Positioning the individual in health care: A typology of the demand-oriented and demand-driven approaches

Tilburg University

Positioning the individual in health care

Rijckmans, M.J.N.

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2005

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Rijckmans, M. J. N. (2005). Positioning the individual in health care: A typology of the demand-oriented and demand-driven approaches. Dutch University Press.

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•1•

UNIVERSITEIT * 0 VAN TILBURG BIBLIOTHEEK

Erratum

Positioning the individual in health care

Atypology ofthe demand-oriented and demand-driven approaches

Positionering van het individu in de gezondheidszorg

Een typologie van de vraaggerichte en vraaggestuurde benaderingen

PROEFSCHRIFT

ter verkrijging vande graad van doctor aande UniversiteitvanTilburgopgezag

van rectormagnificus, prof.dr. F.A. van der Duyn Schouten, in hetopenbaar te

verdedigen ten overstaan van een doorhetcollegevoorpromotiesaangewezen

commissie in de aula vande Universiteit opvrijdag2_{december 2005 Orn I4·IS uur}

door

MADELEINE JEANNE NOELLE RljCKMANS

PROMOTOR:

Prof. dr. H.F.L.Garretsen

COPROMOTORES:

-#--.8

---Dr. LA.M. van de Goor

_...

Dr. I.M.B.Bongers

UNIVI. i •• * .t'; 0 VAN TILBURG

- ... -.2. -,

518»10 HEEK

.ouRG __|

© M.J.N. Rildanans. 2005

Tranzo,FacultyofSocial and Behavioural Sciences;Tilburg University. the Netherlands

Key words: Demand-orientation, demand.

drivencare, typology

Vormgeving:PuntSpatie,Amsterdam

DTP: HAVEKA BV Ide_{grajische partner}

Alblasserdam

Allrightsreserved. Save_{exceptions stated by}

the law. no part of this publication may be reproduced, stored ina_{retrieval system of any}

nature, or transmitted in any form or by any

means, electronic,mechanical, photocopying, recording orotherwise,indudeda_{complete or}

partial transcription. without theprior written permission ofthepublishers,application for

which shouldbeaddressed to thepublishers: DUTCH UNIVERSITY PRESS

Bloemgracht 82hs

I0I5TM Amsterdam.TheNetherlands Telefoon: + 3I Co) 206255429

Fax: + 3I (0) 206203095

E-mail: info@dup.nl

www. dup.nl

Dutch University Press in association with Purdue Univenity Press, West Lafayette,

Ind. U.S.A 62 Rozenberg Publishers,

The Netherlands

ISBN 90 36Io 032 I

Positioning the individual in health care

A typology ofthe demand-oriented and demand-driven approaches

Positionering van het individu in de gezondheidszorg

Een typologie van de vraaggerichte en vraaggestuurde benaderingen

PROEFSCHRIFT

ter verkrijging vandegraad van doctor aan de UniversiteitvanTilburgop gezag

van rectormagnificus, prof.dr. F.A. van der Duyn Schouten, inhet openbaar te

verdedigen ten overstaan van een door het college vanpromotiesaangewezen

commissie in de aula vande Universiteitopvrijdag 2 _{december 2005 Om I4.I5 uur}

door

MADELEINE _{JEANNE NOELLE RIJCKMANS}

PROMOTOR:

Prof. dn H.F.L. Garretsen

----77---1

CO PROMOTORES:

Dr. L.A.M van deGoor _UNIVERSITEIT

*

VAN TILBURG Dr. I.M.B.Bongers

SIBLIO-THEEK

OVERICE_{COMMISSIELEDEN:} 1 TILBURG

Prof. dr. E.W. Roscam_Abbing

L--Prof. dr. I. W.Groothoff

Prof. dr. A.A. de Roo Prof. dr. _I.M.G.A. Schols

© M.J.N. Rilckmans. 2005

Tranzo, FacultyofSocialandBehavioural Sciences;Tilburg University,the Netherlands

Keywords:Demand-orientation,

demand-drivencare,_typology

Vormgeving: PuntSpatie,Amsterdam

DTP: HAVEKA BV Ide_{grafische partner}

A]blasserdam

All rightsreserved. Save_{exceptions stated by}

the law, no part of this publication may be

reproduced,stored inaretrieval_{system of any}

nature,_{or transmitted in any form or by any} means,_{electronic, mechanical, photocopying,}

recordingorotherwise, includeda_{complete or}

partial transcription,withouttheprior written permission ofthe_{publishers, application for}

whichshouldbeaddressed tothe publishers:

DUTCH UNIVERSITY PRESS

Bloemgracht 82hs

1015TM Amsterdam.TheNetherlands

Telefoon: + 3I (0) 20 6255429

Fax: + 3I Co) 20620 30 95

E-mail: info@dup.nl www.dup.nI

Dutch University Press in association

with Purdue_UniversityPress, WestLajayette,

Ind. U.S.A al Rozenberg Publishers.

The Netherlands ISBN 90 3610 032 1

5

Dankwoord

Toen ik in200Ibegon aan

mijn

proefschrift, werdmij verteld dat het eenlijdensweg

zouworden. Niets isminderwaar gebleken. ik heb van elkefasegenoten en heb het heletrajectervaren alseengeweldigeuitdaging. Voorhetbehalen vandeeindstreep

wilikechter_{enkele personenhartelijk}bedanken:

In deeersteplaatsmijnpromotorHenkGarretsen. Alseerste'Tranzo-AIO' heb je me

voor

_mijn

_{gevoelaltijd inhet zonnetjegezet. Te hebt me} vertrouwen in_{mijn eigen}

kunnen_gegeven,jestond_{altijd voormij} klaar alsik_{vragen had en hebt telkens de tijd}

genomen

mijn

ideeen eneventueleonzekerheden met metebespreken. Ook mijn copromotoren Ien van de Goor en Inge Bongers zijn voormij bijzonderbelangrilk

geweest. Jullie hebben mijhet gevoel gegeven eraltijd voor me te zijn, en ik heb dan ooknooittevergeefs aanjulliedeur geklopt. Watdatbetreft heb ikmealtijdterdege

gerealiseerd dat ik het met zo'nbegeleidingscommissie bijzondergoedgetroffen heb.

Bedankt!

Naast_{mijn begeleiders, gaat mijn dank ook uit naarmijncollega's van}Tranzo. In vier jaar tijdisTranzouitgegroeid vaneenclubjedatbijna op 66n handtetellen was naar

eenvolwaardig onderzoeksteam met meer dan₃₀collega's. In die vier jaar heb ik aan

iullieveel_{steun gehad, op hetinhoudelijk vlak, maarook zeker op hetpersoonlijke.}

Hoewel de clubtegroot is omiedereenpersoonlijktebedanken, hoop ikvanharte

dateeniedervan _{iullie dit}dankwoordwel_{persoonlijkopvat.}

Ook ben ik dank verschuldigdaanenkele_personenen _instellingenzonder wie dit proefschrift nooittotstand gekomenwas.Graag dank ik alle experts die hebben

deel-genomen aan hettijdrovende Delphi-onderzoek. Daarnaast ben ikdank verschuldigd

aan de_{drie instellingenvoor geestelijke gezondheidszorg, deGGZ Midden-Brabant,}

deGGZ Eindhoven ende_{vrijgevestigdepsychologenpraktijk}ContextTotaal voor hun

6

die de

tijd

genomen hebben omdevragenlijst intevullen wilikhiervoorhartelijk

bedanken. Zonderjullie bijdragen was dit proefschrift nooittotstand gekomen.

Tenslotte maakik_{graag van}de_{gelegenheidgebruik}enkele_{belangrijke personen uit}

mijn

naasteomgevingtebedanken. Opdeeersteplaatsmijnfamilie: Pi,bedankt voor

ie geloof inmijnkunnen en je kritischevragen inde_{afgelopen vier jaar. Ik heb ervan}

genoten om hetlaatstehoofdstuk samen met joute schrijven. Mammie, jou wil ik

graagbedanken voorje steun, het fungerenalsklaagmuur als het tegen zat en het

urenlang geduldigaanhoren van eindeloze gesprekken tussen pappa enmij. Val6rie

en Lucas, ook_{jullie wil}ik_{graag bedanken. Ook}julliehebben op afroepgewillig

kran-tenknipselsverzameld, artikelenopgezocht envragenlijsten ingevuld. Bedankt!

Terwijl ik richting het einde van het dankwoord ga, wil ik ook _graag

_mijn

beste

vriendin Coosie van der Pol en mijnbandElvix &The_Hounddogsbedanken.Coosje,

jou wilikgraag bedanken voor al onze gesprekkentijdensonze pauzes opde univer-siteit, jesteun op hetpersoonlijke vlak en voor alonze gezellige dagjes 'op stap'. Ik wens je heelveel succes metjouwpromotietraject! Bandleden, bedankt voor al het

plezier datwesamenhebben meegemaakt. dit is voormijtijdenshetrelatiefeenzame

werkde_{broodnodigeontspanninggeweest!}

En tenslotte wil ik mi jn manJos bedankenvoor alles wat hij

mij

heeft gegeven. Ook

jij hebtje (on)gevraagdmoetenbezighouden met 'vraaggerichte of was het nou

vraag-gestuurde' zorg. Tehebtinhoudelijkediscussies metme gevoerd, praktischezaken

aangepakt zoals het verzendklaar maken van meer dan ₄₀₀₀ vragenlijsten en ie

bijdrage inhethuishoudenendaarnaast heb je megestimuleerd,gemotiveerd en me

het vertrouwen_{gegeven dat ik het kon, met name op}demomenten dat ik het zelf niet

zo zag zitten. Echter, het belangrijkste van _{alles: je hebt mij gelukkig gemaakt.}

Schatje, een liefdevollere echtgenoot had ik me niet kunnen wensen! Tijdens het

schrijven vanditdankwoord, laat eriemandweten dat_{hij/zij er ook nog is en aan het}

drukke getrappel in mijn buiktevoelen is het een zeerlevenslustigpersoontje. Jos.

sinds wij elkaarkennen benik_{bezig geweest metmijnproefschrift.}Dithoofdstuk is afgerondenhoewelikervangenoten heb, kijk ikerenorm naar uit om samen met

7

Contents

Dankwoord 5

List offigures and tables 10

List ofpublications 11

Chapteri

General introduction 13

I.I Introduction IJ

I.2 Research questions IZI

I.3 Structure

ofthe thesis IS

Chapter2 Demand-orientation and demand-driven care:

Conceptual confusion in health care 17

2.I Introduction I7

2.2 Demand-orientation I8

2.3 Demand-driven care I9

2.4 Differencesin definitionsbetween key-players 20

2.5 Conclusion 22

Chapter₃ Key concepts Of demand-driven health care:

An approach based on clients' needs 23

3.I Introduction 23

3.2 Researchmethods 25

3.3 Definitions of need anddemand in

demand-driven care 25

3.4 Factorsinfluencingaclient's

needs 30

3.5 Conceptual

framework 3I

8

Chapter₄ Demand-oriented and demand-driven health care:

The development Of a typology 33

4.I Introduction 33

4.2 Methods and

_{measurements 35}

4.2.I Design 35

4.2.2 Datacollection and

analyses 36

4.3 Results 38

4.3.I Expertsconsider demand-orientation and demand-driven careas

_{different 38}

4·3·2 Typical elements of'demand-orientation'

and 'demand-driven care' 38

4.3.3 Dimensions at the base of thedifferencebetween demand-orientedand_{demand-driven care 40}

4.3.4 Thetypology

of

demand-oriented and demand-drivenhealth care 43

4.3.5 Use of the typology inidentifyinghealth care servicesas being demand-oriented or demand-driven 45

4.4 Conclusionsand

_{discussion 46}

Chapter5 A client's perspective on demand-oriented and

demand-driven health care 49

5.I Introduction 49

5.2 Methods and

measurements 5I

5.2.I Data

collection 5I

5.2.2 Measurements 5I

5.2,3 Analyses 52

5.3 Results 52

5·3· I Description

of

research sample 52

5.3.2 Elements consideredas importantby_{clients 52}

5.3.3 Differences in the appreciation

of

elements between

subgroups 55

5.4 Conclusionand

_{discussion 59}

Chapter6 Clients' experiences with ambulatory mental health care 63

6.I Introduction 64

6.2 Methods and

_{measurements 65}

6.2.I Data

_{collection 65}

6.2.2 Measurements 66

6.2.3 Analyses 67

9

6.3.2 Elements recognised inthe provided

mentalhealth care 69

6.3.3 Differences betweenstateand private

institutions 70

6.4 Conclusions and

discussion 72

Chapter_{7 Rejlections on demand-oriented and demand-driven care} within the current health care system 77

7.I Introduction 77

7.2 Demarcation 79

7.3 Thelegal aspects

of

health care 8

7.4 Healthcare

_{finance 84}

7.5 Conclusionsand

discussion 88

Chapter 8 General conclusions and discussion 91

8.I Introduction 9I

8.2 Themeaning

ofthe

conceptsdemand-oriented anddemand-driven_{health care 9I} 8.3 Thehealth careuser's viewondemand-oriented and demand-driven

_{health care 93}

8.4 Thedemand-orientedanddemand-drivenapproaches within thecurrent societal rules,legislation and ways of financing ofthehealthcaresystem 95

10

List of figures and tables

FIGURES

3.I Conceptual

framework 3I

4.1 Dimensions in the

typology 4I

4.2 Typology

of

demand-oriented and

demand-driven

_{health care 44}

4.3 Modelsofthreeexisting

services 47

6.I Examples

of

propositions 67

7.I Levels

of

demand-driven care 80

7.2 Division ofcarebasedon Dunning's _{(1991) criteria 8'7} TABLES 4·I Elements inround I 39

4.2 Elementswithinthe

_{dimensions 42}

5.I Description of researchpopulation 53

5.2 Importance

of

elements intypology according tomentalhealthcare

_{clients 54}

5.3 Differencesinscores

based on age 55

5.4 Differences inscores basedon treatment

_{histor 57}

5.5 Differencesinscores basedon _{education 58}

6.I Description

of

researchpopulation 68

6.2 Degree

of

recognitionofelements fromthetypology 69

11

List Of publications

Chapter2 . Rijckmans, M.J.N., Garretsen, H.F.L. Van de Goor, L.A.M., &

Bongers, I.M.B. 2002. 'Vraaggerichtheidenvraagsturing; een pogingtot conceptueleverheldering.' TSG no. 6,pag._388-392.

· Rijckmans,_M.J.N.,Garretsen, H.F.L., Van de Goor, L.A.M., & Bongers, I.M.B. _2003. 'Demand-orientation and

demand-dri-ven care; conceptual confusion in health care.' Eurohealth, Vol 8, no 5, pag. 33-36

Chapter3 · Rijckmans, M.J.N., Garretsen, H.F.L., Van de Goor, L.A.M., &

Bongers, I.M.B. (2005)· The Socio-Behavioral Modelin

demand-drivenhealthcare. Medicine andLaw._{Medicine and Law no. 24,}

pag· 463-477

Chapter_{4 • Riickmans, M.J.N., Garretsen, H.F.L., Van de Goor, L.A.M., &}

Bongers, I.M.B. (2005)· 'Vraaggerichte en vraaggestuurde zorg

in de praktijk: deontwikkeling van eentypologie'. TSG no 8.

(In press)

• Rijckmans, _{M.J.N., Bongers,} I.M.B., Garretsen, H.F.L. & Van

de Goor, L.A.M. (2005). Demand-orientation and

demand-dri-ven health care; thedevelopment ofatypology. Submitted.

Chapter₅ · Rijckmans, M.J.N., Van de Goor, L.A.M., Bongers, I.M.B., &

Garretsen, H.F.L. (2005). A client's perspective on demand-orientedand demand-driven healthcare. Submitted.

Chapter6 . Rijckmans, M.J.N., Van de Goor, L.A.M., Bongers, I.M.B., &

12

Chapter₇ . Rijckmans, M.J.N., Rijckmans, J.F.A., Garretsen, H.F.L. &

Jans-sen, R.T.J.M. (2005). Een reflectie op vraaggerichte en

vraag-gestuurde zorgbinnen hethuidigegezondheidszorgsysteem.

Submitted.

Abstracts , Rijckmans, M.J.N., Garretsen, H.F.L., Van de Goor, L.A.M., &

Bongers, I.M.B. (2002). 'Demand-orientation and

demand-driven care; _conceptual confusion in _{healthcare' (Abstract).} EHMAannualconference, _{Gdansk/Poland, June 2002.}

Rijckmans, M.J.N.. Garretsen, H.F.L., Van de Goor, L.A.M., & Bongers. I.M.B. (2004) 'Demand-orientation and

demand-driven care: apreliminarytypology' _(Abstract). EHMA annual

conference, Potsdam/Germany, June 2004·

Rijckmans, M.J.N., Garretsen, H.F.L., Van de Goor, L.A.M., &

Bongers, I.M.B. (2004). 'Vraaggerichteenvraaggestuurde zorg:

eeneersteaanzet toteen_typologieopbasisvan visies van

des-kundigen' (Abstract). Nederlands Congres Volksgezondheid

2004· TSG 2004; 82: nr. 3, Pg. 80.

Presentations · Rijckmans, M.J.N., 'Demand-orientation and demand-driven

care; conceptualconfusioninhealthcare'. EHMA annual

con-ference, Gdansk/Poland, June 2002.

Rijckmans, M.J.N. 'U vraagt?'. Kentron-debat, Tilburg.

Okto-ber 2003.

• Rijckmans, M.J.N., 'Vraaggerichteenvraaggestuurde zorg: een

eersteaanzet tot eentypologieop basisvanvisiesvan

deskun-digen' Nederlands Congres Volksgezondheid, Rotterdam, April

2004.

• Rijckmans, _M.J.N., 'Demand-orientation and demand-driven

care;a _{preliminarytypology'. EH}MA annual_conference,

Pots-dam/Germany. June 2004.

• Rijckmans, M.J.N. en Garretsen,H.F.L., 'Vraaggerichtheid en vraagsturing'. Symposium GGZ alacarte,_Tilburg, November

13

Chapter 1

General introduction

'According toa surveyoftwelve European countries, Dutch

medical care meetsthe expectationsofconsumers the best...

followed _bySwitzerlandand _{Germany. Minister Hoogervorst}

[ofthedepartmentofHealth, Welfare and Sports] is _pleased

with the results ofthe study. Heconsiders the indexa positive

contribution as itemphasizes the importanceoftransparency

in health care. According to Hoogervorst, the index focuses on

issueswhich citizens _{consider important, such as} theresults

of_{care' (Ministerie van VWS, 2005)}

1.1 INTRODUCTION

Health care in theNetherlandsis_{currently undergoing}aradicaltransformation

(Merks-van Brunschot, 2004)· In the Netherlands. as inmost European countries. we are witnessingaswingfromsupply-driventodemand-drivenapproachesinhealth care. Manysee demand-orientationanddemand-driven care as thekey-concepts in

inno-vativethinking about health care and welfare _(Van Diest, VanWijngaarden &

Wijn-gaarden,_2002).These concepts are seen as the answer tomanyoftheproblems

con-fronting ustoday in this area. But whatexactlyis meant bydemand-oriented or

de-mand-driven care?Andbefore we can address thesequestions, wemustdetermine:

whatisdemand, and what is need?Interms

of

content, the concepts

demand-orient-ed anddemand-drivenhealth care are not_clearlydistinct, and areoftennot defined

at all(Rijckmans et al, 2003)

Accordingto Verkooijen et al. (2003), thedemand-oriented andthe demand-driven

approach areboth counterparts ofthestronglyinstitutionalsupply-drivenapproach.

Inthesupply-drivenapproach, theexistingsupply is thepoint

of

departure,while in

14 Positioningthe individual inhealth care

attention is paid to how contentclients arewith their treatment, what theirspecific

needs and wants concerning their treatment may be (Veeninga & Hafkenscheid,

2002), as well aswhattheirgoals are(Anthony, Cohen& Cohen, 2000).The

demand-orientedanddemand-driven healthcareapproachesarebelieved tobekey-concepts

in the increasing focus onhealthcare users. It is _{claimed (Tranzo, 200I) that both}

approaches putmore emphasis ontheclient'swantsand needs and that, in this way,

healthcarehelps enhance theclient's experiencedquality of life (Htiyry, I999) Demand-orientation anddemand-driven careare concepts used by many when for-mulating mission statements, policygoals, organisational visions, and advertisements.

However,differentactorsdefine the two conceptsindifferent ways, and thedefinitions

varyfrom 'takingtheclientinto account'. on the one hand,to 'actualsteering by the

demand'. ontheother hand, withtheclient havingthe meanstoinfluencethe service

(Rijckmans etal.,2003) Agreementaboutthemeaning of bothconceptsis necessary

from a scientific point of view, but also fora correct evaluation ofthe _implications

for policyand practice. Inscientificdebates, as well asin _policyand societal debates

concerningwhether or nota_stronglyinstitutionalized_{supply-oriented approach should}

be transformed into a more demand-orientedor_{demand-driven approach, it}is essential

thatthedifferentparties agree on how the concepts aredefined. This requires good communication, especially between different parties, as the expectations that are

raised. can leadtomiscommunication through confusion ofconcepts. Little literature

has dealt with this issue, and there does not seem to be enough insight into the

content and the_{consequences ofthe concepts} ofdemand-orientation and

demand-driven care inthesectorofhealth careandwelfare.Thoughthe concepts are used in

practice on a _large scale, originating from practice, and concerning various _aspects

of health care.there is no unambiguousconceptualframework that canbe applied.

1.2 RESEARCH QUESTIONS

Because of the lackin scientific knowledge about the meaning ofthe concepts, the

topicality of the subject, and the great interest from the field, a PhD study was initiated in May 200I. The aim of this study was to gaininsight intotheconcepts of demand-oriented and demand-driven health care, and fill them in. The main goal

was thedevelopment ofa model forscientific use that could also serve as a tool for

policy andpractice in the field. It shouldserve as a means for thegovernment and health care organisations to shape their vision with respect to the health care user

and acquire insight into the consequences

of

different ways of organizing their

services.

When dealingwithgoalsand means, one mustconsider their meaningtothose who

are affected by them. For such a wayofsorting. theterm _{'typology' is used (Luiten.}

con-GENERAL INTRODUCTION 15

sists ofaunique combinationofelements (Dotyand _{Glick, I994). This study aims}

to developtwoideal typeswith respect to thefilling-inandexecution

of

health care.

Furthermore, since both demand-orientation and demand-driven care aim to give healthcareusers amore central role tomeettheirneeds and wantsmore thoroughly.

this study also aims to develop a concept-instrument with which to evaluate the

degree healthcare usersvalue the concepts.

By reviewingtheproblems defined andthe goals set inthisstudy,thefollowingquestions

wereaddressed':

• Whatis meant bythe conceptsdemand-orientation anddemand-driven care?

· Towhatextent arethe abstractdimensions present inthe currentsupplyofcare?

Howdohealthcareusersvalue theconcepts?

How do the approaches match with current societal rules and legislation and

waysof financingthehealthcaresystem?

1.3 STRUCTURE OF THE THESIS

As statedabove,the meaning ofthe concepts demand-orientedanddemand-driven

health care seems to be unclear.There is little literatureclarifying these concepts, andthe definitions ofthe concepts seem to vary a lot. In Chapter 2, the different

definitions in the scientific and professional literature will be compared and con-sidered, withaspecial focus ontheircommonanddistinctiveelements.

The swingfromsupply-driven careto demand-driven care is fuelled bythe current

trend to putthe individual in theforeground, considering his or herquality of life

and associated individualwishes andneeds. InChapter 3, a conceptual framework

for research will be sketched that takes quality of life as its starting-point. The concepts of 'need' and 'demand' will be explored, and all the factors that may in-fluence_{these concepts.}

Next, in order to identifythe different views thatthe various relevant parties hold,

and to examine to what extent there is consensus in the Netherlands about the

concepts

of

demand-orientation and demand-driven care, the results ofa

Delphi-study will be given, as done among twenty-six experts, based on the Grounded Theory _{(Glaser & Strauss, I967)·} The experts were representatives ofthe relevant

actors in thefield: scientists, healthcareinsurance companies, healthcaresuppliers,

thegovernment, independentadvisory bodies, andclient interestgroups. The study

resulted inatypology of thetwo concepts, presentedinChapter_4,demonstrating the

I. Research questionsare elaboratedin chapters 2 to7. Since these chaptersinclude manuscripts

that havebeenpublished orsubmitted for publicationto_{(inter)national scientific} journals, there

16 Positioning theindividualinhealth care

similarities and differences between the concepts in fivedimensions: _I) Responsi-bility,₂₎ Control,3) Need-determination, 4) Wayofimbeddingoftheviewwithin the

organisation, and 5) Choice.

Then, sincetheemphasis inthedemand-orientedanddemand-drivenapproaches is

onthehealthcareuser'sperspective, inthefinal phase_ofthe study (Chapters 5 and

6), the healthcareuser's viewsofthe_importanceoftheelements in_{the typology, and}

theirexperiences withthe various elements inpractice.Theresearchpopulation, in

whichtheimportanceoftheelements inthetypologywasexplored,wasclients from

the ambulatory mentalhealth care. The goal was toexplorewhich elements met the healthcareusers' wishes and needs. Forthispurpose, aquestionnairewas

develop-ed, based on the typology. Chapter₅focuses onthehealthcareusers'appreciation of

the elements inthe typology.Chapter6explores the experiences

of

healthcareusers

concerningthe presence ofthe different elements

of

either approach in the health

care they received.

In Chapter 7,thepossibilitiesofthenew approaches and the developedtypology will

be considered given the current legal and financial situation. The main question

addressedis'given the current legal andfinancial situation, what are the possibilities

and limitations forthe demand-orientedanddemand-driven approacheswithin the

Dutch healthcaresystem?'

Finally, in Chapter 8, the results ofthis dissertation are summarized and some

17

Chapter 2

Demand-orientation and demand-driven care:

Conceptual confusion in health care

The concepts demand-orientation and demand-driven care are

seen by many as the keywordsin innovativethinking about

health careand_{welfare. These concepts are seen as the}

answer to the problemsconfrontingustoday. But what do

these concepts meanP Literature on clarification of the

concepts is scarce and when they aredefined, thedefinitions

seem to vary a lot between the different parties. For thisarticle

the differentkindsofdefinitions in literaturewere studied and

compared on thebasis ofcommonand distinctiveelements.

In the current literature there seems to bea fundamental

difference between the conceptofdemand-orientation on the

one side and the concept demand-driven care on the other. In

the case ofdemand-orientation, supply steers the demand,

while in puttingtogetherandshaping the supply the demand

will beconsidered. In the caseofdemand-driven care, supply

is _{being steered by the demand, and freedom} ofchoice for the

user is a central element.Additionally, in the caseof

demand-driven care the user even has thefinancial meansto effectuate

this freedom.

2.1 INTRODUCTION

Health care isanalmostpermanent subjectofpublicdebate. Aspectsofdiscussions are broad and ofa_{moral, ethical, economical,legal, organisationaland}

administra-tive nature.Thismakesthefield

of

healthcareextremelyinteresting but at the same

time very complex.

Patient choice has become an important touchstone

of

health care reform across

18 Positioningthe individualinhealth care

of

what _might be called a _{'paradigm flux', now affecting health} service _{delivery in}

nearlyevery advancedindustrialised _{country (Saltman, 1994).} Indevelopinghealth care policy and the organisation

of

health care services, more and more pleas are

being madetointroducedemand-orientationand demand-driven careascounterparts

to a_stronglyinstitutional,supply-orientedapproach. This movement canbeviewed

across all_aspects

of

society,forinstanceinpublic housing,education, social services

and social security (Roo, _{I995)· Janssen} speaks ofa trend over thenext decade, in

whichclient demandswill become the _{departure point,} i.e. 'demand-driven' health

care (Janssen, I997)· TheMinistry ofPublic Health, Welfareand Sports has a

some-whatsimilar point of view thatstatesthat 'demand-driven care'hasbecomeapolicy

aim (Terpstra, I997)

The turning point inthehealth service, from asupply-drivento demand-driven

ap-proach,took place inthe Netherlands in the late_I9804 beginning withthe

recom-mendationsofthe DekkerCommittee. The_{conceptual cornerstone}ofthisapproach

is consumer sovereignty,which assumes that it is possible and useful to letsupply

be steered autonomously by thedemand forcare _{(Grinten, 2000). It} assumes that

consumers are capable

of

makingchoices in relation to the useofservices, and are

highly motivated; they want to choose. The reforms Dekker envisaged have hardly

materialised.Thepossibility

of

personalbudget financingarose only in _{I995, largely}

because

of

lobbying bytheDisability Board.

Much has beenwritten aboutthe dilemmas

of

demand driven care, organisational

difficulties in the execution

of

demand-orientation andthe financial consequences

of

theintroduction ofcarebasedondemand. Incontrast, theliterature onthe clarifi-cation ofthese concepts is quite scarce. Furthermore, the terms have been defined in variousways,ranging frommereclient-orientation, toactual influence on supply

by client driven demand _{(Garretsen. 200I).} To prevent miscommunication, clarifi-cation ofthe different_conceptsis _highlydesirable. Definitionsare discussed below.

In comparing the various definitions, there seem to be some distinctive and

commonelements:

Focus: what is the mainconcern

Power: whohasfinal control

Perspective:professional, individualistic, administrative, economicperspective or

combination

of

these.

2.2 DEMAND-ORIENTATION

Definitions ofdemand-orientation focus on supply and thus on the actions of care providers. Demand-orientation refers to a procedure that care providers (ought to)

DEMAND-ORIENTATION AND DEMAND-DRIVEN CARE 19

mutual effort

of

patient and provider that leads to the patient receiving help that

fulfils his wishes and expectations and at the same timecomplieswith professional standards' (RVZ, 2000). The providerhasknowledge

of

these so-calledprofessional

standards, (often incontrast tothe_{client), who}therefore tendtocontrolthe content

and shape

of

services.

Another definition

of

demand-orientation is '

Policy and practice that aims at

ful-filling the need for public health interventions based on: data concerning the size

and severity

of

population health problems andthe needs, wishes and expectations

of

client organisations as wellas individual clients' _{(Dekker, 2000).} This definition

balances individual subjective wants and the objective needs ofthe whole

popu-lation. Control rests with policymakers and providers, as theydecide onthe weight

of

individualversus collective needs andare_{responsible for financing.}

In contrastto these two definitionsthe _{Dutch Patient/Consumer} Federation uses a

moregeneraldefinition: 'Demand-oriented supply isthat,which onacollective and

individual level,according tothe opinion of the user ortheirrepresentative,

contri-butesoptimallytowards theproblemshe_{encounters' (Goudriaan & Vaalburg, I998)}

However, furtherexplanation ofthisdefinitionreveals that itis similar to that of the

RVZ,ashealthcare supplierswithprofessional knowledgetake accountoftheneeds

and wants

of

usersthroughaprocess ofdemandclarification.

In defining demand-orientation,the focus

ofall

thedifferentdefinitionsseems to lie

inthe process

of

generating a _{service that (to}acertain _extent) contributes towards

the needsand wantsofusers. Finalcontrol is inthe handsofpolicymakers and health

caresuppliers. Suppliers decide to what extent theyarewillingtoaccede tothedemands

andwishes

oftheir

clients. All of this_largelyoccurs froma_{professionalperspective,}

and because

of

information-asymmetry health care suppliers retain theirstatus as

experts. From an administrative perspective. the deliberations ofpolicy-makers on individualversuscollective_{populationneeds help play a role}indemandorientation.

2.3 DEMAND-DRIVEN CARE

Mostdefinitionsaboutdemand-driven care, as well asdemand-orientation, indicate

a process, but in this case thefocus is not so much ontheactions ofthesuppliers or

providers but much more onthepossibilityofchoiceforusers, andthus demand it-selfTheinterdepartmental commissionEtty describes this as:'Theessenceofdriving

demand is thattheinsuredhimselfcandetermine his care. Themain concern here

is the possibility

of

choice. The goal

of

introducing the concept

of

demand-driven

care is to put clients in a more equal position in relation to suppliers, so that suppliers

20 Positioningthe individualinhealth care

they desire, can makechoices fromtheavailable supply,given

of

course thatachoice

of

careoption exists' (Etty, 2000).Thefocus here is onthe processthatservice users

will

gothrough. Asomewhatsimilar definition

of

demand-driven care is used by the

Ministry

of

Public Health, Welfareand Sports.'Indicated demandguides the

quanti-ty andquality ofthe _{required supply' (Ministerie van VWS, 2OOI). Both}

of

these

definitions contain restrictions: choice is limited to available supply and a formal

indication for careis _required.

In contrast tothe above, somedefinitions do not restrictusercontrol: 'The patient/

consumer needs to be in control, for he is 'the client' and also hasexperiential

ex-pertise. Patients andconsumers decide on careoptions. Demand-driven care must

be accompanied bysolidarity, freedom

of

choice and preservation

of

personal

auto-nomy' (NPCF, 200I), and 'Steering demand is translated as the ideal of the free

market,in whichthe supply of careis determinedby autonomous and responsible consumers/patients makingselfassuredchoices on the use

of

health careservices'

(Grinten, 2000). The Board for Public Health Caredefines the concept somewhat

similarly as 'implying that market demand determines the supply of care' (RVZ. 2000). Crucial to all

of

thesedefinitions isthe dependencyofsupply on demand and

thus the dependency of suppliers on patients. This can be further emphasised:

'Having supply guidedby_demand,withdemand actuallyhavingthemeans to guide

supply' (Goudriaan&Vaalburg, IS)98)

The focus

of

different definitions for demand driven care seems to be freedom of

choiceforusers, i.e. the process bywhich individualsselectservices that best address

theirneedsand wants. Control ultimatelyrests with_{users (demand).}The emphasis

in this case is on the individual nature of the _{demand (individualistic}perspective).

Individuals determine both the type and provider of care. As every individual has differentexperiences, eachdemand canbedifferent. The policy for and natureofsupply

arethus tunedtodemand. Demandaffectsthe nature,qualityandquantity

of

supply.

Furthermore, demand-driven care is seen from an _{administrative perspective, in}

which hierarchical budget-driven approaches are _{replaced by more decentralized}

consumer-oriented perspectives. Ultimately, when users also have the financial

re-sourcesto ensurethat suppliersacquiesce totheirdemands. the concept can also be

viewed froman economic_perspective.

2.4 DIFFERENCESIN DEFINITIONS BETWEEN KEY-PLAYERS

Definitions in the literature _{originate from} five different _{key-players: science and} knowledge institutes,governmentand advisory bodies,care_{suppliers, client interest}

groups and others such as _{commercial organisations.} In _comparing the various

DEMAND-ORIENTATION AND DEMAND-DRIVEN CARE 21

Firstly,the extent towhich restrictionsarebuiltinto definitionsvaries. Incontrast to

others, the government and advisory bodies include restrictions on the complying

with client needs and wants, freedom

of

choice and final control. This raises the

question as to what extentthere isactually afocus on demand. Withinthe concept

ofdemand-orientation,theserestrictions need not beacontradiction. Afterall, final

control rests with suppliers, who ought to attend to clients' needs _{and wants}

(de-mand), but who also from a _{professional perspective} canascertain what is best for

the patient.

However,when controlrestswithusers, as in thecaseofdemand-driven care,these

restrictions seemtosomewhatcontradictory tothemeaning

ofthis

concept.

Accord-ing toanumber

of

_{governmental definitions, individuals}ought to have some choice

over servicesand_{suppliers, but constrainedby}available_{supply and need for}

appro-priateindication for care. Tosome extent we can speak

of

freedomofchoice, but this

is only the case when an individual agrees withthe formal indication for care and

available_supplymeets needs and wants. For_{example if}achildis identified as_being

suitablefor_{'special education' because of}abehavioural disorder, he andhis _parents

would then be ableto choose between specialschools in the area _{(available supply).}

However if_{the child (and}hisparents)wouldprefer to go toanormalschool and see

a psychologist once a week,demand-drivencare_{would imply that the type}ofservices

provided would bedependenton demand and thus the needs and wants

of

service

users. In this casehoweverthe needs andwants ofthe child and hisparentswould not be met, given restrictions which

limit

choice toexisting supply. There lies the contradictionin_recommendingdemand-driven care.

Another noticeable difference is that many _{care suppliers do not distinguish}

be-tweenthe terms demand-orientation anddemand-driven care. When theyspeak of

demand-orientation,the elementsfoundintheirdefinitions aresimilarto those for

the general concept

of

demand-driven care, and vice versa. Care suppliers define

both demand-orientation and demand-driven care as: 'Making the client and his

needs and wants the centre

of

_{attention' (ZMOK, 200I). In} the explanation of each

given_{definition, sometimes} thedefinitionleansmore towards the generalized

con-cept

of

demand-orientation(focusing onthe actions

of

suppliers who maintain con-trol), and in othercasestowardsdemand-drivencare(focusing on freedomofchoice

with_{patient control). Examples of}such nuances _{include: 'addressing more clients'}

needs' and 'individualisation of care' on one side and 'service provision tailored to demand' or 'moreauthority fortheclient' onthe other. Inallcases definitions pro-vided bythe governmentand associated advisorybodies are the most restrictive in

nature,while those

of

client interestgroups maximise the level

of

control exercised

22 Positioningtheindividual inhealth care

2·5 CONCLUSION

Although there is some confusion about demand-orientation and demand-driven

care, we canidentifysomecommonthemes. We canconclude thatthere seems to be

afundamental differencebetween the two concepts. Regardingdemand-orientation, the focus is on the extent to which thosewho provide services, take the needs of

individual_patientsintoaccount. _{Largely this is}a matterof_{professionalperspective.}

Indemand-orientation.those supplyingservices stillguide demand.

In the case

of

demand-driven care, the focus is on freedom ofchoice, with the in-dividual patient havingthe final say on the typeofcarereceived. Demand-driven care

is seen more from an administrative _perspective, in which hierarchical budget-driven_approachesare_{replaced by}moredecentralisedconsumer-oriented_{perspectives.} The emphasis is ontheindividualnatureofdemand. Itassumes thatonly individual

patients have the necessaryexperientialexpertise to makeinformedchoices. In some

instances _{patient influence} over demand can be extended even further, giving

in-dividuals the necessary financial resources to ensure that desired services are

pro-vided. Demand-driven care can thus be viewed from an economic perspective.

Supplycan actually be influenced by demand. Wecan conclude that in the case of demand-orientation supplyguides demand,while in thecaseofdemand-driven care,

23

Chapter 3

Key-concepts of demand-driven health care:

An approach based on client's needs

Objective: In mostEuropean countries we arewitnessing a

shift from supply-driven to demand-driven approaches in

health care. According to these approaches, health care

should contribute tothefulfilmentofhealth-care-related

needsofindividuals and, therefore, totheirperceived quality

of life. The purpose of this study is to developa conceptual

frameworkfor research in this new viewofhealth care.

Findings: The authors conclude that the 'felt need' should be

the foundation ofdemand-driven care. The second partofthe

study is based on awidely used Behavioural Model to which

the authors make an _{additional distinction, resulting in a}

conceptualframeworkforresearch, policy and practice

Conclusions: This study makesa startat providing

information about fundamental concepts that are atthe heart

ofthedemand-drivenapproach. In order to contribute to quality oflife, health careproviders should explore the

underlying needswhile developing services inorder to fit the

demand-driven approach.

3.1 INTRODUCTION

In_{several European} countries weare _witnessinga shift

in

health carefrom

supply-driven todemand-driven approaches.inwhich freedom

of

choicefor patients is an

important starting-point. Patient choice is usually associated with the idea of 'con-sumer sovereignty' andthe importance

of

tailoringhealthcare systems to meet the individual demands of its _{users (Calnan,} Halik & _{Sabbat, I998). This reflects the}

current search for anewdefinition ofthe_patients' role,whichcould alsobecalled a

paradigm shiftthat affects thesupply ofhealth care services invirtuallyevery

24 Positioningtheindividualinhealth care

care to demand-driven care is fuelled by the current trend to foreground the

in-dividual and his wishes and needs. This trend is part ofthe wider trendtowards

individualization, which has beenan_{ongoing historical,} social, andculturalprocess

inWestern societiesfor centuries and that has byno meansfully run its course. As

a _{social process,}individualization manifests itselfas_{people's emancipation}vis-b-vis

each other.This implies that, in more andmore areas oflife, people make choices

thatare relativelydissociated fromother people's choices, eventheir near and dear,

andfrom their own choices made earlier or elsewhere. There is less coercion than

there used to be,butthere is alsolessresignation toone's _{destiny (Schnabel, I999)}

The increase in patients' assertiveness dates back to the mid-sixties, when social

upheavals occurred in many countries the world over. Many intellectuals rebelled

againsttheestablished power relations and demanded increased-participation policies.

Publichealth carealsoreceivedits shareofthe mountingsocialdiscontent. The term 'patient'wasoutlawed asamisjudgementoffellowhumanbeings andtheirexistential

problems, and the newterm 'client'becamefashionable _{(Geelen, 2000). In such an}

individual-oriented culture, whichconsiders _'autonomy'

of

_{paramount importance,}

peoplearedetermined to be the captains

of

theirown souls and the masters

of

their

ownlives(Schippers& Gennep, I999). In otherwords, they attempttoarrangetheir

lives in such a way that they manage to

fulfil

their needs as much as possible and

take responsibility fortheir quality of life.The phrase'quality oflife' made its way

in-totheNetherlands fromtheUnitedStates,where it has been veryprominentin health

care debatesfor severalyears _{(Achterhuis, 1988). When the}quality

of

human life is

definedinordertoassistpatients towardsinformed,rational andautonomousdecision

making.quality of life is good if and only if it is goodaccording to the criteria they

themselves have chosen to employ (Htiyry, I999). Thus, ifone conceives of the

individual asan_{autonomous being -}aself-reliantand_independentindividual - with

authority over his own life, then his perception

of

qualityoflife is atthe centreofthings.

This study uses thedefinitions of'health' and 'quality of life' asthese have been

for-mulated by the_{World Health Organization (WHO). Health is} 'A state

of

complete

physical,mental, and socialwell-being and not merely theabsence

of

disease or

in-firmity'

_(WHOQOLgroup, 2994) and quality of lifeis 'Persons' perceptionof their

position in life andinrelationtotheirgoals, expectations, standards, and concerns.

It is abroad-rangingconcept incorporating, inacomplex way, the person's physical

health, psychologicalstate,levelof_{independence,}social_{relationships, personal beliefs,}

and relationshiptosalient features ofthe_{environment' (WHOQOL group, I994)·}

Each individual mayhave differentneeds in_{realizing his life;} differentneeds in the areas of work, socialrelations, and material matters, but also inthe areas ofhealth

care,well-being,and housingconditions andthe health careservicesthey require in

de-KEY-CONCEPTS OF DEMAND-DRIVEN HEALTH CARE 25

mand-drivenapproachinhealthcareimplies thattheindividual'sdemands andneeds

must bemet.Ultimately,theindividual'swishes and needs are the core issues

(Rijck-mans et al.,2002). However, can an expresseddemandbeequated with a felt need

andthus serve asa reliablefoundation forhealthcaresupply that contributes to

ful-filling care needs? Are the care needs felt by the individual actually and accurately

translated intocare demandsformulated by that individualD In this article,which is

part ofa study concerningthedevelopment ofa typologyfor demand-oriented and

demand-driven care, the authors sketchaconceptualframeworkforresearch that has

quality of life as its _{starting-point. This study's} main focus is on _{long-term care, as} thedemand-driven approach is obviouslymore amenable tochronicmental and or

physical conditions than to incidental acute care. The authors willbe dealing with

the process from 'need'to 'expressed demand' and with all factors _{(Goodwin &}

An-dersen, 2002) that may haveanimpact on thisprocess,inordertoexplore thedifferent

variables andgive insight to all different parties in the field and into the ways in-dividuals cometotheirexpressed demands.

3.2 RESEARCH METHODS

To gainabetter understanding ofthe process of howan _expresseddemand for care

is realized and in order to fully interpret the concept

of

demand-driven care, the literaturewasreviewed todefineanswers tothefollowingquestions:

What does the concept 'demand' stand for in demand-orientation and

demand-drivencare?

What factors have an influence ontheexpression ofademand?

· Which theoreticalissues should health_careproviders considerin theirsearch to offerdemand-driven health care services?

The first step in this study was a complete literature search (Psych.lit., Medline,

OCLC Pica) for the concepts 'need','demand' or 'want'inrelation tothe concepts

'de-mand-orientation: or 'demand-driven care'. Thissearchgainedverylittleusefulreferences.

Nextaseries

of

interviewswithexperts inthe fieldof'quality

oflife'

and'health care

policy' followed. Information fromtheseinterviews leadthe authorsin their search

forrelevant articles.The references usedinthosearticles were then used to find new

relevant_{literature (snowball method). Many of}therelevant articles _{concerning need}

and demand pointed towards Bradshaw's _{Classification (Bradshaw, 197'7) and}

literature concerning health care use pointed towardAnderson's Socio-Behavioural

Model (Andersen, I995)· Both models werethen takenas starting points.

3.3 DEFINITIONS OF NEEDAND DEMAND IN DEMAND-DRIVEN CARE

26 Positioningthe individual inhealth care

conceptsdetermine thecontent

of

health care thatis based onclient'swants

(Rijck-mans et al., 2003)· Both concepts have been extensively considered in the field of epidemiological needs research _{(Goudriaan &}Vaalburg, _I998). Recurringpoints of

debateconcern what realneeds are and how they can be measured. In the Oxford

Advanced Learner's Dictionary (OALD, I995), 'need' is defined as a 'basic necessity

or requirement'. However, establishing a _{particular need is not} an _unambiguous matter. The concept of'care needs'is sometimes calleda container concept, in the

sense that needs research can be done from agreatmanyperspectives (Bijsterveld,

200I). Itisclear thatcare needsarerelative to time,place, andculture,butthere are also different definitions

of

needs. In sum, the concept of 'need' is not an

auto-nomous fact. Thedetermination of what a need is and what kind ofcarewould be required is subject to norms, values, and experiences, which may differ over time.

Not everykindof'neediness'willactuallyresult inademand forcare _(Moons,

Kerk-stra & Picauly, _I989); people with the same degree

of

'neediness' may formulate different demands for care and may receive varyingdegrees ofactual care and the

presence ofhealth problems is a very poor predictor ofthe presence of need for

professional care _{(Romme, I979)·} People are different. in sickness and in health.

Asidefrom demographic differences such as age and gender, people alsobelong to different cultures and have different_{personalities, psychological} constitutions, and

life experiences which all impact the ways in which they interprettheir 'diseases'.

They have different ways

of

dealing with the consequences

of

their ailments and,

hence,require different kinds of care. In needs assessment, therefore, it has

mean-whilebecomean accepted fact that the useofaverages isdeceptive. Average

(demo-graphic) citizens,averageresponses totreatments, andaverageoutcomesareusually

inapplicabletoindividualcases _{(Moatti, 2003,} Sartorius, 2000). 'The' need for care,

consequently, is an elusive phenomenon, whichis related to demands for care and

the availabilityandquality

of

actual facilities in acomplex way. How, then, can we definethe concept of need in morepreciseterms

In psychology, the conceptof'need' is one ofthe central themes in explaining hu-man behaviour. A well-known example ofa need-oriented approach to human be-haviouris Murray's need theory, in which he defines the concept of need as a

con-struct which stands for a force in the brain region, a force which organizes

per-ception,apperception.intellection, conationand action in such a way as totransform

in acertain direction an existing, unsatisfying situation (Murray, I938) Needs refer

to organisationaltendencies,which appear to giveunityand direction toa person's

behaviour _{(Stern, I970) Maslow} alsostudiedhuman needsand becamefamous for his Hierarchy

of

Human Needs. He believed that the needs people experience are

hierarchical, in which lower needs have to be met for an individual to experience

KEY-CONCEPTS OF DEMAND-DRIVEN HEALTH CARE 27

relations in order to channel information flows advancing towards them (Linscho-ten, Leemeijer&Heuvel, _I988).Needs are predominantlyconsideredinterms of the

discrepancy between theperception ofan ideal and the perception

of

actual reality.

Yet anotherdefinition is from Freud, inwhichhe states that a need is 'aconscious

knowledge ofadeficit' _{(Freud, IS)40)· From}the perspective

of

psychology, in sum, a

need is an individual'sconsciousperception ofthe state

of

discrepancyin which the

individual finds himself.

In medicalscience examplesofdefinitions of a needaregiven_{by Donabedian (I973)}

and

Willin,

Hallam &Doggett (IS)92). They state that the contentoftheconcept is

de-pendent onthe perspective one reasons from. Donabedian _(I973) emphasizes that, in health care, the termneedshouldbereservedfor_describingacertain undesirable

condition ofanindividual.He defines need as'somedisturbanceinhealth and well-being'. In thisdefinition,need exclusively relates toadisturbance,adisease, or a

pro-blem. The lack, shortage, orwantrefers to ahealth failing inanindividual but not

(yet) to the necessity of care. Fromthispoint of view theundesirable condition may

thenbetranslated intoacertainmeasure or kind of care. Need.therefore, isdefined

as acertain disturbance inthe health and well being ofan individual. In addition,

Donabedian (I973) distinguishes twoperspectives ofthe concept of need, viz., the

clients' perspective and the _{professional perspective.} From the clients' _perspective,

need is theclients' assessment ofthe conditions andsituations inwhich they need

care; fromthe_{professionalperspective, it is the experts' assessment}oftheconditions and situationsin which care is needed. Wilkin et al. _(I992) statethatneeds

assess-ment is dependent on the criteria that are usedtogauge the need. This may be an

ideal standard, aminimum levelthat should notbetransgressed by any individual,

or, thirdly, a level thatis established bycomparisonwith standards

of

other groups

or individuals. Adistinctionsimilarto Donabedian's,which isoften madetodefine

the conceptofneed, is thatbetween objective and subjectiveneed.AccordingtoMoons

et al. (I989), this distinction isalsoconditional uponthe perspective one has in

ma-kingthe assessment, but in this caseitinvolves adifferentsetofterms: anobjective

need (need) is basedon expert criteria, andasubjective need (want) is based on the

perception ofthe person concerned. This is especially evident in Anglo-American literature, wherethedistinctionbetween 'need' and 'want' is_{commonly made.}

When-everthe concept of needisdiscussedinliterature, itisespeciallythisdistinction that

gives rise to a lot

of

debate. 'Need' is oftendefined as theobjective need and 'want'

as the perceived. subjective need. Someobject that, in principle, needs can only be

seen assubjective preferences. 'To talkofobjective need,definedbysomeoneother

than the individual himself, is to open the door to authoritarianism and

infringe-ments

of

individualliberty' (Percy-Smith. I996). 'One mustconsider theindividual

patient as the only person who can balance dissatisfaction and satisfaction in

28 Positioningtheindividual inhealth care

The variousdefinitions ofcareneeds canbesubdivided inBradshaw's_I977

classifi-cation, in which he distinguishes four types ofneeds _definitions, viz., normative

need, feltneed, expressed need, and comparative need_(thesetypes are notmutually

exclusive, but may overlap or even _{coincide) (Bradshaw, I977)· Normative need}

represents the need for care as assessed bythe expert. Some desirable standard has

been formulated. and iftheactualstandard oftheindividualisbelowthisdesirable

standard. the individual has a need. The ideal standard and _{Wilkin's (I992)}

mini-mum level, as well as the definition usedby _{Donabedian (I973) are} also normative

inthis respect. Moreover, thedistinction between objective versus subjective needs

also fits into this classification:objective need equalsnormative need, and subjective need equals felt need.

In the second category

of

needs definitions, feltneed equals want. In Bradshaw's

(I977) view. this is the need for care services experienced byanindividual when such

a serviceisproposedorpresented tohim. Bradshaw's classificationis cited by many

authorsin health careliterature (Dijkstra, 200I, Goudriaan &Vaalburg, I998).

Re-markably, however, they define felt need as a subjective need, that is, the need as it

is experienced by the person demanding care. Whatis beingpresumed here is that

felt need is no more than the need thatarises whenaservice from the actual range

of

services (supply-driven) is being proposed to a person. However, this does not

cover _everything a _{person experiences. Forexample, the need for improved vision}

wouldnever arise before the invention

of

glassesorlenses. Feltneed, therefore, can

gobeyond Bradshaw'sdefinition. Felt needs are thetotality

of

needs experienced by

the individual, independent fromthe existing supply

of

services oranyone

express-ing aninterest in this need. Phrased in this way, this definition also encompasses

Murray's ( 938) and _{Maslow's (r943 ofI970) definitions.}

The thirdtype distinguished_{by Bradshaw (I97'7) is the expressed need,} ordemand.

This refers to that part of the felt need that has actually been translated into a de-mand for care. This transition process from need to demand is infuenced by a

varietyoffactors. The needfor improved vision, for instance, maybetranslated into

a demandfor Brailleoraudio books. In many cases, thearticulatedneed,therefore,

will beaversionoftheoriginal need that hasbeen adapted to context factors. Several

studies identify that care demands are only partially determined by care needs

(Frederiks, 1990; Kempen, 1990;Wierik, 199I)

The comparative need, finally, which also encompasses Wilkin's _{(I992) third}

alter-native, is the need forcarederived fromacomparisonbetween those whoarealready

receiving care andthose with the samefeatures who dotnot receivecare _(Bradshaw,

KEY-CONCEPTS OF DEMAND-DRIVEN HEALTH CARE 29

In order to properly demarcate the conceptual framework for use in the

demand-drivenapproach, awell-foundedchoice had to be madefor which definition of need

was going to be used. Inthis study'quality of life' wastaken as a key concept, since

this is the goal ofthe demand-driven approach, though we were aware that social

realities _{mightpossibly engender} otherfeasiblesolutions.2 _{Quality of life}is defined

in termsofamatchbetween needs and thefulfilmentofthoseneeds. The_{felt quality}

of life, in otherwords, is determined by needs

fulfilment in

thefields ofemotional

well-being, interpersonal relationships and social bonds, materialwell-being, personal

development, physicalwell-being, autonomyandself-determination,and_spirituality

(WHOQOL group, I994)· From theclient's perspective,which isthe centralviewpoint

inthis study, this means thatthe individual's perception

of

quality of life is the key

issue.Iftheperceptionofqualityoflifedepends on thelevelofcorrespondence between

this individual's needs and their fulfilment. we must base ourselves on the needs

perception ofthe individual, or, inshort, the felt need. In otherwords, if we look at

demand-drivenapproachesinhealth care fromtheclient'sperspective,whichpivots

on the individual's perception

of

quality of life, the felt needs

of

those involved are

the needsthat ought tobefulfilled.According to Uss (I993) the term 'felt need' does

not refer tofeelings but to beliefs. A belief is not a need. Felt need for health care

may therefore mean'anopinionofthe individualthatthere is a needforhealth care'

(Liss, I993)· In sum, health care need is a flexible concept. 'Health' is the goal of

health care need,but depending onthe perspectivetherearedifferent components in

the conceptofhealth. Inhis philosophicalanalysis

ofthe

conceptofhealth care need

Liss ₍₁₉₉₃₎ comes up withthedefinition 'P has a needforhealth care if, and only if,

a) there is a difference between P's actual state and a goal, and _b) health care is

necessaryinordertoreach the goal'. Inthisstudy, sincetheclient'sperspective is the

centralviewpoint, theoperationaldefinition ofhealthcare needscould beasfollows:

'A discrepancy in the individual's conscious perception between his actual and his

desirable state of health and/or well-being, which is experienced by the individual as negative'.

Subsequently, we need to gain an understanding of thegapbetween care needs on

the one hand and caredemands on the other.The process

of

translatingcare needs

2. Thischoice was made as,atpresent,the'quality of life'concept isalsoconsidered to beapossible

solution for_scarcityissues. Some _{policymakers from both political}and medical realms believe

that this isthecriterion thatwillallow selectionissues,ensuing fromscarcity, tobeavoided or. at least, tobelargely resolved satisfactorily.Weshould abandonourfocuson sheerlength of life or

survival and. instead. resort to'quality of life'. This wouldalleast allow usto addressissues of scarcity and selection inasocia]lyacceptable way.ThephilosopherAchterhuis_(I988)quiterightly

raisesthe question here whether this conceptwillindeedoffer a way out ofthe scarcity issue or

30 Positioningthe individual inhealth care

into caredemands, apparently,is susceptible tomanyfactors. Bradshaw's taxonomy

also makesclear thatan_{articulated demand for care is only a part of a felt need. So}

the definition ofthe concept

of

demand could run as:

'That part of a felt need forhealth carethat isactually translated into a demand for care'.

3.4 FACTORS INFLUENCING ACLIENT'S NEEDS

In order to be ableto respond to clients'needs, itisessential, first of all,toestablish

how clients translate their felt needs into articulated demands. After all, this study

investigates the extent to which organisations attune their supply to autonomous,

individualclients andthe extent towhich thisconcernstheir articulated demand or

their individually felt need. It is essential, therefore. to have a clear grasp of both

concepts and the factors responsibleforthese differences.

A care needconsists ofa multitude

of

aspects that must be articulated by the in-dividual into a care demand. Aconcretecaredemand ofprofessional health care is

preceded byacourseofevents thathas_{eventually led to a}caredemand as itis_currently

beingexpressedinprofessional care.A health complaint orahealth problem usually

initiates this process,eventually ending in acaredemand,with which anindividual

entersthefieldofhealthcare.Ideally,caredemandswouldnotdiffer fromcareneeds.

Unfortunately. though, this is not the case inreality,inwhich clients'careneeds are

not _{always represented in} the articulated care demand. Often, a _person's

circum-stances are thedeciding factors both inthe formulationandcontent of the care

de-mand, aswell their view

of

where they shouldentertheexistingfield ofalldifferent health care services. The mainfactors involved here include the workload ofthose

offeringvolunteeraid, housing conditions andthe presenceorabsence ofaspouse,

the incidence

of

psychological or psycho-geriatric disorders. depression, and social

isolation Bilsterveld, 2001; Boer, I997; Penninx, I996).Care needs havea

multidi-mensional character. with the various dimensions impacting one anothen The

co-herence between thesedimensionsisoften highlycomplex (Andersen, I995;

Huys-mans, I990)

In his Socio-behavioural_{model, Andersen (I968, I995)}represents thevarious

deter-minants that influence the use

of

health services by way of three interconnected

categories, viz. predisposing orpersonal variables, which influenceuse inclination,

enabling factors, which influence access to facilities, and need factors, which

in-fluence_{people's need to}usehealth services._{The widely used Socio-behavioural model}

(Meer, I998: Goodwin & Andersen. 2002; Coughlin & Long. 2003) attempts to

provide anexplanation forthe processthattakesplace and put it intoacausalorder

(Andersen. I995). According to this model, people's use of health care services,

KEY-CONCEPTS OF DEMAND-DRIVEN HEALTH CARE 31

to making use

of

health care services. factors facilitating their use ofhealth care

services, potentialaccess(Coughlin & Long, 2003), andtheirperceived needofcare.

In contrastwith_{Andersen's (I968, I995) model, this} study makesan additional

dis-tinctionbetween careneeds and caredemands. Care demands are notexplicitly in-cluded inthe model. asitdirectly moves from care need tocareconsumption.

How-ever,inpractice, the actualtransition fromcaredemand tocareconsumption can be

ambiguous. Ifwe assume that articulated demand is susceptible to people's per-ception

of

conditional factors, this may leadto discrepancies. Scarcity, forexample,

may lead to non-consumption of required care in health care practice. This ad-ditional step has beenaddedto Andersen's _{(I968, I995) model.}Theresulting model

(Figure 3.I) can be used asaconceptual frameworkfor furtherresearch.

3.5 CONCEPTUAL FRAMEWORK

Predisposing characteristics:

Socialstructure Geneticfactorsand Demographic

·culture Psychological characteristics: factors:

social network 'autonomy .age

·_{social interactions} '

mintal (dis)functioning gender

·_{family composition} .

cognitive impairment '_{marital status}

'

education 'illness

·_{religion Healthbeliefs:}

· occupation 'attitudes ' mobility ' values ' ethnicity 'knowledge t

Change in + Need , Demand ···_{> Use}

health

Feltneed: 1, ert·eptii„1 4, .1('lita/A '

quality of life '

experience ofsymptoms _{Enabling resources:}

'

perception of own health

Personal/ Community

familyresources: resources:

•Income .costs health care

'_insurance '_availability • social support -regular source of care '_{health personnel}

Figure3.1 Conceptual Framework

In a certain state of_{quality of life,} a _{health problem or complaintmay} occur. This

infringement onthequality of life canbeconsciouslyexperienced by theindividual

as a_{negative discrepancy between} hisactual andhisdesirablestate

of

health_and/or

well-being.Thelevel ofthisdiscrepancy can vary from high tolow,which will have its

influence on the subsequentprocess.Undertheinfluence

of

predisposing characteristics

and_{the perception}of_{enabling resources, a felt need}willeitherbeblocked, orbe