Lecture 2 HSD 501 Supply And Demand PDF

COURSE CODE HSD 501: PUBLIC HEALTH Health Service Delivery: Supply and Demand By Mrs. Muleya Lubaya Lungu Health Service Delivery: Supply and Demand Learning objectives Describe the factors that determine the price and quantity of health care Explain how spending on health can be an investment Describe the factors that determine the demand and supply for health-care services Describe the production function for health Demand Demand Demand refers to the quantities that buyers would be willing and able to purchase at various possible prices per unit of time. Law of demand The law of demand may be stated as follows: other things being equal, if the price of a commodity falls, the quantity demanded of it will increase and if price of the commodity rises, its quantity demanded will decline. Thus, according to the law of demand, there is an inverse relationship between price and quantity demanded, other things remaining the same. Relationship Between Price and Quantity Demanded Relationship Between Price and Quantity Demanded Thus, there is a negative relationship between the price and quantity demanded. In other words, the demand curve slopes downward from left to right. The law of demand can be expressed in the functional form as follows: Qd = f (P, I, PR/T) Where, Qd = Quantity demanded of a commodity P = Price of the commodity I = Income of the consumer PR = Prices of the related goods T = Tastes and preferences of the consumer Demand of health care services The demand for healthcare services refers to the desire or need for medical care and treatment by individuals or populations to address their health concerns and maintain or improve their well -being. It encompasses various aspects, including seeking preventive care, managing acute or chronic illnesses, accessing diagnostic and therapeutic interventions, and utilizing rehabilitation or long-term care services. Demand and Supply of health care services We have so far ignored the issue of what exactly is being traded in this market. “Health-care services” can mean many very different things: Labor time of various trained professionals, such as GPs, specialists, nurses, medical technicians, pharmacists, and many others Procedures and testing, such as magnetic resonance imaging (MRI) scans and laboratory analyses of blood samples Hospital and nursing care services Emergency services such as ambulances Pharmaceutical products (which itself covers a huge range, from bandages to chemotherapy drugs) Demand of health care services Our standard approach to demand is based on the idea that each individual will consume a good or a service up to the point where the marginal valuation from one more unit equals the price of that additional unit. "Everyday Decisions" explains this idea in more detail. Unfortunately, the health-care consumer often has very little idea of the value—let alone the marginal valuation—of the particular treatment being received. The consumer is very often not paying the full price for that treatment because the cost is frequently covered, at least in part, by insurance. Together, these mean that our traditional approach to demand does not work very well for health-care services. The Demand for Health Care-Response to price The law of demand applies to health care as in other markets: as the price of health care increases, you demand less of it. But we must be careful. What matters is the price of health care to you. If you have health insurance, this price may be much lower than the actual cost of providing you with care. Under most health-insurance contracts, the marginal private cost of care to a household is less than the marginal social cost of providing that care. The household has an incentive to purchase a lot of health-care services because its purchases are, in effect, being subsidized by insurance companies. Demand of health care services Another key characteristic of health care is that demand is relatively inelastic. If you are sick and require care, you will purchase health-care services at almost any price. Of course, your ability to purchase health care is ultimately limited by your income, but you are likely to trade off spending on many other products to purchase the medical care you need. This is why we often read stories about people without insurance being bankrupted by medical expenses. Demand for health care-Health as Investment Everyone prefers being healthy to being sick. The demand for health care is in part an expression of this preference. One thing that makes health care different from most other goods and services, though, is that it is simultaneously an investment. Money you spend on being healthy today will also beneﬁt you in the future. There are several different ways in which spending on health care represents an investment. Demand for health care-Health as an investment Mortality One clear impact of our health-care choices can be seen in terms of mortality rates. Mortality rates measure how likely we are to die at different ages. In 2004, the mortality rate in the United States for people ages 15–24 was about 80 out of 100,000, or 0.08 percent. In contrast, the mortality rate for those over the age of 85 was 13,823 out of 100,000, or 13.8 percent. In other words, the typical young person has about a 1 in 10,000 chance of dying in a given year, whereas the typical old person has more than a 1 in 10 chance of dying. Demand for health care-Health as an investment It is not surprising that the mortality rate increases with age—that is, that young people have a lower probability of dying than older people. Infants are an exception: a 6-month-old child is more likely to die than an 18-month-old child because very young children are particularly susceptible to certain diseases. But these average mortality rates disguise a lot of variation, much of which is under our control. There are many behaviors that have predictable effects on our likelihood of dying. Smokers have a higher probability of dying than nonsmokers. Those who are obese have a higher probability of dying than those who are not. Diet, exercise, and risky behaviors (which includes everything from unprotected sex to skydiving) affect mortality rates as well. Demand for health care-Health as an investment Cigarette smoking is linked to lung cancer and thus to mortality. If you compare two similar individuals of the same age, one who is a smoker and the other a nonsmoker, then the mortality rate is signiﬁcantly higher for the smoker. This does not mean that the smoker will necessarily die before the nonsmoker. It means that all else being the same, smoking increases the probability of death. Refraining from smoking is a type of investment in your future. Demand for health care-Health as an investment Our diet also affects our probability of becoming ill and of dying. As with cigarettes, there are often trade-offs between eating and drinking things we enjoy and the effects of such consumption on our long-term health. Making these types of choices is an economic decision. Each of us makes different choices because we value the taste of particular foods differently, and we value our overall health differently as well. If a thirty-year-old discovers he has elevated cholesterol levels that pose a long-term risk of heart disease, he may decide to adjust his diet, perhaps consuming less red meat. If an eighty-year-old learns the same news, he may not think the long- term beneﬁt is worth giving up his steaks for. Demand for health care-health as an investment Productivity Being healthy also means that you can work and earn wages. One of the costs of poor health is lost days at work. This is a cost not only to the individual but also to society as a whole: the economy’s population is producing less output. If you are in poor health, then you risk losing wages for the days when you cannot come to work. Many employers provide insurance for these lost wages through the provision of sick days: if you are sick, you are not expected to work but you will still be compensated up to a contracted number of days per year. In addition, private employers sometimes also offer disability insurance as part of their compensation packages, and you can also purchase insurance directly from an insurance company. Demand for health care-Information problems Health care is an example of a good for which the typical individual is unable to determine the quality of what is being purchased. You can think of other examples, such as legal services and used cars. In such situations, how can we make good decisions? Generally we do so by relying on the advice of experts. In the case of health, these are the doctors, dentists, and other health professionals who are trained to analyze our health situation and make suggestions to us. We listen, try to understand, and, using their advice, make an informed choice. Demand for health care-Health as an investment Suppose you get a phone call from someone telling you they know of a stock, trading on Wall Street, that will double in price the following day. You might be very skeptical, suspecting that they have other reasons for wanting you to buy. Compare this to a conversation with a medical expert. Generally you are going to believe that the expert is acting in your best interests. Although you might get a second (or third) opinion, you do so because health problems are complex and the f ir st expert may have missed something, not because you are afraid the doctor is misleading you in order to prof it from your visit. But why do we trust medical experts so much more than the provider of stock tips? We generally do so because we trust that their incentives are aligned with our goals; that is, we hope that they are motivated to act in our best interests. Factors that affect demand in health care services Here are some key factors that affect demand in health care services: 1. Population demographics: The aging population typically requires more health care services due to age-related illnesses and chronic conditions. Additionally, changes in population size, growth rates, and urbanization can impact demand. 2. Socioeconomic factors: Income levels, employment status, education, and access to health insurance all inf luence individuals' ability to seek and afford health care services. Higher income levels and better insurance coverage often correlate with increased demand for health care. 3. Disease prevalence: The prevalence of diseases and health conditions within a population directly affects demand for related health care services. For example, an increase in chronic diseases such as diabetes, heart disease, and cancer can lead to higher demand for specialized care and treatments. Factors that affect demand in health care services 4.Technological advancements: Advances in medical technology can lead to the development of new treatments, procedures, and medical devices, driving demand for specialized services. However, these ad v anc e m e nts m ay al so i nc re ase c osts, whi c h c an af fe c t accessibility and affordability for certain populations. 5.Government policies and regulations: Healthcare policies, such as the implementation of universal health coverage, expansion of Medicaid, or changes in reimbursement rates, can signif ic antly impact demand for health care services. 6.Cultural and social factors: Cultural beliefs, attitudes toward health and wellness, and social norms can inf luence individuals' health- seeking behaviors and preferences for certain types of health care services. Factors that affect demand in health care services 7. Health care infrastructure: The availability and accessibility of health care facilities, providers, and services within a community or region can affect demand. Areas with limited access to healthcare may experience higher demand for services when compared to areas with well-developed healthcare infrastructure. 8. Public health emergencies and pandemics: Outbreaks of infectious diseases or public health emergencies can result in sudden spikes in demand for health care services, overwhelming healthcare systems and resources. Overall, understanding and addressing the various factors that inf lu ence demand in health care services are essential for healthcare providers, policymakers, and stakeholders to effectively plan and allocate resources to meet the needs of populations. Supply Supply refers to the quantity of a commodity that is available to consumers at a particular price at a particular time The quantity offered for sale varies directly with price i.e., higher the price the larger is the supply, and vice versa. Thus, there is a positive or direct relationship between price and quantity of a commodity supplied. Relationship Between Price and Quantity of a Commodity Supplied Supply of health care services Supply in health care services refers to the availability of healthcare resources, including healthcare facilities, healthcare professionals, medical equipment, pharmaceuticals, and other necessary resources to meet the demands for healthcare services. Supply of health care services Some health-care suppliers have signiﬁcant market power. This does not mean that we can get no insights from supply-and- demand reasoning. But it is trickier to compare the price of health care across countries because we have to consider differences in market power as well. A bigger problem is that some health-care suppliers, such as hospitals, are either government-controlled or not-for-prof it institutions. The standard economic approach presumes that f irms seek to make as much proﬁt as possible, but government or not-for-proﬁt hospitals may not have proﬁt maximization as their goal. The Supply of Health Care Economists often talk of output being produced using a production function that uses labor, capital, and intermediate inputs. The production function can be expressed as: Q = f (X, Y), Where Q = Output, X = Labour, Y = Capital What is the production function of a hospital? The labor in a hospital includes doctors, surgeons, orderlies, technicians, nurses, administrative staff and many others. The hospital buildings are part of the hospital’s capital stock. In addition, hospitals contain an immense quantity of other capital goods, such as hospital beds and diagnostic tools—everything from stethoscopes to x-ray machines. Intermediate inputs in a hospital include dressings for wounds, and pharmaceutical products, such as anesthetics used for operations. Other sectors of the health-care industry likewise employ labor, capital, and intermediate inputs. Supply of Health Care-Doctors If you look at the wall in your doctor’s of fice, you will typically see a large number of framed degrees and other qualiﬁcations. To become a doctor, you must f irst succeed as an undergraduate and then go through multiple years in medical school. After this comes an internship and then you f inally graduate and can practice on your own. In most countries, you must have a license to practice medicine. This makes sense: you would not want anyone to advertise as a doctor regardless of their skill level. Most of us would be unable to tell whether a particular individual was a qualiﬁed professional or a quack. When buyers cannot easily evaluate the quality of the good or the service they are purchasing, it is useful to have external validations of quality. Supply of Health Care-Doctors Licensing provides more than a guarantee of quality, however. It also limits entry into the profession. Suppose you learned that a small group of lobbyists in your hometown wanted gas station owners to be licensed in the same way as physicians. You would quite rightly suspect that their goal was not to guarantee high-quality gasoline. More likely, they would be trying to limit the number of gas stations to increase their market power. Your suspicions would not be allayed if these lobbyists argued that gas was potentially a very harmful commodity, so by licensing the sellers of gas, they were protecting the community. In the case of doctors, the underlying reason for licensing is not so nefarious. But it still creates a barrier to entry that limits competition and increases market power, just as it would with gas stations. Supply of Health Care-Doctors Doctors differ from gas station owners in many other ways. Typically, we suppose that gas stations and other f irms in an economy have proﬁt maximization as a goal. It is this presumption that allows us to develop our theory of supply. Doctors not only think about prof its but also take an oath of of fice, called the Hippocratic Oath, which is as follows: Supply of Health Care-Doctors I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement: I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone… I will not give a lethal drug to anyone if I am asked,…Wikipedia, s.v. “ H i p p o c r a t i c _ O a t h ,” a c c e s s e d M a r c h 1 4 , 2 0 1 1 , h t t p : //en.wikipedia.org/wiki/Hippocratic_Oath. This oath is administered to nearly everyone obtaining a medical degree. Supply of Health Care-Other Health-Care Workers In addition to doctors and specialists, there are many other kinds of workers in the health care industry, including nurses, dental hygienists, administrative staff, technicians, staff in care facilities such as hospices and nursing homes, nutritionists and many others. The health-care industry employs almost 10 percent of all civilian workers in the United States for example. Supply of Health Care-Other Health-Care Workers Hospitals are the most important type of employment site for health-care workers. About three-fourths of the workers in the health-care sector are women. Women are particularly prevalent in nursing care facilities There is a wide variety of occupations within health care: managers, professionals (doctors, dentists, pharmacists, etc.), service occupations (assistants, cooks, cleaners, etc.), and oﬃce workers. There will typically be considerable variation of wages within a sector because of the different occupations of workers in that sector. For example, doctors on average, earn more than nurses. Supply of Health Care-Health Care Capital When we look at an industry such as health care, one way of describing it is by counting the number of doctors’ oﬃces, clinics, and so on. There are many different kinds of establishments that provide health services. Hospitals are only one example; others include doctors’ of fic es, clinics, nursing homes, and so on. Another way to describe the industry is by detailing the number of workers employed in different activities. Supply of Health Care-Health Care Capital The ownership of hospitals is also complicated. Some are private, while others are public. In addition, not all private hospitals are in business for prof it; some are classiﬁed as not-for-proﬁt institutions. Supply of Health Care-Health Care Capital There are other capital goods that enter the production function for the health sector. For example, pharmaceutical production facilities are part of this capital stock. So too is the capital stock of companies that produce the machines, such as MRIs, used in doctors’ oﬃces and hospitals. Supply of health care-Technological Progress Technological advances in health care are truly staggering. Technological progress in this sector, as in other sectors, comprises both product and process innovations. By product innovations, we mean increases in the types of goods and services available to households and doctors. A leading example is the vast array of drugs now available on the market, which is the outgrowth both of research and development at pharmaceutical companies and of publically funded research. Another example is the advanced machinery used in modern health-care facilities. A modern dentist’s of fic e is f illed with high-speed drills, x-ray machines, and other pieces of technology that would have been unthinkable in your grandparents’ day. MRI machines are another example: these are a signif ic ant advance over previous imaging techniques such as X-rays, but they are expensive. Supply of health care-Technological Progress Process innovations refer to how techniques are implemented. For example, surgeons today can perform operations that surgeons of previous generations could not even imagine. The knowledge for these procedures was created by a few people and then taught to others in medical school and other training programs. Process and product innovations come together when you compare how certain procedures are performed now relative to years ago. Consider surgery to repair a hernia. The ﬁrst hernia (hiatal) surgery took place around 1919, and the procedure was risky and painful. Even relatively recently, a procedure like this involved hospital stays, many days lost from work, and a signiﬁcant risk of medical complications. Today, the leading method for surgery uses a piece of capital called a laparoscope—a tube with light that allows a surgeon to see inside a patient’s abdominal cavity. Then, using another instrument, again inserted through a small incision, the surgeon can repair the hernia. Remarkably, this is an outpatient procedure. The patient emerges from the hospital with a few small wounds and can return to work and normal life within a few days. Price Determination-Supply and demand If this chapter were like most others in this book, we would now turn to a discussion of how supply and demand interact in a competitive market to determine the price. Or, recognizing that f irms with market power set prices, we might use the condition that marginal revenue equals marginal cost to talk about price determination. Unfortunately, when it comes to understanding the market for health care, these tools are not as useful. To understand why, imagine you want to book a hotel room in Lusaka. You can call up any hotel and ﬁnd the price of a room. Or you can go on the Internet and check prices either at the hotel’s website or at any number of other sites that provide booking services. You can f ind information about the hotel online, read reviews from previous guests, and talk to hotel staff members on the telephone if you need more information. If you are in the city, you can also walk into a hotel and f ind out the price and the hotel’s amenities. Supply of health care-Technological Progress Now compare this to a hospital. It is much harder to get information about prices, and you cannot simply walk in off the street and purchase an operation. You can in fact ﬁnd out prices for hospital procedures if you look hard enough. But these charges do not necessarily reveal the true price to you as a consumer because they may not include all the costs of doctors and other inputs. If you have insurance coverage, meanwhile, you need to ﬁnd out what portion of any bill will be covered by your insurance. How, then, are prices determined? And, importantly, what price are we talking about: the price you pay or the money received by the hospital? Many of the most important prices are determined by the interaction of a few big players, including the government, insurance companies, and pharmaceutical companies. "Payments to Hospitals and Doctors" gives a sense of the sources of income for hospitals and doctors. Hospitals and doctors get paid by insurance companies, households, and the government. Payments to Hospitals and Doctors Payments to Hospitals and Doctors Because of these programs, the government is a big player in the health- care market. Government decisions determine the demand for health-care services. Governments do not take prices as given. In some cases, the government sets rates for certain procedures, and health-care providers respond. In other cases, the government is involved in negotiations—with pharmaceutical companies. Insurance companies provide additional sources of revenues to the hospital and a doctor. If you are a policyholder and are admitted to a hospital, your insurance company will reimburse the hospital for part of the cost of your care. Payments to Hospitals and Doctors It also reimburses your doctor directly. How much of that cost is reimbursed depends on your insurance policy. If you enter a hospital, say, for an operation, the amount of money the insurance company will pay the hospital is set by an existing agreement. As a result, hospital administrators face a complex set of repayment schedules. Reimbursement rates for a given service depend on who is buying the service Because of these differences in reimbursement rates, doctors and hospitals may sometimes decide not to provide services to certain patients. Doctors sometimes turn down Medicaid patients because of these low rates. Payments to Hospitals and Doctors And what will you pay if you walk into a hospital without health insurance? Hospitals are adopting a policy to improve their f inances: making medical care contingent on upfront payments. Typically, hospitals have billed people after they receive care. But now, pointing to their burgeoning bad-debt and charity-care costs, hospitals are asking patients for money before they get treated. Hospitals say they have turned to the practice because of a spike in patients who don’t pay their bills. Factors that inﬂuence supply in health care services Here are some key components that inf luence supply in health care services: 1. Healthcare workforce: The availability of healthcare professionals such as doctors, nurses, pharmacists, technicians, and support staff is crucial for delivering healthcare services. Factors inf luencing the healthcare workforce supply include the number of healthcare graduates, immigration policies, professional licensing requirements, and working conditions. 2. Healthcare facilities: The number and distribution of hospitals, clinics, primary care centers, and specialized healthcare facilities play a signif ic ant role in determining healthcare service supply. Factors affecting healthcare facility supply include construction and infrastructure development. Factors that inﬂuence supply in health care services 3. Medical equipment and technology: Access to medical equipment, diagnostic tools, treatment modalities, and healthcare technologies is essential for delivering quality healthcare services. The supply of medical equipment and technology is inf lu enced by factors such as innovation, research and development, manufacturing capacity, regulatory approval processes, and affordability. 4. P h a rm a c e u t i c a l s a n d m e d i c a l s u p p l i e s : A d e q u a t e s u p p l y o f pharmaceuticals, medical supplies, and consumables is critical for effective healthcare delivery. Factors inf luencing the supply of pharmaceuticals and medical supplies include production capacity, distribution networks, supply chain management, regulatory compliance, and quality assurance measures. 5. Healthcare f inancing and funding: The availability of f inancial resources, including public funding, private investments, health insurance coverage, and out-of-pocket payments, affects healthcare service supply. Adequate f in ancing is necessary to support healthcare infrastructure development, workforce training, equipment procurement, and service delivery. Factors that inﬂuence supply in health care services 6. Government policies and regulations: Healthcare policies, regulations, and governance frameworks shape the healthcare system's structure, organization, and functioning, impacting healthcare service supply. Regulatory factors include licensing requirements, accreditation standards, reimbursement mechanisms, quality assurance measures, and healthcare delivery models. 7. Public health priorities and planning: Public health priorities, epidemiological trends, disease burden, and population health needs inﬂuence healthcare service supply planning and resource allocation. Strategic planning, needs assessments, and health system analysis help identify gaps in healthcare service supply and prioritize interventions. Factors that inﬂuence supply in health care services 8. Global health considerations: Global health challenges, such as pandemics, infectious diseases, health emergencies, and humanitarian crises, can affect healthcare service supply both l oc al l y and g l ob al l y. I nte rnati onal c oop e rati on, re sourc e mobilization, and coordination are essential for addressing global health threats and ensuring equitable access to healthcare services worldwide. Overall, ensuring an adequate and sustainable supply of healthcare services requires a multi-faceted approach that involves collaboration among policymakers, healthcare providers, industry stakeholders, and the community to address various supply-side factors and improve healthcare system resilience and responsiveness. Models of service utilization (PRECEDE/PROCEED Model, Knippenberg , Andersen) PRECEDE-PROCEED The PRECEDE-PROCEED model is a comprehensive structure for assessing health needs for designing, implementing, and evaluating health promotion and other public health programs to meet those needs. PRECEDE provides the structure for planning a targeted and focused public health program. PROCEED provides the structure for implementing and evaluating the public health program. PRECEDE-PROCEED PRECEDE stands for Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation. It involves assessing the following community factors: Social assessment: Determine the social problems and needs of a given population and identify desired results. Epidemiological assessment: Identify the health determinants of the identif ie d problems and set priorities and goals. Ecological assessment: Analyze behavioral and environmental determinants that predispose, reinforce, and enable the behaviors and lifestyles are identiﬁed. Identify administrative and policy factors that inﬂuence implementation and match appropriate interventions that encourage desired and expected changes. Implementation of interventions. PRECEDE-PROCEED PROCEED stands for Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development. It involves the identif ication of desired outcomes and program implementation: Implementation: Design intervention, assess availability of resources, and implement program. Process Evaluation: Determine if program is reaching the targeted population and achieving desired goals. Impact Evaluation: Evaluate the change in behavior. Outcome Evaluation: Identify if there is a decrease in the incidence or prevalence of the identiﬁed negative behavior or an increase in identiﬁed positive behavior. PRECEDE-PROCEED Implementation Considerations The PRECEDE-PROCEED model provides a structure that supports the planning and implementation of health promotion or disease prevention programs. This model has worked well for many health promotion topics, and can effectively support one-time interventions or long-running programs. Like the Community Readiness Model, PRECEDE-PROCEED invites participation from community members, and has the potential to increase community ownership of the program. When determining whether to use PRECEDE-PROCEED as a model for health promotion or disease prevention programs, it is important to consider whether all parts of the model are appropriate for the program and the resources available to support implementation. It is also important to remember that components of the plan may be adapted over time, as needed. Demand and Supply of health care services Health-care prices are not necessarily determined by supply and demand. The government has a signif ic ant inf luence on prices: for example, the governments in some countries set prices for pharmaceutical products. Even if they are not set by the government, prices may be determined by bargaining between, say, hospitals and drug companies rather than by supply and demand. Furthermore, if people need health-care services, then their demand is likely to be very inelastic (the quantity demanded does not respond much to price changes). Inelastic demand is not, in and of itself, a problem for a competitive market. Demand and Supply of health care services It just means that the equilibrium price could be very high. But if we couple inelastic demand with consumers who lack information and add in some market power by suppliers, then matters become more complicated. Perhaps you already have a sense of why: we have a large group of consumers with very inelastic demand who are relatively uninformed. This sounds like a gold mine for the supplier. Demand and Supply of health care services So it is more than a little misleading to treat health care as something homogeneous that is bought and sold in a single market. Our main point is that the simple framework of supply and demand is not suﬃcient for understanding health care. There are too many different markets, each with its own peculiarities and unusual features. And those features mean that there are several reasons why we might expect ineﬃciency. Firstly, we have already noted, is the presence of market power. Secondly, the various information problems we have mentioned. Thirdly, some aspects of health care have the characteristics of a public good. Assignment 1. How is the demand for health services inﬂuenced by age? 2. List three reasons why the conventional supply-and-demand model may not ﬁt the market for health services well. 3. Give an example of two intermediate inputs into the provision of health-care services. 4. Describe Health seeking behavior 5. Discusses the importance of the theory and concept of PRECEDE-PROCEED for addressing health promotion intervention, and the importance of the review process when applying it to real world settings. 6. Describe health seeking behavior 7. Describe health Needs (actual vs perceived) 8. Describe models of service utilization as follows: a) Knippenberg b) Andersen

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