Concepts of Need and Social Justice

Equality, Equity and Policy: Concepts of Need and Social Justice

Need

Need is an important concept in public health. It is used in the planning and management of health services including health improvement, resource allocation, and equity. However, need is a multi-faceted concept with no one universal definition.

Bradshaw (1972) sets out 4 types of need.

Table 1: Bradshaw’s 4 types of social need

Type of need	Definition	Examples
Normative need	Need that is defined by experts. Normative needs are not absolute and there may be different standards laid down by different experts.	Vaccinations, a decision by a surgeon that a patient needs an operation
Felt need	Need perceived by an individual. Felt needs are limited by individual perceptions and knowledge of services.	Having a headache, feeling knee pain
Expressed need (Demanded need)	Felt needs turned into action. Help seeking.	Going to the dentist for a toothache
Comparative need	Needs identified by comparing the services received by one group of individuals with those received by another comparable group.	A rural village may identify a need for a well or a school if the neighbouring village has one

The need for healthcare should be distinguished from the need for health. The need for health is broader and can include problems for which there is no known treatment.

Mathew (1971) stated that a need for healthcare exists when an individual has an illness or disability for which there is effective and acceptable treatment or care.

In the UK, the NHS often defines need as a “capacity to benefit”. It depends on the potential of preventive or treatment services to remedy health problems (Stevens et al, undated). However, capacity to benefit is not fixed, but subject to current knowledge, the current research agenda, and the cultural and ethical determinants of contemporary society (Stevens, 1991).

Health economists have distinguished need from supply and demand. In the model below need is defined as capacity to benefit; demand is defined as what individuals ask for; and supply is defined as what is provided (i.e. the services that are available). Just as need is influenced by the current research agenda and contemporary culture, demand is influenced by factors such as the social and educational background of an individual, the media and the medical profession. Supply is influenced by historical patterns and public and political pressure.

Figure 1: Need, demand and supply: influences and overlaps

Source: Stevens A, Raftery J, Mant J. An introduction to HCNA.
http://www.hcna.bham.ac.uk/introduction.shtml

Need, demand and supply overlap, creating seven different fields (eight if you include an external field - where services are neither needed, demanded, nor supplied).

Field 1: Services are needed but not demanded or supplied
Field 2: Services are demanded but not needed or supplied
Field 3: Services are supplied but not demanded or needed
Field 4: Services are needed and demanded but not supplied
Field 5: Services are supplied and demanded but not needed
Field 6: Services are needed and supplied but not demanded
Field 7: Services are needed, demanded and supplied

Stevens (1991) gives examples of some of the health care interventions that fall into the various fields. An example of field 3 where services are supplied but neither needed nor demanded is routine Caesarean sections on women with a history of a previous Caesarean section. An example of field 5 where services are supplied and demanded, but not needed, is prescription of antibiotics for uncomplicated viral upper respiratory tract infection.

For health needs assessment See module 1c: Health Care Evaluation and Health Needs Assessment

Social Justice

Health systems are concerned not only with maximising health, but also with the fair distribution of health. However, there is no consensus on what is ‘fair’, the decision is a moral rather than objective one. Below are some of the most common theories of social justice:

Utilitarianism: strives to achieve ‘the greatest happiness for the greatest number’. Benefits must be redistributed from the rich to the poor until there is an equal allocation of benefits to all members of society. Utilitarianism is based on the idea that all people have the same wants and capacity to enjoy benefits. An additional benefit given to a poor person will provide more happiness than if the same additional benefit was given to a rich person. Therefore, in order to maximise happiness in society, benefits must be redistributed (Wonderling et al, 2005).

Egalitarian: Everyone should have an equal opportunity to obtain benefits. No person should be worse off than others except as a consequence of free and informed choices.

Libertarian: Individuals have rights that the state (or other) must not violate. Above all individuals have a right to freedom, the state should not interfere.

Rawlsianism: Because there is a trade-off between efficiency and equity (see section 3: Balancing equity and efficiency) an unequal distribution of benefits in society is regarded as acceptable. However, benefits in society should be allocated so that the benefits of the poorest person are maximised. Rawlsianism is based on the idea that no one knows where they will end up on the social ladder (the so-called ‘veil of ignorance’), therefore society should aim to maximise the benefits of the poorest person (also known as ‘maximin’) (Wonderling et al, 2005).

References

Bradshaw J. (1972) “A taxonomy of social need.” in McLachlan G (ed.) Problems and progress in medical care. Seventh series NPHT/Open University Press.
Matthew GK. (1971) “Measuring need and evaluating services”. in McLachlan G (ed.) Portfolio for health: the role and programme of the DHSS in health services research Sixth series London: Oxford University Press, for the Nuffield Provincial Hospitals Trust: 27-46.
Stevens A, Raftery J, Mant J. “An introduction to HCNA”. http://www.hcna.bham.ac.uk/introduction.shtml
Stevens A (1991) “Needs assessment needs assessment…”. Health trends 23: 20-3
Wonderling D, Gruen R, Black N (2005) Introduction to Health Economics. Understanding Public Health Series. Open University Press: London School of Hygiene and Tropical Medicine.