The relationship between planning and performance can be perplexing, even in simple situations where few people are involved. It becomes much more complicated when plans are made on a vast scale for the benefit of people whom the planners themselves may never meet and whose view of their own most pressing needs may never be asked. How can the gap between the people on the receiving end of planning and the well-intentioned designs of planners often far removed from the recipients best be bridged, so that imagination and resources may achieve the most beneficial result?

Since the 1940s international health...

Understanding the Integrated Health Program requires a look at the organizations that created it: the Nepal government and the international donor agencies. Their goals, structure, and patterns of operation have determined how ICHP was planned and carried out. Cultural differences among the health bureaucracies complicate the planning process: thus, the program that has emerged reflects the interactions among the bureaucratic cultures as well as their linkages to the cultures of rural Nepal.

Since 1951, Nepal has been governed by a constitutional monarchy. Broadly speaking, Nepal’s administrative bureaucracy consists of three levels, with the king and the Palace Secretariat at the...

In the realm of international health aid, donor agencies exert a strong influence over the policies of many recipient governments. Certainly their influence has been strong in Nepal. To understand the decisions that created Nepal’s rural health program, one must first look at the trends in policy among international health agencies and in Western scientific health thinking as a whole, as they have developed in recent decades. It is a history that progresses from early efforts to control epidemics to the modern emphasis on providing rural health services and preventive care.

The nineteenth-century colonial powers entered the field of international...

Because integration was being phased in during the late 1970s, health posts varied considerably in the range of services provided. Broadly speaking, they can be divided into three categories: nonintegrated, partially integrated, and fully integrated. Nonintegrated posts had not yet assumed any responsibilities from the vertical projects; they simply provided treatment for common illnesses. Partially integrated posts had assumed some vertical project responsibilities and had village health workers attached to them to provide outreach services. Fully integrated posts provided all services, including those formerly covered by the vertical projects. In 1978–79, Nepal had 533 health posts: 185 were nonintegrated,...

Planners need different kinds of information about the recipient country at different stages of planning. In addition to information on local administrative procedures and economic resources, they may need only general information about the local culture to formulate an overall policy on financial assistance and project guidelines. But the closer the plans are to the actual delivery of services, the greater the need for detailed cultural information.

The officials I interviewed in the donor agencies and in the government generally agreed that cultural information is rarely used in planning. Among several reasons they gave, the most important were that cultural...

In recent years an ever-expanding body of documents from WHO, UNICEF, USAID, and other organizations concerned with international health has stressed the need to utilize in the planning process appropriate sociocultural information obtained through research at the grass roots. Yet there is little evidence that this advice has had much effect. Decisions continue to be made, as in the past, in accordance with a very different system of dynamics—that of successful bureaucracies. And in part the problem lies in the lack of adequate sociocultural information and in a lack of understanding of the research methods that could provide it....