ABSTRACT
Objetivo: Establecer y cuantificar los determinantes de la estancia hospitalaria en un hospital universitario de Medellín de alta complejidad de Medellín, entre 2013 y 2018, valorar su importancia y modelar la estancia esperada. Metodología: Estudio observacional analítico retrospectivo de datos agregados. Siguiendo el método paso a paso, se corrieron siete modelos con estancia hospitalaria media como variable dependiente y las respectivas variables independientes: complejidad, oportunidad de apoyos diagnósticos, disponibilidad de insumos, casos de estancia prolongada y capacidad financiera. Se seleccionó el mejor modelo usando los criterios de ajuste Akaike e información Bayesiana, junto con las medidas de significancia global y significancia individual de los coeficientes. Se realizaron pruebas estadísticas de validez del modelo y se calcularon los coeficientes estandarizados. Resultados: Los valores medios de las variables más relevantes y su desviación estándar (de) fueron: estancia hospitalaria media, 8,09 días (de = 0,40); complejidad por consumo de recursos, 1,28 unidades (de = 0,07); apoyos diagnósticos, 90,74 mil estudios (de = 10,05); casos de estancia extrema, 4,36 % (de = 0,70), y complejidad por casuística, 1 (de = 0,03). Significancia global F = 55,2, p< 0,001. Significancia de los coeficientes: complejidad por consumo de recursos, p< 0,01; apoyos diagnósticos y casos de estancia extrema, p< 0,001; complejidad por casuística, p< 0,05. Coeficientes estandarizados: complejidad por consumo de recursos, 0,35; apoyos diagnósticos, 0,35; casos de estancia extrema, 0,26, y complejidad por casuística, 0,24. R2 ajustado 0,82. Conclusión: Los determinantes de la estancia hospitalaria en orden de importancia son: complejidad por consumo de recursos, apoyos diagnósticos, casos de estancia extrema, complejidad por casuística, inventario disponible y ganancias brutas.
Objective: To establish and quantify the determinants of hospital stay in a high complexity university hospital in Medellin between 2013 and 2018, assess their importance, and model the expected length of stay. Methodology: Retrospective analytical observational study of aggregate data. While following the method step by step, seven models were used, where mean hospital stay was the dependent variable and the respective independent variables were complexity, timeliness of diagnostic procedures, availability of supplies, cases of prolonged stay and financial capacity. The best model was selected using the Akaike and Bayesian information criterion, along with measures of both overall significance and individual significance of the coefficients. Statistical tests of model validity were performed and standardized coefficients were calculated. Results: The mean values of the most relevant variables and their standard deviation (SD) were: mean hospital stay, 8.09 days (SD = 0.40); complexity by resource consumption, 1.28 units (SD = 0.07); diagnostic procedures, 90.74 thousand studies (SD = 10.05); cases of extremely prolonged stay, 4.36% (SD = 0.70), and complexity by casuistry, 1 (SD = 0.03). Overall significance: F = 55.2, p < 0.001. Significance of coefficients: complexity by resource consumption, p < 0.01; diagnostic procedures and cases of extremely prolonged stay, p < 0.001; complexity by casuistry, p < 0.05. Standardized coefficients: complexity by resource consumption, 0.35; diagnostic procedures, 0.35; cases of extremely prolonged stay, 0.26; and complexity by casuistry, 0.24. Adjusted R2 0.82. Conclusion: In order of importance, the determinants of hospital stay are complexity by resource consumption, diagnostic procedures, extremely prolonged stay, complexity by casuistry, available inventory and gross profit.
Objetivo: Estabelecer e quantificar os determinantes da permanência hospitalar em um hospital universitário de alta complexidade de Medellín, entre 2013 e 2018, valorar sua importância e fazer a modelação da permanência esperada. Metodologia: Estudo observacional analítico retrospectivo de dados agregados. Seguindo o método passo a passo, foram aplicados sete modelos com permanência hospitalar média como variável dependente e as respectivas variáveis independentes: complexidade, oportunidade de apoios diagnósticos, disponibilidade de insumos, casos de permanência prolongada e capacidade financeira. Selecionou-se o melhor modelo usando os critérios de ajuste Akaike e informação Bayesiana, junto com as medidas de significância individual dos coeficientes. Realizaram-se provas estatísticas de validade do modelo e calcularam-se os coeficientes padronizados. Resultados: Os valores médios das variáveis mais relevantes e seu desvio-padrão (DP) foram: permanência hospitalar média, 8.09 dias (DP = 0,40); complexidade por consumo de recursos, 1,28 unidades (DP = 0,07); apoios diagnósticos, 90,74 mil estudos (DP = 10,05); casos de permanência extrema, 4,36 % (DP = 0,70), e complexidade por casuística, 1 (DP = 0,03). Significância global F = 55,2, p < 0,001. Significância dos coeficientes: complexidade por consumo de recursos, p < 0,01; apoios diagnósticos e casos de permanência extrema p < 0,001; complexidade por casuística, p < 0,05. Coeficientes padronizados: complexidade por consumo de recursos, 0,35; apoios diagnósticos, 0,35; casos de permanência extrema, 0,26 e complexidade por casuística, 0,24. R2 ajustado 0,82. Conclusão: Os determinantes da permanência hospitalar em ordem de importância são: complexidade por consumo de recursos, apoios diagnósticos, casos de permanência extrema, complexidade por casuística, inventário disponível e lucros brutos.
ABSTRACT
OBJECTIVE To sort out the common presentation forms and components of the framework of domestic and foreign essential medicine lists （EMLs）， in order to provide reference for optimizing the framework of the Chinese EML. METHODS The latest edition of the EMLs of WHO， China， South Africa， India， Malaysia and other typical countries were compared， and the similarities and differences of the presentation form and constituent elements of the list framework were analyzed. RESULTS & CONCLUSIONS The common presentation forms of WHO and typical countries’ EMLs included version， classifications and symbols， of which management ideas， functions， and implementation difficulties varied； common framework elements included target population， hospital levels， drug use conditions， core and supplementary lists and procurement priority. Through comparison， it was found that the information covered by the Chinese EML was relatively thin， and the framework design had not yet fully played the ideal role in guiding clinical rational drug use and optimizing the allocation of health resources， and there was still some room for improvement. It is recommended that China clarify the characteristics and roles of different presentation forms of the EML， and reasonably set the EML framework based on national conditions and development needs； the multi-dimensional drug information should be supplemented， such as clinical use， economy， and policy attributes of drugs in the EML， to ensure the rational use of essential drugs； it is also necessary to add “the level of hospitals” in the framework of the EML， refine the management requirements for the allocation and use of essential medicine， and optimize the resource allocation of hospitals.
ABSTRACT
Background: Is building physical health infrastructure (PHI) a priority for state governments within the northeastern states (NES) of India? The decentralization mechanism initiated by the government of India to synergize health care across states seems highly unequal. Certain Indian states such as Kerala, Uttarakhand, and Himachal Pradesh have achieved phenomenal progress in the health-care system through a decentralized mechanism. Objectives: The study attempts to examine the PHI of NES and public health resources. Methods: The study has employed the Euclidian Distant Method (EDM) which fulfills various compulsive and instinctive properties; specifically, normalization, symmetry, monotonicity, proximity, uniformity, and signaling inclusively. This method ranks the states in terms of infrastructure availability and public health resources. Second, the correlation was done to see the relationship between the PHI of NES and public health resources. Results: The results of the EDM? show that Arunachal Pradesh ranked the highest in the Index of Public Health Infrastructure, whereas Assam ranked the lowest. The Index of Public Health Resource shows interesting results. Assam has remained at the lowest rank and inconsistency of ranks among the other NES. The correlation between the indices is positive, yet not encouraging. Conclusion: This implies that building up health infrastructure and responding to the demand for health-care infrastructure still stands ignored and rather remained stagnant.
ABSTRACT
Objectives To analyze the allocation of major health resources in each district of Shenzhen from 2015 to 2019, to evaluate the equity of allocation, and to provide a reference for further optimizing the allocation of health resources. Methods Based on the statistics and analysis of the distribution of major health resources in Shenzhen from 2015 to 2019, the Gini coefficient was used to evaluate the equity of health resources allocation in Shenzhen from two dimensions of population and geography, and to analyze the trend of change. Results From 2015 to 2019, the total amount of health resources in Shenzhen maintained a rapid average annual increase of about 7.21%. The number of beds, doctors and nurses per every thousand people reached 3.81, 2.86 and 3.29, respectively. The Gini coefficients of each indicator decreased year by year. The Gini coefficient of population distribution was less than 0.3, and the Gini coefficient of geographical distribution was close to 0.5, exceeding the warning line. Conclusion The total amount of health resources in Shenzhen is insufficient and the distribution is uneven. The government should increase investment in health resources while taking into account the regional balance to improve the fairness of allocation.
ABSTRACT
Objective:To provide information for further development of chronic disease management, by studying the allocation of resources required to provide services in a county in Shanxi province as required by to the pathway of China-Gates Rural Primary Health Care Service project.Methods:A questionnaire survey was made to evaluate the deployment of manpower, equipment, and drugs required by levels of county, township and village medical institutions in the health management services of hypertension and diabetes in the rural areas of Yangqu county, Shanxi province from July to August 2019.Results:A total of one county hospital, 10 township health centers and 101 village clinics participated in the investigation. In terms of service personnel participating in the project, 9 township-level medical institutions were manned with personnel who could provide diagnosis, intervention planning, and follow-up visits, and only one of them had annual evaluators; village-level medical institutions basically didn′t have diagnosis, intervention planning, and annual evaluation staff. In terms of technical equipments, there was a general lack of diabetes assessment equipment at county, township and village level medical institutions. The mandatory equipments for diabetes assessment was equipped for only 80.0%, 79.0%, and 37.8% of the three levels of institutions, respectively. Village clinics lack hypertension assessment equipment and had no diabetes diagnosis equipment at all.Conclusions:The chronic disease management personnel, equipment, and drug supply in the rural areas of a county in Shanxi province are unbalanced among counties, townships, and villages. The quality of chronic disease management services should be improved through effective and rational use of resources.
ABSTRACT
Objective:To analyze the relationship between the structure of health resource supply and the growth structure of medical expenditure in Fuzhou.Methods:In accordance with hospital scale category standards, health resources provided for medium and large hospitals were categorized as high quality resources, while those provided for urban community health centers and township hospitals, and those for hospitals with less than 200 beds were categorized as primary health resources. The descriptive statistical method was used to analyze the health resource allocation and supply in Fuzhou; The structure decomposition method was used to decompose 2016—2019 hospitalization expenditure, and the principal component analysis was used to discuss the influencing factors of differences in the growth structure of hospitalization expenses.Results:In accordance with such factors as the economic development level, health service needs and geographical locations of districts and counties of Fuzhou city, 12 districts/counties were divided into three levels. The number of high-quality health resource medical institutions deployed in the first and second-level regions accounted for 78.95% of all. Among them, GL and TJ districts were equipped with hospital beds accounting for 44.29% of the total high-quality beds of all, while those resources of third-level regions were mostly primary health resources.From 2016 to 2019, medical expenditure of public hospitals kept rising. As found in structural decomposition, scale effect was the fundamental driver, followed by the structural effect, and then the inflation effect. This study identified increased inpatient service demand as the main driver for increased costs. Principal component regression results found that increased supply of high quality health resources as having a positive pull effect on the increase of hospitalization expenditure.For example, expansion of hospital beds at large hospitals contributes positive effect on the cost inflation( β1=0.421, P<0.001). On the other hand, investment in primary health resources could play a constraint role on excessive growth of medical expenditure, while the overall deployment level of their health resources affected negatively the patient flow(beds/per thousand population β2=-0.303, P<0.001). Conclusions:The structure of health resource supply is strongly related to the structure of medical expenditure growth. It is suggested to differentiate the allocation of high-quality and basic-quality health resources and optimize the supply structure of resources. It is also imperative to strengthen the investment in basic health resources and enhance the medical and health service capabilities of related institutions, in order to optimize the flow of residents′ medical visit flow and guide medical expenditure growth in a reasonable manner.
ABSTRACT
Abstract The objective of this study was to demonstrate face validity with a novel resource allocation framework designed to maximize equity into dental booking systems. The study was carried out in 2014. Eleven experts in primary dental care practice in Southern Brazil participated, using a three-round consensus group technique. First, the experts reached consensus on the items to be included in a 5-level diagnostic scale. They identified 21 clinical conditions and categorized them according to the oral health intervention required. Then, they described workload and activity standards for dental staff to carry out health promotion, oral disease prevention, dental treatment, dental rehabilitation, and urgent dental care. Finally, they agreed upon a set of wait times for primary dental care, establishing maximum waits from 2 to 365 days, according to the diagnostic classification. The framework demonstrated potential ability to promote more equitable access to primary dental services, since equal diagnostic classifications share the same waiting times for the dental care they require.
Resumo O objetivo do estudo foi demonstrar validade de face com uma nova matriz destinada a maximizar a equidade nos sistemas de agendamento odontológico. O estudo foi realizado em 2014, no qual participaram 11 dentistas com experiência de trabalho na rede básica de saúde da região sul do Brasil, utilizando a técnica de grupo de consenso em três rodadas de discussão. Primeiro, os participantes chegaram ao consenso quanto aos itens que deveriam estar presentes em uma escala de classificação diagnóstica de 5 níveis. Identificaram 21 condições clínicas de saúde bucal e as categorizaram conforme a intervenção necessária. A seguir, os participantes descreveram as cargas de trabalho e os padrões de atividade recomendados para a equipe odontológica realizar promoção da saúde, prevenção de doenças bucais, tratamento odontológico, reabilitação dentária, e atendimento odontológico de urgência. Por último, os dentistas chegaram ao consenso sobre tempos máximos de espera para atendimento odontológico na rede básica, estabelecendo prazos de 2 até 365 dias conforme a classificação diagnóstica atribuída. Este estudo demonstrou o potencial da matriz de alocação de recursos para promover acesso mais equitativo aos serviços odontológicos da rede básica, uma vez que classificações diagnósticas iguais compartilham os mesmos prazos de espera para o atendimento odontológico requerido.
Subject(s)
Humans , Primary Health Care , Oral Health , Dental Care , Brazil , Health PromotionABSTRACT
The data of registered general practitioners (GPs) in Shanghai Pudong New Area from 2014 to 2017 were collected through literature review and institutional investigation.The status of registered GPs was analyzed longitudinally by the methods of descriptive statistics and comparative analysis.The total number of registered GPs in Pudong New Area was increased from 1 227 in 2014 to 1 469 in 2017 and increased by 19.7％,with an average annual growth rate of 6.18％.But the human resources of GPs in Pudong New Area were not sufficient and the recruitment of GPs in grass-roots increased slowly.GPs in community health service centers in remote rural areas steadily increased year by year,however,the uneven distribution still existed.The proportion of GPs with senior professional titles had steadily increased,but it was still low.
ABSTRACT
The data of registered general practitioners (GPs) in Shanghai Pudong New Area from 2014 to 2017 were collected through literature review and institutional investigation. The status of registered GPs was analyzed longitudinally by the methods of descriptive statistics and comparative analysis. The total number of registered GPs in Pudong New Area was increased from 1 227 in 2014 to 1 469 in 2017 and increased by 19.7%, with an average annual growth rate of 6.18%. But the human resources of GPs in Pudong New Area were not sufficient and the recruitment of GPs in grass-roots increased slowly. GPs in community health service centers in remote rural areas steadily increased year by year, however, the uneven distribution still existed. The proportion of GPs with senior professional titles had steadily increased, but it was still low.
ABSTRACT
Objective • To discuss the health resources and service development of traditional Chinese medicine (TCM) hospitals in Shanghai from 2009 to 2016. Methods • Analysis of the health resources and service development of TCM hospitals in Shanghai from 2009 to 2016 were conducted by calculating composition ratios and growth rates according to the data from the statistical yearbooks. Results • All the indexes of the health resources and services of TCM hospitals in Shanghai, 2009-2016, increased every year, and the numbers of beds, medical technical personnel, licensed (assistant) doctors, registered nurses, outpatients and inpatients increased by 71.72%, 53.80%, 46.83%, 76.84%, 78.20%, and 120.30%, respectively. The proportions of TCM hospitals beds and health technicians in all the city's hospitals increased by 1.70% and 1.18% on the basis of 7.06% and 9.58%, respectively. The year-on-year growth rates of beds ranged from 1.86% to 22.52%, and rates of health technicians ranged from 0.17% to 15.46%. Daily visits each doctor and daily bed days each doctor in TCM hospitals increased by an average of 2.90% and 0.07% a year, respectively. Conclusion • There was a significant increase in health resources and service development of the TCM hospitals in Shanghai from 2009 to 2016, and the work efficiency were improved. And there was a little increase in the proportion of the relevant indexes in all the city's hospitals. However, some problems do exist, such as the weak integral strength and the unstable growth of TCM hospitals.
ABSTRACT
Objective:To discuss on the allocation and service utilization of health resources in maternal and child health care institutions and the existing problems in Guizhou Province,to provide a scientific basis for the further development of maternal and child health care.Methods:It analyzed the situation of health resource allocation,service utilization efficiency and maternal and child mortality in Guizhou province by means of statistical description,comparative analysis and correlation analysis.Results:The average number of health workers per hospital increased rapidly,the average number of beds per hospital grew slowly.The number of outpatient visits,the number of admissions and the number of people discharged were positive growth.The number of bed turnover,the working day of the bed,the bed use rate and the average hospitalization date appeared a certain degree of negative growth.Infant mortality rates,child mortality rates and maternal mortality rates under the age of five were all higher than the national average.Conclusion:Health resources of maternal and child health institutions in Guizhou should be tilted to the grassroots health institutions.It needed to further improve the efficiency of maternal and child health care use,strengthen the training of personnel and enhance the comprehensive service capacity of grassroots organizations.
ABSTRACT
Objective: Participation in social activities is associated with physical and psychological health in the community-dwelling elderly population. We examined the two factors of social relations and community health resources, associated with higher self-rated health levels in the community-dwelling elderly.Methods: A total of 145 community-dwelling elderly people ≥ 65 years old from two neighborhood associations in Nagasaki City were recruited for this study, representing 85% of the officially registered ≥ 65-year-old population in the target area. Face-to-face interviews using a structured questionnaire were conducted by trained interviewers in August 2009, with questions related to sociodemographic characteristics, social relationships, and self-rated health (SRH). Community health resources (type and walking distance from home) were evaluated by one of the authors as a community assessment.Results: Seventy-eight community-dwelling elderly people (25 men and 53 women) participated in the study. Elderly people who reported going out every day were more likely to show higher SRH scores (excellent/good) than those going out less often (OR: 3.7; 95% confidence interval [CI]: 1.0, 14.2; P = 0.056). The numbers of interactions with friends in higher and lower SRH groups were 6.5 ± 8.4 (mean ± standard deviation) and 2.4 ± 1.1 (P = 0.01, Mann-Whitney U test), respectively. The numbers of relatives talking on the phone in higher and lower SRH groups were 2.9 ± 1.3 and 2.2 ± 1.2 (P = 0.031, Mann-Whitney U test), respectively. Meeting scores with friends in higher and lower SRH groups were 7.8 ± 5.8 and 4.5 ± 3.6 (P = 0.068), respectively. The scores of community health resources among higher and lower SRH groups were 21.2 ± 1.5 and 20.9 ± 1.4 (P = 0.547), respectively. The scores of community association/activities in higher and lower SRH groups were 3.9 ± 1.0 and 3.6 ± 0.9 (P = 0.227), respectively.Conclusion: This study indicated the importance of interaction with friends and relatives for maintaining higher SRH among community-dwelling elderly people.
ABSTRACT
In the health service field,health resources and health service supple capacity were related with the resource and capacity in economics.Health resources,health service supple capacity and their relationships were important factors for the cooperation and benign interaction of hierarchical medical institutions.However,inversion of health resources and health dislocation of service supply capacity exacerbated the agglomeration degree of patients in the tertiary medical institutions under the impact of residents' freely searching for medical service concept.Vicious interaction and mutual competition among hierarchical medical institutions had become an important obstacle for the implementation of hierarchical medical services.Therefore,its mechanism needed to be clarified while the corresponding policy recommendations should be proposed.
ABSTRACT
Optimizing the allocation and configuration of type two large-scale medical equipment,promoting the using efficiency of large-scale medical equipment and the level of medical services,which had important significance on protecting the health of residents.It analyzed and summarized the guiding ideology,main principles,allocation standard,basic and specific requirements,and the total number of the allocated type two large-scale medical equipments in Nanchang during the Twelfth Five-Year Plan period,which had certain significance of references on the configuration and planning of type two large-scale medical equipments.
ABSTRACT
Objective:To analyze the equity of health resource allocation in village-level medical institution in China,thus to provide the basis for formulating relevant health resources allocation policy.Methods:Using Lorenz curve and Gini coefficient,the rationality and equity of allocation of village health resources in China were evalua-ted by the equity of population distribution and the equity of geographical distribution.Results:The Gini coefficient of village health workers and health institutions was 0.19 and 0.20 respectively according to population distribu-tion,and was 0.65 and 0.63 respectively according to geographical distribution.The Gini coefficient's difference of village-level health resources in the eastern,central and western regions was small according to population distri-bution,but the difference was larger according to geographical distribution among different areas.Conclusion:The equity of village-level health resource allocation in China was preferable according to population distribution,but the equity according to geographic distribution was poorer.The formulation of health policy should pay more atten-tion to the equity of geographic distribution and allocate rationally.
ABSTRACT
Objective To evaluate the quantity,category and the distribution of health resources of Traditional Chinese Medicine(TCM)in order to advise on optimizing TCM service system.Methods Based on the concept of agglomeration degree,this paper compared and analyzed the agglomeration of TCM resources in terms of medical institutions,their beds and medical workers.Results Currently the agglomeration degree of TCM health resources is found to be low,as TCM medical institutions tend to be small,with most of them being TCM clinics.Conclusions To rationalize the distribution of TCM medical resources,we must increase financial input and provide supportive policies,actively encourage healthy development of TCM medical institutions,strength TCM medical service system development in areas of poor TCM resources.
ABSTRACT
Objective To investigate the status of stroke patients′continuous rehabilitation care and it′s influencing factors in the community. Methods Questionnaires were used to investigate 174 stroke patients from 6 communities of Zhengzhou. Results The implementation of continuous care was not satisfactory. Occupation, medical payment method and medical resource utilization were important predicting factors. Conclusions In order to promote continuous rehabilitation care, the health resources should be fully used, the payment methods of the patients should be improved, and the occupational characteristics should be considered.
ABSTRACT
Objective To design a data management solution based on geographic information system for health service units to deal with health resources of subordinate medical institutions.Methods The whole solution was developed with layer logic function of data service, application and presentation. Storage, transformation and relationship of both spatial data and health service data were totally managed by relational database.Results The system was able to import, export, maintain, sum, query and analyze geography spatial information and health service information.Conclusion A new method is provided to improve capability of health support and health service management efficiency.
ABSTRACT
To explore the allocation and equity of health resource in Changsha between 2007 and 2013 and to provide references for government to carry out regional health planning. Method:General statistical analysis was used to describe changes of health resource allocation in Changsha;from the perspective of the population and geography of the nine counties in Changsha, the equality and change of the configuration among doctors, nurses and hospital beds were analyzed by using the Gini coefficient and Theil index. Results:1) The per capita amount of health resources in Changsha increased gradually, and health resources were mainly concentrated in urban areas. 2 ) The Gini coeffi-cients of doctors, nurses and hospital beds was 0. 24~0. 46 according to population distribution between 2007 and 2013 in Changsha, and the Gini coefficient of all health resources by geography was 0. 59~ 0. 79 and peaked in 2009 to then decrease year after year. Following a comparison of the two kinds of regions, the Gini coefficient of urban are-as was significantly higher than that of rural areas, and the Gini coefficient of nurses was the highest among all health resources. 3) Changes in the Theil index were consistent with the Gini coefficient. The difference in the degree of re-source allocation in urban areas exhibited a rising trend, The Theil index was higher than each regional difference. Conclusion:Overall, the equity of allocation of health resources in Changsha between 2007 and 2013 gradually im-proved year by year. The equity of population configuration was greater than that of geographical configuration, and the equity of rural areas was superior to that of urban areas;the equity of the configuration of nurses was poor. The difference between areas is the main factor affecting the equity of Changsha’s health resource allocation.
ABSTRACT
Objective To assess the equity of health resources configuration in Zhejiang,and provide references for regional health planning.Methods The Lorenz curve,Gini coefficient and Theil index were used to calculate and analyze.Results The Gini coefficient in 2009-2011 calculated by population density was between 0.330～0.343,which meant comparatively rational.The main reason of inequity configuration for hospital beds and nurses was inter-regional difference.Conclusion The Theil index could remedy the disadvantage that Gini coefficient could not reflex the total inequity was brought up by inter-regional or intra-regional difference.The health resource configuration should based on population health need and health service demand.