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HEALTH POLICY AND PLANNING; 14(2): 127134

Oxford University Press 1999

Using problem structuring methods in strategic planning

COLIN THUNHURST1 AND CAROL BARKER2
1Former British Council Project Director, ODA-Funded Components, Second Family Health Project, Pakistan &
DFID-Funded District Health Strengthening Project, Nepal, and 2Head of the International Division, Nuffield
Institute for Health, University of Leeds, & Technical Co-ordinator, Health Systems Strengthening Components,
Second Family Health Project, Pakistan
In this paper1 we present approaches to problem structuring that have been employed to derive planning
guidelines as part of a comprehensive strategic planning process. The approaches were developed for use
in the context of a developing country, where quantitative data is particularly scarce. They rely heavily upon
the informed judgement of technical planning officers. We discuss ways of ensuring that the approach
remains flexible and participative.

Strategic planning within the health sector in Pakistan is in its

infancy. Until recently, planning has consisted largely of the
production of five-year and fifteen-year forward planning
documents, and the preparation of formal documentation for
ad-hoc individual proposals. The former were often elegantly
produced but had little influence on decisions taken; they
made little impact on the parallel, but relatively independent,
process of annual planning, from which the ad-hoc proposals
emerged. Thus, planning has been short-term, and the
achievement of five-year plan and fifteen-year prospective
plan objectives has been disappointing.
Since 1992, the UK Overseas Development Administration2
has been funding a component of the Asian Development
Banks Third Health Project (ADB3) to introduce a process
of strategic planning. Three-year rolling plans are to be
formulated on the basis of a thorough situational analysis and
longer term planning intentions. These can be translated into
short-term programmes, which will be linked into the
achievement of broader health sector objectives (Green et al.
1997). Such plans provide the opportunity, for the first time,
for developing an integrated approach to capital and recurrent expenditure planning.
The strategic planning process employs a planning spiral (as
described in Green 1992). Planning is seen as a continuous
and cyclical process passing iteratively through the following
stages: situational analysis; priority, goal and objective
setting; option appraisal; programming; implementation and
monitoring; and evaluation. In the precise formulation of the
cycle adopted for strategic planning in Pakistan, the stages of
priority, goal and objective setting and option appraisal are
combined in the production of planning guidelines, designed
to ensure that provincial strategy is reflected in district plans.
Although the strategic planning process is designed to
operate at a local (district) level, planning in Pakistan, as most
other areas of health management (and indeed public sector

management in general), remains highly centralized. The

devolution of strategic planning, from provincial to district
level, can be seen as a test-bed for the devolution of other
management and planning powers. Currently, though,
resource levels, and even the quite specific allocation of
resources to particular functions, remain centrally determined. This is a legacy of the well-established bureaucratic
processes inherited by Pakistan from the former British colonial administration.
Thus, planning guidelines form the key element in a dialogue
between centre and periphery. To be effective, they must
facilitate an interaction which enables a locally determined
response to health and health service needs, as identified
within the situational analysis, to be met by an appropriate
allocation of centrally controlled resources.
If we add to the already complex nature of this interaction
that decentralization of the planning process from centre to
periphery is occurring at a time when the periphery is also
being encouraged to build stronger bridges to local communities, an already complicated and potentially highly
charged process of negotiation intensifies in complexity.
Such a setting poses a ready challenge for the emerging
problem structuring techniques of operational research.
Rosenhead (in introducing cognitive mapping, soft systems
methodology, the strategic choice approach, robustness
analysis, metagame analysis, and hypergaming) describes
situations where a process of accommodation between participants is necessary before a problem focus can emerge
which will carry assent and commitment to consequential
actions (Rosenhead 1989). Health planning in Pakistan presents a perfect match to this description. His six characteristics for an alternative paradigm of operational research
(non-optimizing; reduced data demands; simplicity and transparency; conceptualizing people as active subjects; facilitating planning from the bottom up; accepting uncertainty)
almost provide a check-list of the characteristics and requirements of a decentralized strategic planning process.

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Introduction

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Colin Thunhurst and Carol Barker

Thus, the concept of non-optimizing leaves the technocratic

world of traditional hard operational research in which one
well-defined problem will have, as the result of study, one
unambiguously optimal solution. The alternative paradigm
allows that in the real world, problems are multidimensional,
that optimal solutions cannot be found on all dimensions at
once, and that different stakeholders and observers will value
the various dimensions differently. Acceptance of a minimalistic approach to data demands is essential to a planning
process which will be practicable. The three characteristics of
(1) simplicity and transparency, (2) seeing people as active
subjects, and (3) facilitating planning from the bottom up, are
obvious pre-requisites of a planning process intended to
support decentralized decision-making and citizen participation. Acceptance of uncertainty is essential in the real
world of planning.

Health planning in developing countries

Methods of health planning proposed for use in developing

countries have historically reflected a strong epidemiological
orientation. For example, WHO manuals, Fowkes and Creese
(1988) and Vaughan and Morrow (1989) have proposed
methodologies which centre on ranking individual diseases
according to relative importance, effectiveness of service
interventions and the cost of service interventions. This
approach is subject to criticism for a number of methodological and theoretical reasons: it is subject to arbitrariness in
terms of how diseases are aggregated; it promotes a focus on
individual diseases, rather than systemic change; and, as a
consequence, it encourages the creation of individual vertical
programmes (the selective PHC approach).
The danger inherent in such approaches is evidenced by its
most extreme manifestation in the Burden of Disease
approach (Musgrove, 1995) currently being heavily promoted
by the World Bank following the publication of the 1993
World Development Report: Investing in Health. This
approach leans heavily on the DALY (Disability-Adjusted
Life Years), a measure of health gains which would demand
very detailed disaggregated local data if the technique were

Kielmann et al. (1993) present an alternative approach, which

views health improvement more systemically, rather than as
the serial elimination of individual diseases. This incorporates
processes of problem prioritization, premised by a need to
search for underlying causes. This approach derives essentially from the ZOPP (Ziel Orientierte Projekt Planung
Objectives Oriented Project Planning) methodology, used
extensively by the German development agency GTZ. It
shares a number of features with the methodology to be presented below (MacArthur 1994), but its applications in the
health planning field tend to retain an epidemiological focus.
In deriving situation analyses and identifying priority areas of
concern in the Pakistan situation, efforts have been made to
transcend this narrow focus, and to look at the wider range of
concerns which relate to allocating resources to deliver an
integrated health care service concerns about human
resources and their deployment for example; concerns about
physical resources, and about management systems development, among others.

The role of planning guidelines in the strategic

planning cycle
The formal Situational Analysis document closes the preceding turn of the planning cycle and opens the current cycle. It
involves elements of evaluation and reconsiders the fundamental problems being faced within the health sector through
a participative process of consultation. As the strategic planning process develops, it acquires its rolling nature. Threeyear plans, with each year specified in increasing detail, will
be drawn up within the framework provided by five-year and
fifteen-year perspective plans (as described in Green et al.
1997). Emphasis will shift towards the evaluative elements
and raw materials included within the situational analysis
per se, and will provide fine tuning and more geographic
specificity for problems earlier identified in broad terms.
Planning Guidelines will be produced provincially and constitute the provincial response to the problems (and progress)
identified within the Situational Analysis document. In
coming years, depending upon the rate at which provincial
processes of decentralization are advanced in Pakistan,
resources will progressively be deployed at a district level; for
now, the process of resource allocation remains relatively
centralized. Thus Planning Guidelines will, for the immediate
future, be fairly directive documents expressing the provincial level decisions that will have been taken by provincial
planning cells, under the direction of planning committees.

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It has been argued elsewhere (Thunhurst 1996) that, if operations research (OR) practitioners are to venture on to this
particular terrain or swamp (Rosenhead 1992) as it might
now be called by them they must do so fully conscious of the
prevailing currents of development thinking within health
systems. They should be conscious of public sector reforms.
In particular in the health sector context, they must be
mindful of the evolution of primary health care (PHC) and
the need to utilize methods and approaches that are compatible with its underlying principles (concern with equity,
promotion of community participation, focus on prevention,
use of appropriate technology, and promotion of intersectoral approaches). They should also be aware of areas of contestation within the implementation of PHC (particularly
debate as to whether primary health care can be introduced
selectively or comprehensively). Despite the readiness of
individuals and countries to sign up for the primary health
care approach, much room remains for interpretation and
delineation of a strategy for achievement of PHC.

to be employed as part of a locally sensitive planning process.

Again, the presumption is that maximum health gain can be
achieved by targeting individual diseases, reducing health
planning to a process of merely identifying those diseases. It
is argued (Barker and Green 1996) that planning which starts
from a disease focus will be flawed, first because such a focus
diverts attention from really important choices and decisions
(how many staff, what technology choice?); second because
such a mock objective approach tends to neglect the planning context, with its existing system of health provision and
its own power relations.

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Using problem structuring in planning

(These decisions, though, will be informed by and increasingly directed by information supplied from the periphery as
the Situational Analysis is drawn up). Even under a fully
decentralized system, it will be the role of the centre to
explain overall policy and to set the broad parameters within
which localized planning will proceed.
On the basis of the Planning Guidelines issued by the centre,
submissions will be received from the periphery. These will be
analyzed for their consistency with provincial policies and priorities, as embodied in the guidelines, and a Draft Health
Plan for the province produced.

Planning (logical) framework

Throughout the planning cycle use is made of the Planning
(Logical) Framework (Table 1). It is employed, less as a
means of analysis, more as a means of recording and subsequently modelling implementation proposals. A planning
framework is a means of displaying a sequential progression
through a strategy area, enabling us to see how our short-term
activities and objectives relate to our longer term strategy. It
is a specific adaptation of the logical framework more frequently encountered in project management.
Those familiar with DFID project management procedures
will be aware that the planning adaptation of the logical
framework differs from the logical framework used for the
management and monitoring of DFID projects. While the
more familiar DFID version was used in the management of

Table 1.

the project within the context of which this work was conducted, the adapted version expresses the hierarchy of objectives in more precise planning terms and is therefore
appropriate for the planning cycle.
Stages in the planning spiral and the use of problem
structuring technique
In the section that follows we will explore the value of various
problem structuring techniques in the derivation of planning
guidelines. These relate to the stages of the planning cycle
(spiral) as shown in Table 2. The representation presumes a
degree of iteration within each turn of the cycle. These have
been termed the broad programming (or strategic) and
detailed programming (or tactical) levels. At both levels,
comparable techniques are proposed.

Developing the broad strategy

The initial stage in the derivation of planning guidelines is the
development of a broad strategy. This involves the specification of medium-term objectives consistent with national
health service goals (which, it is assumed, are formulated at
the highest policy levels), and taking into account the nature
of health sector problems which currently constitute
obstacles or constraints. Recognizing that many health sector
problems are deep-rooted, and may require sustained
(though not necessarily costly) attention over relatively
lengthy periods of time, the first stage is to prioritize those
broad problem areas that will be selected for attention within
the medium term (three to five years) planning horizon.
The problem tree
Initial exploration of the problem space is undertaken
through a causal analysis of core problems identified within
the situational analysis. This causal analysis will be conducted
using a problem tree. It reduces problems revealed in the

Planning framework

Planning guidelines

Goal
(10 years +)

Medium term objectives

(510 years)

Short term objectives

(35 years)

Inputs and activities

(03 years)

Indicators of
achievement

Means of
verification

Assumptions,
risks and conditions

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The Draft Health Plan will be the document on which

detailed budgeting and negotiation with other departments
takes place. Other departments, particularly the Finance
Departments and the Planning and Development Departments, retain a major say in how individual line departments
utilize resources. Their concurrence with planning proposals
will be required.

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Colin Thunhurst and Carol Barker

Table 2. Stages in the planning spiral and the use of problem structuring technique
Technique

Strategic situational analysis

To define broad problem areas underpinning immediate health

service problems

The problem tree

Priority and objective setting

at the strategic level

To identify selected response to broad problem areas

Convert problem tree into

hierarchy of objectives

Option appraisal at the

strategic level

1. To explore inter-relationship between broad problem response

2. To choose between broad problem responses ( strategy areas)

Mapping
Ranking methods

Priority and objective setting

at the operational level

To identify options within prioritized strategy areas and identify

sectoral response

Detailed problem tree

(hierarchy of objectives)

Option appraisal at
the operational level

1. To explore inter-relationship between options within strategy

areas
2. To choose between options within prioritized strategy areas
( tactical response)

Mapping

Figure 2 shows the decomposition of a core problem concerning the shortage of female staff in rural health facilities.
Identifying actions
Each problem identified will lead to a response. Although, at
this stage, we will not get to the level of specifying detailed
sectoral responses, root causes should be subjected to a preliminary review to ensure that they are areas where some
health sector response is possible. The purpose of the problem
tree is to tease out shorter term actions that will progressively
lead to the achievement of longer term goals. This exercise
can often be very helpful, in its own right, in demonstrating to

Effects

Core problems

Causes
Figure 1. Developing a health strategy: the problem tree (asking
but why?)

decision-makers the deep-rooted nature of many health

sector problems, and thus avoiding easy, but ultimately
unsuccessful, solutions. It can also be valuable for demonstrating the inter-locking and multi-sectoral nature of underlying causes of problems. As well as ensuring that the ultimate
strategy is implementable, this will expose areas where
achievement of goals within the health sector is conditional
upon the response of other sectors. Thus, in the context of
Pakistan, the root problem of the low rates of female literacy
in rural areas very frequently arises. This could (in Strategic
Choice terminology) be signalled as an area of uncertainty. At
an appropriate later stage it will be necessary to consider such
areas of uncertainty further, and make specific assumptions
concerning progress over the immediate planning horizon.
(These will be entered, within the appropriate element, in the
right-hand column of the planning framework.)
Mapping actions into strategy areas
At this stage root causes will still be identified in relatively
broad terms with considerable inter-relationship (and often
over-lap) between areas. To explore the precise nature of
these inter-relationships, identified problem responses will be
aggregated into general strategy areas. All of the actions
identified should be explicitly written down to enable an
examination of the relationship between them. The actions
will be mapped. If two actions are closely related, developing
the two together may lead to a much improved overall
outcome. For example, over-centralized control of day-today activities may require a strategy for decentralization and
may also require management training. It is easy to see that
the process of reducing over-centralization will work much
better if these two strategy areas are dealt with at the same
time. By mapping the actions, we ought to be able to group
objectives together and then consider groups where necessary. These can be termed strategy areas.
The actual process of mapping will employ conventions
similar to those of the Strategic Choice Approach (Friend
1989). Directed arrows will be used where there is a dependency between two actions. Undirected lines represent a

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situational analysis so as to expose the basic problems that

need to be tackled, and what the health services response
might be. A problem tree is constructed by an initial process
of extracting major problems identified and then asking a successive series of but why? questions. The purpose is to differentiate between core problems, their causes and their
effects. Analysis of the root causes of core problems continues until a stage is arrived at where a health service
response can be identified (see Figure 1).

Ranking methods

Detailed strategy
development

Objective

Broad strategy
development

Stages in the planning spiral

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Using problem structuring in planning

131

Shortages of Female Staff

in Rural Health Facilities

Low Recruitment
of Female Staff

Low Knowledge
About Female
Non-medical
Careers

Absence of
Training
Opportunities

Women not Posted

to Rural Areas

Low Status/
Image of Female
Non-medical
Careers

Poor Security
in
Rural Areas

No Incentives
to Work in
Rural Areas

Low Rural
Female
Literacy Rates
Figure 2. Shortages of female staff: an example of deriving strategy

non-dependent link. Figure 3 shows an example of a mapping

which might lead to a possible decision to focus on the group
of actions decentralization/management training/improve
supervision.
Prioritize strategy areas
Planning is a process of making choices between competing
demands on limited resources and allocating these resources

Reduce
Population
Growth

Decentralization

Increase
Proportion
Female
Workers

Improve
Information
System
Focus on
EPI

Management
Training
Improve
Supervision

Figure 3. Mapping strategy areas

in a coordinated manner, in response to identified needs. To

enable choices to be made requires a framework of decisionmaking established on the basis of defined priorities. Priority
setting is ultimately a method of integrating peoples values
and judgements concerning perceptions of importance, with
raw data (Zalot and Lussing 1983).
All the strategy areas listed can not be tackled at once, nor are
they all equally important. Some will cost nothing, others will
be expensive in either time or effort, or both. A ranking exercise can assist in discriminating. It is suggested that only about
two or three priority strategy areas are taken for more
detailed development in any particular year. Generally, one
or two of these will have been carried forward from the rolling
effects of previous years strategic decisions.
A variety of ranking procedures exist, incorporating more or
less sophisticated approaches. As with other technical procedures employed, we have adopted the principle that maximizing participation implies minimizing complexity. The
ranking procedure adopted in the strategic planning process
constitutes ordering responses to a series of questions
grouped according to How important is this issue?, What is
the cost of change and the cost of no change, Does this strategic option affect. . .?, Does this strategic option require the
involvement of sectors other than the health sector?. Table 3
shows such a ranking scheme applied, using a scale of +, ++
or +++ to designate relative importance, a similar scale to designate relative savings, and -, or to designate relative cost,

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Women not
Recruited from
Rural Areas

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Colin Thunhurst and Carol Barker

Table 3. Ranking exercise: low recruitment of female staff

Low knowledge
about female nonmedical careers

Low status/image
of female nonmedical careers

A. How important is this issue?

1. Is change in this area feasible?
2. How urgent is this issue?
3. How large is the population group affected by this policy?
4. How much of health activity is affected by this policy?
5. How popular would resulting improvements be?

++
+++
+++
+++
++

++
++
+++
++
++

+
++
+++
+++
+

B. What is the cost of change and the cost of no change?

1. Will change cost money?
2. Will change save money?
3. Will change cost staff time?
4. Will change save staff time?
5. Will change cost effort in management and planning?
6. Will change save effort in management and planning?

+++
+++
+++
-

++
++
++
-

+
++
+++
-

C. Does this policy area affect:

1. accessibility
2. short-term perception
3. long-term credibility
4. efficiency
5. equity
6. employer policy
7. overall expenditure
8. quality of services

+++
++
++
+++
+++
+++
+++
+++

+++
+
+
+++
+++
+
+
+++

+++
+
+++
+++
+++
+
+
+++

D. Does this strategic option require involvement of other sector?

++

+++

as applied to an illustrative problem area of the Low Recruitment of Female Staff.

The broad strategy
The broad strategy will thus include a statement about health
service priorities. It will offer an approach to dealing with
these, and a suggested sequence in which different strategy
areas should be tackled. This will need to be taken in conjunction with consideration of the financial situation. At this
stage, the first two rows of the planning framework should be
fully specified. Developing the broad strategy will remain a
provincial level responsibility, incorporating provincial level
policy. Increasingly, though, it is anticipated that the influence
of district-level micro planning activities will show through.
Developing the detailed strategy
Developing the detailed strategy will follow similar general
procedures, though responsibility will be progressively transferred to the district level with a negotiated interaction with
provincial planning cells. In early years, provincial planning
cells will also be fairly heavily involved at this stage in a tutelage role.
Within each of the strategy areas prioritized within the broad
strategy, there will exist alternative ways of achieving specified
objectives. Using similar techniques as described above, a
detailed problem tree can be developed for each strategy area.
Within each strategy area, strategic options will be identified

for achieving the specified objectives. At this stage, we would

consider as many realistic options as possible.
Once options have been identified, we would again identify the
appropriate level at which each must be executed. Different
options identified will require a different response by the
health sector. Decisions about which options to consider will
involve dialogue between health sector levels. All options considered feasible will be listed and the health sector response
defined.
The various options will have different implications. Factors
such as cost, and attitude of communities and health workers,
may be important. In order to make priorities, we need to
take these into account. A ranking exercise, such as that
employed above, would again be used.
Following the steps outlined above will allow a detailed planning framework to be developed for each strategy area. This
will establish the medium term objectives within the planning
framework, and to a large extent short term objectives as well.
Given the current status of decentralization within Pakistan,
short term (35 years) objectives will be set primarily at the
provincial level, and inputs and activities defined at the
peripheral (district) level.
The objectives from the planning framework can be translated into planning guidelines. Planning guidelines will take
into account any constraints external to the planning process
(e.g. adjustments necessary to the current levels of recurrent

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Absence of
training
opportunities

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Using problem structuring in planning

133

or capital expenditure). They will also need to communicate

clearly to district level officers what are to be the priorities in
terms of short and medium term objectives. The specification
of inputs and activities will be made by district level officers
using a planning proforma.

people are brought in on an incremental basis, ultimately

involving community members alongside district health planning teams.

Issues of process within the planning process

Conceptually and methodologically, this approach to

developing planning guidelines demonstrates some close
similarities to the Strategic Choice Approach (Friend 1989).
At the stage of the planning cycle at which the planning guidelines are developed, planning officers are working mainly in
the shaping, designing and comparing modes. Thus, analysis
of decision (strategy) areas, through the use of mapping techniques, provides a valuable method for the initial exploration
of the decision space the shaping mode following the
development of the broad problem tree. The approach then
iterates between comparing and designing as options are
explored at the detailed strategy level (within strategy areas),
following ranking of strategy areas (comparing mode) and
prior to detailed prioritization within strategy areas (further
comparing).

Retaining flexibility in the planning process

There are also dangers that in using the planning framework

the process of monitoring can be overly quantitative, stressing the achievement of products over the operation of processes. We have not dwelt on the values of the logical
framework, either in its usage here as a planning framework,
nor as its more frequently encountered usage as a project
framework. This discussion will be developed in another
paper. It suffices to say here that our emphasis is on the planning framework as a means of clarifying and simplifying
monitoring, and upon its use as a discursive tool to aid transparency in discussion.
Retaining participation in the planning process
The way to ensure that the methodology does not become a
mechanism for retaining decision-making within the technocracy of a planning cell lies in the processes within which it is
embodied. Planning guidelines are a response to the situation
review and evaluation of progress which are contained within
the Situational Analysis document. Elsewhere, we have discussed at length how the situational analysis can be conducted
to ensure that participation is maximized, drawing from the
early experiences of community operational research (Thunhurst 1992).
It is, however, of great importance that participation is
actively sought in the stages which follow. The development
of problem trees, mapping and ranking all lend themselves to
group participation. In the course of developing problem
trees it is possible to support the development of group consensus as to the core problems, when at the start of discussion
people may frame the same issues quite differently. Mapping
and ranking, if carried out in groups, allow development of
consensus over values and criteria as well as over the particular judgements to be made about priorities at this point in
time. It is as important to consider who should be involved in
these activities, as to carry out the activities themselves. It is
envisaged that participation will broaden as time goes on and

Hard choices (choosing mode) generally come later as the

next years annual plan, and the two following years outline
plans are firmed up in the three-year rolling plan and the
operational plan for the forthcoming year. The latter, in particular, which will be embodied in the Annual Development
Plan, is subject to significant and influential players, in whose
minds the need to maintain a strategic vision over the future
direction of the health sector will not be uppermost. (It may
indeed prove important, as the strategic planning process
develops, to incorporate some formal stakeholder analysis to
pre-empt and negotiate these other players.) In many
respects, it will be the ability of the health department to
marshal and articulate its medium to long-term proposals,
through the strategic planning process, that will determine its
degree of success in the highly contested short-term planning
arena. This latter stage of the planning process will lend itself
to more game theoretic modes of analysis. But these are
outside the scope of the current article.

Ensuring sustainability
This paper has focused upon the description of the problem
structuring methods developed in the course of the
implementation of the health planning component of ADB3.
Another recent paper says rather more about the process
within which such development took place (Barker et al.
forthcoming). However, any reader familiar with health
systems strengthening project work will rightly wish to know
something of the extent to which these new processes are
institutionalized in Pakistan.
In the course of the development of these processes, the
project team worked successively with the entire staff of the
planning cells in each Province, and also at the Federal level.
All those staff had the opportunity not only to be trained in
the use of the methods described, but also to contribute to the
development of the detailed approach. A national workshop
was the final stage in agreeing procedures. Since the developmental work was undertaken, the planning cells staffs have

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There is a danger in presenting any planning methodology

that it can appear mechanistic and inflexible. If planning
methodologies are allowed to replace planning processes, this
danger is reinforced. Within the strategic planning process
developed for provinces in Pakistan, flexibility lies in the
mixed scanning interpretation of the planning cycle, particularly in its operation from year to year as a spiral. Within
each turn of the spiral, there is regular reference back, to
providers of information, decision-makers and earlier planning decisions. Thus, the evaluative process, which is formally
embodied in the Situational Analysis document, is conducted
constantly.

Use of problem structuring techniques

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Colin Thunhurst and Carol Barker

had the opportunity to meet on an inter-provincial basis regularly and thus to provide mutual support.
The trend towards decentralization has taken root relatively
late in Pakistan but it is now the case that different provinces
are moving at different paces towards the devolution of planning and management functions to the district level. As the
work described here provides a ready-made framework for
the devolution of planning responsibilities, there is every
hope that this work will provide the basis for a usable and
robust approach to problem structuring.

Endnotes
1 This paper has been prepared following the authors engagement under British Aid arrangements. The British Government
bears no responsibility for, and is not in any way committed to, the
views and recommendations expressed herein.
2 From May 1997, the Overseas Development Administration
was re-designated Department for International Development. The
new title, and the acronym DFID, will be used throughout this article.

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Acknowledgements
This study was undertaken within the DFID-funded Health Planning
Component of the Asian Development Banks Third Health Project.
The component was thus jointly undertaken by the Government of
Pakistan and DFID, managed by the British Council and provided
with technical inputs from the Nuffield Institute for Health, University of Leeds. The authors would like to thank DFID for its
support. The opinions expressed in this article reflect the views of the
authors and do not imply agreement from either DFID or the
Government of Pakistan.
The authors would like to thank Mr Malcolm McNeil, Senior Health
and Population Adviser, DFID, for his helpful comments and suggestions.

Biographies
Colin Thunhurst has a first degree in Economics with Statistics and
a Masters degree in Statistics and Operational Research from the
University of London. He has been a Lecturer in Quantitative Techniques in Management and Planning at the Nuffield Institute for
Health since 1987. From 1992 to1996, he occupied two positions, on
leave of absence from the Nuffield Institute, with the British Council
in Pakistan. From 1992 to 1994, he was Health Planning Adviser,
situated within the Federal Ministry of Health in Islamabad, under
the ODA-funded Health Planning Component of the ADB Third
Health Project. From 1994 to 1996, he was British Council Project
Director for the ODA-funded components of the Second Family
Health Project, located in Lahore. From 1997 to 1998 he was Project
Director for the DFID-funded District Health Strengthening Project
in Nepal.
Carol Barker is the Head of the International Division at the
Nuffield Institute for Health in Leeds, where she works in the field
of health policy and planning. She is also the UK-based technical coordinator of the DFID-funded Health Systems Strengthening Component of the Second Family Health Project currently being
undertaken in Punjab and Balochistan Provinces, Pakistan. She
came to Leeds in 1979 following nearly four years in Mozambique,
working in the Ministers Cabinet of Studies in the Ministry of
Health, with particular responsibilities for policy development in the
areas of pharmaceuticals, traditional medicine, and the medical curriculum. Prior to that she worked in Tanzania, teaching at the University of Dar-es-Salaam in development studies in relation to
medicine and science. Recently she has undertaken work in the
Indian sub-continent and in West Africa.
Correspondence: Carol Barker, Nuffield Institute for Health, International Division, 7275 Clarendon Road, Leeds LS2 9PL, UK.

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The degree to which provincial planning officers have adopted

these somewhat sophisticated techniques into their regular
working practices has varied from province to province. Variation has depended mainly on the level of specialist planning
skill exhibited by individual planning officers, on the extent to
which their role in strategic planning has been acknowledged
and encouraged by their senior officers, and on the continued
provision of further technical assistance through the subsequent Family Health Projects. The approaches have not been
presented to planning officers as a complete set, but rather as
a series of aids that can be employed at appropriate stages.
Thus, extensive use is now being made of causal analysis and
the associated problem trees; use of mapping and ranking
methods is more rudimentary.

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