Before and Beyond Objectives and Goals: The Vision

by David Werner

In the planning and evaluation of health programs, often a great deal of discussion is devoted to “objectives” and “goals.” Goals tend to be more general, objectives more specific, but both are—or, it is commonly agreed, should be—clearly defined. They become the fixed landmarks toward which the ship sets sail.

But there is something bigger and more subjective that precedes objectives and goals and that contributes to both their formulation and the strategy of their pursuit. This is the dream of where we would like to go: the vision.

The difference is figuratively—and too often literally—a matter of life and death. Goals and objectives lie “out there,” fixed and defined. They are static, like rocks or ports. But a vision is boundless, fluid and evolving. It is both inside us and beyond us. It is the human response of past and present trailing into the future and beyond. It can be noble or selfish, and is often a mixture of both. It cannot be objectified or tied down in time and space. It canges and grows constantly. It soars:

This may sound very abstract and philosophical, scarcely meat for a ministry of health. Yet such considerations are ultimately pragmatic. For it is the vision of man that shapes and distorts his “objective” choices—and which leads him to both his gas chambers and cathedrals.

Whether the vision of those behind a government or community health program is the shared vision of many or the elite vision of a few, whether it is basically authoritarian or humanitarian, will have a lot more to do with the practical reality of the program than will its stated goals and objectives.

The World Health Organization (WHO) has set as its overall goal “the provision of basic health care to all the world’s people by the year 2000.” An admirable goal—or a frightening one:—depending on how it is interpreted and by whom. As has already been demonstrated, it means radically different things to different people, even among the top experts within WHO’s palatial headquarters overlooking Lake Geneva.

• Does it mean extending our existing professionally controlled, centralized and stiflingly paternalistic health services to “penetrate” the “target” populations of poverty?…Or does it mean working to change the socio-politico-economic structure that perpetuates poverty, hunger, and ill health?

• Does it mean increasing the dependency of the poor on existing institutions that would keep them both poor and powerless? ….Or does it mean helping the poor to organize at the family and community level to take greater control over their lives and health?

• Does it mean “fertility control” through payment of women to take (or pretend to take) the pill, and raids by “health police” to sterilize women and adolescent boys by force to meet required quotas (as we know is happening)?…Or does it mean facilitating social and political changes that will permit the poor to improve their economic base and so discover for themselves—as have the rich—the benefits of a small family?

• Does it mean modifying (yet preserving) a social order that produces increasingly poor health among the rich as it perpetuates poor health among the poor, because it is fundamentally unfair and corrupt?…Or does it mean working together toward a new social order that is sensible, just, and kind?

• Does it mean preserving our “human right” and inalienable “freedom” to exercise unlimited greed while one third of mankind goes hungry?… Or does it mean struggling to overcome human selfishness through human understanding and love?

• Does it obstruct, or does it open the way, for more equitable distribution of power?