments of Health. The initial project scope was aimed at theFederal level and the Provinces of Balochistan and North West FrontierProvince. Under the Government of Pakistan's Social Action Programme, it

INTERNATIONAL JOURNAL OF HEALTH PLANNING AND MANAGEMENT, VOL. 12, 187±205 (1997)

CCC 0749±6753/97/030187±19$17.50&1997 by John Wiley & Sons, Ltd.

*Correspondence to: Andrew Green, Nu�eld Institute for Health, University of Leeds, 71±75Clarendon Road, Leeds LS2 9PL, UK.

was extended after the ®rst year to other provinces (Punjab and Sindh), thuscovering most of Pakistan.It was necessary ®rst to de®ne the characteristics of sustainable health

planning systems and to relate these to the speci®c context of Pakistan. Theproject then developed a revised health planning system. It is too early toevaluate whether the project has been successful in the development ofsustainable improvements to the planning system and whether, moreimportantly, it has led to health improvements. However, an initialassessment of the approach may provide lessons for similar work in othercountries. Implementation of such a major system reform has proved complexand areas of particular concern and fragility are discussed.

CRITERIA FOR A SUCCESSFUL HEALTH PLANNING SYSTEM

Health planning has come under attack in recent years, as failing to provideappropriate mechanisms for sustainable health improvement (Green, 1995).Some of these concerns re¯ect a wider challenge to the role of the State in thehealth sector (World Bank, 1993); and, hence, to planning as the main policytool of the State sector. This article does not discuss the broad role of the Stateper se, but is predicated on a belief that in countries such as Pakistan, with lowlevels of health coupled to a wide diversity in income levels and access to healthcare, there are very strong arguments for a continued role of the State in theareas of strategic policy leadership, ®nancing of health care, provision of basichealth care, and health care regulation. Other more valid criticisms of healthplanning stem from concerns over weaknesses in particular systems andstructures. Pakistan has su�ered from a number of such system de®ciencies.We identify ®rst, therefore, various criteria that we consider essential forsustainable and e�ective health planning.Green (1992) suggests that:

`Planning is a method of trying to ensure that the resources available now andin the future are used in the most e�cient way to obtain explicit objectives.'

It is a response to the shortfall between scarce resources and health needs.The basic conceptual model underpinning health planning is presented in

Figure 1. It represents an approach which places emphasis on needs assessment(in contrast to market-driven demands). This determines the allocation ofresources and translation into speci®ed services within the health system.In the achievement of this, planning is a process which must:

. have a clear system which balances long-term perspective with short-term¯exibility;

. allow the participation of a variety of groups; and

. be integrated with other decision-making processes.

It is as a result of de®ciencies in these three areas in particular that planning hasoften stumbled. We examine each brie¯y.

188 A. GREEN ET AL.

&1997 John Wiley & Sons, Ltd.

Long-term perspective and short-term ¯exibility

Planning can fail for various reasons including the absence of underlyingpolitical support or planning skills. But many of the failings in planning canmore speci®cally be linked to a de®ciency in the planning system itself.

E�ective planning requires a planning system. It must be participative andable to achieve integration. The system should provide an explicit frameworkfor assessing needs and allocating resources e�ciently. The system must also beresponsive to changing circumstance. Change is a constant and unavoidablefeature of health sectors, be it change in underlying epidemiology, populationcharacteristics or in the resource levels available. The planning system must be¯exible. However, it must be able to respond to changes in the environmentwithout losing its sense of direction for the future.

Participation of a variety of groups in the planning process

Successful planning requires a combination of technical and `political' skills.Unfortunately, the political aspect of planning frequently has been neglected.As a result, planning decisions are often seen as isolated, narrow or irrelevantand hence undermined or ignored. Successful planning requires participation inthe process by a number of critical stakeholders (and, in particular, the ®nal

HEALTH PLANNING IN PAKISTAN 189


Figure 1. Health planning framework.

users and service providers) coupled to an overt recognition of the (vested)interests of others in planning decisions.The long-term objective of the health sector is sustainable health

improvement, as re¯ected in a reduction in communities' health needs.Planning processes have often assumed that identi®cation of health needs is atechnical process centred on epidemiological analysis. This has produced anarrow understanding of needs which has often resulted in low utilization ofservices. Participation in the planning process should begin with theidenti®cation of health needs.Within the health sector the medium for the deployment of resources is

health services (whether primary, secondary, or tertiary, preventive or curative,vertical or integrated). Through these, the sector intervenes to change thehealth status of the catchment population. Elegantly designed servicesrepresent a waste of resources if they fail to command the con®dence of thecatchment population. Utilization is a key link between service provision andservice e�ectiveness. Participation of catchment populations in the planningprocess is no guarantee of high utilization, but non-participation carries asigni®cant danger of low utilization.Successful planning also requires participation by service providers. Field

level sta� have a wealth of knowledge concerning the services being providedand the resources being consumed. They are also the key to the e�ectivedeployment of those resources.Health planning which is based upon a clear assessment of health needs will

also recognize the importance of the participation of other sectors. The healthsector on its own can only meet a fraction of the health needs of the populationsto whom it delivers services. Some needs, such as clean drinking water, safe jobs,roads and housing, can only be met through other sectors. Others, such as forhealth education, can only be met in collaboration with other sectors.At a more general level, all planning concerns change. The achievement of

change is a political process requiring planners to command the widest level ofsupport. Planning which is not owned by wider political processes is doomed tofailure. Thus, planners have to engage with politicians as partners in theplanning process rather than as outside irritants that merely `interfere'.The above has stressed the importance of opening up planning processes to a

variety of stakeholders. It is also important that there is an adequate technicalbase to planning to complement the political aspects of planning. Health sectorplanning requires skilled planners, with a range of expertise from economicsand statistics through to epidemiology and public health.

Integration with other decision-making processes

Complex systems, such as health systems, must be broken down intoanalytically manageable parts. It is not unreasonable to analyse separately the®nancial resource system, the human resource system, the physical resourcesystem, and even the information resource system. Planning systems have oftenmistakenly focused on the capital or projectized aspects of development rather

190 A. GREEN ET AL.


than the broader service requirements. However, health planning processesneed to bring these separate systems together. For example, investment inphysical resources should only be undertaken after due consideration of thehuman and recurrent ®nancial resource implications of these investments.

There is a need also to integrate the design and implementation aspects ofplanning. Planning is meaningless if it fails to result in implementation of itsproposals; and yet, the latter function is frequently seen as separate or ofsecondary importance.

HEALTH PLANNING IN PAKISTAN

Formal health planning in Pakistan has a longer history (Khattak, 1996) thanmost other countries. Its origins lie in the Bhore Committee set up in 1943 todevelop strategies for the health sector and which set out a number of keyprinciples including emphasis on equity, preventive health care and communityparticipation (well in advance of the Alma Ata Declaration). Following theindependence of Pakistan in 1947, the health planning process was formallyconstituted as part of the overall Planning Commission's planning system.

Planning has revolved around the production of longer-term 5- and 15-yearperspective plans, and the short-term annual development plan (ADP) andannual recurrent budget. In Pakistan the term development (budget) is usedwidely for what is known elsewhere as capital. Similarly the term revenue ornon-development refers to what is termed commonly recurrent. In this article weuse the more widely accepted terms of capital and recurrent budgets.

Various organizational levels of the public sector are involved in theplanning process, including:

. Federal level Planning Commission, which includes a health section, withresponsibility, inter alia, for overall economic and development policy andfor the production of 5-year plans;

. Federal level Ministry of Health with national responsibility for health policy;

. Provincial level Department of Finance with overall responsibility forbudgets and particular responsibility for recurrent budgets;

. Provincial level Department of Planning and Development with primeresponsibility for the production of the ADP which focuses on the capital(development) budget;

. Provincial level Department of Health with technical responsibility forhealth matters. There are various levels within the department including theSecretariat (policy level), the Directorate (technical responsibility forservices), Divisional and District levels (limited operational management).

The planning process is very structured and formalized with, for example,great emphasis on project proformas. The most well-known is the PC-1 formwhich functions as a project document.



STRENGTHS AND WEAKNESSES OFTHE HEALTH PLANNING SYSTEM

Attaining sustainable improvement in health has proved a di�cult goal toachieve. The basic health statistics and associatedmeasures of social developmentfor the country are disappointing in comparison to other South Asian countries(see Table 1). This can be seen as a comment on the failure of the health planningsystem to respond adequately to the health needs of the population.The health planning system has various strengths on which future

developments can be based. Foremost amongst these is the clearadministrative procedures in place, particularly those concerned with projectplanning. Pakistan also possesses mechanisms for establishing a long-termvision for the future. Linked to each 5-year plan is a 15-year perspective plan.These tend to be rather cursory statements, and for sustainable improvementsin health they must take greater prominence and be accorded greaterimportance. However, a framework does exist. These strengths, however, areoutweighed by critical weaknesses in this system and it is to these that we turn.

Links between strategic and operational planning

It has not been the inability to form longer- and medium-term plans for thefuture that has bedevilled health planning in Pakistan. Rather, it has been theinability to translate these plans into shorter-term actions. Whilst theaccumulated product of ®ve 1-year ADPs has led to the achievement of 5-year plan objectives, this has been more the product of luck than judgement.Longer-term plans have often laid down clear and valid health objectives, butthese have not been linked to the shorter-term plans. Short-term plans usuallyrespond to the immediate perceived needs and are often subject to politicalpressures. Insu�cient time and attention has been paid to the more deeplyrooted and multisectoral nature of many health sector problems. The net resultis plans which have had little e�ect in addressing health problems.

192 A. GREEN ET AL.


Table 1. Comparative indicators of health and social development.

Country

Infantmortalityrate*(1992)

Maternalmortalityrate*

(1980±91)

Femaleliteracyrate*(1990)

GNP percapita{

(dollarsÐ1990)

State sectorhealth

expenditureper capita{

Pakistan 95 500 21 400 6.4India 83 460 34 330 4.5Sri Lanka 15 80 84 500 8.8Nepal 90 830 13 180 3.4Bangladesh 97 600 22 220 3.1Iran 44 120 43 2170 31

Sources: *UNICEF (1994).{ World Bank (1993).

Centralized decision-making

One reason for the limited appreciation of health problems and objectiveshas been the centralized nature of the planning system. As a result, planninghas failed to build upon the knowledge, experiences and perceptions of bothhealth service providers and communities.

Lack of functional clarity

The lack of a sense of cohesive strategy is also the result of uncertainty overrelative functions and roles. The precise relationships between organizationallevels is unclear, leading to ambiguity over policy and management roles. Since1991, health `constitutionally' has been a provincial matter. However, theimplications of this for the functions of the national and provincial levels haveyet to be ®nalized. For example, the Federal level Ministry of Health stillmanages a number of national vertical programmes and has taken the lead ininitiating health reform policies through the Social Action Programme. At theProvincial level, the central management tier is sub-divided into a secretariatand a directorate. The former is intended to take the lead on setting policy andstrategic plans, whilst the latter is responsible for the overall operationalmanagement of health services. However, a lack of shared understanding onthe boundaries between strategic and operational planning often occurs.

Donors also have a strong, and sometimes inconsistent, in¯uence over thepriorities to be addressed with support often channelled through parallel andoverlapping projects. The increasing number of donors, coupled with fundinguncertainty, has further complicated the situation. This is harmful to thestrategic planning process, especially when combined with doubts as to who isleading the processÐgovernment or donors.

Political and bureaucratic roles

Similar ambiguity permeates the relative roles of politicians and civilservants. Both consider that their decision-making territory is regularlyinvaded by the other group. Politicians feel that they have a legitimate rightto set policy and resource allocations. Civil servants see planning as a moretechnical matter with the role of politicians con®ned to broad policy. Bothgroups are wary of each other and there is little systematized interaction.

Planning, capital and recurrent links

Planning is viewed, almost exclusively, as being about the design andimplementation of capital schemes. This is characterized by the role of theexisting planning cells being focused on the ADP and the capital budget, and hasled to a number of planning weaknesses. First, planning has been dominated bythe procedures surrounding the drawing up, and approving, of often complexcapital investment schemes. Second, a separation has arisen between capital and



recurrent budgeting. The Planning and Development Department is ultimatelyresponsible for all capital projects, while on-going services, funded through therecurrent budget, are under the control of the Health Department, subject toguidelines from the Department of Finance. These services, which are not seen asa part of the remit of `planning', have developed in a largely incremental fashion.Furthermore, most capital investments will require future recurrent resources toprovide long-term services. Underfunding of recurrent budgets stems from anarrow understanding of development processes and an ideological primacy ofcapital over recurrent spending. The former is viewed as `productive', withgrowth to be encouraged; the latter is seen as `wasteful' and to be constrained.This view is accentuated by a misconception that development funds, whichoriginate from the Federation, are `free' to the Provinces, whereas recurrentfunds have to be generated provincially.Furthermore, the di�erent decision-making processes have led to the use of

capital budgets as ameansof sidestepping constraints on recurrent budget growth.Thus, projects often e�ectively fund long-term vertical services. The structuralseparation of capital and recurrent budget leads to a failure of coordination andintegration, resulting in services bereft of sta�, running costs and drugs.

The separation of planning and implementation

A common criticism of health sector planning in Pakistan is that it iscompetent at planning but not at implementation. Behind this observation liesa mistaken assumption that the two processes are separable.Historically, institutional separation of planning and implementation

functions has been a key organizational feature of line departments at bothprovincial and federal level in Pakistan. Planning sections have initiated andprepared; development sections have been responsible for implementation. Thenet result is that some sophisticated plans have been produced, but these have satgathering dust, sometimes not read or not understood, and rarely implemented.Planning has been seen as the generation of productsÐplan documents, PC-1forms. `Good' or `bad' plans have been judged by internal criteriaÐ their use oflanguage, their completeness and their internal consistency.

Imbalances in the allocation of resources

Total resource levels entering the sector, whilst low in comparison to richer andmore developed countries, compare favourably with other regional neighbours(see Table 1).At the broadest level, the e�ciency of the health sector can be considered in

terms of provision of resources and services to meet health needs. The absenceof cohesive strategy towards the health sector, the centralized decision-making,and the resultant fragmentation of decision processes has led to inequity andine�ciency in the allocation of resources. Imbalances occur at a number oflevels including:

194 A. GREEN ET AL.


. between di�erent districts;

. between levels of services;

. between expenditure on di�erent budget line items such as sta� and drugs;

. between di�erent health problems.

For example, in Balochistan, salary costs amount to between 70 and 80 percent of total costs in primary and secondary facilities, but are only 48 per centof costs in tertiary facilities. Allocations to hospitals with similar apparentneeds, based on the number of beds and utilization, can vary by a factor of 2.Those to district primary level services vary between 159 and 18 rupees percapita, with an overall provincial average of 37 rupees per capita(Government of Balochistan, 1993). In Sindh, 45 per cent of the totalmedical sta� is located in the main city of Karachi, which has around 25 percent of the provincial population (Government of Sindh, 1994). The healthindicators presented in Table 1 illustrate the major health needs of womenand children in Pakistan. Critical problems exist in the provision of resourcesto maternal and child health and family planning services, and in lownumbers of female health workers, particularly in the least developed provinceof Balochistan. These and other resource imbalances lead to inappropriate,ine�cient and low quality services which, in turn, can be held responsible forthe very low rates of service utilization seen in Pakistan. In Balochistan anaverage of 0.7 visits per person per year is made to government healthfacilities. Even in the State of Azad Jammu and Kashmir, where theutilization of public services is the highest in Pakistan, district utilization ratesdo not exceed 1.5 visits per person per year.

THE APPROACH OF THE PROJECT TO DEVELOPINGSTRATEGIC HEALTH PLANNING

The preceding has argued that the planning system in Pakistan su�ers fromthe three weaknesses identi®ed earlier as being frequently at the root ofplanning de®ciencies in the State health system. The overriding aim of thehealth planning component of the Asian Development Bank Third HealthProject in response to this was to develop a strategic and workable healthplanning system. The approach of the project was based on a number of basicprecepts.

Minimal disruption to existing system

As has been shown, there exists already a strong institutionalized planningsystem in Pakistan. Despite its various weaknesses, it was decided early in theproject that any challenge to the overall planning framework would becounterproductive. This structure was accepted as an existing constraint withinwhich the project had to operate.



Participative approach

Whilst the project included technical assistance in the form of short-termexternal support and a 2-year in-country adviser, it was seen as critical that thedevelopments were designed in partnership with existing planners in order toensure both appropriateness and ownership. Frequent workshops, facilitatedby consultants, were held on particular aspects of the planning system. Theseled to the overall planning system modi®cations. Orientation seminars werealso held for general health managers.

Human resource and planning system development

The project had two main thrusts: system development; and, training. Bothwere seen as critical. The planners already in post or appointed as part of theproject tended to fall into three groupsÐ those who had been involved inplanning for a number of years; medical o�cers with little social science/planning experience; and, social scientists (typically economists) with little healthexperience. Training involved both long-term training overseas (at the time therewere no Pakistan planning courses) and short-term training in-country. Wherepossible, system development and training were linked. Thus workshops wereseen as having a training function alongside their developmental role andstudents on overseas courses were encouraged to engage in project work (in, forexample, Master's dissertations) related to the project.As part of the human resource development, attention was paid to both the

institutionalization of regular planning positions and the beginnings of a careerpath for planners. The project also attempted to develop, through regularmeetings, a network between planners from di�erent provinces in an attempt tominimize professional isolation and to provide opportunities for cross-provincial fertilization.

Emphasis on provincial level

Lastly, the project deliberately aimed at the development of strategic planningsystems at the provincial and, to a lesser extent, federal level.Whilst it was widelyrecognized that appropriate policies of decentralization were being formulatedwhich would lead to greater emphasis on the lower divisional and district levels ofthe service, it was felt that such decentralization needed to occur within a robustand centrally coordinated provincial framework. There are now Family HealthProjects in all the provinces with an emphasis on decentralization, which providean opportunity for developing district planning systems within this framework.

MODIFICATIONS TO THE PAKISTAN HEALTH PLANNING SYSTEM

The objective of the modi®cations has been to develop a planning structurewhich links a strategic vision of health development with shorter-term plans

196 A. GREEN ET AL.


and implementation. This vision can be provided within an enhanced 15-yearperspective plan, with 5-year plans taking on a rolling nature, situating themedium-term objectives within the context of this broader vision. What isrequired is a linking process whereby the achievement of the goals of thelonger-term planning processes can be monitored and shorter-term plansdeveloped, which takes the health sector systematically in the direction laiddown in these longer-term plans. The linking mechanism introduced has beenthat of a 3-year rolling plan.

The rolling plan process embeds the detailed annual plan for the coming yearin a 3-year setting as illustrated in Figure 2. Year 2 schemes are prepared in aless detailed form, containing primarily proposals that are carried forwardfrom year 3 of the previous rolling plan. Year 3 presents proposals in verybroad outline, constituting broad approval to schemes that will then be workedup over the subsequent year before appearing in a future annual plan.

In this way, annual plans acquire both a history and a future. They developout of previous intentions for the sector and they lay the foundations for futuredevelopments.

Rolling plans also link together other planning processes. They provideperiodic (annual) reviews of progress towards 5-year plan objectives. And asone 5-year planning period comes to a close they begin to look beyond the endof that speci®c period, laying the foundations for the early years of thesubsequent 5-year plan periods (as illustrated in Figure 3).

As the process develops, it is to be anticipated that 5-year plans themselveswill adopt more of a rolling nature. As horizons are broadened and 15-year



Figure 2. Rolling plans.

perspective planning achieves more prominence, 5-year plans should be viewedas 5-yearly updates in the progression towards 15-year objectives.The 3-year rolling plans contain within them the ADP required by the wider

planning system. However, they are not intended to be con®ned to capitalplanning and increasingly will be extended to give greater consideration torecurrent funding issues. The plan includes a detailed budget programme forthe coming yearÐessentially the ADP (capital budget) and the recurrentbudget. The short-term budgets are thus set within a 3-year comprehensiveprogramme. The second and third years of the plan are presented in a lessdetailed allocative form, though with clear targets for monitoring.The rolling plan needs to be the product of a process which recognizes the

health sector situation (and its origins) and establishes future direction. Sucha process incorporates a cyclical series of activities referred to as a planningcycle or spiral (Green, 1992). This can be portrayed conceptually as inFigure 4.In practice, certain steps in the planning cycle can be compressed into

de®ned groups of activities. This particularly applies at the stage of goal andobjective setting and broad option appraisal, which can be combined toproduce planning guidelines. The stages of implementation and monitoring areon-going activities and thus not directly time bound within the cycle. Thecontent of the general activities of the planning cycle, as operationalized inPakistan, is shown in Figure 5.

198 A. GREEN ET AL.


Figure 3. The relationship of di�erent planning timeframes.

The annual planning cycle has to be consistent with the existing budgetaryprocess. Pakistan operates a ®nancial year from July to June, with budgetarydeadlines at various points during the year. These largely determine the timingof the major planning activities as set out in Figure 6.



Figure 4. The planning spiral.

Figure 5. Planning cycle activities in Pakistan context.

The planning year starts with an update of the situational analysis with theintention of explicitly basing plans upon an appreciation of the currentproblems. The product of this stage is a document which analyses the healthsector situation from a variety of perspectives. The format adopted comprisessections looking at:

. the general geography, infrastructure and socio-economic context;

. the services and plans of health-related sectors;

. demographic characteristics;

. health problems and needs;

. health services;

. health sector resources.

In assembling such a report the views of service providers (and through themsome form, albeit minimal, of community-based perspectives) have beensought through the use of a questionnaire. This ®eld-based information canthen be linked to centrally generated information such as from the developingHealth Management Information System and ®nancial information.The second major activity involves the drawing up of planning guidelines.

These respond to the problems identi®ed in the situational analysis. Theintention is to provide a strategic policy framework for all those involved inplanning. A high degree of strategic vision is required so that short-termoperational plans can be nested within the medium- and long-term strategy. Theplanning guidelines need to be set within the context of the 15-year perspectiveplans and the 5-year plans. The de®nition of guidelines has proved to be themost technically challenging activity in implementing the planning system

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Figure 6. Annual timetable of planning cycle.

reforms. Ideas of strategy can be di�cult conceptually and translating theseto ®eld o�cers problematic due to their limited operational control overresources.

The planning guidelines are issued to ®eld and programme managerstogether with a planning proforma which invites proposals for schemes andmodi®ed service activities. These are linked to their likely resource inputs underthe capital and recurrent budgets. The active involvement of ®eld managers inpreparing budgets has been almost completely new to them.

The returned proformas are centrally appraised for consistency andconsonance with the planning guidelines and then constitute the basis fordrafting the 3-Year Health Plan for discussion and negotiation with otherprovincial government departments.

INSTITUTIONAL SUPPORT TO THE PROCESS OFPLANNING SYSTEMS DEVELOPMENT

Introduction of the reforms discussed above involves important changes to theplanning processes operating in health departments. A critical factor in thesuccessful implementation of such reforms has been the involvement ofrelevant senior sta� who understand, and are committed to, the modi®cations.Many of the variations in e�ective acceptance of changes between provincescan be attributed to di�erences between such ownership by senior sta� and isoften inversely related to rapid sta� turnover.

Once an institutional momentum has been set up it is vital to establish a clearand adequately resourced process for administering the system. This can beseen to operate at both the policy and technical level.

At the policy level health planning committees have been established in all theprovinces of Pakistan. These comprise senior sta� of the Health, Planning andDevelopment, and Finance Departments. The committee oversees the policydirection of the health department and provides links between the health andother related planning departments. It may be desirable and possible tobroaden the inter-sectoral nature of planning committees in the future.Functionally, the committee meets to approve the various critical stages of theplanning cycle: situational analysis, planning guidelines, and health plans. Anunderlying rationale is to increase the ownership of plans, so that planning isseen as a routine activity central to the operation of the health department.

The body immediately responsible for servicing the planning system is theplanning cell (unit). This gives technical support under the guidance of theplanning committee. The cell also provides coordination and liaison with donors,other departments, and the federal level. Under the Third Health Project, aplanning cell has been established in Balochistan, the existing cell expanded inNWFP, and those in Punjab and Sindh strengthened. Development of thecapacity of planning cells has been a central element in the project. This hasincluded increasing personnel numbers and skills, and organizational change.

The range of tasks now asked of planning cells demands adequate personneland commensurate skills. Tasks range from internal managerial decision



making to technical analysis of health activities. These tasks require to bebroken down, allocated and structured managerially.Important to the success of planning is the attainment of a critical mass of

planning personnel and skills. This is vital both technically and professionally,to develop a peer group to whom planning sta� can relate. Some provinceshave attained this mass internally, but all planning sta� have bene®ted frommeeting colleagues from other provinces. Often this has occurred after years ofalmost total professional isolation.Of critical signi®cance has been the relationship which the planning cell has

enjoyed with the respective Secretary of Health. Where the technical o�cershave been given clear leadership and a direct link to the political process, theyhave ¯ourished. Where these have been lacking, it has been harder for them toestablish purpose and self-identity.Prior to the project, planning cells were principally concerned with capital

investment projects in the health sector, with other recurrent budgetingdecisions being taken in other sections. Expanding the remit of the planningcell to include recurrent budgeting requires organizational changes in healthdepartments, with the linking of capital and recurrent budgeting under thedirection of the planning cell. Varying degrees of organizational change havebeen initiated in each province. Planning cells also need close organizationallinks with health information systems. Historically, information needs havebeen associated with disease control functions, and a broadening towardsplanning and management is necessary.

ASSESSMENT OF PLANNING SYSTEM DEVELOPMENT

Evaluating progress in the development of a planning system requires a clearperception of the objectives and intermediary targets involved in the process.Strategic development of planning systems can be conceptualized as having threestages (possibly occurring in parallel)Ðan initial period of infrastructuredevelopment, which produces service change, eventually leading to healthimprovements. Each stage requires indicators, both quantitative and qualitative,against which progress may be judged. This article has described the ®rst of thesestages. It is too early to judge whether sustainable improvements in health statuswill be achieved as a result of the project; however, we outline here some of theissues involved in making such an assessment.The establishment of a planning infrastructure can be re¯ected in indicators

of inputs or resources, process and outputs. Resource indicators includeplanning cell sta�, skill levels and budgets. Given the importance placed onplanning processes in the project, indicators which can evaluate process will becritical. They will include ownership, attitudes to planning, organizationallinks, and involvement of ®eld o�cers and the wider community. These tend tobe more qualitative.Output indicators have traditionally dominated planning system development,

with a concentration upon visible outputs such as documentation. Undoubtedly,

202 A. GREEN ET AL.


output indicators have a role, particularly in monitoring the establishment ofthe annual planning cycle, where documentary outputs (such as situationalanalysis, planning guidelines and rolling health plans) mark critical stages.What remains critical, however, is that these documents are not seen as the soleevidence of planning system development, but that due weight is paid toresource and process indicators which are of greater importance in thesustainability of planning system developments.

The initial phases of planning infrastructure development have now beenlargely, albeit unevenly, completed in Pakistan. Planning resources have beenincreased with core sta�ng and skills established, though recurrent budgetsstill require modi®cation in the light of increased activity levels in planningcells. Monitoring of process indicators has shown substantial improvements inthe general understanding of strategic planning.

Modi®cations to planning infrastructure are only satisfactory if they produceappropriate service changes. The precise indicators to measure this will dependupon the health sector problems which the planning system is seeking toaddress. In the Pakistan context this is likely to involve change, related to: theprovision of services for women and children and inclusion of family planningand other aspects of reproductive health into the mainstream health system;allocation of resources more equitably between, and within, rural and urbanareas; and, more e�cient expenditure between capital and recurrent costs. Suchchanges should bring about a qualitative improvement in services, enhancingtheir appropriateness and acceptability. Service outputs, especially totalutilization and maternal and child health coverage, are probably fairlysensitive indicators of service quality.

Sustainable improvement in health status will be dependent uponestablishing a planning infrastructure and producing e�ective servicechanges. It will also depend on social and environmental improvementsgiven that the impact from the health sector alone will be much less than thepotential product of inter-sectoral activities.

LESSONS FOR OTHER COUNTRIES

This article has described a project to improve the health planning system inPakistan over a period of less than 5 years, with limited resources. Many of thede®ciencies in the system are apparent in other health planning systems. It istoo early to judge the success of the project. Furthermore, we do not suggestthat the details of the approach taken in this project would necessarily suitother situations. There are no universal organizational solutions and everycountry must be viewed within its own context. However, there are variouslessons from the project which may be applicable elsewhere.

In a project of this sort, which aims to make deep-seated changes toinstitutional processes, the manner of change is as important as the product.There is a need to involve more institutions and individuals than may at ®rstsight appear obvious. This inevitably makes change slower, but is likely to



result in more sustainable improvements. The speed of change is also closelyrelated to the transfer of key sta� which in Pakistan can be a frequentoccurrence. The political nature of planning also suggests a need to beopportunistic in seizing appropriate openings and riding a situation when thepolitical (in the widest sense) climate is unfavourable.One of the critical decisions to be made concerns the judgement as to what is

immutable in the external planning system and which elements can safely bealtered. There is a balance to be attained between overcaution and unnecessaryincursions into existing procedures.The balance between technical activities is also an important and di�cult

judgement. The process su�ered to some degree from too great attention withinthe planning cycle to the analytical stage at the expense of the development ofplanning guidelines. In part this was the result of a desire to develop anapproach to strategic thinking grounded in robust information. In e�ect whatoccurred was the occasional symptom of paralysis by analysis with situationalanalyses in the early years being completed too late to allow for adequateattention to their implications to the planning guidelines.In summary: there is a requirement to develop, in a balanced manner, the

three critical elements of ownership by key stakeholders, robust and workablesystems, and human resource development. In all three of these areas it is easy,with the bene®t of hindsight, to see places where it could have been approacheddi�erently. Whilst there are no easy rules to apply to obtain such a balance, it isa factor that needs to be kept under constant review. A long-term approach isrequired, which focuses on the process of planning system development ratherthan regarding it as a product of only technical interventions. It is easy tounderestimate the time and resources required to achieve such institutional andsustainable change. In part this is a function of the depth and commitment tothe existing bureaucratic processes and the political nature of planning. Thishighlights the di�culties in achieving deep-seated change within as short atime-scale as that of a project.

ACKNOWLEDGEMENTS

The authors would like to acknowledge the constructive comments made bycolleagues and in particular Ms Jacqui Isard, formerly of the OverseasDevelopment Administration. As usual, however, remaining errors in fact orjudgement are the sole responsibility of the authors. The British governmentbears no responsibility for, and is not in any way committed to, the views andrecommendations expressed therein.

REFERENCES

Green, A. (1992). An Introduction to Health Planning in Developing Countries. NewYork: Oxford University Press.

204 A. GREEN ET AL.


Green, A. (1995). The state of health planning in the 90's. Health Policy & Planning 10(1), 22±28.

Government of Balochistan (1993). Situational Analysis of Health in Balochistan (1993).Health Department.

Government of Sindh (1994). Situational Analysis of Health in Sindh 1994. HealthDepartment.

Khattak, F. M. (1996). Health Economics and Planning in Pakistan. Islamabad: Ad-Rays Publishers.

UNICEF (1994). The State of the World's Children 1994. New York: Oxford UniversityPress.

World Bank (1993). World Development ReportÐ `Investing in Health'. New York:Oxford University Press.



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Health planning in Pakistan: a case study