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A systems-oriented approach to the consumption of medical commodities
Sot. Sci. & Med. 1973, Vol. 7, pp. 531-540. Pergamon Press. Printed in Great Britain.
A SYSTEMS-ORIENTED APPROACH TO THE CONSUMPTION OF MEDICAL COMMODITIES* HEIKKI KAITARANTA
and TAPANI PUROLA
Research Institute for Social Security, The Social Insurance Institution,
Finland
Abstract-A systems-theoretical framework applied in an extensive study project for the evaluation of a universal sickness insurance scheme in Finland is outlined. The consumption of medical commodities is regarded as a part of a multiphase process involving interactions within and between different systems. This process is conceptually analysed with major emphasis on three of its phases: 1. Perception of illness-different concepts of illness are introduced by defining illness in terms of systems functioning. 2. Initiation of need and demand for medical commodities-the process of seeking for care and the factors affecting this process are examined. 3. Consumption of and derived demand for medical commodities-the process within the . health sector and the factors affecting this process are examined. Each of these phases is described by a model. The elements of these three models are further integrated to a fourth model describing the functioning of the public health system. The relevancy of the process-oriented research in relation to the cross-sectional or static one within the health field is discussed.
IN 1964 the coverage of social security among the Finnish people was much extended by a new scheme, the universal sickness insurance scheme. The targets of the scheme created a need for research on its effects. A research project, sponsored by the administrator of the scheme-the Social Insurance Institution, was designed to explore the patterns of medical care utilization prior to and after the implementation of the scheme. In planning the project, a theoretical framework was constructed to form a basis for and to direct the research work. Results obtained and diverse facts faced along with the realization of the project produced data for the evaluation of the theoretical framework, which in turn gave initiation for its further development. This development is reflected in the two main reports differing in content according to the before and after phases of the project [l, 21, as well as in a number of other studies based on the same data. The intention of this paper is to give a brief description of the theoretical considerations implied in the above study project. The material introduced here bases mostly on three integrated models, of which empirical applications can be found e.g. in an accompanying paper [3] presenting some results of the project. . The conceptual and theoretical basis applied in these studies was further extended when members of the research team responsible for the project took part in the planning and conducting of the international collaborative study of medical care utilization [4]. In this context, the role of the health system was provided with major emphasis. In the following, the consumption of medical commodities (goods and services) is looked at from the framework of a set of processes between and within different systems (or elements * Presented in the Third International 14-18 August, 1972.
Conferen’ce on Social Science and Medicine, 531
Elsinore,
Denmark,
HEIKKI KAITARANTA
532
and
TAPANI PUROLA
inside a system) which the health field encompasses. From the complexity of processes involved, it is useful to extract seven different but closely integrated stages: Occurrence of a disease. Perception of illness. Perception of need for medical commodities. Demand for medical commodities supplied at the entrance to the health system. Consumption of medical commodities supplied at the entrance to the health system. Derived demand* for medical commodities initiated by consumption at the entrance to the health system. 7. Derived consumption of medical commodities initiated by derived demand. 1. 2. 3. 4. 5. 6.
These stages form a process and have a sequent order in time with several feed-back effects. The sequence expressed holds whether part or all of the stages are gone through, whether a service or a good is in question, and whether utilization is illness-initiated or not. Before entering into a more detailed description of the stages and their interrelations it is necessary to define illness and health from the framework we have adopted : Illness is a state of disorder in the functioning of a system with three integrated elements: Individual’s psycho-biological system, the general system of nature and the general social system. Health, in turn, is the proper functioning of this system. These definitions might be regarded as system-bound versions of the commonly known definition by the World Health Organization. They imply as well the clinical (medical in the traditional sense) as the social or sociological and the psychological concept of illness and health. Let us look closer at the reasoning behind the definitions. First, with the psycho-biological system we mean all the internal elements that form the human organism. These elements are e.g. the psychological, biological, physical and chemical subsystems or-when identified by more specific function--the subsystems of nerves, blood circulation, digestion, etc. These subsystems and the organism they constitute are in a continuous self-regulating and interactive process. Any disorder in this internal system or in any of its elements means dysfunction in the process mentioned, i.e. the whole organism is in the state of disorder; the individual is in the state of ill health. The disorder may be removed by the organism’s selfregulative processes and/or by external manipulation of the organism (treatment), Illness as defined exclusively a state of disorder in the functioning of the human organism has been in the primary interest of the traditional medical science in its efforts to diagnose and treat different diseases. This definition of illness (clinical concept), however, does not give a sufficient basis for the analysis and planning of medical care or social security systems. We come now to another aspect in our definition: dysfunction (state of disorder) in the relation between the individual’s psycho-biological system and those external systems where he is a closely integrated element. These external systems are-as indicated above-the general system of nature and the general social system (the social environment). Disorder in the relationship to the latter system implies the sociological concept of illness. An application of this concept can be found e.g. in the Finnish sickness insurance and invalidity pensions schemes: The degree of disability is defined as a function of the relationship between
a person’s
psycho-biological state and his current occupation or occupational skill of a suitable job. The same state of disorder in the psycho-biological system may thus lead to different states of disorder in the social context depending on the
plus the availability
* Derived demand-demand
for a commodity
resulting from consumption
of another.
533
Approach to the Consumption of Medical Commodities
content of a person’s connections to his social environment. We might speak here of illness as a social state in order to separate it conceptually from the former and more traditional definition of illness as a psycho-biological state. In the latter, both the psycho-biological
system itself and its connections to the general system of nature are involved. To evaluate the concept of illness against the process of individual demand for medical care, it is necessary to extract one specific element from the psycho-biological system for closer consideration. This is a psychological element called cognition. Processes of the cognitive system determine whether and how a person perceives a state of disorder. Since this state of disorder may differ from what could be clinically diagnosed, and since individuals differ in how they perceive the same psycho-biological state, a third concept of illness is introduced: illness as a perceived state. This is the key concept in connection with illness-initiated demand for medical commodities at the entry point. The cognition can be considered a system of observation and control, which directs an individual’s target-oriented behavior. In the case of perceived illness, the target is a state of harmony (proper functioning) within the psycho-biological system and in the relation between it and the social and natural environment. To achieve this target an individual usually has to change his behavior (seek for care, change normal ways of social participation). This can be called an adaptation process. Everything we have told above about the definition of illness is summarized in Fig. 1. As indicated earlier, a diagnosible state of disorder (disease) in the psycho-biological system may or may not precede the perception of illness, and a person may or may not perceive a diagnosible state of disorder. In other words, a person can feel being affected by a disease, which, however, cannot be diagnosed, or a diagnosible disease (e.g. cancer in an early phase) doesn’t take a form of a perceived state of disorder. According to our definition, the person is considered being in a state of ill health in both of these cases. In the latter case, no perceived need for medical commodities is brought about by that state of disorder (simply because it is not perceived through cognition).
Change in participation
FIG. 1. A model defining the different concepts of illness and their interrelations tion and adaptation processes [5]. (See also reference [II]).
in the percep-
1. Individual’s psycho-biological system/illness as a psycho-biological state 2. Individual’s social connection/illness as a social state 3. Individual’s cognition/illness as a perceived state. On the other hand, perceived illness precedes the perception of need for medical commodities in only orie specific (but usual) case, i.e. in the case of (perceived) illness-initiated need. Here the need is for curative commodities, i.e. for care to restore health. Perceived illness is consequently not a necessary condition for the perception of need for all medical commodities, and for the initiation of all demand and consumption processes. In the case of
534
HEIKKIKAITARANTA
and TAPANIF'UROLA
perceived need without any perception of illness, the need is for preventive commodities, e.g. check-ups, vaccinations, vitamines. Because the perception of need-not perceived illness nor diagnosible disease-is the necessary condition for the individually initiated demand for all medical commodities, it is actually the generating stage in the set of processes (or a process as such) that the utilization of these commodities involve. According to our definition of illness and the different combinations of perceived and clinically diagnosible states of disorder, four groups of people with potential initiation of need are formed in the population outside the health system: (1) those perceiving illness and being in a diagnosible state of disorder; (2) those perceiving illness but not being in a diagnosible state of disorder; (3) those being in a diagnosible state of disorder but not perceiving illness; and (4) those neither being in a diagnosible state of disorder nor perceiving illness. In the population mentioned, these groups are all inclusive and mutually exclusive at a point of time. As indicated, an individual belonging to any of these groups can find himself being in a state of perceived need for medical commodities. However, the most usual case where the need for medical commodities is individually initiated concerns the first group mentioned, i.e. those affected by a diagnosible disease (a disorder in the psycho-biological system), which is then perceived through cognition. For this case, Kalimo has developed a model describing the determinants of medical care utilization (Fig. 2). According to it, a change in the individual’s psycho-biological state may lead-under the effect of a number of intervening factors-to perceived need for care (perceived illness in this case), and further on to an estimate of the expected value of use. This decision process is affected by certain sociopsychological factors which can be called predisposing ones in the context of the model. If an affirmative decision is made on the value of use, utilization remains to depend on factors affecting the individual’s opportunities for action. These belong to the so-called enabling factors (availability of services, relative cost of services). A detailed theoretical analysis of the model can be found elsewhere [6]. In a survey about model-building within research on medical care utilization, this model was considered the most advanced as regards the processes involved in seeking for care [7]. This model is closely linked to that presented in Fig. 1 by taking into account the factors that create variation among individuals as regards their cognitive systems and their connections to the external social system and its subsystems or elements : Differences in the cognitive systems and in the social context mean differences in the predisposing and enabling factors. The variation is due e.g. to how individuals are linked to such subsystems as the family, the production and income redistribution systems, the general and local socioecological systems, the health services system at the local and national level, and the sickness insurance system, etc. As emphasized, the model describes those processes and factors which are relevant to the individual initiation of demand for curative commodities supplied at the entry point to the health system, and thus to the situation where a biological disease is the generating item. Further on the model has been taken as a starting point in constructing those entering into the description of processes within the health system [S]. The model presented in Fig. 3 can be considered one of these [9]. As indicated, it deals with the utilization of medical commodities also within the health services system, and takes into account all factors initiating the need for medical commodities. The model uses economic terminology mainly because of its accuracy in the conceptual differentiation involved. This might be considered an unusual feature as regards the subject of the model. However, similar terminology has been used in the same context even earlier, e.g. by Feldstein [lo].
Approach to the Consumption of Medical Commodities
535
Factorsasociated with patient’s decision.making
FIG. 2. Model of factors affecting medical care utilization [6].
The model extracts different outcomes or conceptua1 states (boxes in the figure) brought about in the course of the demand and consumption process, plus the factors (circles) affecting the process or the probability of different outcomes. Characteristics of the Finnish medical services system has directed the designing of the model. Its intention is, however, to reveal certain key concepts related to the facts that every system of medical care is bound to face in its target-oriented functioning-the target being e.g. improved ability to meet the needs of people subject to the system. The box A encompasses the group of people with potential initiation of need for medical commodities, i.e. the group that the conceptual process of the model starts with. This group and further on its process-splitted subgroups are subject to a number of intervening factors
536 F------------,
1 _cl
r--------
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wth
potential
mallatlon of need for medical commodttier
!
I I- -------------------f I
I
I
Sick in medical
Demand for medical
-------
commM.it~es
\
I I I
I_
I
-
I I_
_,
I”e OBrlYed demand 10r I nanmed,calcommod,t,es
, I
L --------
FIG.3.A model describing different outcomes of processes that the demand for and the consumption of medical commodities involve.
(factor groups). factor groups :
Let us proceed
through
the process
in the order expressed
by the different
Factor group 1 (Fl) Factors belonging to this group determine of perceived need for medical commodities.
whether or not an individual falls into a state They incltide symptoms, beliefs, knowledge,
Approach to the Consumption
of Medical Commodities
537
adaptation of health information, attitude to preventive and curative services, etc. These are exclusively so-called predisposing factors. Among them perceived illness is surely the most relevant factor but not a necessary one in determining the probability of a person to fall into either of the outcomes that result: Those with and those without perceived need for medical commodities. Factor group 2 (F2)
These factors concern those without perceived need for medical commodities. They include simply the criteria-whatever these are-by which the medical science defines a person being in a state of ill health or not. Factor group 3 (F3) The group with perceived need for medical commodities is now involved, since perceived need is a necessary condition for individual demand initiation. The factors in question are both predisposing and enabling ones. Among the latter, the most relevant might be the relative cost of commodities (cost of a commodity related to the person’s income or means). Also the person’s comprehension about the expected insurance benefits, and his knowledge about the availability of commodities can play an important role in determining the probability to demand. Factors implied in the economists’ concept of preference function are as well covered by this factor group. Again, two groups are introduced (conceptually at the community level): Those who demand and those who do not. Facror group 4 (F4)
After a decision not to demand for medical commodities is made, the individual is faced with factors affecting his way of handling the need by nonmedical measures-or determining whether or not there is any attempt at all to get rid of the need. These factors are mainly psychological or sociopsychological. Factor group 5 (F5)
At this stage, supply is the key factor. As regards the community level, it is the amount and structure of the supply of medical commodities related to the amount and structure of the demand for them that determines the extent to which demand turns out as consumption, and what the consumption is like. Usually the amount of supply (andconsumption) is less than that of demand. This fact produces the group of people with unmet demand for medical commodities. Factor group 6 (F6)
Consumption at the entrance stage to the health system leads with a certain probability to further demand for medical commodities, to the so-called derived demand. This process is mostly affected by physician’s decisions, which in turn, depend on such partly interdependent factors as consultations with the patient, the patient’s social resources, institutional settings (internal structure of the health system), physician’s knowledge, physician’s estimate of the patient’s need for other commodities than those he can provide, etc. F6 also includes factors that determine the extent to which derived demand for other than medical commodities is resulting from the consumption at the entrance stage, e.g. availability of sickness insurance services.
538
HEKKI KAITARANTAand TAPANI PUROLA
Factor group 7 (F7)
The factors involved here are similar to those of F5, but are linked now to the supply of the commodities that are produced to meet the derived demand, i.e. demand within the health system. Also in this context, it is usual that the amount (and structure) of supply does not totally correspond to that of demand at a certain point of time or within a time interval. Consequently, a group of people with unmet derived demand is introduced besides those who consume. Factor group 8 (FS)
Derived consumption of medical commodities creates to an extent derived demand for nonmedical ones. Factors in question are similar to those of F6, but the patient’s decisions play here a more emphasized role. Factor group 9 (F9)
Again, factors belonging to this group are analogous to those of F5 and F7; only the group of commodities is different: sickness insurance services, disability insurance services, etc. In the course of the whole process described above, four outcomes of special interest from the health-political point of view are produced. These are the boxes C, D, E and F (framed by a plotted line in the figure). The latter two define the internal system of health services. Health policy is here restricted to affecting the functioning of this internal system. A broader content to health policy is given when the former two boxes (C and D) as well as the boxes G and H are taken into consideration. This consideration integrates the health system closer to the general welfare system as regards the evaluation, planning and the decisionmaking process. In this context, the target-oriented interest can be presented in the form of three questions : 1. How to eliminate (in the best possible way) the need for medical commodities among those who are consuming them ? (Boxes E and F involved, problems of adequate treatment, methods of diagnosis, efficiency, productivity, resource allocation within the health sector, etc.) 2. How to meet the demand for medical commodities? (Box D involved, problems of planning the supply by form of care and by area, education of medical personnel, resource allocation to the health sector, etc.) 3. How to create demand for preventive commodities among all, and for curative ones among those with perceived or clinically diagnosible need ? (Box B and C involved, problems of health information, health screening, etc.) A fourth question can be added: How to prevent illness or illness-initiated need for medical commodities? This question refers, however, to commodities that fall outside the model in Fig. 3. These commodities are those consumed collectively, not individually, e.g. measures intended to eliminate risks due to the characteristics of the social and natural environment (improvement of housing conditions, sanitation, prevention of air and water pollution, etc.). What, then, are the processes through which the health system does try to answer these questions, or proceeds in the direction indicated by the questions? The aim of the model in Fig. 4 is to describe these processes along with the attached elements. This model integrates the processes that the definition of illness (Fig. l), the need initiation, demand for, and the
Approach to the Consumption
of Medical Commodities
539
Pubbc dicusslon. Pressure groups
Pubhc health policy _ ____
--__-_--a---------_-----
________-___
t Efml~gy and preventwe medicine _-----a
Epidemiology and public health __-_--------_-
a
Cllnlcal rnedlC -e--w-
Elements am prpcesses
Social system
I
-_
I
I
FIG. 4. Simplifiedmodel of public health systems(see also reference [ll]). consumption of medical commodities (Figs. 2 and 3) imply to those of education, research, information, evaluation, planning, and decision-making systems, which all are elements in the public health system [ll]. The model emphasizes the role of the information system as an essential basis for the target-oriented functioning of the health system. Three information sources are formed according to: (1’) data about the general systems of nature and social environment (etiology and preventive measures involved) ; (2) data about perceived and medical morbidity (epidemiology and health surveys involved); and (3) data about the activities of the systems of treatment, and the sickness and disability insurance (internal systems of commodity production involved). Analysis of information data generates evaluation and planning, which, in turn, produces further needs, recommendations, and plans to be handled under the effect of public discussion and pressure groups by the decision-making element. The latter affects by its decisions all the elements forming the three information sources, and thus the content of information. This is the process that is maintained by the questions presented above. All the models presented in this paper favor the emphasizing of a process-oriented or dynamic outlook instead of the more traditional cross-sectional or static one in connection with health research. The former outlook suggests closer attention to the conceptual and empirical analysis of the health services system and the individualized flow of patients within it. This means further that the research unit should rather be defined in terms of time, e.g. as
HEIKKI KAITARANTAand TAPANI PUROLA
540 an illness pulation
episode, of the
or as a chain
resulting
So far the process-oriented among the that
most
studies
sociological
and
the consumption
studies
have
a sequent
turned
order
of process
disorder,
within
approach-in the
health
administrative of medical depend
the breaking
the broad field.
context
This
to fully
on each
sense
has
imply. explain
out of a disease
or partial
recovery
applied
meant
as concerns
commodities
out to be unable
in time
from
and to the complete
the
vague cause
It is referred
to the mani-
or death.
in this paper-is
lacking
interpretations and here
how- the probabilities
effect
both
in
relationships
to the fact
that
of events
these having
other.
REFERENCES
1. PUROLA, T., KALIMO, E., SIEVERS, K. and NYMAN, K. The Utilization of the Medical Services and Its Relationship to Morbidity, Health Resources and Social Factors. Research Institute for Social Security, 2. 3.
Helsinki, 1968. PUROLA, T., NYMAN,K., KALIMO, E. and SIEVERS, K. Sickness Insurance, Morbidity, and Medical Care Use (in Finnish). Research Institute for Social Security, Helsinki, 1971. NYMAN, K. and KAI~MO, E. National sickness insurance and the use of physicians’ services in Finland.
Sot. Sci. & Med. 7, 541, 1973. World Health Organizationllnternational CoiIaborative Study of Medical Care Utilization. Manual I. Organization and-Development. Baltimore, 1970. 5. PUROLA. T. A Concert of Illness in Social Medicine (in Finnish). Sos.-liiiket. Aikakl. 9. 3. 1971. of Medical Care UtiIization. Research’Institute for Social %x&y, Helsinki, 6. KALIMO; E. Determi&ts 1969. 7. FISCHER, LINDA A. The Use of Services in the Urban Scene-The Zndividuuland the Medical Care System. 4.
8.
Center for Urban and Regional Studies, University of North Carolina, Chapel Hill, 1971. KALIMO,E., KOHN, R. and BEDEN@ B. Interrelationships in the Use of Selected Health Services: Cross-National Study. Med. Care, 10,95, 1972.
9.
KAITARANTA, H. Economic Research and Applications within the Health Sector in Finnish.
A
Unpub-
lished paper. Research Institute for Social Security, Helsinki, 1972. 10. 11.
FELDSTEIN, PAUL J. Research on the Demand for Health Services. In Hea/th Services Research (edited by MAINLAND, D.). Milbank Memorial Fund, New York, 1967. PUROLA, T. A Systems Approach to Health and Health Policy. Med. Care, 10, 373, 1972
A SYSTEMS-ORIENTED APPROACH TO THE CONSUMPTION OF MEDICAL COMMODITIES* HEIKKI KAITARANTA
and TAPANI PUROLA
Research Institute for Social Security, The Social Insurance Institution,
Finland
Abstract-A systems-theoretical framework applied in an extensive study project for the evaluation of a universal sickness insurance scheme in Finland is outlined. The consumption of medical commodities is regarded as a part of a multiphase process involving interactions within and between different systems. This process is conceptually analysed with major emphasis on three of its phases: 1. Perception of illness-different concepts of illness are introduced by defining illness in terms of systems functioning. 2. Initiation of need and demand for medical commodities-the process of seeking for care and the factors affecting this process are examined. 3. Consumption of and derived demand for medical commodities-the process within the . health sector and the factors affecting this process are examined. Each of these phases is described by a model. The elements of these three models are further integrated to a fourth model describing the functioning of the public health system. The relevancy of the process-oriented research in relation to the cross-sectional or static one within the health field is discussed.
IN 1964 the coverage of social security among the Finnish people was much extended by a new scheme, the universal sickness insurance scheme. The targets of the scheme created a need for research on its effects. A research project, sponsored by the administrator of the scheme-the Social Insurance Institution, was designed to explore the patterns of medical care utilization prior to and after the implementation of the scheme. In planning the project, a theoretical framework was constructed to form a basis for and to direct the research work. Results obtained and diverse facts faced along with the realization of the project produced data for the evaluation of the theoretical framework, which in turn gave initiation for its further development. This development is reflected in the two main reports differing in content according to the before and after phases of the project [l, 21, as well as in a number of other studies based on the same data. The intention of this paper is to give a brief description of the theoretical considerations implied in the above study project. The material introduced here bases mostly on three integrated models, of which empirical applications can be found e.g. in an accompanying paper [3] presenting some results of the project. . The conceptual and theoretical basis applied in these studies was further extended when members of the research team responsible for the project took part in the planning and conducting of the international collaborative study of medical care utilization [4]. In this context, the role of the health system was provided with major emphasis. In the following, the consumption of medical commodities (goods and services) is looked at from the framework of a set of processes between and within different systems (or elements * Presented in the Third International 14-18 August, 1972.
Conferen’ce on Social Science and Medicine, 531
Elsinore,
Denmark,
HEIKKI KAITARANTA
532
and
TAPANI PUROLA
inside a system) which the health field encompasses. From the complexity of processes involved, it is useful to extract seven different but closely integrated stages: Occurrence of a disease. Perception of illness. Perception of need for medical commodities. Demand for medical commodities supplied at the entrance to the health system. Consumption of medical commodities supplied at the entrance to the health system. Derived demand* for medical commodities initiated by consumption at the entrance to the health system. 7. Derived consumption of medical commodities initiated by derived demand. 1. 2. 3. 4. 5. 6.
These stages form a process and have a sequent order in time with several feed-back effects. The sequence expressed holds whether part or all of the stages are gone through, whether a service or a good is in question, and whether utilization is illness-initiated or not. Before entering into a more detailed description of the stages and their interrelations it is necessary to define illness and health from the framework we have adopted : Illness is a state of disorder in the functioning of a system with three integrated elements: Individual’s psycho-biological system, the general system of nature and the general social system. Health, in turn, is the proper functioning of this system. These definitions might be regarded as system-bound versions of the commonly known definition by the World Health Organization. They imply as well the clinical (medical in the traditional sense) as the social or sociological and the psychological concept of illness and health. Let us look closer at the reasoning behind the definitions. First, with the psycho-biological system we mean all the internal elements that form the human organism. These elements are e.g. the psychological, biological, physical and chemical subsystems or-when identified by more specific function--the subsystems of nerves, blood circulation, digestion, etc. These subsystems and the organism they constitute are in a continuous self-regulating and interactive process. Any disorder in this internal system or in any of its elements means dysfunction in the process mentioned, i.e. the whole organism is in the state of disorder; the individual is in the state of ill health. The disorder may be removed by the organism’s selfregulative processes and/or by external manipulation of the organism (treatment), Illness as defined exclusively a state of disorder in the functioning of the human organism has been in the primary interest of the traditional medical science in its efforts to diagnose and treat different diseases. This definition of illness (clinical concept), however, does not give a sufficient basis for the analysis and planning of medical care or social security systems. We come now to another aspect in our definition: dysfunction (state of disorder) in the relation between the individual’s psycho-biological system and those external systems where he is a closely integrated element. These external systems are-as indicated above-the general system of nature and the general social system (the social environment). Disorder in the relationship to the latter system implies the sociological concept of illness. An application of this concept can be found e.g. in the Finnish sickness insurance and invalidity pensions schemes: The degree of disability is defined as a function of the relationship between
a person’s
psycho-biological state and his current occupation or occupational skill of a suitable job. The same state of disorder in the psycho-biological system may thus lead to different states of disorder in the social context depending on the
plus the availability
* Derived demand-demand
for a commodity
resulting from consumption
of another.
533
Approach to the Consumption of Medical Commodities
content of a person’s connections to his social environment. We might speak here of illness as a social state in order to separate it conceptually from the former and more traditional definition of illness as a psycho-biological state. In the latter, both the psycho-biological
system itself and its connections to the general system of nature are involved. To evaluate the concept of illness against the process of individual demand for medical care, it is necessary to extract one specific element from the psycho-biological system for closer consideration. This is a psychological element called cognition. Processes of the cognitive system determine whether and how a person perceives a state of disorder. Since this state of disorder may differ from what could be clinically diagnosed, and since individuals differ in how they perceive the same psycho-biological state, a third concept of illness is introduced: illness as a perceived state. This is the key concept in connection with illness-initiated demand for medical commodities at the entry point. The cognition can be considered a system of observation and control, which directs an individual’s target-oriented behavior. In the case of perceived illness, the target is a state of harmony (proper functioning) within the psycho-biological system and in the relation between it and the social and natural environment. To achieve this target an individual usually has to change his behavior (seek for care, change normal ways of social participation). This can be called an adaptation process. Everything we have told above about the definition of illness is summarized in Fig. 1. As indicated earlier, a diagnosible state of disorder (disease) in the psycho-biological system may or may not precede the perception of illness, and a person may or may not perceive a diagnosible state of disorder. In other words, a person can feel being affected by a disease, which, however, cannot be diagnosed, or a diagnosible disease (e.g. cancer in an early phase) doesn’t take a form of a perceived state of disorder. According to our definition, the person is considered being in a state of ill health in both of these cases. In the latter case, no perceived need for medical commodities is brought about by that state of disorder (simply because it is not perceived through cognition).
Change in participation
FIG. 1. A model defining the different concepts of illness and their interrelations tion and adaptation processes [5]. (See also reference [II]).
in the percep-
1. Individual’s psycho-biological system/illness as a psycho-biological state 2. Individual’s social connection/illness as a social state 3. Individual’s cognition/illness as a perceived state. On the other hand, perceived illness precedes the perception of need for medical commodities in only orie specific (but usual) case, i.e. in the case of (perceived) illness-initiated need. Here the need is for curative commodities, i.e. for care to restore health. Perceived illness is consequently not a necessary condition for the perception of need for all medical commodities, and for the initiation of all demand and consumption processes. In the case of
534
HEIKKIKAITARANTA
and TAPANIF'UROLA
perceived need without any perception of illness, the need is for preventive commodities, e.g. check-ups, vaccinations, vitamines. Because the perception of need-not perceived illness nor diagnosible disease-is the necessary condition for the individually initiated demand for all medical commodities, it is actually the generating stage in the set of processes (or a process as such) that the utilization of these commodities involve. According to our definition of illness and the different combinations of perceived and clinically diagnosible states of disorder, four groups of people with potential initiation of need are formed in the population outside the health system: (1) those perceiving illness and being in a diagnosible state of disorder; (2) those perceiving illness but not being in a diagnosible state of disorder; (3) those being in a diagnosible state of disorder but not perceiving illness; and (4) those neither being in a diagnosible state of disorder nor perceiving illness. In the population mentioned, these groups are all inclusive and mutually exclusive at a point of time. As indicated, an individual belonging to any of these groups can find himself being in a state of perceived need for medical commodities. However, the most usual case where the need for medical commodities is individually initiated concerns the first group mentioned, i.e. those affected by a diagnosible disease (a disorder in the psycho-biological system), which is then perceived through cognition. For this case, Kalimo has developed a model describing the determinants of medical care utilization (Fig. 2). According to it, a change in the individual’s psycho-biological state may lead-under the effect of a number of intervening factors-to perceived need for care (perceived illness in this case), and further on to an estimate of the expected value of use. This decision process is affected by certain sociopsychological factors which can be called predisposing ones in the context of the model. If an affirmative decision is made on the value of use, utilization remains to depend on factors affecting the individual’s opportunities for action. These belong to the so-called enabling factors (availability of services, relative cost of services). A detailed theoretical analysis of the model can be found elsewhere [6]. In a survey about model-building within research on medical care utilization, this model was considered the most advanced as regards the processes involved in seeking for care [7]. This model is closely linked to that presented in Fig. 1 by taking into account the factors that create variation among individuals as regards their cognitive systems and their connections to the external social system and its subsystems or elements : Differences in the cognitive systems and in the social context mean differences in the predisposing and enabling factors. The variation is due e.g. to how individuals are linked to such subsystems as the family, the production and income redistribution systems, the general and local socioecological systems, the health services system at the local and national level, and the sickness insurance system, etc. As emphasized, the model describes those processes and factors which are relevant to the individual initiation of demand for curative commodities supplied at the entry point to the health system, and thus to the situation where a biological disease is the generating item. Further on the model has been taken as a starting point in constructing those entering into the description of processes within the health system [S]. The model presented in Fig. 3 can be considered one of these [9]. As indicated, it deals with the utilization of medical commodities also within the health services system, and takes into account all factors initiating the need for medical commodities. The model uses economic terminology mainly because of its accuracy in the conceptual differentiation involved. This might be considered an unusual feature as regards the subject of the model. However, similar terminology has been used in the same context even earlier, e.g. by Feldstein [lo].
Approach to the Consumption of Medical Commodities
535
Factorsasociated with patient’s decision.making
FIG. 2. Model of factors affecting medical care utilization [6].
The model extracts different outcomes or conceptua1 states (boxes in the figure) brought about in the course of the demand and consumption process, plus the factors (circles) affecting the process or the probability of different outcomes. Characteristics of the Finnish medical services system has directed the designing of the model. Its intention is, however, to reveal certain key concepts related to the facts that every system of medical care is bound to face in its target-oriented functioning-the target being e.g. improved ability to meet the needs of people subject to the system. The box A encompasses the group of people with potential initiation of need for medical commodities, i.e. the group that the conceptual process of the model starts with. This group and further on its process-splitted subgroups are subject to a number of intervening factors
536 F------------,
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potential
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!
I I- -------------------f I
I
I
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Demand for medical
-------
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\
I I I
I_
I
-
I I_
_,
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, I
L --------
FIG.3.A model describing different outcomes of processes that the demand for and the consumption of medical commodities involve.
(factor groups). factor groups :
Let us proceed
through
the process
in the order expressed
by the different
Factor group 1 (Fl) Factors belonging to this group determine of perceived need for medical commodities.
whether or not an individual falls into a state They incltide symptoms, beliefs, knowledge,
Approach to the Consumption
of Medical Commodities
537
adaptation of health information, attitude to preventive and curative services, etc. These are exclusively so-called predisposing factors. Among them perceived illness is surely the most relevant factor but not a necessary one in determining the probability of a person to fall into either of the outcomes that result: Those with and those without perceived need for medical commodities. Factor group 2 (F2)
These factors concern those without perceived need for medical commodities. They include simply the criteria-whatever these are-by which the medical science defines a person being in a state of ill health or not. Factor group 3 (F3) The group with perceived need for medical commodities is now involved, since perceived need is a necessary condition for individual demand initiation. The factors in question are both predisposing and enabling ones. Among the latter, the most relevant might be the relative cost of commodities (cost of a commodity related to the person’s income or means). Also the person’s comprehension about the expected insurance benefits, and his knowledge about the availability of commodities can play an important role in determining the probability to demand. Factors implied in the economists’ concept of preference function are as well covered by this factor group. Again, two groups are introduced (conceptually at the community level): Those who demand and those who do not. Facror group 4 (F4)
After a decision not to demand for medical commodities is made, the individual is faced with factors affecting his way of handling the need by nonmedical measures-or determining whether or not there is any attempt at all to get rid of the need. These factors are mainly psychological or sociopsychological. Factor group 5 (F5)
At this stage, supply is the key factor. As regards the community level, it is the amount and structure of the supply of medical commodities related to the amount and structure of the demand for them that determines the extent to which demand turns out as consumption, and what the consumption is like. Usually the amount of supply (andconsumption) is less than that of demand. This fact produces the group of people with unmet demand for medical commodities. Factor group 6 (F6)
Consumption at the entrance stage to the health system leads with a certain probability to further demand for medical commodities, to the so-called derived demand. This process is mostly affected by physician’s decisions, which in turn, depend on such partly interdependent factors as consultations with the patient, the patient’s social resources, institutional settings (internal structure of the health system), physician’s knowledge, physician’s estimate of the patient’s need for other commodities than those he can provide, etc. F6 also includes factors that determine the extent to which derived demand for other than medical commodities is resulting from the consumption at the entrance stage, e.g. availability of sickness insurance services.
538
HEKKI KAITARANTAand TAPANI PUROLA
Factor group 7 (F7)
The factors involved here are similar to those of F5, but are linked now to the supply of the commodities that are produced to meet the derived demand, i.e. demand within the health system. Also in this context, it is usual that the amount (and structure) of supply does not totally correspond to that of demand at a certain point of time or within a time interval. Consequently, a group of people with unmet derived demand is introduced besides those who consume. Factor group 8 (FS)
Derived consumption of medical commodities creates to an extent derived demand for nonmedical ones. Factors in question are similar to those of F6, but the patient’s decisions play here a more emphasized role. Factor group 9 (F9)
Again, factors belonging to this group are analogous to those of F5 and F7; only the group of commodities is different: sickness insurance services, disability insurance services, etc. In the course of the whole process described above, four outcomes of special interest from the health-political point of view are produced. These are the boxes C, D, E and F (framed by a plotted line in the figure). The latter two define the internal system of health services. Health policy is here restricted to affecting the functioning of this internal system. A broader content to health policy is given when the former two boxes (C and D) as well as the boxes G and H are taken into consideration. This consideration integrates the health system closer to the general welfare system as regards the evaluation, planning and the decisionmaking process. In this context, the target-oriented interest can be presented in the form of three questions : 1. How to eliminate (in the best possible way) the need for medical commodities among those who are consuming them ? (Boxes E and F involved, problems of adequate treatment, methods of diagnosis, efficiency, productivity, resource allocation within the health sector, etc.) 2. How to meet the demand for medical commodities? (Box D involved, problems of planning the supply by form of care and by area, education of medical personnel, resource allocation to the health sector, etc.) 3. How to create demand for preventive commodities among all, and for curative ones among those with perceived or clinically diagnosible need ? (Box B and C involved, problems of health information, health screening, etc.) A fourth question can be added: How to prevent illness or illness-initiated need for medical commodities? This question refers, however, to commodities that fall outside the model in Fig. 3. These commodities are those consumed collectively, not individually, e.g. measures intended to eliminate risks due to the characteristics of the social and natural environment (improvement of housing conditions, sanitation, prevention of air and water pollution, etc.). What, then, are the processes through which the health system does try to answer these questions, or proceeds in the direction indicated by the questions? The aim of the model in Fig. 4 is to describe these processes along with the attached elements. This model integrates the processes that the definition of illness (Fig. l), the need initiation, demand for, and the
Approach to the Consumption
of Medical Commodities
539
Pubbc dicusslon. Pressure groups
Pubhc health policy _ ____
--__-_--a---------_-----
________-___
t Efml~gy and preventwe medicine _-----a
Epidemiology and public health __-_--------_-
a
Cllnlcal rnedlC -e--w-
Elements am prpcesses
Social system
I
-_
I
I
FIG. 4. Simplifiedmodel of public health systems(see also reference [ll]). consumption of medical commodities (Figs. 2 and 3) imply to those of education, research, information, evaluation, planning, and decision-making systems, which all are elements in the public health system [ll]. The model emphasizes the role of the information system as an essential basis for the target-oriented functioning of the health system. Three information sources are formed according to: (1’) data about the general systems of nature and social environment (etiology and preventive measures involved) ; (2) data about perceived and medical morbidity (epidemiology and health surveys involved); and (3) data about the activities of the systems of treatment, and the sickness and disability insurance (internal systems of commodity production involved). Analysis of information data generates evaluation and planning, which, in turn, produces further needs, recommendations, and plans to be handled under the effect of public discussion and pressure groups by the decision-making element. The latter affects by its decisions all the elements forming the three information sources, and thus the content of information. This is the process that is maintained by the questions presented above. All the models presented in this paper favor the emphasizing of a process-oriented or dynamic outlook instead of the more traditional cross-sectional or static one in connection with health research. The former outlook suggests closer attention to the conceptual and empirical analysis of the health services system and the individualized flow of patients within it. This means further that the research unit should rather be defined in terms of time, e.g. as
HEIKKI KAITARANTAand TAPANI PUROLA
540 an illness pulation
episode, of the
or as a chain
resulting
So far the process-oriented among the that
most
studies
sociological
and
the consumption
studies
have
a sequent
turned
order
of process
disorder,
within
approach-in the
health
administrative of medical depend
the breaking
the broad field.
context
This
to fully
on each
sense
has
imply. explain
out of a disease
or partial
recovery
applied
meant
as concerns
commodities
out to be unable
in time
from
and to the complete
the
vague cause
It is referred
to the mani-
or death.
in this paper-is
lacking
interpretations and here
how- the probabilities
effect
both
in
relationships
to the fact
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these having
other.
REFERENCES
1. PUROLA, T., KALIMO, E., SIEVERS, K. and NYMAN, K. The Utilization of the Medical Services and Its Relationship to Morbidity, Health Resources and Social Factors. Research Institute for Social Security, 2. 3.
Helsinki, 1968. PUROLA, T., NYMAN,K., KALIMO, E. and SIEVERS, K. Sickness Insurance, Morbidity, and Medical Care Use (in Finnish). Research Institute for Social Security, Helsinki, 1971. NYMAN, K. and KAI~MO, E. National sickness insurance and the use of physicians’ services in Finland.
Sot. Sci. & Med. 7, 541, 1973. World Health Organizationllnternational CoiIaborative Study of Medical Care Utilization. Manual I. Organization and-Development. Baltimore, 1970. 5. PUROLA. T. A Concert of Illness in Social Medicine (in Finnish). Sos.-liiiket. Aikakl. 9. 3. 1971. of Medical Care UtiIization. Research’Institute for Social %x&y, Helsinki, 6. KALIMO; E. Determi&ts 1969. 7. FISCHER, LINDA A. The Use of Services in the Urban Scene-The Zndividuuland the Medical Care System. 4.
8.
Center for Urban and Regional Studies, University of North Carolina, Chapel Hill, 1971. KALIMO,E., KOHN, R. and BEDEN@ B. Interrelationships in the Use of Selected Health Services: Cross-National Study. Med. Care, 10,95, 1972.
9.
KAITARANTA, H. Economic Research and Applications within the Health Sector in Finnish.
A
Unpub-
lished paper. Research Institute for Social Security, Helsinki, 1972. 10. 11.
FELDSTEIN, PAUL J. Research on the Demand for Health Services. In Hea/th Services Research (edited by MAINLAND, D.). Milbank Memorial Fund, New York, 1967. PUROLA, T. A Systems Approach to Health and Health Policy. Med. Care, 10, 373, 1972