In the first chapter we briefly talked about diseases, their prevalence and diagnosis. This chapter covers the path from diseases to provision of care. It is often believed that care is something “physical”; that there are specific “needs” and clearly defined treatments. But this relationship is much more complex. This chapter provides an overview of the system of care provision: what a healthcare system looks like and what issues pertain to the provision and quality of care at the system level.

Need and demand for healthcare

Both need and demand for healthcare are difficult to define. First, there are medical uncertainties: the “need” for some treatment may be diffuse. Do you “need” spectacles if your visual acuity is 95 per cent? Or 70 per cent? Similarly, is there a “need” for anti-cancer treatment that prolongs life for four weeks (on average) but destroys the patient's quality of life? Would your decision change if the patient is 2, 20, 40 or 80 years old? Decisions in these examples depend on patient preferences. Some patients may prefer to live longer even at the expense of quality of life; others may prefer a shorter but better life.

Also, “need” is often not a “yes-or-no” decision; rather, a continuum of potential interventions exists: how many pairs of spectacles do you need per year? Do you need the very latest drug or is the one that was the best therapy five years ago suitable? In essence, “need” for treatment is – as often in medicine – disease-specific; that is, “need” can be defined – if at all – only at the level of a specific disease (such as myopia). In some instances, it is possible – a broken leg or a serious infection; in some instances, it is debatable – a flat foot; and in others, it is seriously contested – physical deformities or performance improvement.

Little is known about patient behaviour. For example, Germans visit a doctor 18 times a year and Scandinavians 6 times. Science can only partially explain why this is the case. We do know that economics plays a role in patient behaviour in the sense that user-fees discourage utilization (RAND experiment; see Section 8.3) or the opportunity costs of utilization, such as travel time, can deter patients from seeking medical attention.