Programs: needs and demands

1
Programs needs and demands

• Associate Professor Hal Swerissen
• Director
• Australian Institute for Primary Care

2
Some revision
3
The full planning model
Causative factors
Population Needs
Factors mediating service seeking
Resource Allocation
Expressed Need
Latent Need
Waiting
Service output/utilisation
Outcome
Direct demand management
Outcome
Outcome
Prevention program
4
Basic Program Model
Needs
Inputs
Activities
Outputs
Impact
Outcome
Cost
Impact
Process -implementation
Process - output
Outcome
5
Basic theory
6
What is need

• demands vs needs
• Social, collective or population vs individual
  needs
• normative models (ideologies, values, rights etc)
• economic models (public goods externalities
  costs benefits)

7
Linking programs and needs

• Needs define the relationship between actions and
  outcomes (ie an needs and actions are tied
  together in program logic)
• So, publicly funded programs are designed to meet
  socially determined needs through the outcomes
  they produce

8
The politics of needs

• equity vs efficiency criteria
• efficiency and the market
• externalities and public goods
• Rawlsian justice as a philosophy of need

9
Assessing need

• Felt
• Expressed
• Compared
• Normative
• Latent or unmet need

10
Felt need

• What the people say they need
• Generally measured through surveys, interviews,
  focus groups, citizens juries etc

11
Felt need

• Can become a wish list
• Therefore important to test strength, priority
  commitment to resource allocation to meet felt
  needs
• There may be no consensus in the community about
  priority of needs to be met

12
Expressed need

• Actual requests for services or programs
• Generally measured by the volume of presentations
  or referrals. Usually information is gathered
  from service records, but can also be by agency
  surveys and direct observation (e.g. monitoring
  the use of a bicycle track)

13
Expressed need

• Most common problem is inadequate data on the
  relationship between personal characteristics,
  the nature of the services provided and the
  effectiveness of the services
• Usually little information on what factors
  mediated the expression of need

14
Normative need

• Expert views on what is needed
• Either measured through focus groups, interviews,
  and surveys. A common approach is to use delphi
  techniques which iterate information gathered
  from experts to reach consensus positions.
• Or population studies designed by experts (e.g.
  incidence, prevalence studies)

15
Normative needs

• Expert views may not coincide with
  consumer/community priorities
• Experts may not agree on priorities, causal
  models etc
• Data evidence on expert categories may be
  inadequate

16
Comparative need

• Level of need is inferred by benchmarking against
  level of services or programs in comparable
  settings (e.g. staff ratios, bed ratios, per
  capita funding etc)
• Usually measured through service/program data
  which is adjusted for population parameters

17
Comparative need

• Benchmarking reflects existing rather than ideal
  circumstances (e.g. staff ratios may be
  inadequate everywhere)
• May not capture unique local circumstances and
  priorities

18
Latent or unmet need

• Different options
• The gap between population need and service
  utilisation.
• The gap between expressed need and population
  need
• The gap between expressed need and service
  capacity
• Measurement depends on definition. Most commonly
  measured as the waiting list. Also waiting list
  plus those with defined need not seeking a
  services (e.g. the discouraged unemployed
  persons) using derived measures.

19
Needs equity

• Equity of access, utilisation and outcomes
• Geographic or locational equity
• Population characteristics (cultural, socio
  economic etc) equity
• Equity across different types of needs
• Affirmative action and equity

20
The needs study
21
Defining the parameters scope

• What is the purpose what are the resource
  decisions?
• What is the population, community or group?
• What types of need are in scope?
• What is the service system capacity?
• What is the expressed need?
• What is the latent plus unmet need?
• What barriers and obstacles to change exist?

22
Population program planning
Causative factors
Population Needs
Factors mediating service seeking
Resource Allocation
Expressed Need
Latent Need
Waiting
Service output/utilisation
Outcome
Direct demand management
Outcome
Outcome
Prevention program
23
Purpose resource decisions

• Is this an service program, agency, community or
  funder study?
• Is this a study to allocate additional resources
  (e.g. growth funds)?
• Is this a study to argue for additional growth
  resources?
• Is this a study to reallocate existing resources
  to improve equity?
• Is this a study to reallocate resources between
  different types of responses for the same need
  (e.g. prevention vs treatment)?
• Is this a study to reallocate existing resources
  between different types of needs?

24
Purpose resource decisions

• Do not do need study when
• Allocation based on direct or indirect formula
  for specific service outputs (all decisions have
  been made)
• No reallocation is possible
• If needs study proceeds consider the scope from
  service program, agency, community or funder level

25
The population

• Usually defined by geographic catchment or proxy
  plus eligibility or entitlement criteria
• Can also be enrolled populations (e.g. insurance
  funds)
• Can also be setting based (e.g. schools, work
  places)
• Often community profile produced for the
  population including demographic, social,
  cultural, economic, health, environmental
  characteristics
• Usually interested in population trends over time
  (forecasting)

26
Gaps Analysing need-response match

• Have to develop model that relates needs and
  responses
• Have to define and measure level of population
  needs, expressed need, service capacity and unmet
  need
• Gap difference between current capacity and
  population need latent plus unmet need)

27
Needs model model
28
Service response model
29
National Health Framework

• Health outcomes
• Conditions, functions, well being, life years
• Health determinants
• Behaviours, living/working conditions, personal
  resources, environmental factors
• Health system performance
• Accessibility, efficiency, accessibility/equity,
  appropriateness, capability, safety, continuity,
  acceptability

30
Population data
31
Population need parameters

• Decide on prevention or service delivery and
  then
• Incidence, prevalence numbers of people defined
  as having the need by stage on continuum
• Extent of causative factors
• Incidence, prevalence data - ABS population
  survey work. Also use proxy measures synthetic
  estimates

32
Accessing demographic data

• Data source how to access it
• Types of variables
• Geography (Australia, state, LGA, etc)
• Age gender
• Country of birth language proficiency
• Employment profession
• Income socio-economic indices (SIEFA)
• Population mobility

33
Demographic data worked example

• Identify question
• Consider geographic area
• Consider related variables
• Create table(s) for question
• Identify data source(s)
• Gather data
• Enter data into table

Example of a Country of Birth table
34
Accessing health status data

• Data sources how to access them
• Types of variables
• Life expectancy Disability Adjusted Life
  Expectancy (DALE)
• Deaths
• Illness prevalence and incidence
• Years lived with disability (YLDs)
• Years of Life Lost (YLLs)
• Disability adjusted life years (DALYs)
• Risk factors

35
Health data - worked example

• Identify the question
• Consider geographic area
• Consider specific variables
• Age
• Smoking
• Create data table
• Identify data source(s)
• Census
• National Health Survey

Example of a table created for smoking as a risk
factor
36
Health data worked example cont..

• Identify proportion of smokers nationally for the
  age group using National Health Survey Data
• Identify total number of people in the age group
  of the geographic area using Census data
• Create age adjustment calculation enter into
  table to identify number of people
• Age adjustment (Percentage of smokers/100 x total
  number of people in age group)

37
Service system response data
38
Service capacity

• Measured as the current service outputs in
  relation to specific need(s)
• Number of people treated level of service
  provided or episodes provided or cases provided
• Related to the current service inputs
• Expenditure or service delivery EFT
• The ratio of outputs to inputs is a measure of
  efficiency
• Important to measure equity of access

39
Expressed need

• Number of people requesting service by type of
  need within the defined service system
• Measured as requests for services at service
  system intake
• Expressed need includes those who receive service
  waiting

40
Waiting

• Includes appropriate and inappropriate waiting
• Measured by waiting categories (e.g. urgent, semi
  urgent, routine) plus time waiting
• Inappropriate waiting list people at risk or
  with significant impact on QoL due to waiting
• Inappropriate waiting should include drop outs
  estimated waiting due to closed book

41
Latent need

• People with a defined need who do not seek
  service (e.g. undiagnosed, social stigma,
  personal preference etc)
• Measured as population need expressed need

42
Factors mediating service seeking

• Lack of information
• about need (e.g. undiagnosed cancer)
• about services
• Structural or institutional barriers (e.g. money,
  eligibility, distance)
• Service system unresponsiveness (e.g. gender,
  CALD, service system stigma)
• Personal preference

43
Causative factors

• Social and economic (institutional)
• Community organisational
• Physical environment
• Personal and behavioural
• Biological and constitutional

44
Unmet need the gap

• People who are waiting inappropriately plus those
  have a need but have not sought services
• Measured as population need service system
  capacity
• But more commonly as people waiting for
  inappropriate time

45
The needs study process
46
Steps

• Service system review
• Key stakeholder identification initial
  consultation
• Data collection
• population needs, expressed needs, waiting
  latent need
• service response capacity
• factors mediating service seeking
• Causal analysis
• Identify quantify service system gaps
• Prioritise needs

47
Service system review

• Document the available information on population
  needs, factors affecting service seeking,
  expressed need, service capacity, unmet need
  obstacles to change
• Should have a map of the service system
  including referral flows and relationships
  between relevant agencies
• At the end of this phase there should be good
  description of the population and the service
  system
• Scope varies depending on study sponsor (service
  program, agency, community, funder)

48
Key stakeholders

• The key stakeholders will usually include funder,
  provider and consumer representatives
• Purpose of initial consultation
• Get agreement on the service system review
• Get an initial impression of the match between
  the unmet needs identified in the review and
  direct experience
• Identify data information sources and issues
• Identify barriers to change and boundaries for
  recommendations

49
Data collection

• Demographic data (ABS)
• Social and health indicators on specific needs
  (AIHW specific surveys) but also proxy
  indicators like pension benefit data
  statutory reports (deaths etc)
• Expressed needs waiting lists (DHS, Cw, data
  from statistical returns agency surveys)
• Service capacity (DHS, Cw, data from statistical
  returns agency surveys)
• Factors mediating service seeking (consumer focus
  groups, key stakeholder interviews)\
• Causal analysis (literature review expert
  opinion)

50
Data collection

• Can also supplement with
• Felt need
• Comparative need
• Normative need
• Should always include measures of equity of access

51
Identify quantify gaps

• gaps are defined by unmet need and inequity of
  provision
• Have to decide on definition of unmet need (see
  earlier)
• Analysis
• capacity limitations
• factors mediating service seeking (including
  service coordination issues)
• Consider barriers facilitators ( -) to change

52
Determining priorities

• Generate a quantified list of unmet needs and the
  analysis
• Make initial recommendations about growth /or
  reallocation
• Present to stakeholders and get feedback
• Modify recommendations
• Finalise

53
Issues in needs assessment

• Technical
• Data, time, resource limitations for study
• Political strategic
• Resource limitations for new capacity
• Service program vs agency vs community/population
  vs funder interests
• Staffing and capability (vs capacity) limitations