A planning programming budgeting system for a university student health service

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A planning programming budgeting system for a university student health service
Berry, Waldron, 1924-
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Subjects / Keywords:
Budgeting ( jstor )
College students ( jstor )
Colleges ( jstor )
Diseases ( jstor )
Health care industry ( jstor )
Health care services ( jstor )
Physicians ( jstor )
Planning programming budgeting ( jstor )
Student health services ( jstor )
Universities ( jstor )
Dissertations, Academic -- Management and Business Law -- UF ( lcsh )
Management and Business Law thesis Ph. D ( lcsh )
Program budgeting -- Florida -- Gainesville ( lcsh )
bibliography ( marcgt )
non-fiction ( marcgt )


Thesis - University of Florida.
Bibliography: leaves 219-238.
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Dedicated to Dott


The writer wishes to express his profound gratitude

to members of his supervisory committee, Drs. William V.

Wilmot, Jr., Ralph H. Blodgett, Charles W. Fristoe,

John H. James and Ralph B. Thompson, whose counsel was

extremely helpful. Dr. Wilmot, the chairman of the

committee, was particularly contributive and frequently

interrupted a very busy schedule to provide timely and

important suggestions.

Special thanks are due Wilmer J. Coggins, M.D.,

Director of the Student Health Service at the University

of Florida, who provided significant assistance in the

research and showed great understanding and interest.

Dr. Ben Barger, Dr. Ewen M. Clark, Mr. Stephen Pritz

and the other members of the staff at the Student Health

Service were always helpful and most cooperative.

. i.



ACKNOWLEDGMENTS ..................................... iii

LIST OF TABLES ........................................ vi

LIST OF CHARTS .................................... vii

ABSTRACT ........................................... viii


I. INTRODUCTION ................................. 1

The Nature and Importance of
the Problem ........................... 8
Methodology ............................ 11
Sources of Data ......................... 13
Scope and Limitations ................. 14
Results .................................... 18
Related Research and Literature ......... 19
Overview ................................ 27

CEDURES AND LIMITATIONS ................. 29

Concepts ............................... 36
Guidelines and Procedures ............... 40
Limitations ............................. 50
A PPBS for the University of
Florida ................................ 58


Historical Development .................. 71
Setting and Rationale .................... 77
Operation ................................ 84
Goa s .................................... 87
Objectives .............................. 87
The University of Florida Student
Health Service (SHS) .................. 104


Chapter Page


The Problem ............................. 113
Some Approaches to the Problem .......... 115

SERVICE: A MODEL ....................... 141

Statement of Objectives ................. 146
Program Structure ...................... 148
Current Programs and Previous
Accomplishments ...................... 154
Recommended Improvements in
Existing Programs ..................... 168
Future Projects ........................ 176

HEALTH SERVICE .......................... 182

RECOMMENDATIONS ........................... 198

Findings and Conclusions ................ 198
An Appraisa .............................. 207
Recommendations ........................ 209

BIBLIOGRAPHY ...................................... . 219

BIOGRAPHICAL SKETCH ................................ 239


Table Page

1. Some Basic Differences Between
Budget Orientation ...................... 34

2. A Typology of Health Service Systems
Associated with College Com-
munities ................................ 135

3. Comparative Statistics: Services
Provided by University of
Florida Student Health Service .......... 156

4. Incidence of Diseases Students at
the University of Florida
Fiscal Year 1969 ........................ 157

5. University of Florida Mental Health
Service and Research Project
Annual Activity Report July 1968-
June 1969 ................................. 158

6. Space Requirements ......................... 180


Chart Page

1. Student Health Service, University
of Florida-October, 1969 .................. 105

2. Planning Activity Sequence .................... 185

3. Format for Budget Preparation-
Auxiliary Units ............................ 1883

4. A "Crosswalk" Format .......................... 195


Abstract of Dissertation Presented to the Graduate Council
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy



Waldron Berry

August, 1970

Chairman: W. V. Wilmot, Jr.
Major Department: Management and Business Law

A more effective means of allocating scarce resources

to organizations supported by public funds is necessary. One

management tool which has been employed for such purposes is

a planning-programming-budgeting system (PPBS).

The problem in this exploratory research is to

determine what relationships exist between budgeting incre-

mentally and budgeting under the PPBS concept in the case of

a particular university student health service.

First, the literature was searched to identify a

conceptual framework of PPBS and to study the development

and nature of university student health services. Also an

investigation of the University of Florida Student Health

Service (SHS) was accomplished by following the guidelines

of a field study. Data were gathered through unstructured

interviewing, by observation, from documentary materials


and through participation in the activities of an inter-

disciplinary task force formed to implement PPBS in the SHS;

and a model was developed by appropriately relating this

information. Cost-benefit analysis is an important part of

PPBS; therefore, the literature regarding the benefit side of

the analysis is discussed.

Findings emanate from the study and conclusions are

drawn. There was generally a lack of qualified, experienced

personnel, and implementation of PPBS was attempted too

quickly and on too broad a scale. Strong leadership and under-

standing of the potential value of the PPBS approach are

prerequisites for success although initial acceptance stems

from the value of PPBS as a vehicle for justifying require-

ments rather than as an effective internal management tool.

The Director of the SHS was a strong leader, and PPBS seemed

to enhance his control. He could observe more accurately

the cost of programs, had an opinion on the degree of program

effectiveness and could judge whether the benefit was worth

the cost.

Planning for and implementing PPBS by the interdisci-

plinary task force formed in the SHS seemed more progressive

and imaginative than accomplishments by largely administrative

groups. PPBS required the SHS staff to evaluate their

activities and to set future objectives. Communications

between administrative levels of the SHS and the parent

Health Center were not smooth and this caused unnecessary

work and obstacles for SHS personnel.

Finally, recommendations were made. Responsibility

for initial implementation of PPBS should not be divided.

Additional personnel qualified in PPBS concepts and principles

should be recruited or available personnel trained.

A method of evaluating the effectiveness of the

programs of the SHS and the utilization of its facilities

should be developed in order to provide benefit measures

necessary for cost-benefit analyses. A possible approach

would be to combine information from interviews designed to

reveal health habits of students with more precise physio-

logical data from polyphasic health testing.

Legislators should be familiarized with the concepts

and principles of PPBS. If this is not done, PPBS will fail

of its intended purposes.

The problem of determining benefits has been

discussed; however, cost analysis, although treated briefly,

requires further research.



A planning-programming-budgeting system (PPBS)

attempts to link forward planning to budgeting through

programming and to provide information which will help

the manager to make resource allocation decisions. The

first task in implementing PPBS is to identify objectives

of the organization and to group required activities into

programs which will accomplish these objectives. Where-

ever practicable, alternative means of accomplishing

objectives are specified and costs and benefits associated

with each alternative are systematically compared. The

desired course of action is normally chosen according to

objective criteria which have been selected; however, the

decision is the responsibility of the appropriate decision-

maker. PPBS emphasizes the output of a program whereas

traditional budgeting stresses inputs or objects of

expenditure. Future costs and benefits are estimated and

considered in the systematic analyses of alternatives.

The future is also reflected in the program arcl financial

plan which is a multiyear budget divided according to

program categories, subcategories and program elements.

Schult:e (1968, pp. 26-27) describes this plan as a


- 2 -

tabularar record of an agency's proposed activities,

measured in both physical and financial terms and grouped

by output-oriented categories."

Terminologically, PPBS is relatively new, but many

of the concepts of which it is comprised are not (Novick,

1966, p. 1). The establishment of the process in the

Department of Defense by Secretary McNamara in 1961

provided considerable publicity; but President Johnson's

directive of August, 1965, which instructed other major

agencies in the Federal Government to establish PPBS and

use the Defense Department model as a general guide,

provided a very important impetus to widespread imple-

mentation of the process in the public sector. Even with

such impressive support, however, there still exists

confusion and a general lack of understanding of PPBS,

significant terminological trouble, and overstatement of

potential and progress challenged by repeated reviews of


The confusion and lack of understanding are not

surprising. Enthoven (1967, p. 2) apparently equates

systems analysis with PPBS. Novick (1969, p. 60) equates

program budgeting with "the planning-programming-

budgeting systems abbreviated to PPB." Hitch (1967,

pp. 10-11) provides some clarity by explaining that PPBS

is embraced by two management techniques which are program

- 3

budgeting and systems analysis. Confusion returns, however,

when he mentions that "program budgeting" is sometimes

shortened to "programming" and "systems analysis" is

replaced by such terms as "cost-effectiveness analysis,"

"cost-benefit analysis," "operations" and "operations

research." McKean (1968, p. 135) -maintains that "cost-

effectiveness analysis,' "systems analysis," "operations

research" and "economic analysis" are simply terms used

for different applications of cost-benefit analysis, which

he describes as estimates of certain costs and benefits

associated with various alternative courses of action.

On the other hand, some authorities attach different

meanings to such terms as PPBS. Churchman (1968, p. 81)

admits his frustration with the matter and explains that

various writers allow their backgrounds to affect their

definitions. Another likens the confusion surrounding PPBS

with the fable of the blind men and the elephant and believes

the trouble results from individuals concentrating on various

aspects of the process (W. A. Carlson, 1969, p. 2). Escarraz

(1968) discusses still other diverse views of the subject.

It has been clearly recognized, even by proponents

of PPBS, that overstatements of potential have too often

accompanied discussions of PPBS and perhaps the establishment

of the process in the Federal Government. President Johnson

advised that through PPBS we will have the ability to

- 4 -

Identify our national goals with greater precision.

Determine which of these goals are the most urgent.

Develop and analyze alternative means of reaching
these goals most effectively.

Inform ourselves accurately of the probable costs
of our programs.

Improve the performance of the Federal Government
to insure the American taxpayer a dollar's worth of
service for each dollar spent. (Johnson, 1967a, p. 3)

The primary critics of PPBS who strongly emphasize

limitations and other shortcomings are authorities from the

political science and public administration areas. Also,

it is no secret that members of Congress do not support all

aspects of PPBS (U. S. Congress, 1968b, p. 5). Most of

these individuals are strong proponents of the political

decision-making process.

J. W. Carlson (1969) reports on the progress and

prospects of PPBS in the Federal Government and discusses

some limitations and achievements which have become apparent

since the establishment of PPBS in 1965. Basically, he

believes that the ideal has not been accomplished through

PPBS; however, when compared with accomplishments during

the pre-PPBS period, progress has been significant. His

closing remarks clearly indicate that capability at the

state and local levels to implement the PPBS approach is

- 5 -

becoming very essential. For all practical purposes,

$26 billion of federal expenditures were administered by

state and local governments in the fiscal year 1970

(J. W. Carlson, 1969, p. 634).

In 1967, the State Legislature of Florida created

the Florida Office of State Planning (Chapter 23, Part 1,

1967 Florida Statutes). Although it was not explicitly

stated that this organization would implement PPBS in state

government in Florida, the terminology used implied such

responsibility and it was so interpreted. Realizing that

the state's public institutions, including the University

of Florida, might soon be formally directed to employ PPBS

techniques, several organizations at the university, in the

second half of 1969, expressed an interest in commencing

appropriate investigations concerning the PPBS process. One

of these organizations was the Student Health Service.

There are many organizations within the University of Florida

which are similar in nature and have comparable objectives;

however, the Student Health Service is particularly unique

and implementing PPBS in this organization presents a

definite challenge. One aspect of the challenge is the

current state of health services in general. As former

Secretary of Health, Education and Welfare, WVilbur Cohen,

said, "there is no real orderly system in the United States

today for determining the optimum location, size and use of

health facilities" (1968, p. 46).

- 6 -

A system also seems to be lacking in the operation

of most student health services. This is not to say that

all should be alike, because as universities and colleges

vary in size, financial condition, and other aspects, their

objectives and programs probably should differ. Neverthe-

less, there would seem to be many systems that are pertinent

to student health services.

The Committee for Management Systems of the American

College Health Association was appointed in 1969 and is

already attempting to develop a uniform cost reporting

system which could result in very useful comparative data

from participating student health services throughout the

country (Averill, 1970). If a standard of measuring

program output effectiveness could be developed, it should

be possible to perform cost-benefit analysis. This type of

analysis is, of course, a key element in PPBS. Measuring

costs can be difficult, but measuring output effectiveness-

or even accurately defining the output of a particular

program-is extremely challenging in the health field. The

problems of output definition and measurement and the

question of standardizing measures of quality of output so

that there can be useful product comparisons have been of

recent concern to some very competent economists (Somers

and Somers, 1967, p. 35).

- 7 -

There are other problems and characteristics of

student health services whose effects on the implementation

of PPBS are pertinent but are not so obvious. For example,

programs or emphasis placed on programs might differ from

other health organizations, because health problems of the

college student usually do not include diseases of infancy

and degenerative diseases; however, emotional problems of

maturation and adolescence can be very important (Farnsworth,

1964, p. 16). Unfortunately many university administrations

believe their concern should be directed toward providing

education and not promoting or maintaining student health,

except for emergency care (Ginsburg, 1955, p. 8).

Summerskill (1955, p. 71) found that policies of colleges

toward responsibility for students' emotional and physical

welfare include noninvolvement in nonacademic affairs of

the student, token programs of involvement and serious

regard for students' total welfare. Apparently a very

important factor in the student health service operation

is this particular aspect of the philosophy of the univer-

sity administration. A related question of much signifi-

cance concerns the most effective way organizationally

for a director of a student health service to relate to the

university administration (Farnsworth, 1964, pp. 9-10).

Also a point of discussion is the maintenance of con-

fidentiality of medical information about students.

- 8 -

Expectations of members of the university community who do

not appreciate the full impact of the legal, moral and

ethical obligations of the physician to maintain such

confidence causes some to question whether medicine can be

practiced in a university student health service as if the

service were a detached medical facility and not part of a

university (Coggins, 1970a). As noted previously these

latter problems and characteristics of student health

services have a more indirect effect than other problems

on PPBS implementation; nevertheless, their presence en-

hances the challenge of the overall problem.

The Nature and Importance of the Problem

The specific problem which will be investigated in

this research project will be to determine what, if any,

relationships exist between budgeting traditionally

(incrementally or decrementally) and budgeting within the

conceptual framework of a planning-programming-budgeting

system in the case of a particular university student health

service. This investigation will, of course, require the

development of a model which will include all or some of

such elements as program structure, objectives, measures

of accomplishment of objectives (output measures), program

memoranda, special analytic studies and program and finan-

cial plans. Typically, these have proved to be formidable


- 9 -

Although the Department of Health, Education and

Welfare has prepared a number of program analyses related

to health, there is little discussion or specificity about

the programs themselves or representation of sequential

relationships (Gross, 1969, p. 135). With regard to student

health services, apparently no models of consequence have

been developed; therefore, it is hoped that the product of

this investigation will help fill a large research gap.

The Chairman of the Committee for Management Systems

Development, American College Health Associaticn, when

queried concerning attempts to adapt the PPBS model to

student health services, replied: "A few scattered attempts

have been made at other health centers, but they have been

at best primitive and cannot be considered to be functioning

in the true sense that the PPB system was intended" (Averill,


Since it is planned that the State of Florida will

commence changing to PPBS in fiscal year 1971, the timing of

the project, as far as gaining maximum, immediate benefit is

concerned, is excellent. However, the local situation and

the problem as originally stated are part of a larger problem

which seems to be prevalent throughout the country.

It has been evident for some time that many univer-

sities supported primarily by public funds are experiencing

increasingly more difficulty in acquiring the resources

- 10 -

which university officials believe are adequate to provide

quality education and services (including medical service).

Reasons for these difficulties in attaining needed funds

are varied; however, important competing programs such as

welfare and highways, as well as higher taxes and unusually

high rates of inflation experienced in recent years,

particularly in 1969, are cited (Maxie, 1969, p. 33).

There are some persons familiar with the situation

who believe that past methods used by "institutions" to

gain necessary resources will not, suffice in today's

environment. Hitch (1967, p. 16) who moved as Assistant

Secretary of Defense, Comptroller, under McNamara to

Chancellor of the University of California, believes such

institutions as armies, navies, universities and hospitals

are ready for some management techniques which will induce

some efficiency. According to Hitch, generals, admirals,

educators, doctors and hospital administrators do not

believe that dollars matter because "national security" or

"quality of the next generation" or "life" is at stake.

Hitch believes that these programs are important but that

dollars do matter and that rules of economy and efficiency

should be followed to achieve as much a possible from

scarce resources. Many legislators appear to be taking a

similar view although they may tend to make decisions on

many occasions in the political decision-making process

- 11 -

with only secondary attention given to economy and efficiency.

If PPBS will assist in establishing a decision-making process

which will suggest ways of allocating scarce resources more

effectively, then this information should be known. Hope-

fully, this investigation will contribute to a better

decision-making process.


This research is an exploratory study and consists

of the following phases.

First, a thorough search of the literature was

accomplished to identify a conceptual framework of PPBS,

including methods and formats which could be used to indicate

possible applications of PPBS to a specific university student

health service.

Second, a study of the development and nature of

student health services in general was accomplished by

examining the literature; and a careful investigation of the

development, rationale and operation of the University of

Florida Student Health Service in particular was completed

by generally following the guidelines of a field study.

Data were gathered primarily through unstructured interviewing,

by observation, from documentary materials and through partici-

pation in the activities of a task force formed by the

Director of the Student Health Service in 1969 "to begin

- 12 -

-organized planning for two purposes. The first, is to use

the techniques of systems analysis as an aid in acting on

long range goals of the Student Health Service. The second,

is to use the above data to support the planning and design

for a new building for student health" (Coggins, 1969, p. 1).

In large measure, the first and second phases were

performed concurrently.

Third, a PPBS model was developed by appropriately

relating the information gained in the first two phases.

The objective of this model is to provide the bases for

analyses from which information can be gained which assists

in decision-making at the Student Health Service, particu-

larly in the area of resource allocation.

Fourth, comparisons will be presented of data from

a program and financial plan for the Student Health Service

with data developed by traditional budgeting methods to

determine what, if any, relationships exist between elements

of the program and financial plan and the traditional budget.

Fifth, conclusions are drawn concerning pertinent

relationships between PPBS and traditional budgeting and

the potential utility of the model in the student health

service setting.

Finally, appropriate recommendations are made.

- 13 -

Sources of Data

A few scattered attempts at application of PPBS

to university student health services have been made but

with relatively little success (Averill, 1970). Quantities

of PPBS literature have emanated from RAND Corporation and

some of this was used to assist in establishing a conceptual

framework of PPBS concepts of cost analysis and techniques

for measuring benefits. Otherwise, much of the literature

from RAND deals with PPBS related particularly to Defense

Department problems. There is considerable additional

literature which deals primarily with PPBS concepts, poten-

tials and limitations. Although not dealing with health

problems in particular, some of this literature is general

enough, or situations in other areas of interest are

similar enough, that it could be used. There is some

literature available which deals with the economics of

health, health costs, measuring various aspects of health

care, especially benefits, which has been used for background

material as well as a source of quantitative data where pos-


A principal source of data was government

publications, particularly those from Congressional

committees which have recently investigated PPBS in the

Federal, state, and local governments and those that have

delved into American health care problems. Also there has

- 14 -

been useful guidance published by the Bureau of the Budget

for use by the various federal agencies which is appro-

priate for this research since the State of Florida planning

authorities appear to be following this guidance in a gen-

eral way. The Department of Health, Education and Welfare

has published several program analyses of various diseases

as well as specific guidance to their several agencies

concerning the implementation of PPBS in the Department.

This information proved particularly useful.

As suggested earlier, a major portion of the data

was developed from a field study at the University of Florida

Student Health Service. The data were collected through

unstructured interviews, observation and analysis of docu-

mentary materials.

Scope and Limitations


This research includes the development of a model

and analysis of selected aspects of the model, both of

which relate to the student population at the University of

Florida. The stated trends of college health programs are

changing to include (1) episodic health care for students'

dependents, faculty and staff, as well as environmental

surveillance and health promotion and (2) the coordination

of the college health activities with activities and health

- 15 -

resources outside the college community such as local,

state, federal, public and voluntary health programs and

resources (Gage, 1969, p. 1). There is no argument with

the inclusion of the additional segments of the population

or the extramural activities; however, the critical feature

lacking is that there has been little analysis of the kind

required by PPBS performed on any aspect of student health

activities. It is hoped that by analyzing the smaller

population initially, the model can be expanded later to

include the additional elements, and analysis will be more

effective than if the entire problem were approached in

this investigation. This seems especially true since the

trends mentioned still appear to be in the conceptual stage

in many instances.

The model and analysis include interrelationships

which exist within the student health service. Interrela-

tionships between activities within the student health

service and outside are discussed and represented in the

model; however, a thorough study of such "outside" inter-

related activities is not an objective of this investigation.


Limitations associated with PPBS are numerous and

will be discussed in more detail later; however, limitations

of primary importance to this investigation concern the

- 16 -

development of the program structure, measurement of total

costs and effectiveness of various student health activities

and programs and the selection of appropriate criteria

(McKean, 1968, pp. 131-135; Hitch and McKean, 1960, pp. 158-


These limitations, of course, derive from a number

of causes. There probably is not one program structure

that is unquestionably the best. For example, particular

activities may take place in more than one program and,

therefore, may be placed in different programs. Changing

the program structure when deemed necessary does no great

violence to the PPBS approach, however.

Allocating costs to various elements of a particular

program or to various programs generally includes a certain

amount of arbitrariness and, therefore, impreciseness.

Measuring effectiveness of these elements and programs is

usually even more difficult. The latter problem may occur

because objectives stated have been very vague at best, or

inaccurate or nonexistent at worst. Also, the qualitative

nature of health care makes the development of precise

measurements of effectiveness formidable. Establishing

appropriate criteria is similarly arduous because of the

qualitative nature of health; however, there has been

little need for criteria because of an apparent lack of

incentive to develop alternative courses of action.

- 17

Somers and Somers (1967, p. 5) mention that data

concerning the health field are fragmentary and dispersed

among institutional sources which are not well known. They

also note that characteristics of the health field make

economic analysis very difficult. For example, institutions

which represent a major portion of the supply of health

services are noncompetitive, nonprofit institutions; price

has a relatively minor part in the determination of the

demand for and distribution of health care; and consumer

choice also plays a relatively minor part "in a field where

the consumer is a reluctant buyer, the financing is often

through third party instrumentalities, and the consumer

typically lacks the knowledge, confidence, or any practical

mechanism for exercising meaningful decision as to the

character, quality, or quantity or services to be rendered"

(1967, p. 5).

With respect to the trouble associated with the

development of precise measurements, Enthoven's counsel is

followed. He states, "We try to measure those things that

are measurable, and insofar as possible, to define those

things that are not, leaving to the responsible decision-

makers the job of making the difficult judgments about the

imponderables" (Enthoven, 1967, p. 9). Realistic proponents

of PPBS make no claim that it will produce decisions.

Enthoven (1969, p. 902) also points out that his experience

- 18 -

has been that criteria are usually very crude initially

and not very satisfying but serve as a useful and necessary

starting point for the development of more satisfactory


Resu ts

Although a PPBS model has been developed which

-represents a specific university student health service,

it is hoped that the model can serve as a prototype for

other university student health services. In all cases,

the purpose of the model is to provide more and better

information to the decision-maker which will assist him in

making more effective decisions concerning long-range

planning and the allocation of scarce resources.

In attempting to determine what, if any relationships

exist between budgeting traditionally and budgeting within

the conceptual framework of PPBS, a conversion matrix or

"crosswalk" has been constructed. This is a means of trans-

lating from a program budget to the traditional budget or

appropriation/budget structure and is necessary during

periods when both methods of budgeting are being used. This

is currently the situation in the Federal Government.

The yardsticks for measuring costs and benefits of

the several programs as well as the criteria which are

selected are rather crude in many cases; however, it is

- 19 -

*intended that they will activate argument which will result

in the development of more precise measures and serve as a

point of departure in the further development of more

refined criteria.

In some cases, appropriate output measures may be

determined but necessary data are unavailable. In such

situations, procedures are suggested to commence the col-

lection of the necessary information. The PPBS effort should

not stop because of the lack of desired data but should con-

tinue with less desirable measures with knowledge of the

weakness and also that under the circumstances a crude

measure is probably better than no measure at all.

Related Research and Literature

During the sixties, while PPBS increased in use and

popularity in some areas, neither results of research nor

other types of literature were produced which discussed the

operation of university student health services according

to the concepts of PPBS. Even current, general literature

about the nature of the operation of a student health service

is relatively sparse.

The Journal of the American College Health Association,

where information is exchanged about medical practice in univ-

ersity student health services, recently published a revision

of Recommended Standards and Practices for a College Health

Program with a supplement, "Ethical and Professional

- 20 -

Relationships" (October, 1969). This publication represents

a very substantial effort and helps in the formulation of

objectives of individual student health services; neverthe-

less, little guidance was provided on the method of measuring

the accomplishment of the objectives cited. Terminology

included planning, programming, budgeting, programs and

program objectives; however, the use of PPBS or concepts

and rationale related to it was not suggested.

Generally, there is not much evidence that PPBS has

been installed in many of the country's medical facilities.

Nevertheless, there does seem to be useful information

available, although some applies to specific parts of PPBS,

e.g., the measure of program effectiveness.

Opponents of PPBS such as Wildavsky (1966, 1969),

Mosher (1967, 1969) and Lindblom (1959, 1961, 1963 with

Braybrooke, 1965) seem to be primarily concerned with the

possibility that PPBS proponents are attempting to replace

the political decision-making process. Also Mosher (1969,

p. 161) has pointed out that PPBS is not as well suited for

some types of organizations as for others.

Schultze (1968) has addressed the first concern

effectively in his attempt to synthesize the political

approach to decision-making and the analytic approach

suggested by PPBS. Schultze believes that the PPBS analyst

is naive if he ignores political constraints and thinks that

- 21 -

"efficiency alone produces virtue" just as he believes

that a decision-maker cannot ignore resource constraints and

think that "virtue alone produces efficiency" (1968, pp. 75-


With respect to the second concern, Hitch (1967,

p. 16) agrees that PPBS may be implemented with varying

degrees of effectiveness but points out the danger of dis-

crediting the entire concept of PPBS if attempts are made to

move "too far too fast." He believes it can be useful in

most situations and specifically points out the potential in

the health field, as does Enthoven (1967, p. 9). Novick

(1969, pp. 63-64) expands implementation suggestions and

provides more detailed recommendations for two alternative

courses of action. One of the alternatives would aim for

implementation of PPBS in 18 months to two years. The other

suggested course of action assumes the positive value of the

PPBS concept and includes specific instructions related to

taking some"great leaps" and putting PPBS into effect in

the current planning and budget cycle.

In 1965, the Department of Health, Education and

Welfare (HEW) was directed to implement PPBS, and Rivlin

(1969) describes what occurred during a three-year period

after implementation and suggests some valuable lessons that

were learned. Of particular interest is her description of

two types of program evaluation followed. One is roughly a

- 22 -

pass-fail process which is performed for Congress, while the

other tries to identify successful ways to commit funds to a

cited objective and increase average program effectiveness.

She also discusses the performance of other important aspects

of PPBS such as analysis of alternative courses of action and

the planning cycle under PPBS (Rivlin, pp. 914-921). Some of

the information in this paper appears to be transferable and

useful during the process of implementation of PPBS in a

student health service.

Grosse's paper (1969) may be even more useful since

it is entirely directed to the health field rather than the

three fields of health, education and welfare. He discusses

some of the data that need to be known in order to make

resource allocation decisions and describes approaches em-

ployed in the Department of Health, Education and Welfare

(HEW). In order to gain better understanding, his four-step

procedure would include (1) problem identification, (2) assign-

ment of current and potential activities to the problem,

(3) learning the status of activities' resources and (4) under-

standing the political environment (Grosse, 1969, pp. 1199-

1200). He also has useful discussion on developing information

and measuring program output. The very important point is

made that measures might be quite crude at first, e.g., in

terms of such initial program impacts as persons covered, and

then refined to such ultimate benefits as cases cured and

- 23 -

productive years added. These and other implementation

procedures are explained in much more detail in a guidance

manual provided by HEW (1968b). In this manual, all PPBS

terms are defined, sample program structures are illustrated,

output data are discussed and the preparation of a "cross-

walk" is explained, among other things. HEW has also pub-

lished several program analyses such as Cancer (October,

1966b), Arthritis (September, 1966a), Selected Disease-ControZ

Programs (September, 1966e) and Kidney Disease (1968a). As

cited above, these program analyses have been criticized

by Gross (1969, p. 135) because the programs are not

specified in adequate detail and also because no model

displaying sequential relationships is shown.

Another source of very specific and useful guidance

is the Bureau of the Budget (U. S. Congress, 1968a). When

President Johnson (1967c, pp. 1-2) directed that PPBS would

be implemented throughout the executive branch, he also

designated the Bureau of the Budget to supervise the initi-

ation-and operation of PPBS. Budgeting may be performed on

an incremental basis in which last year's budget is used as

a base and increased or decreased by a percentage of the

base. "Zero-base" budgeting has no base and each budget

item must be thoroughly justified each year. Incremental

budget procedures have normally been followed in the govern-

ment but PPBS is zero-base oriented, in that current programs

- 24 -

are evaluated on the basis of stated objectives rather than

last year's budget (Schultze, 1968, pp. 79-80). Schultze

(1968, p. 80) points out that personnel in his agency had

not intended to require a zero-base review for all program

elements, but admits there was a lack of selectivity by his

subordinates. The result was the submission of reams of

paperwork which represented "comprehensive analyses" but

actually were not worth much. The important point for any

organization using PPBS to realize is that realistic criteria

must be selected by which programs or program elements will

be identified for analysis in depth. A very recent pub-

lication from the Bureau of the Budget provides even more

useful guidance, in that examples of various required sub-

missions such as a program memorandum, a special analytic

study, a program and financial plan and the federal budget

by program structure are illustrated (J. W. Carlson, 1969,

pp. 676-762).

There have also been publications which address the

specific problem of measuring the effectiveness of programs

in terms of output, which PPBS emphasizes. This is a chal-

lenging task and one that has not been addressed effectively

because objectives to be measured have not been well stated,

-or useful measures or desired related statistics have not

been available, and there has been considerable reluctance

to commence with crude measures. As indicated above,

- 25 -

Enthoven (1969, p. 902) encourages the use of crude measures

if these are all that are available, since this will initiate

argument which will produce more refined measures. A recent

conference addressed this problem of assessing effectiveness

and, although it pertained to child health services, the

concepts and possible measures discussed appear to be quite

transferable to this project (Bergman, 1967). In one paper,

for instance, measurement of the input (e.g., health per-

sonnel, facilities, patients), intervening factors (e.g.,

appointment keeping and utilization) and ultimate criteria

or output (e.g., death, disability and disease) are con-

sidered as parts of the medical care process (Haggerty,

1967, p. 62).

At the same conference, White (1967, p. 24) correctly

points out the extremely important role that the definition

of objectives plays in the evaluation of effectiveness of

health care for adults as well as for children. He speaks

of a "performance" budget and distinguishes between activi-

ties ("seeing children") and performance.

Fein, taking the economist's viewpoint and discussing

the benefit-cost rates, verifies a pitfall cited above when

he warns that trying to be too "scientific" will delay

progress and quotes Voltaire who reportedly remarked: "The

best is the enemy of the good" (1967, p. 50). With regard

to relating the benefit of the benefit-cost ratio to earning

- 26 -

power, Fein was criticized because it was suggested that

if such measures were used, handicapped children and young

adults as well as older adults would probably not receive

treatment (Fein, 1967, p. 52). This argument does little

violence to PPBS, however. Benefit-cost analysis is a tool

to provide more and better information to the decision-

maker, and criteria on which decisions are based are meant

to be selected by the decision-maker and not provided by

the analyst.

The condition of data in many areas is also

unsatisfactory; however, there are suggestions available

concerning this problem area. Linder (1968, pp. 360-361)

believes that more is needed than a death rate to determine

an acceptable health index for the country and proceeds to

discuss new techniques which may assist in judging the

health of the nation. He tells of the many problems associ-

ated with medical case records collected by physicians or

compiled in hospitals and believes that it is necessary to

go to those persons about whom medical information is

desired. Sullivan (1966) discusses some conceptual problems

related to the development of a health index.

In a later chapter, appropriate information from

these and other sources is examined more carefully in an

effort to induce a conceptual framework, including procedures

and formats, which reflects the PPBS approach and may be used

to assist the decision-maker in a university student health


- 27 -


In Chapter II much of the literature concerning

PPBS is reviewed. Generally the information includes the

PPBS approach, the so-called traditional (incremental or

decremental) method of budgeting and the political decision-

making process. The purpose of the review is not to prove

or disprove the utility of the various approaches but to

establish advantages and disadvantages of each and partic-

ularly to discover possible applications of the PPBS to a

university student health service.

Chapter III is essentially a discussion of university

health services. It begins with the development of student

health service and ends with the current status of university

health services. It draws heavily on the Recommended

Standards and Practices for a College Health Program and

includes a brief but specific discussion about the Student

Health Service at the University of Florida.

Cost-benefit analysis is a very important aspect of

the PPBS approach; however, relatively little has been

developed with respect to measurement of the benefits of

various health programs. This is such an important aspect

of the PPBS approach that Chapter IV is devoted to a review

of the rather limited information regarding possible criteria

for the measurement of the output of health programs.

- 28 -

In Chapter V a program structure for the Student

Health Service at the University of Florida is outlined

and the various program categories, subcategories and

program elements are explained.

Chapter VI compares budgeting at the Student Health

Service at the University of Florida according to the

traditional method with a PPBS approach to the same task.

To facilitate this comparison, a "crosswalk" procedure is


Findings are reported, conclusions are drawn and

recommendations are suggested in Chapter VII.



Opinions of PPBS range all the way from President

Johnson's (1967b, p. 2) claim that it is a new and revolution-

ary way to plan, program and budget to that of the quizzical

political scientist (Mosher, 1967, p. 70) who is still

looking for the differences between the PPBS concepts es-

poused by David Novick, RAND Corporation and the Defense

Department and the traditional program budgeting which

supposedly originated several decades ago. There are varying

accounts of the origin and development of PPBS (Schulte, 1968,

pp. 1-17; Shick, 1968; Novick, 1966); however, only a

relatively brief description of this information seens neces-

sary for this investigation, since the primary concern re-

lates to the concepts, guidelines and procedures which have

been developed in the Federal Governnent since 1961 or by

others who have demonstrated expertise in the field and

whose contributions seem useful in addressing planning,

programming, and budgeting problems in a university student

health service. Limitations of PPBS are also of prime inter-

est and several have materialized during implementation


- 9 -

- 30 -

Novick (1966, p. 1) states that program budgeting

was introduced into the Federal Government in 1942 by the

War Production Board. Although he is unable to pinpoint the

origin in industry, he believes DuPont was practicing some-

thing very much like program budgeting before 1924. He briefly

traces the development of program budgeting to the implemen-

tation directive by President Johnson in 1965 by explaining

theControlled Materials Plan with which he was closely

associated during World War II and cites later steps in the

federal development taken by the Bureau of Reclamation, the

Coast Guard and the RAND Corporation.

Schultze (1968, pp. 1-17) arrives at President

Johnson's directive to implement PPBS by a substantially

different route and gives much credit for his explanation

to a "perceptive article" by Shick (1966). Both authors

essentially describe the evolution of budgetary techniques

of which PPBS is the latest major improvement and in some

respects represents, according to Schultze, "a quantum jump

from the past" (1968, p. 5). Borrowing from Anthony (1965),

Schultze explains that a budget may have the roles of fi-

nancial control, managerial control and strategic planning.

Although he defines each role, he uses the purpose of the

roles to explain succinctly the significance of various

governmental developments:

Both financial and managerial controls take the objectives
of federal programs, their design and specification, and
the level at which they are carried out as given. The

31 -

purpose of these controls is to insure that approved
programs are operated honestly, efficiently, and ac-
cording to the provision of the law. Strategic planning,
however, brings into the budgetary process precisely
those decisions about program objectives, specifications
and level which are taken as given in the financial and
managerial control functions. (Schultze, 1968, p. 6)

Unlike 'ovick (1966) who credits industry for the

origin of PPBS, Shick (1966, p. 245) places the first stage,

which is primarily concerned with expenditure control, in the

Federal Covernment during the period 1920-1935. During this

period of "control orientation," the Budget and Accounting

Act of 1921 was significant and established an executive

budget for the first time since Hamilton's days as Secretary

of Treasury. The Bureau of the Budget was established; how-

ever, budgeting and policy making were completely separated,

and "paper clip efficiency" took precedence over more general

management practices (Schultze, 1968, pp. 8-10).

During the New Deal Era, the President's Committee

on Administrative Management (the Brownlow Committee appointed

in 1937) criticized the forcefu] emphasis placed on control

by the Bulreau of the Budget and strongly urged that it change

its emphasis to coordinating, under Presidential direction,

the elements of the rapidly growing federal structure. Ac-

ceptance of the suggestion and the shift to a management

orientation became effective as the Bureau of the Budget

transferred organizationally from the Treasury to the Execu-

tive Office :1 the Presidn-t. It. subsequently, increased

- 32 -

its staff tenfold with persons trained in public administration

rather than in accounting as had predominated when the emphasis

was on control. In 1949 the Hoover Commission labeled the

practice of budgeting according to activity as "performance

budgeting" (Schick, 1966, pp. 249-250).

Chronologically, Shick (1966, p. 251) places the be-

ginning of the planning orientation phase in the mid-1950's

when Novick, Smithies, McKean and other economists strongly

suggested that the budgetary process be reformed by drawing

from economics and systems analysis. The performance budg-

eting concept which then guided the budgetary process drew

heavily from cost accounting and scientific management, and

references in the literature described budgeting as a manage-

ment tool and equated the budget to a "work program." Manage-

ment-oriented performance budgeting developed functional

budget categories and attempted to increase efficiency of

particular activities by supplying work-cost measurements.

However, program budgeting is oriented toward planning at-

tempts to provide for sound policies by supplying the decision-

maker with useful cost and benefit data related to alternative

courses of action in accomplishing established objectives and

by providing nonsubjective criteria which are necessary for

effective accomplishment of the established objective. Ob-

jectives are generally fixed in performance budgeting; where-

as, objectives are continuously in the process of being

- 33 -

refined in PPBS. Shick summarizes many of his ideas with a

table (see Table 1) which depicts the nature of various

characteristics of the elements of the budgetary process as

they are related to the three primary budget orientations

which occurred during the 1920's.

Many of those best known for questioning the utility

of PPBS are political scientists and public administrators;

however, there is typically a reasonable amount of opposition

from many persons in organizations simply because of resistance

to change. Schultze (1968, p. 2) explains that PPBS using

cost-benefit analysis is designed to provide answers to

problems by ascertaining the most efficacious solution based

on objective criteria; whereas, political decision-making

renegotiation between individuals and groups who frequently

do not use objective criteria and, at the same time, possess

significantly differing values. Pursuing either approach to

the exclusion of the other does not seem to be the most real-

istic decision-making practice. In many decision-making situ-

ations, it is not possible or practicable to develop the one

best solution; therefore, a certain amount of compromise or

arbitrariness is necessary. This is especially true in the

health care field because of difficulties in meaningfully

quantifying elements required for decision-making. Never-

theless, quantification and observance of objective criteria

where possible are useful just as it is useful to understand

that substantially differing values must be considered in


Some Basic Differences Between Budget Orientation

Characteristic Control Management Planning

Personnel Skill

Information Focus

Key Budget Stage

Breadth of

Role of Budget Agency


Type of Choice

Control Responsibility

Management Responsibility

Planning Responsibility


Organizational Link





































Source: Shick, 1966, p. 258.

- 35 -

many decision-making situations. Hopefully this problem may

be recognized and objection dismissed when it is understood

that PPBS is not meant to replace all other forms of, and

aids to, decision-making but rather to assist significantly

in decision-making because it aims to supply more and better

information to the decision-maker and sometimes this creates

difficulties. It seems reasonable to assume however, that

most serious decision-makers would desire the maximum amount

of useful information available.

The first two phases of the changing budget orien-

tation emphasized control and efficiency, respectively; how-

ever, Schultze briefly explains how PPBS goes beyond control

and efficiency in at least three ways with respect to the

Federal Government:

S. (1) it is concerned with the specification of ob-
jectives and the selection of programs; (2) it presup-
poses that decisions on these matters can be aided by
systematic analysis, using criteria which are, at least
in part, not political; and (3) it establishes a planning
system that tends to strengthen the authority of the
upper tiers of the executive hierarchy-the President
and his department heads-against the lower tiers of
hierarchy-the heads of subordinate bureaus and offices.
And in so doing it significantly affects the web of re-
lationships between the executive and the Congress.
(Schultze, 1968, p. 16)

Schultze cautions that in each of these areas, PPBS

is potentially in conflict with the political decision-making

process. It is not the purpose of PPBS to replace the politi-

cal decision-making process and Schultze (1968, p. 101) spends

much time in assessing the appropriate relationship between

- 36 -

the analytic method employed by PPBS and the political process.

This relationship is crucial since the survival of PPBS de-

pends on consideration of "political constraints" in program

selection which vary from program to program.


Enthoven (1969), Schultze (1968) and J. W. Carlson

(1969) have all been intimately connected with implementing

PPBS in the Federal Government and all explain the process in

somewhat different terms. In some instances the differences

seem to be more apparent than real and in other cases differ-

ences appear to be slight but are meant to represent improved

instructions or explanations. Schultze (1968, pp. 19-24) has

listed six aims or tasks of PPBS which seem to represent the

concepts of all three authorities. First, PPBS requires a

careful and specific definition of the objectives of the pri-

mary areas of activity of the organization. This requirement

presents some very difficult problems initially. At times

objectives are stated in such general terms that their ac-

complishment cannot be measured and, therefore, are useless.

In other cases they have been so narrowly defined for ease

of measurement that they are likewise not very useful as a

primary objective of the organization. It is crucial that

the relationship between objectives and criteria (or output

measures) is thoroughly understood. Objectives may have to

be revised in order that meaningful criteria can be developed

just as criteria may have to be less statistically elegant

(at least initially) than is desired in order that some neas-

sure of accomplishment of a meaningful objective can be made.

Of course, simply defining an objective in a meaningful way

can be a torturous task in itself.

PPBS is output-oriented; therefore, the second task

is to determine what the output of each program is and how it

will be measured. For example, using the number of patients

seen by a doctor as a measure of the effectiveness of a pre-

vention program in health care would not be desirable since

patients examined are inputs rather than outputs and do not

necessarily indicate the effectiveness of a prevention pio-


Third, the total costs of the program must be meas-

ured. This is possibly a less difficult task than measuring

output in most cases, but it is by no means a simple task.

There are frequently indirect costs which are difficult to

detect. but, nevertheless, should be provided to the decision-

maker and considered before making the decision. Necessarily,

a certain amount of arbitrariness accompanies allocation of

costs and impreciseness accompanies arbitrariness. Addition-

ally, future costs of the various programs must be estimated

and listed. Program recommendations have been accepted be-

cause the future benefits were emphasized and more than

- 37 -

- 38 -

justified the initial costs, but in some cases costs of future

years became prohibitive and the program had to be abandoned

after much money had been spent but long before the pay-off

period. Knowledge of costs of programs for future years-

even though they are rough estimates-will provide the decision-

maker with much information needed to avoid such long-range

-situations where benefits are more apparent than costs.

The fourth aim of PPBS is to develop programs and

objectives for future years. Certainly with respect to many

programs in the health care field, it would be difficult to

accomplish all potential objectives in one year. For example,

if it were desired to provide complete health care for de-

pendents of students, it would probably be necessary to phase

in such a program over a multi-year period with various sub-

programs and objectives established for each of the years.

There have been some problems in this area of PPBS implemen-

tation in the Federal Government. Rivlin (1969, p. 919),

J. W. Carlson (1969, p. 623) and Schultze (1968, pp. 22-23,

97-101) provide different views of the fact that the Bureau

of the Budget now instructs the various departments that the

program and financial plans "should reflect the future impli-

cations of current and past program decisions of the agency

head and, subsequently, of the President" (U. S. Congress,

1968a, p. 6). It should be noted that no provision is made

to reflect the implications of future decisions and associated

- 39 -

projected costs. (This point will be discussed in more

detail later when program and financial plans are described.)

Fifth, if PPBS is followed, alternative courses of

action will be considered normally by comparing costs and

benefits of each program and supposedly selecting that course

of action which provides a specific benefit for the least

cost when compared with other alternatives or provides the

maximum benefit for a specifically prescribed cost. This

approach does not produce the obviously correct answer be-

cause of the precise quantitative data compared with the

single quantitative criterion. The job is much, much more

difficult, especially in the health care field and is

fraught with pitfalls stemming from the need to make nu-

merous qualitative judgments. (These limitations will be

specified in some detail later in this chapter.) It is

necessary to understand the value of using cost-benefit

analysis as a framework within which to think about the types

of choices that have to be made by the decision-maker

(McKean, 1968, p. 142).

Finally, after subjecting the appropriate policies

and programs to analyses along the lines described above,

the results should be combined with the budgetary process.

The results gained through the analytic process described

should provide data that will enhance the probability of

occurrence of more effective decisions. Schultze finally

summarizes the goals of PPBS as:

- 40 -

. the specification of objectives, the evaluation
of program output as it relates to objectives, the meas-
urement of total systems cost, multi-year planning, the
evaluation of alternative program designs, and the inte-
gration of policy and program decision with the budgetary
process. (Schultze. 1963, p. 24)

Guidelines and Procedures

Since President Johnson assigned the Bureau of the

Budget the responsibility of supervising the implementation

of PPBS throughout the executive branch of the Federal Govern-

ment, the most authoritative information and instructions with

respect to PPBS are contained in BoB Bulletins 68-2 and 68-9

(U. S. Congress, 1967f, pp. 9-34, and 1968a, pp. 1-19). Also,

even more current information is provided by Jack W. Carlson

(1969), Assistant Director for Program Evaluation of the

Bureau of the Budget. More specific guidance for areas of

particular interest to this investigation are contained in

a publication from the Department of Health, Education and

Welfare (1968b). Utilizing information from these documents

does not mean revisions may not be suggested, and some of

the instructions may be of too general a nature because of

the level of the organization for which they were developed;

however, since state, county and municipal organizations will

be working with organizations of the Federal Government, it

does not seem realistic to attempt to develop a thoroughly

original format. Accordingly, this investigation will be

- 41 -

pursued generally using the terminology and elements employed

in the publications cited. If additional, pertinent data are

developed by the State of Florida or by the University of

Florida, these, of course, will be used as applicable.

J. W. Carlson lists the following component parts of

PPBS: "(1) Program structures which display each agency's

physical and financial activities according to objectives or

common outputs; (2) issue letters which summarize the agen-

cy's and Budget Bureau's list of major policy issues in need

of analysis and evaluation during each planning and budgeting

cycle; (3) special analytic studies which reflect intensive

analysis of particular problems; (4) program memoranda which

register agency choices between alternatives and summarize

relevant analysis affecting the decisions; and (5) programs

and financial plans which display for the past 2 and next

5 years data on the financial inputs and physical outputs

resulting from proposed and past commitments" (1969, p. 613).

According to the Bureau of the Budget, activities

in the program structure should be grouped together in a

manner that allows cost-effective analysis of alternative

courses of action to be performed; consequently, each group

should contain activities with common objectives or outputs.

However, program categories need not and probably will not

coincide with appropriation/budget structure categories or

with organizational structures. Usually the program structure

- 42

of an organization will include program categories, program

subcategories and program elements which are established

according to the following general criteria specified by the

Bureau of the Budget:

a. Program categories-The categories in a program
structure should provide a suitable framework
for considering and resolving major questions of
mission and scale of operations which are a proper
subject for decision at the higher levels of
management . .

b. Program subcategories-Subcategories should provide
a meaningful substantive breakdown of program cate-
gories, and should group program elements producing
outputs which have a high degree of similarity.

c. Program elements---A program element covers agency
activities related directly to the production of
a discrete agency output, or group of related out-
puts. Agency activities which contribute directly
to the output should be included in the program
element, even though they may be conducted within
different organizations, or financed from different
appropriations. Thus program elements are the basic
units of the program structure.

Program elements have these characteristics: (1)
they should produce clearly definable outputs,
which are quantified wherever possible; (2) wherever
feasible, the output of a program element should be
an agency end product-not an intermediate product
that supports another element; and (3) the inputs
of a program element should vary with changes in
the level of output, but not necessarily propor-
tionally. (U. S. Congress, 1968a, p. 3)

An example of a portion of the program structure

developed for the Student Health Service at the University

of Florida and with four levels of classification is shown:

- 43 -

2 Remedial Measures

2.1 Diagnosis and Evaluation

2.11 Inpatient
2.111 Intake
2.112 Evaluation
2.113 Discharge or Transfer

Developing the program structure can be very diffi-

cult but useful simply because it requires an explicit

statement of objectives as well as a determination of how

accomplishment can be measured. A careful analysis of this

nature can also indicate gaps in missions of an organization

as well as possible trade-offs and alternatives that may

be detected and considered (J. W. Carlson, 1969, p. 617).

Although the program structure is the framework of

PPBS, the primary elements of PPBS are three documents:

the program memorandum (PM), the special analytic study

(SAS), and the program and financial plan (PFP). Program

memoranda concern major program issues (MPI) which are

specific questions that require answers during the current

budget cycle. Typically these questions will come to the

head of the organization in the form of "issue letters"

from the person charged with implementing and monitoring

PPBS. In the Federal Government, the Director of the

Bureau of the Budget sends out the issue letters, although

it is possible to establish a major program issue through

verbal discussion and without a formal letter. Major

- 44 -

program issues are developed so that the most important

problems can be determined and analyzed, since competent

PPBS analysts are somewhat limited throughout the federal

agencies (J. W. Carlson, 1969, p. 618). The Bureau of the

Budget provides the following guidance concerning major

program issues:

A Major Program Issue is a question requiring decision
in the current budget cycle, with major implications
in terms of either present or future costs, the di-
rection of a program or group of programs, or a policy
choice. The most important feature of the statement
of a Major Program Issue is the identification of
specific alternative courses of action, and the costs
and benefits of each. (U. S. Congress, 1968a, p. 2)

Instructions from the Bureau of the Budget in 1967

indicated that a program memorandum should be prepared on

each program category (U. S. Congress, 1967f, p. 10); how-

ever, this apparently was considered impractical with re-

spect to the somewhat limited analytic resources of the

agencies. Also, one former Director of the Bureau of the

Budget (Schultze, 1968, p. 80) indicates that some of his

employees may have been less than selective in their require-

ments for analyses. At any rate, BoB Bulletin 68-9 instructs


A PM presents a statement of the program issues, a
comparison of the cost and effectiveness of alternatives
for resolving those issues in relation to objectives,
the agency head's recommendations on programs to be
carried out, and the reasons for those decisions. PM's
therefore provide the documentation for the strategic
decisions recommended for the budget year. (U. S.
Congress, 1968a, p. 2)

- 45 -

The strategic analytic studies simply show the de-

tailed analyses that led to the decisions articulated in

the program memoranda. Some of the strategic analytic

studies analyze problems which are applicable only to the

current year while others are continuing studies which might

be established to gain more useful data, to study the effec-

tiveness of program objectives and possible alternatives as

conditions change over time and to gain information which

seems likely to prove useful regarding future major program

issues (U. S. Congress, 1968a, p. 2).

The document which is derived from the aforementioned

documents and elements is the program and financial plan.

It is defined by the Bureau of the Budget as

a comprehensive multi-year summary of agency programs
in terms of their outputs, costs, and financing needs
over a planning period covering the budget year and
four future years, or a longer period if this is appro-
priate to agency programs. (U. S. Congress, 1968a, p. 2)

Although program memoranda deal only with major program

issues, program and financial plans will portray a summa-

rization of costs, benefits and financing needs for all

programs. Accordingly, the PFP is regarded as the basic

planning document of PPBS by the Bureau of the Budget.

Alice Rivlin (1969), Assistant Secretary for Planning and

Evaluation, HEW, until March, 1969, disagrees with this

belief and claims that the Bureau of the Budget now allows

consideration of future budgeting implications of only past

- 46 -

and present decisions rather than requiring a comprehensive

multiyear program and financial plan which includes budgetary

implications of future decisions. Further, she accuses the

Bureau of the Budget of backing away from forward planning

with their change in procedure because a plan from which

implications of future decisions have been removed is no

longer a plan. She believed the Bureau of the Budget made

the change so that the administration would not be embarrassed

by plans being exposed that could indicate a strategy or be

criticized when, in fact, no decisions had been made or ap-

proval given.

Schultze (1968, pp. 26-30, 97-101), Director of the

Bureau of the Budget during this implementation period, recog-

nized and discussed the problem cited by Rivlin and the di-

lemma that existed. Although he realized that the change in

procedure took away the forward planning aspect of the program

and financial plan, he feared that if longer term projections

were allowed without some constraints they would tend to be

"pie-in-the-sky" estimates and of limited value. Moreover,

if longer term plans were approved and later it was deemed

wise to stop or cut back the plan, he could visualize con-

siderable resistance. He suggests a compromise solution.

First, a PFP should be prepared on the basis of future impli-

cations of past and present commitments. Second, the head

of the agency could also prepare plans which considered

- 47 -

longer term programs and related financial implications;

however, this second plan would be tentative in nature and

used primarily as an internal management tool by the par-

ticular agency head.

J. W. Carlson (1969, p. 623) is more specific in

his criticism of requiring consideration of financial impli-

cations of future decisions as outlined in the original in-

structions for the preparation of program and financial plans.

According to Carlson, the original instructions resulted in

a series of "lengthy wishlists" which reflected the desires

of the heads of agencies if funds were generally unrestricted.

Many agencies indicated annual increases in program expend-

itures of about 25 per cent. Some agency heads attempted

to be more politically astute and asked for smaller increases

which seemed more likely to gain approval. Carlson believes

that without consistent constraints on the availability of

future funds, this type of program and financial plan prepa-

ration is of little value. The fact still remains, however,

that with the content of the PFP limited to future impli-

cations of past and present commitments, the PFP is not

really a document representing forward planning in its true


One problem that arises for all organizations de-

rives from the need to establish a direct relationship be-

tween the program structure which is the framework of PPBS

- 48 -

and the appropriation structure used as a framework on which

to base monetary appropriations. In other words, the organ-

ization must determine its requirements in terms of the

program category/budget structure and then translate these

requirements into appropriation/budget structure terms. This

is accomplished by developing a "crosswalk" which provides

a means of converting from the program structure of PPBS to

the appropriation structure. This conversion will be re-

quired until the U. S. Congress and state legislatures ap-

propriate funds according to program categories, subcategories

and elements rather than according to traditional or func-

tional categories. Relatively little specific information

is found in the literature with respect to the development

of a crosswalk. However, HEW provides some quite specific

directions to its agencies concerning the relationship be-

tween the program structure and the appropriation/budget

structure. The crosswalk is described as "a simple table,

the stub of which lists program categories and the columns

of which show appropriations and budget activities" (U. S.

Department of Health, Education and welfare, 1968b, pp. 16,


Important in this translation is the program budget

code which is a six-digit code derived from the normal ap-

propriation code and assigned to each operating program

which is a combination of resources and activities that

- 49 -

have the same management and a common source of funding.

There is also a program category code which is a six-digit

code assigned to a program element and indicating the lo-

cation of the program element in the program structure.

Each of the operating programs is assigned to a category

in the program structure. Frequently one operating program

will be assigned to more.than one program category but this

simply illustrates that operating programs have more than

one purpose. The program budget codes allow the multi-

objective nature of the operating programs to be identified

and analyzed through the program structure of PPBS and to

be translated again via the crosswalk into the operating

program of the appropriations structure.

If there is a head of an organization who wants to

use PPBS and he has a competent staff of analysts, there is

a high probability that the system can provide significant

assistance to the top-level decision-maker who wants to make

his own decisions and understand why he makes a particular

decision (U. S. Congress, 1968d, p. 6). There has also

been a considerable amount of criticism directed at PPBS;

however, much of the faultfinding may be somewhat emotional

in nature and deriving from those who prefer the political

decision-making process to one emphasizing analysis. Never-

theless, there are real pitfalls and problems related to

PPBS which should be seriously considered even by enthu-

siasts of this analytic approach.

- 50 -


When President Johnson decided to implement PPBS

in the Federal Government, he overruled suggestions from

some members of the Bureau of the Budget to follow a step-

by-step procedure and approach and implement PPBS in a few

agencies at a time on a selective basis. Hindsight suggests

that a less rapid rate of implementation might have been

more effective (U. S. Congress, 1968b, p. 2). The suc-

cessful development of PPBS in an organization requires

thorough understanding and a high degree of patience by

those charged with the responsibility of implementation,

a cooperative attitude by most of the other organization

members and a continuously demonstrated high interest on

the part of the top manager. Premature attempts to install

PPBS before such an environment can be developed runs the

risk of failure or at least less than the most effective

operation. On the other hand, waiting until the situation

seems precisely "ripe" can allow the opposition time to

entrench themselves firmly enough to thwart any attempt at


If approval is gained to implement PPBS, many

operational problems can be anticipated. There will be

problems working out objectives, developing programs and

accomplishing the remaining requirements of PPBS. Initially

- 51 -

it will probably be necessary to work under the normal

appropriation/budget structure as well as the program struc-

ture of PPBS. This will require much additional paperwork,

the development of a crosswalk and will undoubtedly cause

many to wonder if the initial or foreseeable results are

worth the additional effort. Accordingly, it has beer.

recommended that the program structure be as similar to

the appropriation structure as practicable (Novick, 1965,

pp. 293-294). Charles Zwick, Director of the Bureau of

the Budget in 1968 was quite specific about this in his

commentary accompanying PPBS guidelines to the heads of

executive agencies. At this time he commented:

Bulletin 68-9 reflects recognition that a "two-
track system"-one geared to program analysis and a
separate one to appropriations-may result in confu-
sion and an undue burden of effort on both agency and
Bureau staff now involved in working with similar data
in both systems. In Bulletin 68-9 we have, therefore,
asked that agencies consider changes in their program
structures to assist in integrating program and ap-
propriations structure, where such changes will not
impair the usefulness of the program structure for
analysis and program decisions. (U. S. Congress,
1968a, p. 18)

It is generally understood that analysis is a very

important requirement for a successful PPBS and many have

expressed fear that analysis will provide irrefutable an-

swers and thereby obviate the need for judgment by the

decision-maker and generally downgrade his role. Schlesinger

52 -

(1968, pp. 3-7) recognizes this possibility but believes

that a more important question is whether the decision-

maker will allow all appropriate analysis to be performed

". even when it is his own hobby horses which are under

scrutiny? How many hobby horses are there? Are they off

limits to the analysts?"

Several authorities indicate that adoption of PPBS

will probably cause a centralization of power through con-

trol and there will be a shift of this control from the

lower levels of management to top management or the top

executive (Shick, 1969; Capron, 1969; Mosher, 1969). It

generally is reasoned that since PPBS will provide the top

decision-maker with more and better information about pro-

gram categories, he will be able to make effective decisions

himself rather than finding that many of the required de-

cisions have been made by the time recommendations reach

him (Shick, 1969, p. 143).

There have been many references to the Defense

Department as the prime mover of PPBS and the implication

has frequently been that this analytic approach to decision-

making allowed Secretary McNamara to gain the control the

Secretaries of Defense should have had in the past. Mosher

(1969, p. 163) is quite specific on the point and states

that acquisition of strength by the Secretary of Defense in

his associations with the Joint Chiefs of Staff, the military

- 53 -

"services, the U. S. Congress, and private industry was

possibly the most significant outcome of PPBS in the

Department of Defense. The assertion that under traditional

or incremental budgeting procedures followed by agencies of

the Federal Government, budgetary power resides in large

measure at the lower levels of management reinforces

McNamara's accomplishment (Shick, 1969, p. 143). However,

recent information (Heiman, 1970) would attribute the shift

of power to the methods of McNamara and his Assistant

Secretary of Defense, Systems Analysis, Alain Enthoven,

rather than to PPBS. According to this account, the Joint

Chiefs of Staff and the military services submitted budget

estimates which reflected the monetary amounts necessary to

fulfill every United States commitment made throughout the

world. This practice was required by McNamara but, according

to the current Secretary of Defense, Melvin Laird, such a

budget estimate was unrealistically high. Nevertheless,

after the request was submitted as required, the Office of

the Secretary of Defense would lower the estimate by about

30 per cent ". .thus annually emerging as heroes who

overcame the greedy brass" (Heiman, 1970, p. 43). In fact,

a Draft Presidential Memorandum which indicated the com-

position and funding of the various program categories of

the whole Department of Defense was prepared by Enthoven's

organization and the military services were given one month

- 54 -

to request reconsideration. Typically, the rebuttals were

disapproved. Certainly this was an example of the power

of an organization shifting to the top; however, the changing

decision-making process did not seem to derive from PPBS

techniques. In fact, it would appear that the advantages of

the PPBS approach were not being exploited. Although the

military services were displeased with the way PPBS was

forced upon them in the past, they currently agree that the

situation required them to develop an analytic capability.

Accordingly, they now feel perfectly capable to assume the

role of decision-makers within PPBS guidelines as articu-

lated by the Defense Department (Heiman, 1970, p. 45).

Recognizing the limitations of PPBS under these

circumstances, Secretary Laird has more or less reversed

the process and pushed much of the decision-making downward.

Although the Office of the Secretary of Defense still pro-

vides ceilings and general fiscal guidance to the Joint

Chiefs of Staff and the military services, these organi-

zations may make various analyses and choose trade-offs

within the general fiscal guidance. Now analyses are being

transmitted to the Office of the Secretary of Defense for

review rather than the other way around (Heiman, 1970,

pp. 44-45).

There should be some flexibility in establishing

PPBS and changes in policies indicating such flexibility

- 55 -

are apparent in the Federal Government. For example, the

Bureau of the Budget has changed its requirement from com-

prehensive projections of all contemplated programs to

projections related only to programs which have been approved,

now requires program memoranda on only major program issues

and not on "matters small and large, peripheral and central,

and back burner and front" which produces useless volumes

that gathers dust on the shelves, and encourages organiza-

tions to develop a program structure which is as compatible

as possible with the appropriation structure and still allows

useful analyses within the framework of PPBS (U. S. Congress,

1968b, pp. 3-4).

It is most important to understand that if the top

manager is not reasonably enthusiastic about installing

PPBS, this approach to decision-making will probably not be

very successful. Undoubtedly, McNamara's strong support and

very active participation contributed significantly to the

establishment and development of PPBS in the Defense Depart-

ment. Schelling was even more specific on this point when

he said:

PPBS works best for an aggressive master; and where
there is no master, or where the master wants the
machinery to produce his decisions without his own
participation, the value of PPBS is likely to be
modest and, depending on the people, may even be
negative. (Schelling, 1968, p. 2)

There are some very difficult problems to be faced in

developing a program structure. Schultze (1968, p. 32) has

- 56 -

warned against striving for an "ideal" program structure,

the existence of which he categorizes as one of the mis-

conceptions of PPBS. Fisher (1966b,p. 27) warns that months

or even years could be spent developing the "perfect" pro-

gram structure but suggests that since the perfect structure

does not exist, about two months of intensive work is needed

to develop a useful initial program structure. This is a

very difficult job and Quade (1966b,pp. 19-26) discusses

some associated problems under the heading of limitations.

He warns particularly that systems analysis is not scientific

research because, even though attempts are made to maintain

standards of scientific inquiry and follow scientific methods,

the purpose of the analysis is primarily to suggest courses

of action rather than to predict outcomes. Although there

is an attempt to emulate engineering and use the results of

science to accomplish things economically and efficaciously,

differences are apparent when the approach is applied to

national problems. It becomes evident that value systems

applicable to the problems are difficult to discover and

methods of testing validity are also generally unavailable.

Further, systems analysis is less objective than many believe

because of the judgment and intuition that enters into model

designing, determination of relevant factors, selecting

alternatives, choosing criteria and the like. However,

Quade believes that following a "party line" unconsciously

- 57

represents the most hazardous pitfall faced by the analyst

and, further, that this situation exists to some degree in

all organizations. After citing the pitfalls, he specifies

that necessary incompleteness of analysis, lack of methods

to predict the future and the inexact nature of measures of

effectiveness are limitations which restrict analysis to an

advisory role.

There never seems to be enough resources to perform

an analysis with the degree of thoroughness and accuracy

desired by the analyst. Usually there is a time limitation

and also a monetary restriction which forces the analysis

to be cut short and thereby submitted in incomplete form.

It can only be hoped that the most important factors have

been considered. Even if time and money were not limited,

the intangible and incommensurable nature of some of the

factors would probably preclude appropriate consideration.

The best that can be done is to provide the decision-maker

with as thorough a description of the relevant factors as


Methods of forecasting are constantly being improved

but still it is not possible to be certain about the future;

accordingly, it is appropriate to predict future events in

terms of ranges of possible futures. Certainly this type

of analysis is usually much better than no analysis, but

succeeding events can be disastrous if suggested courses of

- 58 -

action are accepted without considering their contingent

nature. On occasion, quantitative values are assigned and

the analysis may appear so elegant that an undeservedly

high degree of validity and accuracy may be imputed to the

recommended course of action emanating from the analysis.

A considerable number of possible problems and

limitations associated with PPBS have been cited because of

past tendencies to overstate the utility of PPBS; neverthe-

less, this statement of conceivable problems is not intended

to downgrade the very substantial, potential value of PPBS.

Rivlin (1969, p. 922) has called PPBS a "commonsense ap-

proach to decision-making." She believes that it may assume

other titles but that the decision-maker needs to plan

ahead, determine the effectiveness of programs, develop

alternatives and systematically analyze them, and arrive

at decisions with the aid of the maximum amount of useful

information. This is the essence of PPBS.

A PPB3 for the University of Florida

The principal guidance document for implementing a

PPBS at the University of Florida was written by W,. K.

Boutwell (1970), Assistant Dean of Academic Affairs, who

also was responsible for providing much of the verbal,

day-to-day guidance to the various colleges, administrative

and support units, the J. Hillis Miller Health Center, and

- 59 -

the Institute of Food and Agricultural Sciences. The first

two parts of the publication were the "Introduction" and

"Purposes and Concepts of PPBS," and both contained infor-

mation very similar to that available in publications of

the Federal Government which explained concepts and objec-

tives and described the content and preparation of documents

which would be developed by federal agencies implementing

the PPBS. The integration of planning, programming and

budgeting is considered a key feature of this approach as

well as the system portion of the PPBS. Boutwell believes

that the PPBS approach causes heads of subordinate units to

make decisions with the knowledge that budget dollars will

be allocated on the basis of the efficacy demonstrated in

the accomplishment of organizational objectives. He suggests

that the following list of activities must be accomplished

in the indicated sequence if a system which relates budget

dollars to the achievement of objectives is to be established:

a. identification of the needs of the segments of
society which are being served,

b. identification of potential objectives for the

c. identification and evaluation of alternative
ways of accomplishing potential objectives,

d. determination of which objectives will be
pursued and how they will be pursued,

e. programming of the resources required to accom-
plish chosen objectives,

f. development of a budget from the resource pro-
gram, and

- 60 -

g. evaluation of how resources are actually being
utilized and how well objectives are being ac-
complished. (Boutwell, 1970, pp. 2-3)

He also indicates that several documents are common

to previous implementation of the PPBS. These are the pro-

gram structure, the program and financial plan (PFP), special

analytic studies (SAS), program memoranda (PM), and program

change proposals (PCP); and these instruments are explained

in turn, All have been previously discussed in this chapter

with the exception of the PCPs which, according to Boutwell,

may serve two purposes:

1. To provide detail data about changes requested
in the Program Memoranda

2. To provide a mechanism for requesting changes in
the Program and Finrancial Plan and operating bud-
get during the operating year. (Boutwell, 1970,
p. 6)

Allegedly the serving of these two purposes allows

the program memorandum to be a "thinking document" and can

result in a "current" program and financial plan by allowing

needed flexibility. Program change proposals were not

discussed in guidance from the U. S. Bureau of the Budget

(1967d); however, program change requests (PCR) and program

change decisions (PCD) are discussed in Department of Defense

Instruction 7045.7 (U. S. Department of Defense, 1969).

In Part 3.0 of his paper entitled, "A PPB System for

the University of Florida," Boutwell modifies the PCP and

uses the term "proposed program requirement" (PPR) which he

- 61 -

describes as "showing the detailed resource implications

of each program proposal in the program memorandum" (1970,

p. 7). This area seems to include one of the essential

differences between the federal and the state implementation

of PPBS. Perhaps the stage of progress of each partially

explains this difference. As mentioned previously, early

guidance from the U. S. Bureau of the Budget (U. S. Congress,

1967f, p. 10' required that information be submitted in the

program memorandum on each program category; however, later

guidance (U. S. Congress, 1968a, p. 2) requires data only

on major program issues. Apparently the earlier requirement

called for too much analytical capability to prepare and,

further, submissions were not examined thoroughly or at all

in many cases (U. S. Congress, 1968b, p. 4). The program

memorandum at the University of Florida is to be a descrip-

tion of the objectives and proposed plan of the organization

for the next six years. The other key elements of the PPBS

are the proposed program requirements (PPR) and a six-year

academic program and financial plan (SYAP&FP). The program

structure is, of course, critically important; however, this

has been developed by the State Bureau of Planning and the

Office of the Chancellor of the State University System.

It is then necessary for each organization of the State

University System to "plug into" the program structure at

the appropriate location. The program structure which has

been adopted is as follows:

- 62


3.3 Advanced and Professional Education

3.31 Instruction

3.311 Lower Division
3.312 Upper Division
3.313 Graduate
3.314 Advanced Graduate
3.315 Post Graduate

3.32 Creative Activities and Research

3.321 Basic Research and Creative Scholar-
3.3211 Natural Sciences
3.3212 Social Sciences
3.3213 Humanities
3.3214 Professional

3.322 National Objectives

3.323 State Objectives
3.3231 Business, Agriculture, and
Consumer Services
3.3232 Crime Prevention and Control
3.3233 Education
3.3234 Health
3.3235 Manpower and Employment
3.3236 Natural Resources and
Environmental Studies
3.3237 Recreation and Culture
3.3238 Social and Rehabilitative Services
3.3239 Transportation
3.3240 Governmental Direction and Support

3.33 Public Service

3.331 Business, Agriculture, and
Consumer Services
3.332 Crime Prevention and Control
3.333 Education
3.334 Health
3.335 Manpower and Employment
3.336 Natural Resources and
Environmental Studies
3.337 Recreation and Culture
3.338 Social and Rehabilitative Services
3.339 Transportation
3.340 Governmental Direction and Support

- 63 -

3.34 Organized Activities

3.341 Home Management Houses
3.342 Teaching Hospitals
3.343 Farms, Dairies, etc.
3.344 Teaching Theaters

3.35 Instructional Support

3.351 Libraries
3.352 Instructional Resources
3.353 Media
3.354 Exhibition Facilities
3.355 Publications

3.36 Student Support

3.361 Primary
3.362 Secondary

3.37 Administrative Direction

3.371 Legal Obligations
3.372 Discretionary Obligations
3.373 Advisory Services to the Field
3.374 Liaison
3.375 General Support
(Boutwell, 1970, pp. 8-9)

Since the Student Health Service is not primarily

an educational organization, some problems are created. This

is especially true since in June, 1970, the State Bureau of

Planning had not developed definitions for Student Support:

Primary and Secondary which appeared to be appropriate places

for the Student Health Service to "plug in." A table in the

Boutwell paper (1970, pp. 11-12) shows how the various

organizations at the University of Florida relate to the

State University System program structure; however, the

Student Health Service is omitted. Fortunately, organizations

are allowed some flexibility in this matter.

- 64 -

Very specific instructions are provided for the

Six-Year Academic Program and Financial Plan (SYAP&FP).

The purpose of this document is to show what resources will

be required to accomplish the objectives of the organization

for the next six years. It is indicated that the adminis-

trator should expect that funds in specific amounts will be

available in coming years if the plan is approved now.

Historically, such an expectation has not proved to be

realistic; however, prior planning should be of benefit.

The last portion of the instructions concerning the SYAP&FP

seemssignificant. It states:

The SYAP&FP will be updated annually by making adjust-
ments in previously approved plans. Hence, the pre-
viously approved plan will form the basis for devel-
oping a new plan. The annual update will take the
form of additions to and subtractions from the previous

Currently we have no approved plan which can be modified
to form our 1971-76 SYAP&FP. We must start from scratch
in developing such a plan. Thus, our first effort will
require more work than will be required in future years.
However, because we are establishing the basis for
future planning exercises we must do a good job the
first time around. Every effort should be made to make
out [sic] year resource requirements as realistic as
possible. Otherwise we will have a meaningless plan
and will have to start all over again next year.
(Boutwell, 1970, p. 13)

Next, the main purpose of the Program Memorandum is

explained as follows:

The primary purpose of a Program Memorandum is to explain
the numbers in the organization's SYAP&FP. It does this
by providing a narrative description of the organiza-
tion's objectives and how they are to be accomplished.
(Boutwell, 1970, p. 13)

- 65 -

Finally, instructions concerning the Proposed

Program Requirement (PPR), which is the third main document

to be prepared, are given:

The programm memoranda should not contain detailed
information about resource requirements. Only
summary figures should be shown in the Memoranda.
The detailed data for each program proposal in the
Memoranda should be contained in an attached Proposed
Program Requirements . The PPR's are to be used
by the heads of the major budgetary units to make
changes in the SYAP&FP as programs are added, changed,
or deleted .

A separate PPR must be submitted for:

1. Continuation of existing programs in each
program category

2. Each proposed improvement in existing pro-
grams in each category

3. Each proposed new program

4. Each proposed program deletion.
(Boutwell, 1970, pp. 14-15)

Instructions are completed by assigning specific

responsibilities for preparation of various organizational

program memoranda and SYAP&FP to selected key personnel

including the Executive Vice President, the Vice President

for Academic Affairs, the Provost of the Institute of Food

and Agricultural Sciences, the Provost of the J. Hillis

Miller Health Center, Deans of Colleges, Directors of

Academic Support Units, Department Chairmen, the Vice

President for Business Affairs, the Vice President for

Student Affairs, and the Dean of University Relations.

The Director of the Student Health Service was not mentioned

66 -

'but it is assumed-under existing organizational structure-

that the Director of the Student Health Service will be

responsible to the Provost of the Health Center for carrying

out this function.



An understanding of a wide variety of historical

and operational data associated with college health pro-

grams should facilitate the development of meaningful organ-

izational objectives and related program structures, costs

and benefits which are necessary if PPBS is to aid in more

effective allocation of current and projected resources

to a university student health service. Quite obviously

all college health programs will not fit the same model.

There are variances in size and composition of the patient

population, geographic location of the school, institutional

philosophy concerning responsibility for health care, type

of financial support and other factors which affect a health

program. Some of these health facilities are "university"

or "college" health services rather than "student" health

services because they have been extended to serve faculty,

administrative staff, and dependents of students. A few

are cooperating with extramural health facilities and are

engaged in community projects. Nevertheless, it is believed

that enough similarities exist in order to establish a use-

ful conceptual approach which will lead to objectives and

- 67

- 68 -

a program structure which may be feasibly modified as

required by the operation of the particular health service.

Following the "Recommended Standards and Practices for a

College Health Program" (October, 1969, p. 42), the term

"university" or "college" will be used interchangeably to

refer generally to "any institution for higher education."

Also when it is not particularly important to the discussion,

no distinction will be made between "student" health ser-

vices and those that include other members of the college

community as well.

In his keynote address to the American College

Health Association, Philip R. Lee, Assistant Secretary,

Department of Health, Education and Welfare, commented:

The first fact that is evident is the lack of facts
available about college health services today. We
know too little about the health status of students
and faculty, about the effectiveness of different types
of programs, or even about the manpower and facilities
available to provide the needed services. (Lee, 1967,
p. 8)

He further complains that a thorough survey of college and

university health services has not been performed since

1953; consequently, it is very difficult to determine needs,

resources or program effectiveness. He cites other data

which imply that much information is sorely needed. In

1957 there were 285 institutions represented in the Ameri-

can College Health Association. In 1967 there were over

500 member institutions but this still represented somewhat

- 69 -

less than 25 per cent of all colleges and universities in

the United States. Between 1955 and 1965 student enroll-

ment in colleges and universities advanced from 2.5 million

to 5.7 million; however, by 1975 this enrollment figure will

reach 8 or 9 million. Due to the lack of data, Lee cannot

be sure of numbers of physicians available to universities

and colleges on a full-time basis; he estimates the figure

to be 1,000 and believes an additional 7,000 are available

on a part-time basis. Lee (1967, p. 8) indicates that full-

time physicians are preferable; however, Groom (1968, p. 32)

points out pitfalls facing those who spend too much time

performing routine examinations on generally normal patients

(college students) and suggests that the use of part-time

physicians who supposedly have more occasion to sharpen

their diagnostic acumen outside the university might be a

very effective alternative.

Finally, Lee (1967, pp. 8-10) cites additional

areas of concern with respect to college health services.

He believes that these services are less than comprehensive

since only 100 or so colleges have fully organized mental

health programs, although this is perhaps one of the most

needed programs for college students; only 31 provide

dental care; and only about 6 per cent provide medical care

to dependents. There has been relatively little accomplished

with respect to protection of faculty and students from

- 70 -

environmental hazards. Preventive medicine is cited as a

relatively weak area. A survey of 1,221 faculty members

at the University of Michigan points this out dramatically:

800 had defects which had not previously been recog-

21 had malignant lesions

81 had diabetes mellitus

51 had unrecognized hypertension

9 had coronary artery disease with prior occlusion

4 had glaucoma

3 had multiple sclerosis

500 had never had a complete physical examination

200 had not received a physical examination within the
previous five years

10 had not been examined by a physician since being
discharged from military service (the problem here
being that the service was in World War I). (Lee,
1967, p. 9)

Also with respect to preventive medicine, very little has

been done concerning the provision for medical services

related to family planning. In the same area of preventive

medicine, there has been a lack of coordination of effort

regarding narcotics, drug abuse, and alcohol information

and education. Lee also points out that there is a sur-

prising lack of coordination between medical schools and

college health services. He believes there are good op-

portunities to perform cooperative research in particular

areas specifically significant in student groups (he

71 -

specifically cites upper respiratory infection, attempted

suicide, trauma and drug abuse) which would not be possible

in many cases for the college health services to undertake


Historical Development

A survey of the historical development of college

health services will possibly provide useful insights by

showing how these organizations reached their current stage

of development. Boynton (1952, 1962) and Hurtado (1963)

agree that President Stearns of Amherst College first recog-

nized the desirability of providing for the health needs

of college students in about 1861 and appointed Dr. Edward

Hitchcock as the first medical director of a department of

physical education and hygiene. Boynton (1962, pp. 294-301)

discusses what she considers milestones in the development

of student health services. She confirms that for many

years the student health services were oriented toward physi-

cal education and did not become medically oriented until

after World War I. Any change in emphasis, she points out,

usually occurred as a result of reactions to epidemics, a

student death or a possible solution to student absence

from class. For example, she credits the University of

California with the development of one of the first compre-

hensive college health programs and cites information

- 72 -

written in 1913 by Dr. G. F. Reinhardt of California.

It may be a surprising statement that the University of
California infirm-ary with its large daily clinic and its
hospital facilities owes its existence less to a direct
effort to improve student health than an effort to im-
prove class attendance (Boynton, 1962, p. 295).

It was learned that absence was occurring because of sickness

and not idleness and a health service which offered medical

care and infirmary facilities to the student was opened in

1901. A typhoid epidemic in 1903 at Cornell University and

at the University of Wisconsin in 1907 provided a stimulus

for improved student health facilities at these two univer-

sities but had little effect on programs at other colleges.

Boynton did not describe many highly significant events as

far as the medically oriented developments of student health

services were concerned during the period 1861-1930's.

Hurtado was much more critical in his descriptions

of the lack of accomplishments from the establishment of

student health services until the 1930's but is quite posi-

tive that the trend toward medically oriented student health

services was much in evidence in the 1930's. After recog-

nizing the change in student health services for the better,

he cites future challenges that must be overcome if college

health services are to fill a desired role.

Hurtado (1963, p. 294) considered the period 1861-

1930's a period of professional stagnation for physicians

in the student health services. He points out that the

- 73 -

founders combined physical education, mental hygiene, public

health, clinical health and education to form "student health"

and that the emphasis shifted from one component to the other

for 75 years. During very early years, the physicians in

colleges worked closely with athletic teams and served in

areas closely related to physical education.

Policies that emanated from these early relationships

probably had much to do with the general opinion that student

health and physical health were very closely related. This

development caused many college administrators to consider

college physicians as physical education teachers and this

view has not been completely erased. Later, student health

came to be related more with health instruction rather than

physical education and the physician became more a teacher

of hygiene than of physical education. During the same pe-

riod, many universities placed emphasis on health education.

One of the results was that college physicians emphasized

teaching and their clinical acumen was frequently impaired

as a result; however, to make the situation worse, their

teaching ability was being challenged by graduates of schools

of education who had been trained specifically for such

duties. Surely many physicians had second thoughts about

entering the student health field when they realized that

their clinical ability would probably suffer and they would

also have to acquire teaching capability which their

- 74

profession did not normally require. This period which

Hurtado classifies as "professional stagnation" ended in

the 1930's and he describes the period as follows:

So for three quarters of a century the college physician
was neither recognized or respected as a medical man
possessing medical or surgical skills. In some instances
he turned out to be an excellent teacher of hygiene and
health; he was a good mixer, personable, friendly, and
genuinely interested in the students' welfare; but,
medically, the scope of his professional activities was
limited to the treatment of sprained ankles and running
noses. (Hurtado, 1963, p. 294)

The definite change in orientation of student health

services toward medical problems is very apparent now in

large numbers of colleges and universities; however, the

speed and magnitude of the change has generally varied di-

rectly with the foresight and support of college and uni-

versity administrations. Still, one question that requires

continuous investigation and concern is "How can the college

health service most effectively relate with the college


Hurtado (1963, p. 294) assures that the change in

emphasis to clinical service health programs that was so

clear in the 1930's and grew stronger as time passed is a

permanent change. He proceeds to discuss some clear re-

quirements and challenges that accompany this which must

be met if college health programs are to continue to pro-

gress toward truly comprehensive programs. The main thrust

of Hurtado's (1963, pp. 294-299) discussion of requirements

- 75 -

concern the need to recruit highly qualified members of a

medical staff whose patient population will be changing

very significantly in size and composition. On the one hand

the potential physician for the college health service must

be fully qualified with respect to formal training and intel-

lectual ability; yet, he must have the ability, the patience

and the understanding to deal with health problems unique

to the college student. Further, the potential patient

population has been changing significantly as the college

health services have proceeded along their evolutionary


The size of the college enrollments has been growing

very rapidly and associated with this growth has been dra-

matic change in the composition of the student population.

Since the 1940's older students have been returning to col-

lege for special programs, to complete work for degrees or

to gain credits which enhance their possibility for promotion

in business or other areas. The age span of the student

population has extended from 18 to 60 and this offers a

different clinical picture to the college physician than

the previous 18-24 range which was once common. The numbers

of graduate students and foreign students have consistently

increased which adds to the heterogeneity of the student

population. As college health programs have become more

comprehensive, medical services have been offered to

- 76

dependents of students,faculty and administrative staff and

their dependents. Privileges offered to these latter groups

may be abbreviated initially, but the trend appears to be

toward the offering of more comprehensive medical care to a

broader population. As universities have employed personnel

who are under the Workmen's Compensation Law, there has

been an increasing requirement to evaluate the mental and

physical status of these prospective employees and the col-

lege health service has performed the task. These changes

have been occurring for several years and the rate of change

seems to have been more intense in recent years. There is

no indication that the trend, which has greatly increased

the volume and scope of medical responsibilities at colleges

throughout the country, will change significantly in the

near future. Hurtado (1963, p. 298) concludes that the pro-

gress made in college health services in the last ten years,

which has included an emphasis on clinical medicine, may

soon lead to college medicine being considered a medical

specialty. This development, he believes, will allow the

college physician to be recognized as an experienced and

competent clinician and, therefore, deserving of the same

professional standing as his colleagues in private practice.

Such a development would surely assist in recruiting ade-

quate numbers of well qualified medical staff personnel.

- 77 -

Setting and Rationale

It is difficult to generalize about the question

of attitudes concerning college health services by college

administrations due to the lack of current information and

the significant variations between colleges. The key ques-

tion seems to concern the philosophy of responsibility for

student health assumed by the college. If the college does

not assume a reasonably full amount of responsibility, then

limited resources allocated to student health services will

probably be minimal as will be the resulting health services

provided the student. Of course, resources allocated to

student health services will be minimal if resources for

the college are generally scarce, irrespective of the col-

lege's philosophy of responsibility for student health.

The last relatively thorough survey of health services in

colleges (Moore and Summerskill, 1954) indicated that there

was no standard student program in any of the colleges.

This survey was accomplished by personal interviews with

the health service director or his representative at 1,157

colleges. Although the data are now relatively old with

limited utility in some areas, some of the possible expla-

nations of wide variations in the health programs surveyed

might still be pertinent to the question concerning which

colleges accept varying degrees of responsibility for the

provision of health services at colleges. The survey

- 78 -

(Moore and Summerskill, 1954, pp. 101-102) showed that

differences in health services by geographic areas were

not great, although health services provided in the west

were somewhat less comprehensive than in other areas. It

was found that urban colleges provided somewhat limited

services and this was attributed in large measure to the

fact that many students lived at home and utilized services

of family physicians or local medical services. More com-

prehensive health services were offered by public schools

(e.g., state, federal) and somewhat fewer services offered

by denominational schools. Health programs in four-year

colleges were more comprehensive than those in two-year

colleges and colleges offering graduate and undergraduate

programs tended to provide more comprehensive health pro-

grams. Colleges with a general and professional training

curriculum provided more services than did liberal arts

colleges. The greatest variations in health services were

associated with the size of enrollment of the school. A

rather significant finding was that not only did the larger

colleges provide more comprehensive health services as well

as more complete facilities and larger medical staff but

that these variations were wholly attributable to the availa-

bility of funds. Less money per student for health services

was available at the colleges with smaller enrollments.

These variations between colleges with small and large

- 79 -

enrollments seemed to be attributable to variations of

philosophy with respect to the amount of responsibility for

provision of student health services which should be ac-

cepted by the college. Summerskill (1955) is more specific

concerning descriptions of philosophies and how many col-

leges seem to have which philosophy but leaves many un-

answered questions as to philosophies. He writes:

Behind the survey data stands the college's conception
of this responsibility. The policy of some colleges
is to steer clear of involvement in nonacademic facets
of their students' lives. Other colleges have estab-
lished token programs. Still others show earnest con-
cern with student welfare beyond its intellectual
components. (Summerskill, 1955, p. 71)

Thus it is very difficult to generalize concerning

philosophies or attitudes of college administrations with

respect to college health services. Certainly some giant

strides have been made by college health personnel, and

attitudes of college administrators toward college health

services have probably changed somewhat since the above

data were gathered. Nevertheless, current information of

this nature is needed because knowledge of the most effec-

tive manner in which to relate with college administrations

is a critical requirement for college health personnel.

Performance of this task effectively requires knowledge of

attitudes of college administrations toward college health

services and their philosophies concerning the degree of

responsibility for student health which will be accepted

by the college.

- 80 -

The effective operation of a college health service

is also dependent on knowledge of the attitudes of the

patients. Farnsworth (1964, p. 2) indicates that attitudes

of personnel working in health services, as well as patient's

attitudes, must be known if the health service is to be ad-

ministered effectively. With respect to aims of student

health services, he cites the following: (1) to induce

utilization of health service by the student when he re-

quires health care, (2) to gain confidence of the student

when he is being treated so that he will follow instructions,

especially when in an outpatient status and (3) to get the

student to follow suggestions which will prevent many health

problems, e.g., refraining from using tobacco, "pep" pills

and drugs, receiving inoculations, following suggestions

regarding proper diets and proper amounts of sleep and fol-

lowing safety practices which should minimize accidents.

Farnsworth (1964, pp. 2-4) also points out that the

degree to which the student utilizes college health services

depends somewhat on how he perceives the service and its

utility. This, in turn, is dependent upon the student's

background as well as the image in the academic community

reflected by the particular health service. Some studies

have shown that patients from working-class backgrounds

tend to feel they have more limited rights with the phy-

sician and, therefore, are hesitant in asking the physician

- 81 -

questions and do not expect much personal attentiveness

from him (Farnsworth, 1964, p. 3). If impersonal service

is observed at a student health service, then the beliefs

of those who expect impersonal treatment are reinforced.

Accordingly, students with such opinions will probably use

college health services only in emergency cases. Also,

there is evidence which suggests that some physicians alter

their communications with patients according to social

class. For example, some physicians will not provide much

information to patients of a lower social class because

they doubt that such patients have the education to under-

stand explanations of their condition (Farnsworth, 1964,

p. 4).

According to Farnsworth (1964, p. 4), the fact that

college health services are organized on a bureaucratic

basis leads many students to expect impersonal and less

effective health care then they would receive from a pri-

vate physician. This situation creates a problem for col-

lege health services and they are thus challenged to convince

the student that the so-called bureaucratic organization

is not less competent but, on the contrary, is capable

of providing better health care than a private physician

because of the available facilities. Since Farnsworth

indicated that studies have suggested that patients expect

less satisfactory care from a bureaucratic organization,

- 82 -

a study (Franklin and McLemore, 1968) performed with college

students at the University of Texas suggests that this atti-

tude might not be as strong among students as believed.

Certainly one study is far from convincing but the results

are interesting and reinforce Farnsworth's (1964, p. 3) sug-

gestion that research concerning students' attitudes about

college health services would be very useful.

In the study conducted by Franklin and McLemore, it

was assumed that "students use the fee-for-service, private,

doctor-patient relationship as the standard against which

to measure the services of the Student Health Center" (1968,

p. 58). Consequently, the investigators expected the stu-

dents to evaluate negatively the health care obtainable at

the health center when compared to that obtainable from

private physicians. Instead of this finding, however, the

results indicated that more students evaluated the health

center favorably than unfavorably with male students evalu-

ating the health center more favorably than did the female

students. It was also found that the students used ser-

vices of the health center more than they used the services

of private physicians; although, the utilization of the

health center by the students declined as the length of

enrollment increased. Also, the generally unfavorable atti-

tudes of female students toward the health service deteri-

orated even more as the length of enrollments increased

(1968, p. 59).

It was expected that the students would evaluate

the health center unfavorably with respect to the services

of private physicians due to the "bureaucratized" nature

of the health center organization and the generally unfavor-

able attitudes toward bureaucracy. This expectation was

reinforced because of some of the specific complaints of

this nature by the students and observed by the investiga-

tors. Since the students did not evaluate the health ser-

vice negatively, the investigators believed that possibly

the students did not place such a high value on the services

of the private physician or possibly they (the investiga-

tors) had overestimated the amount of student complaints.

Results of further questions which were asked to check the

validity of these two possibilities were interpreted as

indicating that the students evaluated the services at the

health center favorably but considered services of private

physicians more favorably. This was further interpreted

to mean that people preferred services of private physicians

but did not reject organized medicine.

Perhaps more significant was the response of stu-

dents to the statement, "Other students at this university

tend to evaluate their Student Health Center positively."

Ninety-two per cent of the females and 75 per cent of the

males related their negative attitudes toward the health

center to the evaluations and opinions of their fellow

- 83 -

- 84 -

students. The fact that the female students were less favor-

ably inclined toward the health service was partially attrib-

uted to the fact that the females on the campus studied were

less autonomous and more influenced by opinions of fellow

students. Although Franklin and McLemore (1968) realize

their findings may not be valid in other settings, certainly

the need for more research regarding attitudes of students

toward college health services should be of inestimable

value to the director of a student health service.


There are probably not two college health services

exactly alike-nor should there be when it is considered

that each of the hundreds of existing organizations have

different requirements, problems and qualities. It has been

clear for several years, however, that there was a need to

develop standards which could be used as guides for the many

health services. One physician (Bergy, 1961, pp. 159-161)

related the need for recommended practices and standards

for college health services to the requirements of justifying

new programs or changes in policy to college administrations.

According to this authority, provision of the "finest care"

cannot be accomplished at his university because of budg-

etary and sociopolitical pressures as well as an apparent

lack of confidence by administrative officials that an

- 85 -

optimum program for student health care could be developed.

Accordingly, when new programs or policies are suggested,

answers are required as justification to such questions as

"What is the best we can do under the circumstances? What

do they do at other schools? What are the recommended mini-

mum standards for schools of our size and mission? What

are we legally required to provide?" He also wrote that

standards could protect the college health service from im-

proper requests and presumptions by administrators. Such

requests and expectations included the requirement for nurses

to practice medicine or pharmacy or physicians to undertake

tasks without proper equipment and facilities. Regretfully,

it is probable that such situations exist; nevertheless,

such justification for the development of standards and prac-

tices seems overly negative.

Standards and practices for a college health program

were developed by the American College Health Association

in 1964 after about five years of work and then revised in

1969. Each of the "Recommended Standards and Practices for

College Health Program" was published in The Journal of the

American College Health Association (October, 1964; October,

1969). The President of the American College Health As-

sociation, Dr. Robert W. Gage, described the "Recommended

Standards!tpositively when he editorialized:

- 86 -

These standards are best seen as a statement of basic
principles and relationships, interpreted in terms
which are sufficiently specific to provide practical
guidelines for program development. Health programs
which are consistent with them may be considered sound,
even if open to substantial improvement; programs which
fail to meet all of the standards may have areas of
great strength and may represent superb achievement in
the face of limited resources. (Gage, 1969, p. 1)

The statement was addressed to the problem of developing

standards that would be useful to a wide range of types of

college health programs and did not pretend to represent

an optimum program for any particular health service. He

also indicated two definite trends in college health pro-

grams that require attention. One is the desire to develop

a college health program which will serve the "entire insti-

tutional community." This includes students, student de-

pendents, staff and faculty with special emphasis on

environmental surveillance and health promotion. The second

trend emphasizes the coordination of the health care re-

sources of the institutional and extramural communities.

This second trend would include industrial workers and resi-

dents of depressed and affluent areas alike. Such a popu-

lation, according to Gage (1969, p. 1), would "create an

ecological system which is a unique vehicle for studying

human health problems and developing means for resolving


In discussing the 1969 statement of standards, the

goals and objectives are listed in the introduction and

- 87 -

much importance was given them as a base from which to

develop the statement of standards. For this reason as

well as the need to establish a point of departure for the

development of organizational objectives for the Student

Health Service at the University of Florida, authoritative

lists of goals and objectives of a comprehensive health

program are reproduced below


1. To promote and maintain those conditions which will
permit and encourage each individual to realize opti-
mum physical, emotional, intellectual, and social

2. To control those factors in the community and its
environment which may compromise this well-being.

3. To guide the individual in the acceptance of health
as a positive value in life.

4. To stimulate the capacity of the individual to make
healthful adaptations to the environment.


1. Organizing staff and facilities for:

a. Prevention of health hazards and problems for all
members of the academic community (including iden-
tification and recognition of potential problems
prior to their development).

b. Early recognition of developing problems (in-
cluding in the clinical area, pre-symptom diag-
nosis of potential illness and use of screening

- 88

c. Prompt and effective remedial action in the
presence of recognized health problems (for in-
stance, high-quality care, readily available
under conditions which encourage timely and ap-
propriate use).

d. Rehabilitation of all members of the community
who have health handicaps, acute or chronic, to
maximum attainable restoration of well-being and

e. Education of the community for healthful living,
including concern for both individual and con-
munity well-being. This is to encompass develop-
ment of both content and methods for health

f. Control of environmental factors influencing
health. This should include the elimination or
control of noxious or harmful elements (physical
and emotional) and the insurance of a creative
climate which encourages development of health
and well-being.

2. Encouraging use of resources under conditions which
promote their effectiveness.

3. Promoting participation among the components of the
community (students, faculty, staff, administration,
health services) in the interest of developing goals
and objectives and of sharing satisfactions and prob-
lems, including the development of ethical standards
for relationships which recognize the need to handle
certain types of information with discretion and

4. Recognition of the importance of the performance of
research for its dynamic influence on the health

5. Continuous program evaluation, including specific
attention to high quality.

6. Coordinating of health resources of the institution
with those of the community beyond.

7. Developing and promoting health career opportunities.
("Recommended Standards and Practices for a College
Health Program," 1969, pp. 41-42)

- 89 -

According to the introduction of the "Recommended

Standards" (1969, p. 41), there were two notable changes

from the 1964 effort. First, the material was more effec-

tively organized according to plan rather than written by

independent authors interested in a particular discipline

and then related by means of a very lengthy introduction.

Second, most of the quantitative standards such as recom-

mended doctor/patient and patient/bed ratios were omitted.

Since there are such a vast number of variables which arise

when comparing colleges, it was believed that comparison of

such ratios was not very useful. The "Recommended Standards"

(1969) were divided into five major parts: general infor-

mation; health programs-services and activities; health

personnel-qualifications, duties and education; physical

plant; and business management.

In the first section, the importance of the phi-

losophy of the institution as well as its goals and pri-

orities were stressed. Since a health service is basically

a supporting facility for the institution, it is obviously

important to know the institution's goals as well as its

philosophy concerning its responsibility for health care

of the students and other members of the academic community.

Also, the method in which the health service will relate

to the administration of the institution should be clear.

Every effort should be made to arrange for the health