|Medicine - Epidemiology (ECHO - NOHA - Network on Humanitarian Assistance) (European Commission Humanitarian Office, 1994, 120 p.)|
|Chapter 2: Health Care Planning|
The notion of PRIORITIES and OBJECTIVES (once again) raises the question of whether health planning is really justified. Why plan?
A - Economic rationale
Resources are (relatively) scarce and the needs (relatively) great > necessity for choices. Hence the concern for (economic) efficiency in the use of resources.
Possible objection: the market could take care of these choices. "Orthodox" (i.e. liberal) economic theory seeks to demonstrate that the allocation of scarce resources in order to satisfy numerous needs is best achieved by giving free rein to the forces of supply and demand. "Market equilibrium" will thus be attained through pricing, providing that is:
- free competition is allowed to operate (in this particular instance, providing there is no monopoly over the supply of health care and no State intervention in order to regulate the price of health care services)
- the participants in the exchange (supply and demand) are fully informed about the state of the market.
B - Political (or social) rationale
This implies the reference to value judgements such as:
- "access to health care (or even just "health") is the
fundamental right of every individual"
- "health is one of the essential goals of social development"
- "health is a means of progress" (by increasing the productivity of labour).
These value judgements are fairly widely accepted, irrespective of political systems, civilisations and cultures.
The mechanisms of the market however (where supply partially creates its own demand, where demand is only ever solvent demand, where perfect information does not exist, etc.) are not capable of fulfilling the requirements contained in these value judgements. Hence the (social/ political) concern for the equitable distribution of health care services and opportunities to enjoy good health.
C - Scientific/technical (or public health) rationale
In the health care sphere, there is always a slight mismatch between supply/demand/needs (Cf. diagram below). This is true of many other goods or services (e.g. education, housing, food, clothing, insurance) but the health care sphere is special in that the information required to form some idea of
- the significance of the distinction between (stated) demand and
- the match between demand and the available supply (= health care)
Normally eludes the individual or community concerned and / or is beyond their powers of judgement. This is because in the health care sphere
- there is a very powerful "emotional charge":the focus is on the body, suffering, vitality, appetite for life, in other words "goods" with regard to which, the general public and individuals alike, can be both very demanding and highly irrational
- the "demander" (i.e. the patient or anyone seeking some form of medical care) is invariably in an inferior position in relation to the "seller" (the health care system):handling information is hard enough for someone in good health, and illness further diminishes their ability to determine whether supply, demand and needs are suitably matched
- needs can be defined in a very precise manner by a particular authority (medical science) generally recognised as being impartial and unconnected with the "health care market".
In the health sphere more so than in the case of other goods and services, we are thus a very long way from the theoretical model of political economy, which posits a "supplier" and a "demander" who are perfectly informed about the state of the market and behave in a rational manner. Hence the (public-health) concern for voluntarist improvements to the existing health care system:greater efficiency (by matching supply to needs), high-quality care, etc.
These three types of rationale remain equally valid if you believe that health care policy should be much more comprehensive than simply organising the medical profession and care.Thus,
- as regards the availability and quality of food,
- dietary habits,
- environmental health,
- drinking water supplies,
- safety (road, domestic),
- general hygiene,
- working conditions, etc.
there are no "markets" as such, where trade in goods or services could ensure a proper match between supply, demand and needs.
Diagram:Supply, demand and needs in the health sector
Important - In public health, in order to avoid lengthy debates about the concept of "need", the accepted definition is an operational (practical) definition, rather than a conceptual (theoretical) one:needs are anything defined as such by members of the health care profession in the light of the available knowledge.
Example - Health care needs = "the estimated manpower and quantity of services required, in the opinion of professionals and according to the state of the art in medical science, in order to provide an optimal level of health care" (T. Hall).
However hard the various authors of public health manuals may try to get away from this operational concept of needs, in everyday practice it is invariably the latter which prevails.