PRINCIPLES OF HEALTH PLANNING IN THE USSR G. A. POPOV Doctor of Medical Sciences Deputy Director, Department of Planning and Finance, ‘Mintsry of Health of the USSR Professor of Social Medicine and Public Health Administration, ‘Central Institute for Advanced Medical Studies, Moscow WORLD HEALTH ORGANIZATION GENEVA‘Reprinted 1978 (UK) World Health Organization 1971 Publications of the World Health Organization enjoy copyright protection in accordance withthe provisions of Protocol 2 ofthe Universal Copyright Convention. Nevertheless governmental agencies or learned and professional societies may Feproduce data or excerpts or illustrations from them without requesting an futhorization from the World Health Organization. For rights of reproduction of translation of WHO publications én soto, appli cation should be made to the Office of Publications and ‘Translation, World Health Organization, Geneva, Switzerland, The World Health Organization welcomes such applications, ‘The designations employed and the presentation of the material in this publi- cation do not imply the expression of any opinion whatsoever on the part of the Director-General of the World Health Orginization concerning the legal status fof any country or territory of of its authorities, or concerning the delimitation of is frontiers. The author alone is responsible for views expressed in this publication,CONTENTS Preface Introduction. eee Cuarrer 1. Th Definition of heath planing Hh planing a ation ising Principles of health planing Heath indices and incestors, sors snd siandards Characteristics of realistic health plan Allocation of priries and pubic healt policy Economie aspects of public health = Planning as @ continuous process, ‘Methods of health planning Regiment for Health planning Organization of planning work ‘ORY OF HEALTH PLANNING Cuaerer 2. THE LEVEL OF HEALTH Morbidity data... Morbidity data for the USSR Morbidity data for other counties ‘Unrecognized disease and mass sereening ‘alth forecasting in the USSR (Cuaprer 3, OUTPATIENT AND HOSPITAL CARE FACILITIES ‘Ourpatient care Hospital eare CHAPTER 4, MEDICAL MANPOWER Definitions»... Se ‘General practitioners and family physicians Specialists ‘Medical manpower in the USSR Medical manpower in other countries - Views of WHO Expert Committees. 22S sodaon " 13 B 4 15 1 19 2 2 a 28 30 36 38 0 50 ot 3 93 9s 109 12Carrer 5, METHODS OF PLANNING THE TRAINING OF MEDICAL PERSONNEL rr “otal requirements for spesaists and the manpower balance ‘Wastage due to specialists ceasing to practise their profession Movement of medical personnel . « Paar Sexratio of specialists... se ‘Additional requirement for medical personnel Drop-out of medical students... Determination of intake of medical stdents Rate of training of specialists... Use of saturation factor and tai Nino on pong owp meaiiigaxtitoa Conclusions (Cuarrer 6, NoRMS AND STANDARDS ‘Norms and standards i the USSR... ‘Norms and standards for medical eare ‘Norms and standards for medical manpower ‘Annes. Indios for us in publi health planning and in cvatuating the effectiveness of medical care tae 16 6 47 120 120 2 12 12 ns 126 i 18 129 129 133, 146 168PREFACE It is now widely recognized that national health planning is the key to ‘achieving the most eficient utilization of available resources for the improve iment of the state of health of the population. For this reason, governments in an increasing number of countries are now engaged in national health planning; others, particularly in the developing countries, are becoming increasingly aware of its advantages. There is therefore a growing demand ‘for information on health planning techniques and in particular on those ‘used in countries with a long experience of plannin, National health planning has been practised in the USSR since its earliest days, so that a vast amount of experience has been gained as a result of several decades of constant endeavour in this field. Because of language difficulties, however, much of the information on the planning techniques used in the USSR has not been readily accessible to readers in other countries. It was with the aim of making suck information available to planning personnel outside the USSR that WHO invited Dr G. A. Popoy to prepare the present publication. It is realized that every country will develop tts own public health system, adapted to the social, econonale, and cultural conditions that it is called upon to deal with. In the same way, every country must develop its own individual health planning techniques. Nevertheless, experience in health planning in one country can be of value in another, provided that it is understood that the methods found to be successfid under a given set of conditions cannot necessarily Be taken over unchanged but may have to be suitably adapted for use under different conditions. For this reason, it is hoped that this publication will be of use to those concerned with health planning even in countries differing widely from the USSR in social ‘structure, level of economic development, and culture.INTRODUCTION A field of inquiry can be called a science only when the phenomena with which it is concerned can be expressed numerically. In the words of D. I. Mendeleev: “Science begins when measurement begi exact science without measurement is unthinkable.” As far as medi is concerned, the medical statistician W. Farr pointed out as long ago as 1839 that “Medicine, like the other medical sciences, is beginning to abandon vague conjecture where facts can be accurately determined by observation; and to substitute numerical expressions for uncertain assertions.” Health planning, in particular, with which this publication is con- cerned, is impossible unless the various aspects of the health of the com muaity and the medical care available to it can be given numerical expression, Apart from a brief discussion of the theory of health plan- ning, therefore, the main emphasis is on the different indices available for this purpose and the values of these indices under various conditions, ‘A health plan consists essentially of such numerical data, some of which may be laid down in norms and standards. The value of health planning is shown by the successes achieved in the ficld of public health in the USSR; these are due to a considerable degree to the planned nature of the economy of the country and of its various sectors, including public health, Thus infant mortality, the traditional index of the level of health, fell from $1 per 1000 in 1950 to 26 per 1000 in 1968 (the figure for 1913 wes 269 per 1000). Commu- nicable diseases, such as smallpox, plague, cholera, and malaria, have ‘been completely eradicated, while the incidence of poliomyelitis, diph- theria, and whooping cough has been greatly reduced. As far as medical care facilities are concerned, the total hospital bed complement had reached 2 567 300 by 1969, or 10.6 beds per 1000 population, as compared with 13 in 1913. Between 1960 and 1969 alone, a further 828.000 hospital beds were made available. Th2 number of physicians in the country in 1969 had reached a figure of 643.000, or 26.6 per 1000010 PRINCIPLES OF HEALTH PLANNING IN THE USSR population, while paramedical personnel amounted to 2.043700, or 84.3 per 10.000 population, Tis clear, in view of the foregoing, that an account of the theory and practice of health planning in the USSR, in form accessible to readers outside that country, must be of considerable interest it is the im of this publication to provide such an account, although some formation is also given for other countries for purposes of comparison. It is based on many years of practical experience in health planning in the USSR and in teaching this subject in courses for public health administrators at the Central Institute for Advanced Medical Studies in Moscow.CHAPTER 1 THEORY OF HEALTH PLANNING In many countries, the health services, i.., all those personal and community services, including medical care, directed towards the pro- tection and promotion of the health of the community, have grown up in a haphazard manner. This is, to a certain extent, the inevitable result of the fact that the way in which these services have developed hhas been determined partly by the interests and the fears of the public (and especially by the fear of epidemics of communicable disease) and partly by the discoveries made from time to time by medical research. ‘The increasing complexity of medicine, the links between the social, economic, and cultural conditions prevailing in a community and its health status, together with the increasing use of economic planning, hhave, however, made it both desirable and possible for such haphazard growth to be replaced by orderly and efficient development, In order to achieve this aim, health planning is necessary. Interest in health planning has increased markedly over the last ten years. This is largely the consequence of the increased interest of governments in planning for economic and social development as a Whole, as a means of achieving the systematic organization and rational deployment of national economic and manpower resources. Never- ‘theless, health planning is also possible in countries where planning on a national scale does not exist. It is clear, however, that in such coun- tries, the difficulties encountered by planning teams will be much greater than those met with in countries, such as the USSR, where the economy is fully planned. Other factors have also helped to increase interest in health planing ‘There is, for example, a growing appreciation of the fact that ill health and disability are a serious handicap to the development of the economy, and that the losses that they can cause can be reduced by measures to safeguard the health of the labour force. In this way, absenteeism due to illness can be reduced, the curation of working life increased, etc. From this point of view, the development of public health can be regarded =e2 PRINCIPLES OF HEALTH PLANNING IN THE USSR as a major factor in promoting economic and social development, and it is clearly essential that health planning should form an integral part of planning for such development. In addition to the foregoing, the cost of providing and operating a system of health services is now so great as to be beyond the resources available to voluntary agencies or private bodies, so that the trend is, towards increasing government intervention in this field. This is asso- ciated with the development throughout the world of State social security systems, and the tendency for health services to be closely linked with such systems. ‘A further factor of importance is that the methods used in epidemio- logy, which have proved so successful in the control of communicable disease, are being increasingly applied to certain noncommunicable diseases, such as cancer, cardiovascular disorders, other chronic and degenerative diseases, and road accidents. In this way, the field covered. by public health has been greatly increased. ‘The increasing interest in health planning is reflected in the activities of WHO in this field. Since 1951, four WHO Expert Committees on Public Health Administration have been concerned largely with this subject. The technical discussions at the Eighteenth World Health Assembly, held in 1965, were also devoted to health planning. Several ‘meetings to discuss this subject have taken place under PAHO/WHO. sponsorship in the Americas. In addition, a WHO regional seminar ‘on national health planning was held in Manila, Philippines, in June 1964, and a WHO inter-regional seminar on the subject in Addis Ababa in October 1965. The problems involved in health planning are of extreme complexity as a consequence of the large number of economic, social, and cultural factors that may aflect the health of the population of any given country (it is for this reason that planning teams must be multidisciplinary in character and include, for example, sociologists, demographers, statis= ticians, and cconomists, in addition to experts on public health). An additional complication is that, even within any particular country, with a public health system of a given type, certain regions may have special features, whether demographic, economic, geographical, oF medical in character, and therefore special requirements from the point of view of medical care. This complexity should not be used, however, as an argument in favour of allowing health services to grow sponta- neously, or the adoption of a trial-and-error procedure, whereby the same mistakes are made by different countries in solving the same problems.THDORY OF HEALTH PLANNING B DEFINITION OF HEALTH PLANNING A definition of health planning was given by the WHO Expert Committee on Public Health Administration, in its fourth report, in the following terms: “The planning of public health services means the careful, intelligent interpretation and orderly development of these services, in accordance with modem knowledge and experience to mect the health needs of a nation within its resources.” A WHO report on national health planning in developing countries, published in 1967, contains a number of other statements of importance from the point of view of an understanding of the nature of health planning, Thus it points out that “national health planning is an integral part of general social and economic planning”. In addition, it states that planning “includes the provision of professional personnel from the political sciences as well as the medical sciences to give administrative direction to comprehensive health programmes. Throughout the whole planning process. .. there is room for a variety of specialists, including those from the socialsciences, to assist the health team, both in planning and in implementation.” It also refers to “the concept of planning” as multidisciplinary undertaking in which a number of different disciplines co-operate in organized teamwork, preparing a plan that is finally acceptable to the government and will have financial and admin- istrative support for its implementation”.* Finally, the comment is made that “it cannot be overstressed that planning is a continuous process. Every few years new plans will need to be prepared to take account of the progress achieved, both in health and in other sectors of development.” Public health planning in countries in which planning is carried out at the national level constitutes a scientifieally based system of State and social measures which make it possible most fully to match the needs of the population for medical care and sanitary-epidemiological services to the economic resources available for the satisfaction of these needs. HEALTIC PLANNING AND NATIONAL PLANNING It is necessary to define the relationship between the health plan and the national plan for the economy as & whole, in countries where 5 Wid HID Org techn Rep, Ser, 1961, No. 215, 4 THE OF tl, Rep Se er N304 PRINCIPLES OF HEALTH PLANNING IN THE USSR such a plan exists; in the USSR, for example, health planning is an integral part of the planning of the entire national economy. The ‘material and cultural needs of the population, including the need for the various forms of medical care, are continuously increasing, and can be satisfied only by the rapid development of the economy of the country as a whole. This in turn calls for the rational utilization of the available resources, and hence for national planning. From this point of view, public health can be considered as one of the numerous sectors of the economy to which an appropriate proportion of these necessarily limited resources has to be allocated. The essential problem to be solved in national planning, in fact, is that of the allocation of the available resources to the different sectors in such a way that harmonious overall development is the result. ‘As far as public health is concerned, the position is complicated by the fact that, although health services can contribute to economic and social development, not all such services contribute to economic objectives, as already pointed out. The WHO report on national health planning in developing countries, mentioned above, concludes, in fact, that itis difficult to produce any “scientific” basis for determining what proportion of national resources should be devoted to health services, and that health spending is not, in practice, determined by any clear criteria; further research is therefore needed on the criteria for the distribution of resources between the health and other sectors.? Once a decision has been taken, however, on the resources to be allocated to the health sector, health planning will ensure that these resources Will be used in the most effective way in satisfying the needs of the population for the various forms of medical care. PRINCIPLES OF HEALTH PLANNING ‘A number of principles on which health planning should be based were enunciated by the WHO Expert Committee on Public Health Administration in its fourth report? These include the following: 1. Government policy in the field of public health must be clearly defined, and the general form and scope of the plan determined. 2. The national public health policy must be in conformity with the economic and social development of the country. 3. Health planning must be carried out by some competent agency, whether this is a board, council, ministry or department of public WL Huh Ong. tc. Rap Sr, BET, No. 35,2223. 1 lh te tcl Rip. Ser tel, No. 218, 1620,‘THEORY OF HEALTH PLANNING 15 health; this agency must include representatives of all the governmental bodies concerned with public health and of all other interested organiz- ations. 4, The scope of the types of health service and of the population covered by any particular plan must be comprehensive in character. 5. The health plan must take into account the concrete demographic, social, cultural, economic, and administrative conditions existing in the country concerned. 6. The plan must take into account the relationships between the central ministries responsible for various duties in the field of public health and provide for the co-ordination of all programmes aimed at protecting and improving health. 7. The plan must be drawn up for the specific period necessary for the achievement of the objectives laid down; it must be sufficiently flexible to allow for certain variations, in the course of the planning period, resulting from changing conditions or the acquisition of further information, 8. The measures provided for in the plan must be within the limits imposed by the available resources of the country, whether in terms of finance, manpower, or information, not only at any given time but also taking into account any progress which it is assumed will take place. 9. Atall stages of the development and implementation of a national plan, the conscientious observation, recording, and evaluation of the fulfilment of the plan are necessary. HEALTH INDICES AND INDICATORS, NORMS AND STANDARDS Reference has been made to the use of “indices” in the planning procedure (the term “indicator” is also used). Such indices or indicators provide a measure of the level of health of the community concerned and of the medical care facilities and personnel available to it. Accord- ing to the report of a WHO Study Group on the Measurement of Levels of Health, indices can be divided into the following three groups: (@ those associated with the health status of persons and populations in a given area (vital statistics, nutrition, etc.); @) those related to physical environmental conditions having a ‘more or less direct bearing on the health status of the area under reviews and (©) those concerned with health services and activities directed towards the improvement of health conditions (availability and use of hospitals, physicians, and other health personnel). Wd Org tech. Rap. Sr 957, No 127,1816 PRINCIPLES OF HEALTH PLANNING IN THE USSR In addition, the Group considered that indices could be constructed for different aspects or groups of aspects of the problem, and that such aggregation could be continued until all relevant aspects were fully covered, in which case the index might be called a comprehensive index? Such an index would be of great value both for purposes of international comparison and for the assessment of changes with time within a given area. The Group considered three possible indices of this type, but pointed out that they would still need to be supplemented by specific indices? such as infant mortality, the death rate from communicable diseases per 100.000 population, and indices of health services and activities. The question of health indices was also discussed by a WHO Expert Committee at a meeting held in 1966,* and it was concluded that such indices could be divided into: (1) indices of resources (money, manpower, facilities, and organiz~ ation); and Q) indices of health and disease (mortality, morbidity, disabi rates and ratios, and levels of health). ‘A health plan can be expressed in terms of the values of certain indices, different indices and numbers of indices being used at the different levels of operation. The number of indices used increases the more closely the plan is concerned with a specific establishment. ‘The system of indices used in health planning is constituted by the sum total of the interrelated statistical indices which express the overall development both of public health as a whole and ofits various individual sectors. ‘The magnitude of the different indices is determined by measuring the corresponding factors and varies with the special methodological features of the way in which they are built up; this is determined, in turn, by the extent to which they reflect the phenomena and processes concerned. Thus the most general index of the medical care provided to the population is the availability of medically qualified personnel. This is only approximate in character. A more complete and objective expression of the medical care provided can be obtained by analysing the indices for the availability of care in outpatient establishments and polyclinics, hospital care, care in sanatoria and health resorts, sanitary and epidemiological services, the number of occupied posts for physicians in the various specialties, indices of the utilization of posts for phy- sicians, etc. 1 rec ap Ser 1287, 80197, 1 1961, No. 350,15.‘THEORY OF HEALTH PLANNING 7 ‘Natural indices are those expressed in mumerical terms or in terms of various physical units (length, area, volume, weight, power, etc.); financial or cost indices are those which express economic factors in financial terms. In the USSR a small number of indices are fixed by the Government: ‘the number of hospital beds, the total number of physicians required, ‘the number of beds in sanatoria, the number of persons to be admitted to medical training establishments, and the scale on which capital construction is to be carried out. ‘At the lower administrative levels, the indices used cover the development of specialized forms of medical ‘care, uéastoks (see p. 52), the care of specific groups of the population (women, children, industrial workers, efc.), the training of medical personnel, etc. From the highest level of the administration to the lowest, each index is defined in precisely the same way. The indices included in the plans for the lower levels are combined to form a single State plan. It should be noted that the values of certain indices may be specified by the planning agencies or embodied in legislation, as in the USSR, when they take on the character of norms and standards, ‘The precise definitions of these terms, and examples of such norms and standards, both in the USSR and in'other countries, are given in Chapter 5. ‘The system of indices used in health planning in the USSR is given in the Annex. (CHARACTERISTICS OF A REALISTIC HEALTH FLAN ‘An attempt was made at the technical discussions at the Eighteenth World Health Assembly to state concisely the chief characteristics of a realistic health plan? It was said that such a plan should be simple, comprehensive, flexible, phased, costed, limited in time as regards each step, fully acceptable to the community, and capable of evaluation at each stage. Alternatively, the importance of the following character- isties was stressed: (1) comprehensiveness and balance in considering objectives and arranging priorities; Q) flexibitit G) efficiency in the use of resources; and (4) adequate consideration of manpower requirements, both exist- ing and potential. * World Healt Organization (165) Reon of jh eh Ucaion ot the Behe Word Heath seca Weak ening, Gsser (sepia tne: i fecha Dacor18 PRINCIPLES OF HEALTH PLANNING IN THE USSR ‘The drawing up of a health plan must be based on an expert evalu- ation, from the demographic and sanitary-hygienic points of view, including quantitative and qualitative indices of medical care and tech- nical and economic calculations. Such an evaluation must be the result of an all-round analysis of the requirements, the extent to which these requirements are satisfied, the resources available, and the laws governing, the development of public health at each concrete stage of development, ‘The planned rates of growth of the system of public health establish~ ‘ments, capital construction, and the training of medical personnel give a concrete indication of the qualitative aspect of public health and its place among the other sectors of the national economy. Health planning must also provide for the correct relationships, within public health, between the various forms of medical and sanitary care available to the population: sanitary and epidemiological services, curative and prophy- lactic services, the training of personnel, etc. Thus, for example, within curative and prophylactic care, it is necessary for outpatient and ppolyclinic care, domiciliary care, hospital care, care in sanatoria and health resorts, etc, to be in the correct proportions. Optimization in planning is aimed at achieving the most rational solutions of the problems of the planning period, as well as the creation of the prerequisites for further development in the subsequent planning period, by the carrying out of the various phases of the construction ‘of public health establishments, the training of physicians and para- ‘medical personnel, and the solution of organizational and other problems, c.g. the eradication of communicable diseases and the reduction of the morbidity due to such diseases, etc. ‘Medical care, whether it takes the form of outpatient care, hospital care, or care in sanatoria and health resorts, according to the classification adopted in the USSR, is essentially a single process. For this reason, the three sectors just mentioned cannot be considered in isolation if a realistic health pian is to be obtained. If such a unified approach to health planning is not adopted, some particular form of care may be unjustifiably starved of resources or, in the opposite case, preferentially developed at the expense of other forms. ‘There may also be unnecessary duplication where, as a result of the system of organization adopted, certain groups of the population, such as children and industrial workers, are covered both by the general health services and by specialized services, In practice, where faulty planning leads to a failure to provide the means necessary to satisfy the requirements for a certain type of medical ‘care, these requirements are satisfied in some other way. This can, however, be an unsatisfactory solution to the problem of providing the population with adequate medical care, e.g., where a shortage of hospitalTHEORY OF HEALTH PLANNING 19 beds leads to a compensatory increase in the amount of domiciliary care, since such cate is much more costly than hospital care (eee p. 60). ALLOCATION OF PRIORITIES AND PUBLIC HEALTH POLICY ‘There is general agreement that a health plan cannot be considered as realistic unless it is based on a system of priorities. This is simply the consequence of the fact that, at any given time or over any given period, the available resources are inevitably limited so that it is impos- sible for the public health authorities to solve simultaneously all the problems with which they are confronted. It is necessary, therefore, fo draw up an order of priority and to concentrate attention on one particular sector of public health and the solving of certain problems. Although this must obviously result in the development of other sectors being temporarily held back, it is still essential for the various parts of the health plan to be in harmony with one another. In the USSR, this question of the allocation of priorities is considered under the heading of the designation of what is known as the “key sector”, icc, the designation of that part of the plan whose fulfilment is essential to the fulfilment of the rest of the plan, Priority is then given, in the allocation of the resources of the public health system apital investment, equipment, and medical personnel), to the solution of the problems of this sector. The designation of a key sector does not mean, of course, that all the other multifarious aspects of public health are ignored. The question of the allocation of priorities is necessarily closely associated with that of the aims of the health plan, and therefore with public health policy; from this point of view, the plan can be regarded as the expression of this policy in numerical terms. The determination of the aims of the plan, and consequently of the order of priority of its various sectors, is am extremely complex problem, and can be solved only on the basis of a thorough analysis of the existing situation and the ‘way in which this is likely to develop in the future, ‘As an example of the selection of key sectors, the health plan for 1966-70 of the USSR * provides that, over this period, the most important tasks are as follows () reducing morbidity and mortality, particularly among childre ) eradicating communicable diseases or still further reducing their incidence; Popor, OA: (1966) Pinel of pblcdealh plrning ite USSR, Genera, Worl Haak Crease ospashed aacament NUHIN WS20 PRINCIPLES OF HEALTH PLANNING IN THE USSR ) effecting an all-round improvement in the standard of medical @) improving the management of medical research and the utiliza tion of research personnel; () improving the quality of medical training and the placement and utilization of qualified personnel; © improving the material and technological basis of the health services; and (1) improving the supervision of the working and living conditions of the population. Jn more general terms, the WHO Expert Committee on Public Health Administration felt that, in the establishment of priorities, emphasis should be placed on prevention; on the provision of services for people engaged in productive work and for mothers and children; and on work that affects the health of the largest number of people and contributes most to the improvement of the nutritional standard of the population? Itis clear, in addition, that the economic aspeets of public health must have a bearing on public health policy and the allocation of priorities. ECONOMIC ASPECTS OF PUBLIC HEALTH ‘The question of the economic aspects of public health has already ‘been touched upon briefly inthe discussion of the relation between health planning and national planning (see p. 14). As pointed out in a recent ‘WHO report:! “Many countries, consciously or unconciously, use what may be broadly called economic principles to establish priorities. The emphasis on prevention rather than cure is one such principle, The cost of curative services for a disease can be saved if the incidence of that disease can be reduced or if it can be totally eradicated. Secondly, the common emphasis on saving the lives of younger people in whom there has been considerable social investment and who still have major contributions to make to production represents another choice. ‘The choice of diseases that can be prevented at relatively low cost rather than those that can be prevented only at high cost is a third type of decision with an underlying economic motive. The decision to provide somewhat better health services in areas or for occupations where the loss of skilled manpower or of working hours is of greater value to the economy is a fourth example.” 5 tat Ong. teca. Rep Ser 1961, No. 25,12. * Wl Orta: Rap Ser Ber, No. 38,THEORY OF HEALTH PLANNING a The fact that public health can make 2 contribution to economic development does not mean, however, that it is to be regarded purely as a branch of economics, and that health services should be concerned exclusively with increasing production. The resources allocated to medical care or to measures for the improvement of industrial hygiene should not be considered solely from the point of view of profitability. Public health is essentially humanitarian in character, and its function is to satisfy the need of human beings for a healthy life. In the words of the above-mentioned WHO report? health services “contribute to ‘other aspects of human welfare that are very real, however hard they may be to measure”. ‘The economic aspects of public health can also be considered from the narrower point of view of the economic problems of public health administration. These include the comparison of the various types of organization for the provision of medical care, the efficient organization of the work of medical personnel, the location of medical care establish- ments, the cost of the various types of medical care, etc. For this reason, it is necessary for public health administrators to learn to use the basic concepts and techniques of economics, and training courses for such administrators should include courses on cost accounting and budgeting. A systematic approach to these questions is an important part of health planning. PLANNING AS A CONTINUOUS PROCESS ‘The process whereby the economy of a country develops is essentially contisuous in character, The selection of a particular interval of time for planning purposes is therefore purely arbitrary. In addition, no plan can allow fully for the advances in science and technology that will take place during the period which it covers. It is also probable that, after a certain period has elapsed, the various sectors will no longer be inline with one another. Itis necessary, therefore, to regard planning as a continuous process and, from time to time, to introduce corrections into the plan or to revise it with the aim of maintaining the equilibrium between the requirements of the population, which are constantly grow- ing and changing, and the resources available for satisfying them. From this point of view, it is essential for the length of the period covered by the plan to be sufficient, not only to enable the measures envisaged by the plan to be put into effect, but also to enable the extent to which the plan has been fulfilled to be assessed at any given time. AS ATE Hh Org. techn. Rep. Ser, 1967, No, 280, 292 PRINCIPLES OF HEALTH PLANNING IN THE USSR ‘a result, the length of the planning period will depend on the length of time required for the results of a planning decision to become appa- rent. For example, progress in the implementation of a plan for the construction of medical care establishments can easily be checked (provided that the necessary statistical data are available) over a compara- tively short period, so that such construction can be dealt with in a short-term (one-year) plan. This is not true, however, in the case of the training of physicians and nurses, where the result of a planning decision cannot become apparent until three to six years have elapsed, In this field, therefore, long-term plans are necessary. ‘A further consequence of the fact that planning is a continuous pro- cess is that there must be no discontinuities at the end of each planning period; each plan must link up smoothly with the next one, (METHODS OF HEALTH PLANNING ‘The planning methods employed in the USSR include the analytical method, which involves the following stages: (a) the division of the ‘process under investigation into its constituent parts; (6) the determina- tion of the effect of the individual parts, and especially those considered to be the most important, on the process as a whole; (c) the drawing of the appropriate general conclusions. Another method used is that of expert evaluation, based on a comprehensive evaluation of the require= ‘ments for medical care, the extent to which they are satisfied, the resources available, ete. In cost-benefit analysis, the cost of a particular project is balanced against the benefits or practical effects expected to result from it. ‘The balance method is aimed at ensuring that needs and resources are in balance with one another. ‘The method of ratios and Proportions ensures that all the different parts of the plan are in the correct proportions. In the USSR, in particular, a standard ratio of medical facilities to population size is of great importance in planning the development of the health services. This ratio, which is approved by the Ministry of Health of the USSR, is based either on special scien- tific investigations or on the practical evaluation of existing medical care services! The establishment of norms and standards is also of great importance in planning the development of the health services (Gee Chapter 5). Tt is essential in health planning to ensure that the maximum results are obtained for the minimum expenditure of resources. Such optimi- zation can now be more easily achieved with the aid of computers and Gh 62 Th pang of np ees ath USS, Co WHO Reglonat once tr Euiops tanpeaned Socaneat EOROUL B annaTHEORY OF HEALTH PLANNING 2B certain new mathematical techniques, As already pointed out, the factors affecting the health of the community are extremely complex, and the planner may well be confronted with large quantities of data, the processing of which would be very slow without the use of computers, In addition, operational research is now available as a technique for applying scientific methods of analysis to the problems of complex organization. It has been widely applied in industry, but since health is now among the ten major industries of industrialized society, the implications for public health practice in general, and for health planning in particular, are obvious? Another optimization technique of great potential value in health planning is that known as systems analysis, which involves the use of linear programming. Reference should also be made to queuing theory, ie. the application of probability theory to the study of the delays or queues produced at servicing points, Finally, mention should be made of computer simulation? If a set of parameters can be defined, together with the relations between them, the resulting finite range of situations can be quickly explored by means of acomputer. It is thus essentially a method of determining in advance the consequences of the various possible changes that may be made in a complex system and is therefore of obvious application in health planning, since the direct use of the experimental method in the field of public health is not possible. ‘tis of interest in this connexion that the WHO research programme in epidemiology and communications science includes a study of the ways of using collected data in the formulation of a health plan, and that a project for this purpose is envisaged at the provincial level in Colombia. [REQUIREMENTS FOR HEALTH PLANNING ‘Health planning is possible only if certain data are available, These comprise, in the first place, data on the size of the population and its make-up in terms of age, sex, and occupation. Data on the distribution of the population are also needed. In the second place, data are needed on morbidity, morbidity involving a temporary loss of working capacity, infant mortality, mortality from particular causes, ete. Finally, data are required on the medical care facilities and personnel available. Such 2 Ween cope and metodo of reach npc ath prt, Gene, won a iste acumen OM RESORT F395 "62 Crone, (96, 23,38624 PRINCIPLES OF HEALTH PLANNING IN THE USSR data should be available for a number of years preceding the period to be covered by the plan. If the necessary data are lacking, as is the case in a large number of countries, planning must be preceded by special investigations to determine the health status. Even where data are available, special investigations of morbidity and mortality may never- theless be necessary. Such investigations often take the form of a sample survey, the required information being obtained by the examina- tion of a representative sample of the population. The results of a number of such studies on morbidity in the USSR are considered in Chapter 2. ORGANIZATION OF PLANNING WORK Various approaches to the procedure to be adopted in drawing up ‘health plan have been described. Thus a WHO Expert Committee has stated that every sectoral plan calls for: (1) an accurate assessment (diagnosis) of the existing situation; (Q) the definition of the means recommended to improve efficiency in the operations of the sector; (3) an estimate of personnel needs, category by category, together with an indication of the facilities needed for staff training; (4) the costing of the various activities, project by project, taking into account and listing separate (@ capital expenditure (buildings, vehicles, and equipment), @) recurrent expenditure on personnel and materials; (8) a description of the expected results, in terms as concrete as possible; (6) as accurate as possible an estimate of the expected economic effects; and () recommendations for activities in other sectors, e.g., nutrition, health education, and environmental health, In the USSR, it is considered that the preparation of a health plan may be divided into three fundamental stages: (1) the assessment of the existing state of affairs and of the way in which this is likely to develop in the future; (2) the determination of the requirements of the population for medical care, both at the present time and in the future; ) the establishment of suitable indices (see below) for use in the health plan for the planning period concerned. In greater detail, the planning procedure might involve: "Wid Uh Ort Rep. Ser 196, No. 30,24THEORY OF HEALTH PLANNING 25 (1) the analysis of the nature and extent of disease among the popu- Jation, the size of the population and its distribution, e.g., as between turban and rural areas, the various regions of the country, ete., and the extent of any population movements; (®) the analysis of the availability of the various forms of medical care, covering both medical care establishments (hospitals, sanatoria, health centres, maternity hospitals, ete.) and medical personnel, as well as the efficiency of utilization of the different facilities, the distribution of the personnel, etc.; G) the forecasting of the changes to be expected in the nature and extent of disease, and in the size of the population, its age group structure and geographical distribution, etc.; (4) the establishment of the aims of the health plan and the targets to be specified; (S) the establishment of the norms and standards to be incorporated into the plan, and the assessment of the extent to which the requirements for the various services are satisfied; (©) the preparation of the health plan by means of the special methods already mentioned and its correction and bringing into balance with all the other sectors of the national economy; () the carrying out of evaluation studies to determine the extent to which the objectives and targets of the plan have been attained, and the revision of the plan in the light of the results of such studies. ‘The procedure and time-limits for the preparation of the national economic pian in the USSR are fixed by decision of the Government. On the basis of these directives, the various ministries and authorities work out and send, to the organizations under their authority, the necessary instructions on the drawing up of the plans for the areas or sectors for which they are responsible (area or sector plans). At each administrative level, ie., at the level of the rayon (municipal- ity), oblast (kraj or autonomous Republic), constituent Republic, and the USSR as a whole, the following systems of agencies participate in Grawing up the health plan: the supreme organs of Soviet power (the Councils of Ministers, the Executive Committees of the Soviets of Workers’ Deputies), the planning agencies (the State Planning Agencies of the various constituent and autonomous Republics, and the oblast, municipal, and rayon planning agencies), the public health agencies of the Republics and local authorities (since the public health budget is drawn up in parallel with the preparation of the health plan), and the standing committees on public health ofthe Supreme Soviet of the USSR, the Supreme Soviets of the constituent Republics, and the local soviets of workers” deputies.26 [PRINCIPLES OF HEALTH PLANNING IN THE USSR The State Planning Agency of the USSR, after examining the draft plans thoroughly, submits them to the Council of Ministers of the USSR, gives its opinion on these draft plans, and also submits a summary of the draft national economic plan to the Government. The plan, after approval by the Council of Ministers of the USSR, is submitted for confirmation to the Supreme Soviet of the USSR, after which it has the force of law. ‘The plan, after confirmation, is then forwarded to the authorities at the lower administrative levels (the constituent Republics, oblasts, municipalities, and rayons) where, after the necessary corrections have been made in the light of the changes made in the first draft and the indices worked out in detail, it is confirmed at sessions of the Supreme Soviets of the constituent or autonomous Republics and of the soviets of workers’ deputies of the krajs, oblasts, municipalities, and rayons (Gee Fig. 1, which shows the way in which the heaith plan is prepared and approved in the USSR), FIG. 1, PROCEDURE FOR THE PREPARATION AND APPROVAL OF THE NATIONAL HEALTH PLAN IN THE USSR facet tt]CHAPTER 2 THE LEVEL OF HEALTH “No more fundamental problem confronts the health administrator than the measurement of the level of health of his community.” It is this, in fact, that determines the medical care required by the community, and the nature and extent of the health facilities needed. The determina tion of the level of health is therefore an essential prerequisite for all health planning. Since the concept of health does not lend itself easily to objective measurement, most measurements of health are in fact ‘measurements of disease, For this reason, data on the nature and extent of disease, ic., morbidity data, are of fundamental importance in health planning. It will be realized, of course, that climatic and geographical conditions may markedly affect morbidity. In particular, the organizational structure of the health services is largely determined by factors such as population density, the distribution of the population, the state of the roads, transport facilities, communications, etc, ‘The higher the popu- lation density, for example, the larger the size and the greater the eff- ciency of the medical care establishments that can be constructed. ‘Before any study of the morbidity of a community can be undertaken, data on the population of that community are clearly necessary. In addition, for the purposes of long-term health planning, information on probable changes in the population over the planning period is required. During this period, for example, the population may increase, or significant changes in the distribution of the population as between the various age groups, or between urban and rural areas, may occur. Information is also needed, for example, on the number of persons employed in industry and agriculture, the population of the various individual towns and regions of the country, etc. It must be remem- bred, in addition, that the development of public health may itself Sri28 PRINCIPLES OF HEALTH PLANNING IN THE USSR have an effect on population growth by reducing mortality and may, jn many cases, be the most important factor in determining such growth. Tn the USSR, the population data employed in health planning are supplied by the statistical and planning agencies. They include data on the birth rate, mortality, the natural growth rate of the population, the distribution of the population between urban and rural areas, etc. Population forecasts are based on the data for life expectancy and for the fertility of women ia the various age groups. Urban and rural areas are considered separately, and any special features of the adminis trative unit concerned are taken into account. Account is also taken of the movement of the population from villages to towns and from one region of the country to another; these will be affected by the construc- tion of industrial undertakings in particular regions, as envisaged by the corresponding plans for economic development, and by the growth of the associated industries and services, ‘An account is given below of the various forms of morbidity data used in health planning. No individual morbidity index is adequate alone, however, as a means of assessing the level of health. The dift ferent indices must therefore be used in combination in the study of the diseases of greatest importance so as to determine, for example, their significance in causing patients to attend medical care establishments, in reducing the working capacity of the population, and in causing death, MORBIDITY DATA ‘The morbidity data used in determining the level of health include data on total morbidity, data on cases of acute communicable diseases and of certain non-communicable diseases, data on hospital patients, data on sickness with temporary loss of working capacity, and data on ‘mortality and causes of death, i.c., on that part of the morbidity where the disease concerned has a fatal outcome. Essentially, all morbidity data of the types just mentioned are the consequence of the fact that the patients concerned have deliberately sought medical care, Such data cannot provide a true measure of morbidity, however, since much disease remains unrecognized and many patients are unaware of their need for medical treatment. This state of affairs is sometimes referred to.as the “hidden burden of disease”; the term “the iceberg of morbidity” is also used. For this reason, morbidity data obtained by the mass screening of various groups of the population, or of representative samples of the population as a whole, are of particular interest and call for special consideration.‘THE LEVEL OF HEALTHC 2» Data on total morbidity In the USSR, total morbidity is assessed on the basis of the number of first consultations, i.e., of first visits by patients to a physician, or vice versa, It is assumed that this index correctly reflects not only the nature and extent of disease, but also the way in which the disease pattern is tending to change. It must also be assumed that the degree of development of the health services in such that those seeking medical care can obtain it, that the necessary medical care establishments and facilities are available, etc. It is then possible to study the prevalence of disease among the population, ie., the number of persons who seek medical care in any given year, both for disease as a whole and for specific diseases. Data on cases of acute communicable disease ‘The notification of cases of communicable disease is one of the oldest and most firmly established sources of information on morbidity, It is of limited value in determining the level of health however, since ‘many communicable diseases follow a mild course, the information provided may be inadequate (for example, itis not always stated whether the diagnosis is based on the clinical picture or on the results of bacteri logical tests), and there is often no procedure whereby the diagnosis can be corrected. In addition, notification may be incomplete. Thus, for ‘example, in England and Wales at the end of the Second World War, only about £ of the cases of typhoid and paratyphoid fever, # of the measles cases, and between $ and } of the whooping cough cases were reported. A French study of 400.000 cases of disease notified to the social security agencies for the Paris area indicated an average annual rate of 291 cases of measles per 100 000 persons in the social security system, while the average rate of new cases officially reported was only 83 per 100 000 population Data on cases of non-commuricable disease Increasing interest is being shown in morbidity data for non-eommu- nicable diseases.* This is the consequence of the fact that, as the app cation of the results of medical research brings more of the communi- cable diseases under control, information concerning them becomes less ‘useful in assessing the level of health, In addition, the changing demo- graphic pattern in many countries is leading to an increase in the propor tion of the elderly among the population, and hence to an increase in nent orn meen ne ey se cee es Rutt Siang ae RO30 PRINCIPLES OF HEALTH PLANNING IN THE USSR the incidence of chronic and degenerative diseases, with which public health has therefore to be concerned to an increasing extent, Data on hospital patients Dats of this type make it possible to determine the diseases for which hospital treatment is required, the number of cases of such diseases, the characteristics of hospital patients (sex, age, ete), the mortality, etc. Data on morbidity with temporary loss of working capacity ‘These are of great importance in connexion with industrial by They take the form, for example, of the number of cases and number of working days lost, per 100 workers, and are an expression of the effect of the various diseases on working capacity, the economic losses result- ing from disease, etc. Data on mortality and cause of death Such data provide a measure, as already mentioned, of the incidence of those diseases baving a fatal outcome. ‘They are precise in character, since they are concerned with a precisely measurable phenomenon. In addition, it is relatively easy to organize the collection of mortality data and to process the data collected, and coverage is generally complete. AS a result, mortality data provide one of the most valuable means of assessing the level of health of the community. Until comparatively recently, in fact, most countries relied essentially on mortality data in obtaining an indirect criterion of the level of health; at the same time, provided that the medical and statistical services are adequate, it is possible to make valid comparisons between the data for different periods in a given country or between the data for different countries for a given period. International comparisons, of course, must be based on the adoption of standard definitions, criteria, and methods in the determination of the causes of death, if the results are to be valid. ‘Nevertheless, mortality data have certain limitations; this is essen- tially the result of the fact that death is only one of the possible con- Sequences of disease. Furthermore, the use of mortality as an index of the level of health is misleading in countries where the mortality is low but there is a high incidence of disease or disabling conditions, for the reduction of which highly developed and costly health services are necessary. MORBIDITY DATA FOR THE USSR [As mentioned above, the methods used in the USSR to record data ‘on total morbidity make it possible to study the incidence and spread‘THE LEVEL OF HEALTH 31 of acute diseases as well as of certain diseases following a prolonged course (chronic diseases) that have well-defined clinical characteristics or that frequently take on a more acute form. It is possible to obtain data on their development, the prevalence of disease among the popula- tion, and the newly detected cases of disease in the year under consideration. ‘The primary sources of information used in the USSR in the prepa- ration of norms for the requirements of the population for medical care are constituted by statistical data, forms specially filled in for each patient seeking medical care by means of routine medical observation, and the primary records of medical care establishments, Data on first consultations at outpatient clinics and polyelinics (on the assumption that medical care is readily available), as recorded in the primary records of medical care establishments, provide a reliable basis for the study of morbidity and the preparation of norms for medical care, Itis still necessary, however, for the statistical data to be subjected to expert assessment and also for comprehensive medical screening examinations to be carried out. Urban areas Studies of the morbidity of the urban population of the USSR, based ‘on the number of first consultations per 1000 poptlation, carried out at different times and in different regions of the country, show that there is no essential difference in this index as between one town and another, both for disease asa whole and for the main nosological entities. Certain differences in the incidence of particular diseases are the result of causes specific to each individual disease, e.g., in an induenza epidemic, the attitude of the physician to the differential diagnosis of influenza and acute catarth of the upper respiratory passages, ‘This essential identity of the morbidity of the urban population has been demonstrated by @ number of studies carried out in the USSR between 1937 and 1959, the figures found falling within the range 1061.8 to 1387.0 first consul- tations per 1000 population 23° In recent years, a number of large-scale studies have been carried out on the morbidity and norms for requirements for medical care of the population in various economic and geographical regions of the country; such studies have been undertaken at more than 40 medical esearch institutes. Of these studies, the most interesting were those carried out, under the direction of I. D. Bogatyrey,! in the five to Ste el of i of he poplin of Meco, Meco + Rode (Bah eat alse nach” Sem vite oe ele Hany "Adanailon O36) Vin Seti Seton MecnBeénoe, 1. (96) (Morb and orm for mest car fr hub poplin, Mos,2 [PRINCIPLES OF HEALTH PLANNING IN THE USSR of Stupino, Rube#noe, Celjabinsk, Kopejsk and Dneprodzertinsk, and similar studies carried out in the town of Elgava (in the Latvian SSR). Studies of morbidity and norms for requirements for treatment and prophylaxis, based on the records for the town of Aktjubinsk (Kazakh SSR) and carried out in 1966-67 under the direction of the author, fave the following results. On the average, per 1000 population, the umber of cases of disease, as determined from the number of first consultations, was 882 (this did not include diseases of the teeth and buccal cavity), For men the figure was 879.9, and for women it was 885.8. In addition, the special group of first consultations in connexion with abortion, childbirth, disorders of the climacteric, and anomalies of refraction and accommodation amounted to 90.2 per 1000 population; for men, the figure was 9.1 and for women it was 158 (see Table 1). Morbidity indices (based on the number of first consultations) are comparatively high for children during the first two years after birth, after which they gradually decrease, reaching 2 minimum at 13-15 years fof age, ‘The number of frst consultations reaches a maximum for the ‘age-group 20-29 years of age, as shown by Fig. 2. The number of first consultations is essentially the same for both men and women; if, however, first consultations in connexion with childbirth and abortion are included in the figure for women, there is a marked increase in the indices for young and middle-aged women. Itis of interest to compare the figures forthe total morbidity obtained in recent years with analogous data collected during the 1920s. ‘Thus, according to the data obtained by Rodestvenskij? in Tver in 1925, there were 2034.1 cases of disease (1857.7 for men and 2181 for women) per 1000 population,-while sample surveys carried out in Perm in 1926 to 1927 gave figures of 2167 cases of disease per 1000 men and 1691 per 1000 women. ‘Thus the total morbidity (expressed in terms of the number of first consultations per 1000 population) of the population of industrial towns has decreased by a factor of nearly two; for certain specific diseases, the figures are as follows: Rat of aber of ses ‘Rheumatism and similar diseases 23 Purulent diteases of the skin and subcutancous tissues 4“ Diseases ofthe digestive organs 35 Tuberculosis 2 + Rondevensi M1 (192) Norby among workers aaa CSI Iaertlly 9 the pop fe ‘nthe Ural bb i 1981927 a Sica stds ok occupational ind ening ie fn nay a Toe 182 Sites I'Goumetiadat, Moncon. i Velo Mono33 ‘THE LEVEL OF HEALTH = — ( O41 ¥ S4AUND) SNOLLYNINVNS ONINTERIDS JAISNAHTAWOD IO SNVAN A@ GHYIAOOSIG SISVD “IVNOLLIGGY 40 AFENON SL Ch (© OL 1 SHAWND) SNOLLVLINSNOD ISU JO WAWWAN FHL NO Csva ASNIGALLAV JO NMOL AHL WOX NOWVINdOd OWI Aad ASVASIA JO SASVD JO AAEWAN TZ ‘DLL34 PRINCIPLES OF HEALTH PLANNING IN THE USSR TABLE |. TOTAL MORBIDITY, BASED ON NUMBER OF FIRST CONSULTATIONS, KAZAKH SSR, 1966-7 Communicable diseases Parasitic diseases Injuries, Poisoning Bete Industrial and Gecupational diseases <> ° Diseases caused by vitamin deficiencies Rheumatism se se eee es ees Tneluding? Theumatic heart disease. Diseases of metabolism and allergice Including? ‘bronchial asthma ‘malignant neoplasms . benign neoplasms Diseases of the sndactine system including: Thyroid diseases... Dizeates of the haematops Morea divorders oh ‘cerebral atherosclerosis and other cere brovascular disorders (excluding high blood pressure with cerebral haemor- rhage) cia lumboracral” fadiculis, “neuritis” and ‘neuralgia of the sciatic nerve » neuroses and psychoneuroses . < Diseases of the organs of sigh Tneluding: glaucoma Diseases of the ears, nose, and throat chronic otitls . ee chronie tons Diseases of the respiratory organs - Including? ‘chronic bronchitis and bronchitis not ‘otherwise specified 5 bronchopneumonia chronic suppurative disease of the lunes Pneumosclerosis and emphysema... Disetzes of the clreulacory organs Including atherosclerotic cardiosclerosis Fi custeons Both sexer ia 7 595 22 V6 ol 77 IN THE TOWN OF AKTJUBINSK,‘THE LEVEL OF HEALTH 35 TABLE I (continued) per 18 popcation hypertension . Crees ofthe alas Disescs ofthe gestive orgie includ ee ‘hronte gastritis ‘wise specified 152 gastric and duodenal less 35 feiss es ells] 88 Diseases of the Bones, muscles and joints | S44 i | 8 fxezema « . 51 Diseater of the Kidneys and urinary race 13 Diseases of the male sexual organt 25 Diseases of the female sexual organs a3 including’ olpies na f= ‘rotion of the cervix Ty | = ‘Sopher and saipingicis wi | = Congenital developmental defect 03 | 03 DBiaoteor of pregnancy, disorders of childbirth {and the postntal perlod « . ne | Diseases of the newborn =» A ts | Te Diseases not covered by the classification and hot precisly defined sss = | 53 | AS Total. | 28 | e709 Abortions... -| 26 First consultations on accoune of pregnancy. | 514 | — Disorders ofthe climacteric rs | Ou ‘Anomalies ef refraction and accommodation | 1:2 | 14 Myopia et) 6a | Te Grand total « so aes, Rural areas Studies carried out during the pre-revolutionary period showed that the morbidity of the rural population of what i now the USSR, as measured by the number of first consultations per 1000 population, depended to a large extent on the availability of medical care and the distance of the patient’s home from the medical care establishment concerned, Thus, for example, one study showed that the distance36 PRINCIPLES OF HEALTH PLANNING IN THE USSR between the village and the establishment was inversely proportional to the amount of medical care provided. It is of interest in this connexion that Haavio-Mannila, in a study of rural health services in Finland, found that, as distances increased, the amount of care provided decreased, but the proportion of indigent families cared for rose ‘The numerous studies carried out in the USSR, especially in recent years, on the disease pattern and the extent of disease in rural areas ‘where medical care is fairly readily available have shown that the total number of consultations per 1000 population lies in the range 700-1000 ‘and above. In particular, studies carried out over the period 1962 to 1964 gave a figure of 1227.1 first consultations per 1000 population in the case of villages provided with some form of medical care establish- ‘ment; the figure for villages not so provided was 815.5 per 1000 popul: tion. "It can be concluded, therefore, that, where medical care facilities are readily available to the population, the total morbidity of the rural population is close to that of the urban population. In addition, a ‘number of individual diseases were studied in the same way and it was, found that the disease pattern in rural areas was also close to that in urban areas. MORBIDITY DATA FOR OTHER COUNTRIES In spite of the large differences that exist between the public health system of the USSR and the systems of other countries, the data obtained in these countries on the total morbidity of the population, as well as that of certain age groups, are very similar to the corresponding data obtained in the USSR. In Czechoslovakia, sample surveys carried out over the period 1955- 58 in the Brno district, which has a population of one million, showed a morbidity of 12275 cases of disease per 10 000 population for men and 14 047 per 10 000 population for women.* The results of the study of the total morbidity of the population of Romania in 1959-62 (on the basis of data on consultations at outpatient establishments) showed that, in 1961, there were 844 cases of disease per 1000 population in urban areas and 456.8 in rural areas.? In England, studies carried out by means of interviews between 1943 and 1952 showed that, per 1000 population above 16 years of age, 5 20) Sad ofthe ae ofthe Hk ihc ons Fil re, mali: Greta Wo ici a i For wae vr‘THE LEVEL OF HEALTH 37 there were 1199 cases of disease among men and 1657.4 among women. From the data of another study, carried out between 195S and 1956 in England and Wales, based on the examination of the medical records Kept by 171 general practitioners in 106 different areas of the country, the morbidity was found to be 10.832 cases for men and 12943 for ‘women per 10.000 population of the corresponding sex.? In the USA, the investigations of Sydenstriker showed that there were 1081 cases of disease (943 among men and 1210 among women) per 1000 population of the town of Hagerstown.’ The data of Collins showed that, over the period 1938-43, there were 1379 cases of disease per 1000 population of both sexes in certain districts of the city of Baltimore. Summarized data published in 1955 for six different sample surveys of the total morbidity of the urban population, carried out at various times and in different cities, showed that there were, on the average, 1064 cases of disease per 1000 population.* The information given by the President’s Commission on the Health Needs of the Nation showed an average total morbidity of 1323 cases of disease per 1000 population of both sexes Higher figures for the total morbidity have been published in the cease of Japan. According to the data obtained by a sample survey, Which involved the taking of the previous history of 500000 persons in various areas of the country, the total number of cases of disease per 1000 population per year was 2000 (of which the number of cases of acute nasopharyngitis and general catarthal diseases amounted to 711 per 1000 population) A special feature of the American and Japanese data is that the total morbidity is higher for women than for men. This is largely the result of the methods of study used, in which interviewers visited all the households in the sample areas and filled in the items of the question- naire used, usually in accordance with the statement made by the house- wife, who naturally remembered her own illnesses more accurately than those of the other members of the family. eee Bb rahe it of ie Si aes en:38 PRINCIPLES OF HEALTH PLANNING IN THE USSR [UNRECOGNIZED DISEASE AND MASS SCREENING ‘The problem of unrecognized disease in relation to efforts to deter~ mine the level of health of a community has already been mentioned. As pointed out by Logan: “Routine morbidity statisties provide infor- mation on only those patients who seck medical help, not on those with disease but without symptoms or with symptoms that are unrecog- nized. Only one in nine cases of anaemia is recognized and treated in Britain, so that most of the 14% of British women with less than 81% haemoglobin remain untreated... A survey of 78% of the popu- lation of Wensleydale showed that 25% to 30% of females aged 15-34, 129% of females aged 55-64, and 20% of both sexes over 65 were anaemi If this prevalence were applied to the average British general practi tioner's panel of 2250, it would include 242 anaemies, but only 1 in 9 is recognized and treated.” In addition: “As against the 12 known Concomitant strabismus + 176 Grqnd tonal AAs will be seen from this illustration, the area above the waterline” corresponds to the number of first consultations; the upper right-hand part of this area corresponds to the known cases of chronie disease for Which the diagnosis was not confirmed by the medical screening exami- nations (17.6 per 1000 population), Al the cases of disease and all patients whose first consultations were in connexion with childbirth or abortion (973 per 1000 population), shown above the “waterline” in the illustration, received care in outpatient2 PRINCIPLES OF HEALTH PLANNING IN THE USSR FIG. 3. THE ICEBERG OF MORBIDITY AND THE MEDICAL CARE OF THE URBAN POPULATION IN HOSPITALS AND OUT-PATIENT ESTABLISHMENTS AND POLYCLINICS' lanes case ty mea sewing ual atinbie ee ‘osm ry eda te so nimerat et Comat ass vera ferry ee bese henge asso N\ Sect ol cos aiiny mestese 152 aso oe of ene aia rt el ts 0 cosy mean gh ‘dl ce LZ a sie ebm 2 pees FEED topntcae clinics and potyclinies; of these, 187.7 per 1000 population were hospi- talized on account of disease, abortion, or childbirth during the year. According to the expert assessment, of all those consulting a curative ‘or prophylactic establishment for the first time, an additional 29.5 per 1000 population required hospital care. ‘The area on the right, below 1 The gues shown ae pet 100 population ofthe town of Akins (Kesakh SSR.‘THE LEVEL OF HEALTH 4a the “waterline”, corresponds to the additional 684.8 cases of disease ‘and abnormal conditions discovered; of these, 445.2 per 1000 population (on the left, below the “waterline”) required care at an outpatient clinic or polyctinic, while 28.4 of them required hospital care, For the purpose of obtaining a complete picture of morbidity, based on the number of first consultations and the results of compre- hensive medical screening examinations, reference may be made to the data on the stomatological care required by the various age groups, obtained by G. A. Novgorodcev who, in 1961, carried out the mass screening of 48 160 persons in five towns: Stupino (Moscow oblast,) Minsk, Tashkent, Leningrad, and Petrozavodsk (see Table 3) TABLE 3, STOMATOLOGICAL MORBIDITY: FIRST CONSULTATIONS AND RESULTS OF MASS SCREENING IN FIVE TOWNS IN THE USSR, BY AGE GROUP, 1961 | proponent hve | troperson fore | Number sting cane | Tepaaaeeiae Sine at Toaahe ear | Scening emia | ue eee Upto! 4s Pett ae i ae | ri ea 1s 23 [tee n3 2633 ba soe os welll | wo | 5039 Be | Gand over! || 2 | | total . 48 78.6 _ she gumber ef eran eng tomatoe are ort Staessen ater hance ces thedpene mone wh “he icous membranes afte bucc evr aecrring smeng chleren the mass scconig war carved actin toe totam Examination of the data showed, as can be seen from the table, that on the basis of the results of the mass screening, 78.6% of the population required stomatological care on account of diseases of the teeth and buccal cavity on the day on which the screening was carried out; in 1 Riso 9,4, 8 Noam 6 A196 repo eae of tomate“4 PRINCIPLES OF HEALTH PLANNING IN THE USSR contrast, the data on the number of first consultations (over a period of ‘one calendar year) showed that only 34,8% of the population, or 44.4% of those requiring such care, actually sought stomatological care during that period. HEALTH FORECASTING IN THE USSR A plan for any sector of the national economy, including the health services, must answer the question: what actions are really possible and in what order will they best lead to the achievement of the goal? The problem is not whether or not itis necessary to try to achieve optimality in plans, but of how to achieve the best results for the least material expenditure and use of staff. Consequently, health planning always consists in a search for optimum solutions, otherwise it loses all meaning. ‘The increase in the scale of development of the material and technical basis for the health services, the increase in staff numbers, the inereas- ingly complex structure of the organizational forms in which medical care is given, and the marked increase in the number of factors to be ‘measured which determine requirements for medical care, together with the development of medical research and the revolution in science and technology, markedly increase the number of feasible ways in which the health services can develop and at the same time make it a more complicated task to choose the best way. ‘The existence of a huge and constantly increasing number of different combinations of ways of developing particular health services and specialized forms of medical care makes it necessary to seek new methods of solving the problem of ‘optimal planning. The establishment of optimality criteria in planning decisions is made considerably easier by the emphasis on economics and mathematics in much reasearch on planning standards and by experiments on the application of modern computer techniques to planning. Scientifically based planning of the development of the national economy as a whole and of every sector of it, including the health services, makes it necessary to take more closely into account the effects of the latest achievements in medical research and in related fields and. of the latest technical developments. For this reason, it is essential not only to plan scientific and technical progress but also to foresee its future, This task is performed by forecasting scientific and technical developments, ie., defining the main trends and tendencies in the devel- ‘opment of science and technology and the possibilities of making prac- tical use in the future, and in particular in health planning, of the results of research in the fields of economics, sociology, social hygiene, demo-THE LEVEL OF HEALTH 43 graphy, medicine, health statistics, public health administration, and other related sciences. Since a one-year economic plan, because of its short-lived effect on the development of the economy, culture, and the health services, cannot, hhave any decisive consequences for the development of these sectors of the national economy, long-term plans covering 5-10 years and plan forecasts for longer periods are prepared. ‘The purpose of a one-year national economic plan is to ensure the uninterrupted and co-ordinated operation of all sectors of the economy uring the year, and a smooth transition to the next one-year plan, Mistakes in the one-year plan are measured in a few percent or even fractions of 1% and in the health services, on the basis of the approved indices, plans are fully implemented or even exceeded. The five-year plan is already long enough to determine in what direction and at what speed various sectors of the national economy are to develop. ‘The drawing up of a five-year plan, even on a highly scien- tific basis, cannot be as accurate as that of a one-year plan. Tt is essential to prepare forecasts in order to draw up health plans both for one year and for longer periods (5-10 years). Scientific and technical progress and the rapid growth of human knowledge make it impossible to forecast reliably 30-40 years ahead, since the development of science and technology sometimes proves even the boldest of assum- pions in this connexion to have been unfounded. A period of 10-15 years, however, is commensurate with the time which experience has Shown to be necessary for a discovery to pass from the stage of funda ‘mental research to that of practical application. Even so, such plan forecasts may be quite wide of the mark. For this reason, several variants of any given plan are worked out, based on pessimistic, optimistic, and intermediate assessments of the situation. Forecasting can be undertaken in connexion with particular problems and not as a part of the drawing up of a long-term plan, or plan fore- cast, for an entire sector of public health, Forecasts may be made of population numbers and structure, the health of the population, the morbidity and its character, ete. On the basis of the forecasts, it becomes possible to determine bbeforchand the material and labour resources needed and to concentrate them in those scientific and technical sectors which are of decisive importance for reducing morbidity and mortality, improving public health, and consequently increasing the effectiveness of social production, At the same time, it is equally important to detect new tendencies, trends, and ideas in the development of science and technology ot the lack of promise of particular investigations, programmes, and research in progress at the moment.46 [PRINCIPLES OF HEALTH PLANNING IN THE USSR ‘The difference between a forecast and a plan, in le, is the fact that a forecast is a necessary precondition, a scientific hypothesis, a search for possible ways of realistically solving the problems of the development of science and technology, whereas a plan reflects the technical and economic decisions already taken. A forecast only out lines possible variants in the developments arising from a particular decision, whereas a plan, on the basis of one decision out of all those possible, defines the final result, the period required to achieve it, the volume of work involved, the sources which will provide the money needed to finance it, and the executants. A plan is a directive, a basie document for the guidance and organization of scientific and technical progress at the national level, or in a particular sector of the economy, undertaking, or establishment. ‘The forecasting of progress in public health may touch on a whole range of problems, of which the most important are the following: (1) forecasting changes in the environment (housing, urban and rural planning, water supply, waste disposal, sewerage systems, the disposal of sewage and wastes, the prevention of the radioactive pollution. of rivers, open and closed bodies of water, the air and the soil, noise control, etc.); (2) forecasting the social well-being of the population (real incomes, work, leisure, dict, education, etc.); G) forecasting demographic shifts (birth rate, death rate, natural population increase, the composition of the population by sex, age, and social and occupational group, the distribution of the population between town and country and between different regions, migration, ete); ‘@ forecasting the morbidity and its character, the eradication of ‘communicable diseases or the reduction in their incidence, the health status of the population and of individual population groups, etc.; (5) forecasting the assumed development of the organizational forms of medical care and the provision of sanitary and epidemiological services to the population; (© forecasting the further specialization of medical care and the differentiation between medical specialties. The establishment of long-term norms and standards for medical care, the sanitary and epidemiological services, the supply of medica ‘ments, the system of public health establishments, medical personnel, Jabour requirements, etc. By forecasting scientific and technical progress, it is possible to determine and define the most promising directions to be followed byTHE LEVEL OF HEALTH 47 scientific and applied research in connexion with the tasks listed above, without accomplishing which it is impossible to draw up a long-term heaith plan. Estimation of the prospects of scientific and technical progress in the USSR and other countries helps to determine the trends, specific features, and particularities in the development of individual health services and specialized forms of medical care. The correctness of the solutions found to these problems is confirmed by the use of the conclusions and proposals derived from these forecasts in economic plans for health. About one hundred different methods are used in the theory and practice of forecasting scientific and technical progress. For example, in making very long-term forecasts (10 to 20 years or more) of demogra- phic changes, the morbidity and its character, the further development of specialized forms of medical care, and the differentiation of medical specialties, use can be made of many methods, but they can be divided into three main groups: (1) extrapolation methods; (2) forecasting by experts; (3) use of models. Extrapolation methods are based on a study of the quantitative and qualitative indices relating to the problem under consideration over a number of years in the past, followed by a logical projection of the trends that ‘they show into the period covered by the forecast, the ‘various factors that may cause these indices to change being taken into account. ‘There are three widely used types of forecast as to the development of the health services and their different sectors and problems: (1) the index does not increase with time (e.g., the total morbidity, the number of attendances among the urban population, the proportion of the population hospitalized, ete.); (2) the index increases annually by the same amount, ic, its growth follows an arithmetical progression (@g., the inerease in the number of hospital beds, etc.); (G) the index increases annually by the same percentage, as compared with the previous year, i.e. it increases by geometrical progression; this third type of relationship is known a an exponential function. Forecasting by experts involves discussion of the problem by expert specialists, who then Work out a general sotution and recommendation. Expert forecasting is carried out either by the group method or by ‘obtaining the individual opinions of the experts concerned. When the ‘group method is used, the work is based on a direct exchange of opinions between the experts. "It is also possible to make use of the opinions of other specialists on the development of the problem or particular aspects48 PRINCIPLES OF HEALTH PLANNING IN THE USSR of it, The individual method consists in sending questionnaires to specialists. ‘The replies are then sampled and the opinions expressed are processed; those replies which are outside certain previously specified limits are eliminated. The use of models involves the construction of informational and ‘mathematical models; an informational model, for example, generally consists of a table in which the headings are the names of the technica economic indices of the phenomenon to be forecast, while the body of the table consists of the values of these indices obtained from the infor- mation available (the literature on medical and technical research, special scientific investigations, theses for degrees, etc.). ‘The various methods used in scientific and technical forecasting are generally employed in combinations of different kinds. In the USSR, forecasts in respect of the main problems of the devel- ‘opment of the national economy are worked out by scientific and tech- nical committees set up by the State Committee for Science and Techno~ logy of the Council of Ministers of the USSR, the State Planning ‘Committee of the USSR, and the Academy of Sciences of the USSR, the help of scientific research institutes also being enlisted. Scientists in scientific and economic organizations who are qualified specialists are drawn into this work in the scientific and technical committees. FIG. 4, DIAGRAM SHOWING INTERRELATIONSHIPS RETWEEN FORECASTING AND PLANNING IN THE USSR ‘SENT a TEDINGAL FOREST SECTORAL VE-YEAR PARE o-oFoATAG PLANS (ONG-YEARECOOME PAKS Reports and proposals on forecasts are sent to the Council of Minis- ters of the USSR. They are later used in the practical activities of the‘THE LEVEL OF HEALTH 49 State Planning Committee of the USSR and the State Committee for Science and Technology, as well as by all the ministries and authorities concerned, as a scientific basis for drawing up long-term and current economic plans. In this way, the working out of forecasts precedes the drawing up of plans and determines their scientific and technical content, as will be seen from the diagram (Fig. 4) showing the interrelationships between forecasting and planning from the point of view of the national economy.CHAPTER 3 OUTPATIENT AND HOSPITAL CARE FACILITIES Examination of the morbidity data discussed in the preceding chapter enables the health administrator to assess the magnitude and nature of ‘the problems facing him in attempting to raise the level of health of the community. To complete his assessment of the situation, he has then to consider the extent to which the various medical care facilities are available to the population and the efficiency with which they are utilized, which is the subject of the present chapter, as well as questions of the availability, distribution, utilization, and training of medical personnel, which are discussed in Chapter 4, Medical care can be divided essentially into outpatient care, a term which also covers domiciliary care, supervision at follow-up centres (Gee p. 51) and mass screening, and hospital care. OUTPATIENT CARE Since outpatient care occupies such an important place in the publ health system of the USSR, an account will first be given of the situation in that country. Outpatient care in the USSR In the USSR, outpatient care covers a larger proportion of the population than any other type of medical care. In particular, compa- ison of the data for 1968 for the outpatient establishments of the Ministry of Health of the USSR with those for hospitals shows that 1646 million patients attended outpatient establishments in that year, while 47.4 million patients, including maternity cases, were hospitalized, ‘Thus for every patient who went into hospital, 42 attended an outpatient establishment. This situation is the consequence of the steady growth — 50 —OUTPATIENT AND HOSPITAL CARE FACILITIES 41 in outpatient care which has taken place since 1940, as shown by the following figures: n enter of panded, me ilion) 1940 550 1950 680 1360 11534 1968, 1646 Data obtained from studies carried out by the N. A. Sematko Institute for Social Hygiene and Public Health Administration show that the great majority of attendances at outpatient clinics and poly- clinics were for purposes of diagnosis or treatment, i.e., on account of disease; these studies were undertaken during the period 1965 to 1968 in eight different towns (Stupino, Tol’jatti, Kopejsk, Celjabinsk, Rostov, Bendery, Orel, and KiBiney). Such attendances emounted to 72%-73% of the total in the case of utastok physicians and surgeons (Gee page 52 for the definition of uéastok), 69% for ophthalmologists and otorhinolaryngologists, 58% for industrial physicians and neurolo- ists, 47% for phthisiologists, and 32% for paediatricians and obste- tricians and gynaecologists. In the above-mentioned towns, attendances for prophylactic purposes constituted 20.8% of the total for area polyclinics and 24.3% for indus- trial polyetinies. These attendances were in connexion with care at follow-up centres (see below) and the prophylactic screening of the population. Urban areas. Outpatient establishments in urban areas providing care outside hospitals, in the public health system of the USSR, comprise polyclinics, outpatient clinics, follow-up centres, and children's and women’s clinics. OF these, the most important are the polyclinics and ‘outpatient clinics; in 1968, the number of establishments of this type ‘was about 29000, The term “follow-up centre” (in Russian, dispanser) calls for Some explanation; itis used to designate an establishment which carries out long-term surveillance, including regular examination and any treatment needed, of individuals and groups with special needs, such a5 children, pregnant women, the elderly, key scientific workers, ‘and patients suffering from certain forms of chronic disease (e.g., tuber culosis, mental disease, and goitre) ‘The extent of the outpatient care provided can be assessed on the basis of the number of outpatient atiendances, including domiciliary Visits, per person per year. The increase in this index from 1940 to 1968 can be seen from the following fi2 PRINCIPLES OF HEALTH PLANNING IN THE USSR Number of eatin axtennees 1940 1 1930 1 1960 a5 1968, 98 AAs between the different constituent Republics, this index varied from 75 to 11.4 attendances per person per year. Of fundamental importance from the point of view of the organiza~ tion of the work of the various outpatient establishments is the adminis- trative structure of the country. Administratively, the USSR is made up of 15 constituent Republics, some of which include areas or territories Known as autonomous Republics. Each constituent Republic is divided into oblasts, and each oblast into rayons; the population of an oblast is usually between half a million and several million, while that of a rayon may be only a few thousand in rural areas, or a3 much as half a million in Moscow. Other administrative units are the kraj, which i a province containing an ethnic group large enough to constitute an independent oblast, and the okrug, which is an area containing a recog- nized ethnic group, but not one possessing national autonomy. For health purposes, each rayon is divided into utastoks (medical districts) ‘A wtastok is the community unit serviced by a physician called a “therapist”. In urban areas, several types of uéastok exist: therapeutic uéastoks, which cover an adult population of about 2000, paediatric uuéastoks, which cover a child population of 800 to 1000, obstetrical and gynaecological utastoks, and industrial uéastoks, covering about 2000 workers at a particular factory or group of factories. Rural areas. In rural areas, outpatient care is provided in the first instance by what are known as “feldsher-midwife posts” (the feldsher is the highest grade of medical auxiliary in the USSR and corresponds to the medical assistant employed in certain other countries), the para- medical personnel at the outpatient clinics and polyclinics of the uéastok and rayon hospitals, and the midwives of the maternity homes of collee- tive farms. The average number of consultations per person per year in rural areas in 1968 was 3.1, while the value of this index varied from 2.1 to 4.4 in the different constituent Republics. In the case of feldshers, the average value of the index for the USSR as a whole was 3.5, and the range of values for the different Republics was 1 to 4.4 ‘The wide variation in the value of the index shows that the problem of providing adequate outpatient care in rural areas has not yet been completely solved, especially from the point of view of ensuring that such care is quantitatively and qualitatively the equal of that providedOUTPATIENT AND HOSPITAL CARE FACILITIES 3 to the population of urban areas, This is partly because not all the medical care establisments in rural areas are fully staffed, and partly because the provision of medical care in these areas is hindered by such factors as the low population density, the state of the roads, transport, communications, etc. (see below). Climatic and geographical factors. Climatic and geographical factors may markedly affect the health status of the population and the disease pattern. The density of the population, its distribution over the area concemed, the state of the roads, transport facilities, communications, ete., play a large part in determining the forms of medical care provided. A high population density may make it possible to set up curative and prophylactic, and sanitary and epidemiological, establishments that are Iarger in size and more economical, and thus to increase the degree to which health establishments perform specialized functions; as fer as medical personnel are concerned, this situation makes it possible for them to be distributed and utilized in a more rational manner. This is of particular importance in relation to the organization of the medical care of the rural population, which amounts, on the average for the USSR as a whole, to 44% of the total (the figure varies from 69% to 36% in the various constituent Republics), and in view of the Iow population density (10.7 inhabitants per km*). In health planning, account must be taken of the indices of the distribution of the population over the area of the country, which include: (I) the index constituted by the average number of persons living in a single population centre (obtained by dividing the total population, of a rural area by the number of population centres in that area); (2) the index of proximity; this is a measure of population density and shows how close population centres are to one anothers itis found by dividing the area by the number of rural popuiation centres and taking the square root; ) the geometrical service radius; this is the radius of a circle of ‘area equal fo that of a rural utestok, and is given by: (eg, where S = 168 km#, R= 1685.14 = 7.3 km); (4) the average service radius, ie., the arthmetic average of the dis- tances between population centres and those centres in which a curative and prophylactic establishment staffed by a physician is located; (5) the maximum service radius, jc., the greatest distance between 1 population centre and a centre in which a curative and prophylactic establishment staffed by a physician is located4 PRINCIPLES OF HEALTH PLANNING IN THE USSR (6) the “average proximity radius” which, it is claimed, expresses not only the distance between a population centre and a centre in which a curative and prophylactic establishment staffed by a physician is located, but also the proximity of medical care to the bulk of the opulation; POG) the median, ie the radius (ix km) which expresses the availa bility of medical care to the rural population; half the population of the rural uéastok lives within this radius, TABLE 4. DATA FOR THE CALCULATION OF THE, VARIOUS SERVICE RADII FOR THE PETROVSKI} RURAL UCASTOKe lotance cn my f| leenre rom = Population of care oeunine arate Ko lesablSherent sets Sen ae "Name of population cence | petrove®. oo. 1409 ° | Wvanowia 200 4 | Niza Jar 200 3 | Verh 500 ‘ 300 5 250 3 250 7 109 4 Semenovkoe 150 5 | Pervomajskoe 250 5 | Tot. phylacic exablshment sed by & phran, For the Petrovskij rural utastok, the values of the above radii, on the basis of the data given in Table 4, are as follows: Geometrical radius 7.3 km Average radius 2 S2km Maximum radius 18 km ‘Average proximity radius: 5.6 km Median 5. Ken (85% of the population live within this radivs) Comparison of urban and rural areas. It is of interest to compare ‘the extent to which outpatient medical care is available in the urban and rural areas of the USSR. Such a comparison is possible on the basis of data on consultations, ‘These are given in Table 5 for the v specialties.‘OUTPATIENT AND HOSPITAL, CARE FACILITIES 35 Trends in the development of outpatient care, The number of out- patient establishments and polyclinics has increased markedly in recent years, and there has also been a large increase in the number of physi-

You might also like

• The Subtle Art of Not Giving a F*ck: A Counterintuitive Approach to Living a Good Life

  

  From Everand

  The Subtle Art of Not Giving a F*ck: A Counterintuitive Approach to Living a Good Life

  Mark Manson

  Rating: 4 out of 5 stars

  4/5 (5813)
• The Gifts of Imperfection: Let Go of Who You Think You're Supposed to Be and Embrace Who You Are

  

  From Everand

  The Gifts of Imperfection: Let Go of Who You Think You're Supposed to Be and Embrace Who You Are

  Brené Brown

  Rating: 4 out of 5 stars

  4/5 (1092)
• Never Split the Difference: Negotiating As If Your Life Depended On It

  

  From Everand

  Never Split the Difference: Negotiating As If Your Life Depended On It

  Chris Voss

  Rating: 4.5 out of 5 stars

  4.5/5 (844)
• • Magazines
  • Podcasts
  • Sheet music
• Principles: Life and Work

  

  From Everand

  Principles: Life and Work

  Ray Dalio

  Rating: 4 out of 5 stars

  4/5 (608)
• The Glass Castle: A Memoir

  

  From Everand

  The Glass Castle: A Memoir

  Jeannette Walls

  Rating: 4.5 out of 5 stars

  4.5/5 (1716)
• Grit: The Power of Passion and Perseverance

  

  From Everand

  Grit: The Power of Passion and Perseverance

  Angela Duckworth

  Rating: 4 out of 5 stars

  4/5 (590)
• Sing, Unburied, Sing: A Novel

  

  From Everand

  Sing, Unburied, Sing: A Novel

  Jesmyn Ward

  Rating: 4 out of 5 stars

  4/5 (1104)
• Hidden Figures: The American Dream and the Untold Story of the Black Women Mathematicians Who Helped Win the Space Race

  

  From Everand

  Hidden Figures: The American Dream and the Untold Story of the Black Women Mathematicians Who Helped Win the Space Race

  Margot Lee Shetterly

  Rating: 4 out of 5 stars

  4/5 (897)
• Shoe Dog: A Memoir by the Creator of Nike

  

  From Everand

  Shoe Dog: A Memoir by the Creator of Nike

  Phil Knight

  Rating: 4.5 out of 5 stars

  4.5/5 (540)
• The Perks of Being a Wallflower

  

  From Everand

  The Perks of Being a Wallflower

  Stephen Chbosky

  Rating: 4.5 out of 5 stars

  4.5/5 (2104)
• The Hard Thing About Hard Things: Building a Business When There Are No Easy Answers

  

  From Everand

  The Hard Thing About Hard Things: Building a Business When There Are No Easy Answers

  Ben Horowitz

  Rating: 4.5 out of 5 stars

  4.5/5 (348)
• Bad Feminist: Essays

  

  From Everand

  Bad Feminist: Essays

  Roxane Gay

  Rating: 4 out of 5 stars

  4/5 (1018)
• Elon Musk: Tesla, SpaceX, and the Quest for a Fantastic Future

  

  From Everand

  Elon Musk: Tesla, SpaceX, and the Quest for a Fantastic Future

  Ashlee Vance

  Rating: 4.5 out of 5 stars

  4.5/5 (474)
• Her Body and Other Parties: Stories

  

  From Everand

  Her Body and Other Parties: Stories

  Carmen Maria Machado

  Rating: 4 out of 5 stars

  4/5 (822)
• The Outsider: A Novel

  

  From Everand

  The Outsider: A Novel

  Stephen King

  Rating: 4 out of 5 stars

  4/5 (1850)
• The Emperor of All Maladies: A Biography of Cancer

  

  From Everand

  The Emperor of All Maladies: A Biography of Cancer

  Siddhartha Mukherjee

  Rating: 4.5 out of 5 stars

  4.5/5 (271)
• The Sympathizer: A Novel (Pulitzer Prize for Fiction)

  

  From Everand

  The Sympathizer: A Novel (Pulitzer Prize for Fiction)

  Viet Thanh Nguyen

  Rating: 4.5 out of 5 stars

  4.5/5 (122)
• Angela's Ashes: A Memoir

  

  From Everand

  Angela's Ashes: A Memoir

  Frank McCourt

  Rating: 4.5 out of 5 stars

  4.5/5 (441)
• Brooklyn: A Novel

  

  From Everand

  Brooklyn: A Novel

  Colm Toibin

  Rating: 3.5 out of 5 stars

  3.5/5 (1947)
• The Little Book of Hygge: Danish Secrets to Happy Living

  

  From Everand

  The Little Book of Hygge: Danish Secrets to Happy Living

  Meik Wiking

  Rating: 3.5 out of 5 stars

  3.5/5 (401)
• A Man Called Ove: A Novel

  

  From Everand

  A Man Called Ove: A Novel

  Fredrik Backman

  Rating: 4.5 out of 5 stars

  4.5/5 (4610)
• The Art of Racing in the Rain: A Novel

  

  From Everand

  The Art of Racing in the Rain: A Novel

  Garth Stein

  Rating: 4 out of 5 stars

  4/5 (4203)
• Steve Jobs

  

  From Everand

  Steve Jobs

  Walter Isaacson

  Rating: 4.5 out of 5 stars

  4.5/5 (807)
• The World Is Flat 3.0: A Brief History of the Twenty-first Century

  

  From Everand

  The World Is Flat 3.0: A Brief History of the Twenty-first Century

  Thomas L. Friedman

  Rating: 3.5 out of 5 stars

  3.5/5 (2259)
• A Tree Grows in Brooklyn

  

  From Everand

  A Tree Grows in Brooklyn

  Betty Smith

  Rating: 4.5 out of 5 stars

  4.5/5 (1929)
• The Yellow House: A Memoir (2019 National Book Award Winner)

  

  From Everand

  The Yellow House: A Memoir (2019 National Book Award Winner)

  Sarah M. Broom

  Rating: 4 out of 5 stars

  4/5 (98)
• Devil in the Grove: Thurgood Marshall, the Groveland Boys, and the Dawn of a New America

  

  From Everand

  Devil in the Grove: Thurgood Marshall, the Groveland Boys, and the Dawn of a New America

  Gilbert King

  Rating: 4.5 out of 5 stars

  4.5/5 (266)
• Yes Please

  

  From Everand

  Yes Please

  Amy Poehler

  Rating: 4 out of 5 stars

  4/5 (1898)
• Team of Rivals: The Political Genius of Abraham Lincoln

  

  From Everand

  Team of Rivals: The Political Genius of Abraham Lincoln

  Doris Kearns Goodwin

  Rating: 4.5 out of 5 stars

  4.5/5 (234)
• A Heartbreaking Work Of Staggering Genius: A Memoir Based on a True Story

  

  From Everand

  A Heartbreaking Work Of Staggering Genius: A Memoir Based on a True Story

  Dave Eggers

  Rating: 3.5 out of 5 stars

  3.5/5 (231)
• The Woman in Cabin 10

  

  From Everand

  The Woman in Cabin 10

  Ruth Ware

  Rating: 3.5 out of 5 stars

  3.5/5 (2521)
• Fear: Trump in the White House

  

  From Everand

  Fear: Trump in the White House

  Bob Woodward

  Rating: 3.5 out of 5 stars

  3.5/5 (738)
• Wolf Hall: A Novel

  

  From Everand

  Wolf Hall: A Novel

  Hilary Mantel

  Rating: 4 out of 5 stars

  4/5 (3811)
• John Adams

  

  From Everand

  John Adams

  David McCullough

  Rating: 4.5 out of 5 stars

  4.5/5 (2409)
• On Fire: The (Burning) Case for a Green New Deal

  

  From Everand

  On Fire: The (Burning) Case for a Green New Deal

  Naomi Klein

  Rating: 4 out of 5 stars

  4/5 (74)
• The Light Between Oceans: A Novel

  

  From Everand

  The Light Between Oceans: A Novel

  M.L. Stedman

  Rating: 4.5 out of 5 stars

  4.5/5 (789)
• Manhattan Beach: A Novel

  

  From Everand

  Manhattan Beach: A Novel

  Jennifer Egan

  Rating: 3.5 out of 5 stars

  3.5/5 (792)
• The Constant Gardener: A Novel

  

  From Everand

  The Constant Gardener: A Novel

  John le Carré

  Rating: 3.5 out of 5 stars

  3.5/5 (104)
• The Unwinding: An Inner History of the New America

  

  From Everand

  The Unwinding: An Inner History of the New America

  George Packer

  Rating: 4 out of 5 stars

  4/5 (45)
• Rise of ISIS: A Threat We Can't Ignore

  

  From Everand

  Rise of ISIS: A Threat We Can't Ignore

  Jay Sekulow

  Rating: 3.5 out of 5 stars

  3.5/5 (137)
• Little Women

  

  From Everand

  Little Women

  Louisa May Alcott

  Rating: 4 out of 5 stars

  4/5 (104)