A description of the process by which the Cleveland metropolitan communitydeveloped a health goals plan is presented. The three basic elements thatmade up the framework of this project were a concept of health,involvement, and utilization of knowledge.

A NEW MODEL FOR COMMUNITY HEALTH PLANNING

Aiildred C. Barry, M.Sc. (Soc. Admin.), and Cecil G. Sheps, M.D., M.P.H., F.A.P.H.A.

Introduction

PLANNING is not a new idea for indi-vidual health agencies. Each plans its

own operations and may engage in somecollaborative activity as part of a com-munity planning effort. Nor is planninga new notion for the community. Wehave all been witnesses to, if not partici-pants in, community planning in variousfields and under various auspices-health and welfare planning, hospitalfacilities planning, mental retardationplanning, and the like.

There has been growing dissatisfac-tion with the effectiveness of such plan-ning. It is generally episodic and lim-ited in scope. When it has been broad, ithas rarely done more than provide aconsensus for some general principlesthat are already fairly clear. Frequentlyits objective has been to set prioritiesamong competing needs presented by in-dividual agencies. Often, too, the focusis on a "plan" not "planning." The"blueprints" produced may reflect eitherthe most loudly articulated demands andpower influences, or result from a studyby an outside consultant with little localinvolvement or commitment to action.Also, recommendations are often ori-ented primarily to the present-to im-mediate problems and conditions.

In other words, planning has gen-erally not been comprehensive, nornecessarily oriented directly to a chang-

ing society and goals for the future; ithas not found the way to maximizeknowledge in the structuring of com-munity service systems; and it has notbeen seen as a consciously developedand continuing planning-action process.We present here a case history of one

metropolitan community's attempt tofind new formulations for studying com-munity health and new approaches tocommunity-wide health planning andaction, with the ultimate objective beingto raise the level of the community'shealth and to make better use of its re-sources.

Space does not allow a full descriptionof the project nor a summary of itsfindings. Those interested may refer tothe project publications listed in Ap-pendix A. Our emphasis here is on theconceptualization and implementation ofthis planning process.

Conceptual Framework

No single part of the project wasunique, but its totality was. This totalityis suggested by the following elementsof the process used:A broad inclusive concept of health;An emphasis on prevention and positive ap-

proaches;A study based on specific goal formulation

rather than on the traditional approach ofstudying needs, agency programs, or diseaseentities;

Responsibility vested in a local, representa-

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tive leadership group; with consultants andexperts from different specialties to serve thiscommittee;A high degree of involvement and chal-

lenging demands upon participants;A plan for, and a commitment to, action.

The project was initiated by theHealth Planning Board of the WelfareFederation of Cleveland as part of a re-vitalized community planning effort.Responsibility was vested in the HealthGoals Committee which developed andconducted the project and receivedspecial funding of approximately $250,-000 from local foundations and the Pub-lic Health Service.The Health Goals Committee was com-

posed of over 50 lay and professionalleaders (Appendix B). Its chairman wasa prominent Cleveland industrialist withan extensive record of activity in com-munity affairs and long experience inhealth problems on the local and nationalscene. The committee members wereselected because of professional com-petence, positions of influence, or demon-strated community leadership. Occupa-tional coverage included managementand labor, public officials, the health pro-fessions, law, education, and administra-tion. A Steering Committee of ten wasset up. After formulating general objec-tives it called upon three consultantswho, it hoped, would have "the abilityto be innovative and creative." The threeconsultants, brought in separately atfirst, offered to serve as a team, and thisteam, with one replacement, servedthroughout the project (Appendix C).

Project objectives were stated as fol-lows:"To develop a model of a healthy community

using the best available knowledge and ex-perience about health collected by nationalexperts and molded into the model by Cleve-land leaders with consultant help."To compare Cleveland's present health pic-

ttire against the Model, to:determine how we fall short;set goals (what we need to do to reach the

ideal );develop priorities among these goals, based

oni iml)ortance, feasibility and the predicta-bility of restults so that the resources whichour community can command will be used tomaximum benefit for the health of our people."To decide how these goals can be achieved

by:seeking community agreement on the value

of the model and the desirability of achievingthe goals;working for implementation of these goals

in orderly fashion in accord with priorities;making full use of the programs which

now exist;but not hesitating to encourage change, to

subtract, add or modify if such is in the com-munity's interest."

The method used is suggested in theobjectives. There were three concurrentactivities, one addressed to formulationof the model; the second to collection ofinformation about Cleveland's healthprofile for comparison against themodel; and the third to description andanalysis of the process, as such.The formulation of the model was the

primary activity and the one emphasizedin this paper. In brief, this was the pro-cedure. Health parameters were agreedupon and 30 subjects were selected forintensive study. An expert for each sub-ject was invited to write a positionpaper, answering the question: If a com-munity were fully utilizing the existingscientific knowledge in your field, whatshould be done and what would be theconsequences both in terms of improvedhealth and in the effort required? Foreach subject a local panel of lay andprofessional persons was chosen tostudy the position paper and discuss itwith the writer. This interaction processclarified points of agreement and issuesthat needed further attention. The posi-tion paper and the panel's commentsthen went to the full Health Goals Com-mittee for final resolution.

After this review, the 30 subjects;were grouped into nine goals with more-detailed subgoals. Under each, the key-elements for goal achievement were out--lined. This formed the basis for the first

FEBRUARY, 1969 227

half of the Health Goals Model. Thematerial was then reformulated into con-clusions and recommendations applica-ble to systems for the preparation, de-velopment, and delivery of health serv-ices. Twelve "systems statements," classi-fied either according to functional orstructural systems, comprise the secondpart of the model.

The second strand in the over-allmethod was to get a picture of Clevelandand its health in order to make an assess-ment against the model and to identifyaction targets. This activity was con-ducted by staff. Demographic, healthstatus, and health expenditure data werecompiled into a Source Book; and in-formation about health facilities andservices was organized according to thenine families of goals and compiled ina Profile volume which also containssuccinct statements of what the com-munity does and does not have asmeasured against the goals.The third concurrent activity, namely,

recording and analysis of process, wasconducted by staff with advice fromspecial consultants.The various resources used by the

project and the roles they played aresummarized in Appendix D. Approxi-mately 700 different individuals and allhealth-related organizations in the com-munity were directly involved in theproject.The project covered a span of five

years from the time of the initiation ofthe idea to issuance of the reports in1966. Since that time, although initiatedduring the course of the project, an ac-tive implementation program has beenstarted.

Examination of Elements in theConceptual Framework

Earlier we listed a number of ele-ments which combine to make up theconceptual framework of this project.Let us now examine these in more de-

tail. For this purpose we can group theminto three concepts: (1) the concept ofhealth; (2) the concept of involvement;and (3) the concept of utilization ofknowledge.

1. The Concept of HealthSome inclined to the WHO definition

with inclusion of housing, employment,and other social conditions contributoryto health; others favored more usualhealth categories with precisely definableparameters. The consultant team de-veloped the concept of a continuum withthe best conditions at one end of thespectrum and the worst at the other, withfour over-all program objectives whichwere stated in sequence as: (a) positivehealth; (b) prevention of the onset ofdisease or injury; (c) early recognitionand treatment of disease and injury; and(d) prevention of severe disability,social isolation, and untimely death.

Positive health posed many problemswhich were not resolved. The other threeserved as the working framework withinwhich specific health subjects wereidentified and studied and, as describedearlier, became the basis for the ninegoals. Incidentally, the consultants satis-fied themselves that all diseases of majorsignificance to a US metropolitan com-munity fell into one or more of thesecategories.With respect to positive health, partici-

pants experienced much frustration. Theobjective was stated as "full realizationand maintenance of physical, emotional,and intellectual potential throughoutlife, from prenatal period to old age."The problem was how to deal with en-vironmental factors and such intangiblesas "values." The committee finally recog-nized that it could not deal adequatelywith this vast subject.The over-all concept of health and the

interrelationship of the various partswere set forth in a Diagrammatic Sum-mary (Appendix E). This diagram wasa useful tool for the committee because

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members could see the relationship ofeach part studied to the whole. Theywere reminded of the supportive dataupon which the model was built andthat the purpose of the model was to de-velop a program of action. Also, theycould see how each subject under studyrelated to the four original program ob-jectives and tied into the whole frame-work of the model.

2. The Concept of InvolvementThe principle here is that if a person

becomes involved in a project, con-tributes to it, and learns from it, he de-velops the interest and commitmentneeded to support the findings and a pro-gram of community action.

In our project this involvement wasstructured to take various forms and re-sulted in directly involving 700 people.The central core was the Health Goals

Committee. During the last two years ofthe project, this committee met aboutevery six weeks for a brief social periodfollowed by three hours of discussion.Materials were sent in advance whichthe members were expected to, and did,study. The most demanding event wasan all-day and evening session, duringwhich the goals part of the model wascompleted and a beginning made onmajor conclusions and recommendationsfor the second part on Systems. Due toa combination of social and intellectualinterchange over the course of severalyears, a strong group identity emergedaccompanied by respect for the point ofview and knowledge of each individual.For example, lay people became moresophisticated about health; physiciansand other health personnel gainedgreater understanding about politics andthe dynamics of social change.A second form of involvement-and

the most extensive, numerically-wasprovided through the panels. As notedearlier, a panel of local people was in-vited to meet with each author of aposition paper. Care was taken by the

Steering Committee to select persons ofrecognized professional competence ormeaningful nonprofessional experience.There were 345 different individualswho took part in the panel meetings. Anumber of people who could not attendparticipated by sending in their com-ments, and records of the degree ofparticipation were kept. Often panelmembers wanted to know the outcomefollowing their discussion and expresseda desire to plunge immediately into im-plementation of specific proposals. Theywere encouraged to take whatever stepsthey could, but were told that implemen-tation of the project as a whole mustawait an orderly sequence.A third form of involvement was by

those who answered the questionnaires.This was particularly meaningful in thecase of the 43 health agencies wherepersonal interviews were held with thedirector.A fourth type of involvement was pro-

vided by the sponsoring organization.The Board of Trustees, Health PlanningBoard, and other groups which carriedany type of project responsibility heardperiodic progress reports and, as theproject came to an end, committed them-selves to a program of implementation.

Finally, there were individual inter-views both during the project primarilyto seek information and at its close toencourage favorable response to themodel. Of particular importance wereconferences with the mayor, the super-intendent of schools, the Board cf CountyCommissioners, and other dignitarieswhose public recognition would provideadded community sanction.

3. The Concept of Utilization ofKnowledgeTechnical knowledge from the experts

who prepared the position papers wasaugmented by the professional compe-tencies of the consultant team, membersof the Health Goals Committee, andpanel participants. This was further en-

FEBRUARY. 1969 229

riched by contributions of others, suchas physical planners, police in charge oftraffic and emergency transport, andpersons who had personally experiencedbreakdowns in the health delivery sys-tem.

Another type of knowledge, system-atically introduced, was drawn fromcommunity organization. Several panel-ists, members of the committee, and staffhad either formal training or experiencein this field. Also, special consultationon community organization and processanalysis was utilized.The interaction and fusion of thought

which occurred between the continuingconsultants and staff undoubtedly playeda significant part in helping the HealthGoals Committee, itself, synthesize con-tributions from various disciplines.Twenty-seven consultant-staff meetings,some of two-day duration, were heldover a four and one-half year period.The consultants brought to these con-ferences technical knowledge of highprofessional quality and breadth ofscope, and information about nationaldevelopments and trends. Staff broughta perception of the community gen-erally, information about individualsand events specifically, and special skillsin community organization. The inter-action in this group resulted not onlyin a fusion of knowledge but the formu-lation of concepts and procedures im-portant for committee work. The com-mittee, as well as the consultant-staffgroup itself, recognized this as a sophisti-cated and stimulating form of consulta-tion.

Thus, the Health Goals Committee hadavailable to it a vast amount of profes-sional knowledge which it could fuse,assimilate, and use because of a processwhich included two unusual methodc:the position paper panel review pro-cedure, and the continuing consultant-staff team interaction.The involvement of the Health Goals

Committee through this process resulted,

over the months, in changed attitudesand a growing commitment to action.For example, as one position paper afteranother was reviewed, it became appar-ent that broad health surveillance andepidemiologic information were essen-tial and were lacking; that greater con-trols were needed; that health problems,such as dental and nutritional inade-quacies, were prevalent; that environ-mental conditions contributing to chron-icity remain unrecognized; that, ineffect, there was a wide variety of healthproblems for which there was no reliablesource for information or control, andno centralization of authority necessaryfor an effective attack.

It finally became clear that the solu-tion to many of these problems laywithin the realm of public health, andthat the existing structure for publichealth was grossly inadequate. The solu-tion appeared to be some type of multi-county public health structure, yet gov-ernmental jurisdiction and other con-siderations seemed to make this approachunrealistic. Furthermore. it would evenbe difficult to combine the six health de-partments within the county into a singleunit. All major health studies since 1944had recommended a single hlealth depart-ment but adequate community supporthad not been forthcoming. In fact, a re-cent recommendation, which had pro-posed metropolitan government with apublic health unit, liad engenderedstrong community opposition and hadbeen voted dowvn by the electorate. As aresult, many of the Healtlh Goals Com-mittee members started with a convictionthat no proposal for a county health de-partment could be acceptable. Nor didthey initially think it really matteredmuch. However, as the committee re-viewed the position papers, it becameconvinced that many of its health ob-jectives could not be achieved withoutat least a county-based operation. Withthis conviction, it resolved to exploreanew how it could achieve this presurn-

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ably unachievable objective. It developeda proposal calling both for a county pub-lic health authority and for multicountyplanning and development. Effortstoward this dual objective have sincebecome a key part of the implementationprogram.

Conclusion

It is still too early to assess objectivelythe impact which this particular com-munity-wide health planning effort hasor will have on the Cleveland metropoli-tan community. Yet events to date seemto validate some of the major assump-tions on which this Health Goals Projectwas developed; namely, that community

health planning can embrace the com-prehensive concept of health and cancouple expert professional knowledgewith a high degree of citizen leadershipinvolvement.The process analyst has called the

unifying theme of the project "creatingnew ways of achieving a healthy com-munity." Drawing from her analysisand our own observations, we concludethat the Health Goals Project did inducea creative reexamination of conventionalanswers and methods; and that it didresult in new formulations for studyingcommunity health, new approaches tocommunity health planning, and a deepinvolvement and commitment of widelyrepresentative community leadership.

Mrs. Barry is Director, Health Planning and Development Commission, TheWelfare Federation (1001 Huron Road), Cleveland, Ohio 44115. Dr. Sheps,formerly General Director, Beth Israel Medical Center, and Professor of Com-mutnity Medicine, Mount Sinai School of Medicine, New York, N. Y., is nowDirector, Center for Health Services Research, University of North Carolina,Chapel Hill, N. C.

This paper was presented before the Medical Care Section of the AmericanPuiblic Health Association at the Ninety-Fifth Annual Meeting at Miami Beach,Fla., October 25, 1967.

APPENDIX A-OFFICIAL PUBLICATIONS, CLEVELAND HEALTH GOALS PROJECT

"Health Goals for Greater Cleveland: Summary"A composite of the basic volumes, prepared for general distribution. 290 pages.

Volume I-"Health Goals Model for Greater Cleveland"Major report of the Health Goals Committee. Details the Health Goals; the Key Elementsfor achieving goals, and the Community Systems recommendations for the preparation,development and delivery of health services. 351 pages.

Volume II-"Supplement to Health Goals Model for Greater Cleveland"An appendix to the Model, containing the digests of Position Papers, panel and committeediscussions for the 30 health topics studied. 252 pages.

Volume III-"Greater Cleveland and Its Health Profiles"An overview of existing health services and facilities in Cuyahoga County, organized bygoal categories. 349 pages.

Volume IV-"'Greater Cleveland and Its Health: Source Book"An overview of demographic data, health expenditures, and health status for CuyahogaCounty. (Published 1964. Out of print at this time. Available on a loan basis only.) 225 pages.

Volume V-"Process Analysis"A description and evaluation of the project by Process Analyst. 410 pages.

(Copies may be purchased from the Welfare Federation, 1001 Huron Road, Cleveland, Ohio 41115.)

FEBRUARY, 1969 231

APPENDIX B-MEMBERS HEALTH GOALS COMMITTEE AND STEERING COMMITTEE BYOCCUPATIONAL GROUPS*

Health Goals SteeringCommittee Committee

Lay LeadershipBusiness and industryOrganized laborLay women leadersLawyers

Public OfficialsMayor, city managersJudgesBoard of county commissionersPublic administrationOEO administration

Foundations-civic and welfare organizationsHospital administration, planning, and Blue CrossPhysicians

Public health, public institutionsPrivate practice and organized medicineUniversity Medical Center

Case WRU administration and professional schools(other than medical school)PresidentVice provostDean, School of DentistryDean, School of NursingDean, School of Social WorkProfessor, Social Work-Community Organization

Dentists-organized dentistryBoard of Education administration

16(6)(2)(4)(4)

7(2)(2)(1)(1)(1)

4

4

17(4)(6)(7)

6

1

1

56Total* As finally constituited.

APPENDIX C-HEALTH GOALS CONSULTANT TEAM

Position at beginning Position at closeof project of project

Chief consultant-1962-1966Cecil G. Sheps, M.D., M.P.H.

Associate Consultant-1962-1966Irvin J. Cohen, M.D.

Professor of Medical andHospital Administration,Graduate School of PublicHealth, University ofPittsburgh, Pittsburgh, Pa.

Assistant Chief MedicalDirector, VeteransAdministration,Washington, D. C.

General Director,Beth Israel Medical Center,New York, N. Y.

Executive Vice-President,Maimonides Hospitalof Brooklyn,Brooklyn, N. Y.

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12

4

10

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Associate Consultant-1962William H. Stewart, M.D. Chief, Division of Community Surgeon General,

Health Service, Department US Public Health Service.of Health, Education, and Department of Health,Welfare, Washington, D. C. Education, and Welfare

Washington, D. C.Associate Consultant-1963-1966Conrad Seipp, Ph.D. Associate Professor of Health Associate Professor of

Planning, Graduate School Health Planning,of Public Health, University Graduate School ofof Pittsburgh, Pittsburgh, Pa. Public Health,

University of Pittsburgh,Pittsburgh, Pa.

APPENDIX D-RESOURCES USED BY HEALTH GOALS PROJECT SUMMARY

Welfare FederationA federation of 230 health, welfare, recreation, education, and civic organizations serving

Metropolitan Cleveland. Board of Trustees of 45 lay and professional members.Health Council

One hundred and sixteen members, 75 of whom represent 43 health agencies; parentbody of Health Planning Board and Health Goals Committee.

Health Planning BoardThirty-nine members, representative of citizen interests, health agencies, and key com-

munity organizations; community health planning function, responsibility for initiatingHealth Goals Project.

Health Goals CommitteeFifty-six lay and professional members; over-all responsibility for project. Total meetings

held-28 (June, 1961, through 1962-4; 1963 through June, 1966-24).Steering Committee

Ten members; active during first half of project in charting course, selecting consultantteam and panelists. Total meetings held-19 (September, 1961, through 1962-8; 1963through 1964-11).

Position Paper WritersTwenty-seven experts from outside Cleveland area.

Panelists: reactors to position papersFive hundred and sixty-four invited, 345 attended; average attendance at panel-20.

Special Ad Hoc CommitteesAppointed to deal with particular problems: mental health, public health organization,

positive health, public relations.Consultant Team

Ongoing team of three national experts who worked with staff and committee. Con-sultant-Staff total meetings-27 (some for two days), (1962-3; 1963 through June, 1966-24).

Special ConsultantsShort-term special consultation on mental health, positive health, dental health, public

health organization, community organization, and process analysis.Staff

Project director, M.Sc.S.A., Community OrganizationProcess analyst, Ph.D., M.S.W., Community OrganizationResearch associate, M.D., M.P.H.Operations associate, M.A.Health planning associate, M.P.H. (in late stages of project).

FEBRUARY. 1969 233

APPENDIX E-DIAGRAMMATIC SUMMARY OF CLEVELAND HEALTH GOALS PROJECT.WITH EXPLANATORY DETAIL, FEBRUARY 1966

Programming (action)

(plans being developed)

Time Schedule -

Model completed by mid-1966Programming - concentrated effort beginning mid-1966.

For detailing of above, see next pages.

(mailing date)

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M 0 D E L (Planning)

Part One Part Two

Goals Sys tems

Sub-goals & Key elements FunctionalStructural

A-Bs ) Supportive dataProfile) summarized

I

1963

to

1966

1966

&

ff.

Supportive Data

Position papers )Panel reports SCommittee minutes )

Source Bookdemographics, etc.health statusProfile-(survey)

Summarizedin A-Bs

'4 +

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COMMUNITY HEALTH PLANNING

APPENDIX F-DETAILING OF DIAGRAMMATIC SUMMARY

MODEL-Part One

Goal I ReproductionSub-goals & Key elements for achievement

Profile } (Supportive data summarized)

Goal II NutritionSub-goals & Key elements for achievementA-B

} (Supportive data summarized)Profile

Goal III Dental HealthSub-goals & Key elements for achievement

Profile (Supportive data summarized)

Goal IV Infectious and Communicable DiseasesSub-goals & Key elements for achievementA-B

} (Supportive data summarized)Profile

Goal V Trauma and SafetySub-goals & Key elements for achievementA-B

} (Supportive data summarized)Profile

Goal VI Chronic DiseasesSub-goals & Key elements for achievement

Profile (Supportive data summarized)

Goal VII Handicapping ConditionsSub-goals & Key elements for achievement

Profile } (Supportive data summarized)

Goal VIII MobilitySub-goals & Key elements for achievementA-B (Supportive data summarized)(No separate Profile, see Goals VI and VII)

Goal IX Mental DisordersSub-goals & Key elements for achievementA-BPf (Supportive data summarized)Profile

Positive Health

Prevention ofOnset of Disease& Disability

Early Recognition& Treatment ofDisease &Disability

Prevention ofSevere Disability,Social Isolation &Untimely Death

I

FEBRUARY. 1969 23S

APPENDIX G-SYSTEMS FOR THE PREPARATION. DEVELOPMENT. AND DELIVERY OFHEALTH SERVICES

MODEL-Part Two

IntroductionA. Functional Systems

1. Systems for the Collection, Evaluation, and Dissemination of Information (Intelligence)2. Systems for Professional and Technical Education3. Systems for Education of the Public: Community Health Education4. Systems for Control, Regulation, Standard Setting, and Enforcement (Controls)

B. Structural Systems1. Health Systems

a. The Hospital Systemb. The Voluntary Health Agency Systemc. System for the Effective Development and Administration of Public Healthd. The Health Professions

2. Other Systems with Health or Health-related Functionsa. The School Systemb. The Welfare Systemc. Governmental Bodiesd. Community-wide Planning and Development

Other Considerations: Community Life, Financing, Priorities

Two-Day Noncredit Courses Offered

The Health Sciences Centre, University of British Columbia, is offering severaltwo-day noncredit courses for practicing nurses. Applicants from nearby states in theUnited States will be accepted. The courses include: Human Sexuality, Saturday andSunday, March 8-9; The Maternity Cycle Viewed as a Developmental Crises, March20-21; Preoperative Nursing Care, May 1-2; Nursing Assessment, May 8-9; andNursing the Adult with Long-Term Illness, May 15-16. All courses but the firstlisted start on Thursdays.

For further information, write: Continuing Education in the Health Sciences,Task Force Building, The University of British Columbia, Vancouver 8, B. C., Canada.

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