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Public health functions 

Public health functions
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date: 20 June 2019

The concept of need is interpreted in different ways. The principle adopted in this chapter is that need is defined by the notion of ‘capacity of benefit’. This means that need derives its meaning from the various pathways in which it can contribute to the achievement of a particular objective, i.e. it is ‘instrumental’. Here we focus on need in relation to healthcare; a need for healthcare can be seen to be instrumental to the achievement of the objective of health. As a consequence, the type of healthcare that is needed in any given circumstance is a function of factors such as the level of prevailing resources, the availability and effectiveness of healthcare, and the perspective and values of whomsoever is making the assessment.

Need is a critical concept in the pursuit of efficient healthcare, in terms of maximizing health benefits, given the limited resources. There are a number of tools such as programme budgeting and marginal analysis and quality-adjusted life years (QALY) league tables which enable decision makers to systematically allocate resources efficiently according to need. Recent policy initiatives such as the Oregon Health Plan, the World Bank’s essential package concept, and the Commission for Macroeconomics and Health have also incorporated cost-effectiveness as a basis for determining need to ensure best use of limited resources.

Need is also useful in planning for the equitable allocation of resources as it provides a measure by which policy makers may pursue objectives such as ‘equal access for equal need’ or ‘equal use for equal need’. The application of these principles in practice can be seen most readily in health needs assessment exercises such as those carried out in the United Kingdom in the 1990s and the various needs-based resource allocation formulae that have been employed over recent decades in the United Kingdom, Australia, and recently in a number of low- and middle-income countries. One of the challenges in implementing these policies is in ensuring that any measure of need takes into account social values, absorptive capacity constraints, and is sensitive to variations in mortality and morbidity. These are issues that provide a focus for future research on this topic.

There is a beguiling simplicity about the proposition that healthcare services should be designed to meet the needs of the community. Indeed, the healthcare policies of a great many countries have as a key goal meeting the needs of the population. Faced with the obvious appetite for healthcare exhibited by virtually all communities exposed to it, it is traditional to distinguish between wants and needs: Wants, by implication, being less rational, possibly even related to greed. Needs, by contrast, are seen as objective states, things that can be measured and agreed upon by rational people often on behalf of those who have them, as deserving attention.

The purpose of this chapter is first to explore the concept of need and its relevance within a public health framework. The purposes for which need might be measured—for action in the clinical and population settings and for planning—are then reviewed. Some currently available measures of need are then examined and some conclusions are drawn. Given the elusive nature of the concept of need, a glossary of relevant terms used in this chapter is provided in Box 12.1.1 as a reference point for readers.

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