For Review Only
P11C01 Health needs assessment
Journal: Oxford Textbook of Global Public Health
Entry ID Draft
Manuscript Type: Chapter
Date Submitted by the 
Author: n/a
Complete List of Authors: Kelly, Mike; University of Cambridge Department of Public Health and 
Primary Care, Primary Care Unit
Powell, Jane; Univerity of the West of England, Centre for Public Health 
and Wellbeing
Bartle, Natalie; Private onsultant
Keyword: healthealth needs assessment, health economics, utilitarianism, capabilities theory, health inequalities, social justice
 
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Health Needs Assessment 
Michael P. Kelly, Jane E. Powell, Natalie Bartle   
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Introduction
The idea of health needs assessment is, on the face of it, straightforward - 
estimate the health needs of a population or sub group in a population and 
organize services accordingly. The English National Institute for Health and Care 
Excellence (NICE) defines Heath Needs Assessment as “a systematic process 
used by NHS organizations and local authorities to assess the health problems 
facing a population. This includes determining whether certain groups appear 
more prone to illness than others and pinpointing any inequalities in terms of 
service provision. It results in an agreed list of priorities to improve healthcare in 
a particular area” (NICE, nd).  In the United Kingdom health needs assessment 
has been used in a wide variety of settings.  These have included Immigration 
Removal Centres (NHS England 2015), local NHS Organizations (NHS Kent and 
Medway, 2013); and by Local Authorities (Horsley and Hollingsworth, 2014; 
Derby City Public Health – Knowledge, Intelligence and Strategic Planning 
Council 2017).  In an uncomplicated world the assessment of health need and 
health-care need should be a tool for tackling inequalities, a pre-requisite for the 
allocation of resources and the first step in planning and evaluating care 
(Stevens and Raftery, 1997).  In practice however, measuring health needs is not 
straightforward.  It raises difficult questions about health-care, equity, equality, 
fairness and justice (Gillam, Yates et al 2012). 
Needs assessment embraces a variety of methods and techniques to gather 
information about populations (Health Development Agency, 2003). In the UK 
traditionally it has meant taking ‘a population-based, epidemiological and public 
health approach to the planning of health interventions’. That means using data 
about population patterns of health to do rational planning in order to meet the 
particular needs of all, or parts, of the community, taking account of equity, 
efficiency and affordability. In principle, this approach to needs assessment might 
be used as the basis for planning in any health system (Clarke. Powell et al 
2009). It aspires to ‘maximize the appropriate delivery of effective health 
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interventions or care …in an evidence based way … [to] maximize equity’  
(Powell, 2006).   
Globally however, the term health needs assessment is more widely used and 
deployed to mean a range of different things.  Sometimes the approach is highly 
specific focusing on particular risks or specific diseases (Allchorne and Green 
2016; Cicero, Rosticci et al 2014; Nacul, Stewart et al 2014; Cox, Sherrill-
Mittleman et al 2013).  Sometimes it is aimed at special sub-groups and 
populations (Vyas, Chaudhary et al 2013; Ash and Mackereth, 2013) or for 
specific services (Ingold and Hicks, 2015), and particular populations at particular 
points in the life course (Pretty, 2014).  In the United States its currency includes 
linkages to charity hospitals and the needs of disadvantaged groups who might 
be eligible to use the hospital facilities or to determine what sorts of services 
ought to be provided (Apatu, Hamadi et al, 2018; Van Gelderen, Stacey et al 
2018). The US 2010 Patient Protection and Affordable Care Act created a new 
legal requirement for non-profit hospitals to conduct Community Health Needs 
Assessments (CHNA) every three years to maintain not-for-profit status with the 
Internal Revenue Service (Fischer, Schwimmer et al 2018; Rosenbaum, 2013) 
and various techniques have been used to do this (Stone, Sierocki et al 2018; 
Franz, Skinner et al, 2017; Mathews, Coyle et al 2015; Pennel, McLeroy et al 
2015).  Practice varies widely (Becker, 2015; Alfano-Sobsey, Ledford et al 2014). 
The website of the US Centers for Disease Control and Prevention (CDC) 
defines Community Health Assessment as a systematic examination of the 
health status indicators for a given population that is used to identify key 
problems and assets in a community. The ultimate goal of this kind of community 
health assessment is to develop strategies to address the community’s health 
needs and identified issues. A variety of tools and processes may be used 
according to CDC to conduct a community health assessment; the essential 
ingredients of which are community engagement and collaborative participation. 
https://www.cdc.gov/stltpublichealth/cha/plan.html   Health needs assessment 
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has also been used in the US in Medicaid enrolment (Leininger, Friedsam et al et 
al 2014).  
In disaster zones the term denotes ways of getting emergency provision to the 
population in the most acute of circumstances (Hong, Song et al, 2017; Malilay, 
Heumann et al 2014) or assessing need after disaster has struck (Subaiya, 
Moussavi, et al 2014).  There is no single method or methodology applied, and 
the term health needs assessment or just needs assessment has come to refer 
to any way of making an assessment of need.
The UK population-based, epidemiological approach to health needs 
assessment.
We begin by focusing on the approach to needs assessment which originally 
drew heavily on epidemiology and health economics. In this view assessment of 
need must include an assessment of the effectiveness of interventions to meet 
identified health needs (Mooney, 1992). The assumption is that the relative total 
need can be measured sufficiently by just a few factors such as mortality or 
morbidity rates. It emphasises quantification and objective comparative 
measurement. This type of needs assessment is usually dependent on existing 
or available data, it seldom involves generating new information from primary 
research because this would be too expensive and take too long. Health needs 
assessment tends therefore to be based pragmatically on the routine data 
sources that are there already (Clarke, Powell et al 2009). 
There are a number of distinct steps. It begins with clear problem definition. To 
do this, two questions need to be considered. What do we want to find out about 
the population, and how can we go about finding it out? A series of further 
questions can then be asked to help clarify the process: why is this assessment 
needed now, who will be affected, what would the consequences be of doing 
nothing, how much time is available, how can the results and the 
recommendations be presented to maximal effect, are sufficient resources 
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available, and how will the needs assessment be itself assessed and evaluated? 
(Clarke, Powell et al 2009). 
A detailed project plan identifying the component parts of the exercise should be 
prepared. Central to the exercise will be an epidemiological assessment, which 
will determine how many people in the population need care and at what level 
and what services are available for them. It is important to identify the 
denominator population, that is the total population or relevant sub- population 
because otherwise it is very difficult to interpret prevalence (total number of 
cases) and incidence (new cases in a given time period) (Clarke. Powell et al 
2009).  Collecting data like this tends to be more straightforward in developed 
countries. In less developed countries data systems tend not to be so reliable, 
although where data systems are less than optimal other options may be 
available (Bonnefoy, Morgan et al 2007).
Details of the structure of the population need to be built into needs assessment; 
the age, ethnic, occupational and geographical contours of the local population 
and the patterns of health inequalities will be assessed and described (Kelly, 
2010a).  The level and severity of the diseases of interest need to be examined 
at this stage too, along with an assessment of the prevalence of relevant risks - 
for example levels of smoking, physical activity and alcohol consumption. In a 
population with a significant number of Afro Caribbean people an assessment of 
sickle cell disease might be a particular focus of interest, in a mining community 
chest disease might command attention. The absolute number of people 
suffering from the condition, and the degree of severity can then be calculated 
(Clarke, Powell et al 2009).  If assumptions have to be made in the absence of 
data and proxy variables are used, these must be made explicit.
The next stage is sometimes to develop an assessment of the clinical 
effectiveness of interventions for the condition or conditions of interest. There are 
a variety of ways of assessing effectiveness. However, if we are concerned to 
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determine the clinical effectiveness of a medicine, or some other kind of 
intervention, we will get a more accurate assessment if we use evidence in which 
a control is used and potential biases are minimized. If this is so, we can be 
reasonably sure that the observed size of the effect is a consequence of the 
intervention not some other biasing factor. Some commentators suggest that 
using only evidence drawn from the top of the evidence hierarchy to assess 
clinical effectiveness is the way to do this (Clarke, Powell et al 2009). The 
evidence hierarchy is a device which categorizes studies according to the 
methods they have used and the degree of bias which is associated with the 
methods. Randomized controlled trials (RCTs) and the meta analyses of such 
trials rest at the top of the hierarchy as these methods are deliberately designed 
to reduce bias and offer the greatest certainty that the observed relationship 
between the independent and the dependent variable is the consequence of that 
relationship, not some other factor. 
It is possible to make an assessment of the effectiveness of interventions by 
examining clinical trial data for its quality or bias. So it would be quite 
appropriate, but very time consuming, for someone conducting a needs 
assessment, who is interested in the effectiveness of particular treatments, to 
examine RCT findings directly. An easier route is to use the evidence of 
effectiveness which has already been appraised for its quality in for example 
Cochrane reviews. These are produced by Cochrane (formerly the Cochrane 
Collaboration), a world-wide network of reviewers conducting quality appraisal of 
primary intervention studies. Alternatively, data examined by the National 
Institute for Health and Care Excellence (NICE) who conduct clinical and cost 
effectiveness analyses of new technologies, treatment pathways and preventive 
interventions in England can also be consulted. The assessment of effectiveness 
is based on a set of principles which collectively are known as Health Technology 
Assessment (Kelly and Moore, 2012).  
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After the effectiveness analysis is complete a synthesis of the evidence is then 
undertaken of the epidemiology in the local population, incidence and 
prevalence, underlying risk factors, treatments and interventions ranked 
according to effectiveness, along with evidence of cost effectiveness and actual 
costs. These will, of necessity, be imprecise, but if assumptions are made explicit 
they will suffice as a starting point for needs assessment (Clarke, Powell et al 
2009).
Once data have been collected on the local population of interest, the next stage 
is to compare locally derived data with data from other places in a comparative 
needs assessment. This allows an appraisal of the degree to which local 
provision is consistent with what might be expected on the basis of the 
comparisons. This is sometimes difficult because rates of interventions vary both 
within and between countries, but the process is about putative differences 
between the observed and the expected values rather than exactness. It is 
important to consult with stakeholders at this point and genuine community 
participation is important. Rapid needs assessment may come into play where 
statistical and other data are unavailable (Clarke, Powell et al 2009). All of this is 
brought together in a “case for change “document” which will outline what is in 
place, what ought to be done, what stakeholders believe should be done and 
what the community want done. Costed options are essential to inform 
redistribution of resources. The final step is to act on the needs assessment and 
implement a plan.
Health systems are complex socio-technical arrangements consisting of people, 
cultures and practices, organizational structures, equipment and technologies. 
Health systems are constrained, because whatever the system, the resources to 
fund them are finite. Because of finite resources it is not possible to do 
everything, to fulfill every need or to adopt every new drug, procedure or device. 
At the same time demand for health services rises because expectations of what 
medicine can achieve increase. People, especially in advanced societies, 
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frequently think that they deserve or have some entitlement to – that they need - 
the best and most up to date medicines and procedures. The availability of a 
medicine therefore often creates the demand and the need for it – patients want 
it and doctors want to use it. All of this adds to the demands on the resources in 
the system. 
Health systems have to adapt to constantly evolving inputs in the form of new 
medicines, medical technologies and approaches to medical and surgical 
interventions. Decisions have to be made about the adoption and use of these 
new things. In addition, the health needs of populations are complex and change. 
For example, the age and ethnicity distributions of populations alter. Not only do 
populations change, but health systems themselves also evolve. Needs 
assessment, is one means of deciding how to allocate scarce resources to 
prioritise and tackle need in the face of these complexities. A needs assessment 
provides a basis for decision making, which will include local knowledge and 
understanding of the nature of communities, their socio-demographics and 
physical environment. Health needs assessment consists of a range of 
techniques to assess and meet need in a rational and systematic way against 
this background of complex and changing systems, population diversity, 
evolution and increasing expectations and demand. An understanding of the 
social environment and the social relationships within those environments is 
essential to successful implementation of needs assessment. 
Later in this chapter we explore some of the difficulties attached to this approach. 
However, it is very important to remember that applying rational principles in this 
way arose from an understanding that the operation of an unmanaged system in 
which historical patterns of supply, the generosity of benefactors, the preference 
of medical practitioners to live in attractive areas, and their wish to provide 
services that were consistent with their interests led to very unequal and 
inefficient distribution of resources. So whatever the imperfections of the 
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approach just described, it was born out of a desire to do things better and more 
fairly.
Other techniques for doing needs assessment.
Other techniques may be and have been used to assess need. It has been 
recommended in the US in the context of the Affordable Care Act that community 
health assessments use such principles as: multisector collaborations that 
support shared ownership of all phases of community health improvement, 
including assessment, planning, investment, implementation, and evaluation; 
proactive, broad, and diverse community engagement to improve results; a 
definition of community that encompasses both a significant enough area to allow 
for population-wide interventions and measurable results, and includes a 
targeted focus to address disparities among subpopulations; maximum 
transparency to improve community engagement and accountability; the use of 
evidence-based interventions and encouragement of innovative practices with 
thorough evaluation to inform a continuous improvement process; and, use of the 
highest quality data pooled from, and shared among, diverse public and private 
sources (Rosenbaum, 2013).  
A very wide range of methods have been pressed into service in the US. Becker 
notes that “Research designs vary across states and agencies, and little is 
known about the reliability or representativeness of results.” (Becker 2015:15). 
Telephone and door to door surveys have been used to ascertain people’s self-
reported health needs (Stone, Sierocki et al 2018).  Routine data and records 
(Franz, Skinner et al 2017; Alfano-Sobsey, Ledford et al 2014), community health 
partnerships and community surveys (Mathews, Coyle et al 2015), key informant 
interviews, focus groups, mixed methods designs (Becker, 2015:15) and opinion 
surveys (Alfano-Sobsey, Ledford et al 2014) have all been used.  
Community participation and community engagement are particularly 
emphasised “community participation and mobilization in CHA processes 
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includes the following: recognizing the community as a unit of identity; building on 
strengths and resources; facilitating collaborative partnerships; emphasizing 
locally relevant problems and an ecological perspective; promoting power 
sharing, co-learning, and capacity building; improving cultural sensitivity, 
reliability, and validity through quality community participation; increasing 
community trust and ownership; developing community systems through a 
cyclical and interactive process“ (Pennel, McLeroy et al 2015: 104).   Pennel, 
McLeroy et al (2015) note that the following should be included “gathering and 
analysing quantitative and qualitative data; using data to identify health issues; 
using broad social determinants of health to identify influences on health issues, 
including environment, behaviour, socioeconomics, and culture; identifying 
resources and resource gaps; identifying health disparities; engaging and 
mobilizing the community; organizing and sharing findings; setting health 
priorities; developing an action plan to address health priorities; implementing 
action plans; and providing opportunities for continual feedback with community 
members” (Pennel, McLeroy et al 2015: 103). But they also note that this broad 
public health approach, may be at odds with the way that hospitals apply more 
biomedical principles.
In England, Joint Strategic Needs Assessment (JSNA) develops analysis and 
strategy for current and future health and care needs of local populations to 
inform and guide the planning and commissioning of health, wellbeing and social 
care services within a local authority area. Health in All Policies (HiAP) aims to 
identify interactions between strategic targets, policies and strategies and 
population health and wellbeing (Public Health England and the Local 
Government Association, 2016) utilising “Health Lens” assessment (Kickbusch, 
Williams et al 2014). Health Lens Analysis has five essential elements that make 
the most of opportunities to implement ‘Health for All’ actions for potential 
population health impact and value. These are: -
1. To engage in order to innovate and establish and maintain strong 
collaborative relationships across sectors and disciplines. 
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2. To determine agreed policy focus among stakeholders to achieve take-up, 
reach and delivery of programmes and services. To gather evidence and 
data: to establish insight on population health need in the policy areas of 
focus. The use insights and inference drawn from big, digital routine data 
sources within JSNA., is increasingly common. 
3. To generate policy recommendations and a jointly owned final strategy 
report. 
4. To navigate to help steer recommendations through the decision making 
process. 
5. To evaluate to determine the effectiveness of the health lens
Health economics and needs assessment.
Over the last several decades, two important techniques have come into general 
use to assist the allocation of resources in the face of scarcity in health systems; 
health technology assessment which helps to assess effectiveness of 
interventions and cost utility analysis in health economics, to help assess cost 
effectiveness (Kelly, Morgan et al 2010). We have already discussed health 
technology assessment above in the context of assessments of effectiveness. 
We now turn our attention to the contribution of health economics. 
As a starting point we look to Utilitarianism – which is the ethical basis of the 
discipline of economics. Utilitarian ideas, theories and techniques are concerned 
with the common good or the greatest happiness of the greatest number 
(Bentham, 1834). Utilitarianism in allocation of resources for the common good of 
society has much to commend it. But the tools and techniques do tend to favour 
the status quo. They do not challenge or on the whole try to amend existing 
resource allocations that might be considered to be unfair or unequal. Utilitarian 
tools and techniques if applied without critical reflection implicitly approve existing 
resource allocation and aim to improve social welfare starting from that point. 
They make what might be viewed as conservative changes to re-allocate 
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resources, so that at least one person is made better off and nobody else worse 
off (Pareto,1935).   
 
Utilitarianism, or the greatest utility of the greatest number, is the ethic that 
continues to guide economic thinking, tools and techniques and is also central to 
the ethic of health needs assessment. However, at the end of the nineteenth 
century, the future direction of economics as a discipline was influenced by the 
introduction into mainstream economic theories of mathematical thinking from the 
physical sciences and engineering.  
Economics moved away from broad questions of how resources should best be 
applied for the good of society - a mix of value judgement on social welfare and 
observation of facts, to empirical testing of hypotheses using data.  For example, 
economists became very interested in the relationship between unemployment 
and inflation and used empirical testing of data to test hypotheses about these 
variables. 
A new more scientific language and a range of tools and techniques emerged 
from economic theories which tended to distance themselves from the messy 
details of complex human behaviour. The legacy of these changes still survives 
within economics. A quick perusal of the main economics journals today reveals 
numerous articles containing strings of equations to test hypotheses, as well as 
outlining the intricacies and new derivatives of different economic techniques and 
tools and how to apply them rigorously. In addition, the need within the 
economics discipline to find mathematical solutions to applied problems has 
guaranteed survival of the basic assumptions of the economic way of thinking i.e. 
people, firms and institutions are perfectly rational and behave predictably, as if, 
they have perfect information and control over environment and events. In 
economics, people are assumed to be equal and social/cultural and 
environmental/place variations between them are not acknowledged explicitly. So 
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when health needs assessment is viewed as rational, this is the underlying 
rationality. 
Health economics has developed particular techniques and tools, in particular the 
Quality Adjusted Life Year (QALY) (Cohen and Henderson, 1988). This 
technique is steeped in utilitarianism - allocating resources efficiently for the 
common good - in this instance fair allocation of health technologies and other 
interventions in the face of finite resources. Economic thinking is predicated on 
the notion that most resources are scarce and have limits, but demand on those 
resources is potentially infinite. This creates choice and opportunity cost meaning 
that once resources have been allocated and used, they cannot be reallocated 
and used again in another way (Powell, 2007). Health has been characterised as 
a multidimensional, dynamic concept subject to changing human expectations 
and revision over time (McGuire, Henderson et al 1988). The economics of 
health has therefore also developed over time to reflect these changes. Since the 
Second World War, successive generations of theorists have sought to embrace 
new ideas about health. For example, economic, social and psychological 
aspects of health have been included to reflect changing expectations, the nature 
of health systems, stage of economic development and passing time (World 
Health Organisation, 1947 1948; 1958). From the late 1980s in developed 
countries, definitions of health broadened considerably to reflect the notion that 
wellbeing is inseparable from and crucial to health, and in turn, both are 
influenced by society as a whole (Bowling, 2001).   
Cost utility analysis and the QALY have been widely used around the world in the 
assessment of the cost effectiveness of new drugs and of other types of clinical 
interventions. But it has proved less well suited to assessing preventive public 
health type interventions. The literature identifies a number of conceptual, 
methodological and practical difficulties in evaluating the effectiveness and cost-
effectiveness of primary prevention interventions (Lorgelly, Lawson et al, 2010).  
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There are difficulties of producing evidence of cost-effectiveness for public health 
guidance and methodological difficulties associated with applying health 
economic techniques to public health interventions (Kelly, McDaid et al, 2005). 
These difficulties and issues spring from the focus on efficiency within economic 
evaluation techniques to the exclusion of the determinants of health and 
inequalities in health, which are central preoccupations in public health 
(Barendregt, 2006).  This is important because as we will show, health needs 
assessment is itself premised on principles of economic efficiency as well as the 
principle of equity. And so the same problem that applies to the application of 
simple cost utility analyses to preventive interventions also applies more broadly 
to health needs assessment. 
Equity, efficiency and health economics
Health systems may be characterised by the way they organise, finance and 
deliver resources to attempt to balance competing health and wellbeing 
objectives. Equity in the distribution of resources is the main objective of a health 
system where citizens have entitlement and equal access to the means of 
achieving good health and wellbeing according to health need. Efficiency in the 
allocation of resources- where the cost of good health and wellbeing is minimised 
and the benefits maximised- is often prioritised by governments over equity in 
order that the overall cost of a health system as a proportion of GDP, is 
controlled. Efficiency and equity are generally viewed as competing objectives 
that most health systems fail to reconcile because both objectives cannot be 
optimised at the same time – creating an equity-efficiency trade-off. This in turn 
raises concerns about social justice and generates philosophical arguments 
about where the balance between efficient resource allocation and equitable 
distribution of health resources to meet health need, should lie. Early forms of 
health needs assessment and similar approaches - social audit and rapid 
appraisal - attempted to establish the size of different health needs and to 
prioritise and allocate resources pro rata on that basis. 
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Health economic techniques and tools were directed at inefficiencies in the 
allocation of healthcare resources and ‘the need for healthcare’ defined as 
‘capacity to benefit’ from healthcare became recognised as a key aspect of 
health status. As a consequence, the health intervention needed in any given 
circumstance is a function of factors such as the level of prevailing resources, the 
availability and effectiveness of health interventions, and the perspective and 
values of those making the assessment. Over time notions of health need have 
come to be defined as a result of momentum in economic discourse and debates 
and the development and proliferation of common currency quality of life 
measures that reflect the outcome and efficiency of interventions to improve 
health and wellbeing. 
Health systems and the equity-efficiency trade-off
We next examine how economic conditions influence the inter-relationship 
between equity, efficiency and cost describing debates about resource allocation 
in Beveridge and Bismarckian health systems. These systems take their names 
respectively from William Beveridge whose report was used as the basis for the 
policies which helped establish the Welfare State in Britain in the 1940s (Ross, 
1952) and Prince Otto Von Bismarck who set up the first schemes of national 
insurance in Germany in the 1880s (Taylor, 1955; Thomson, 1957). We outline 
the ways theories of justice underpin equity-efficiency trade-offs, explaining the 
background to the emergence of new policy concepts and techniques of 
assessing, measuring, evaluating and prioritising efficient and equitable 
allocation of resources. The nature of the determinants of health and the role of 
physical and social environment in the improvement of community health 
outcomes are considered with respect to equity, need and efficiency. 
Healthcare is financed and provided free at the point of use by government 
through taxation in Beveridge-type health systems. Beveridge health systems 
differ from Bismarck-type systems in which healthcare is financed by multiple 
employer-based insurance schemes and taxation in which providers are privately 
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rather than publicly owned. Both types of system however face the same 
problem of increasing demand in the face of finite resources to fund the systems. 
In recent decades, some reformers of health systems and health policies have 
attempted to create market incentives within the system to control overall 
healthcare expenditure, increase quality, bring down prices and increase choice 
(Bevan, Helderman et al 2010) - for example, providing a choice of provider for 
healthcare treatments and services as a way of taking some people off waiting 
lists. However, the economic and social trade-off is that this comes at a price - 
leaving those who cannot afford to move to languish on the longer waiting list. 
Alternatively, other systems that prioritise access and give universal coverage to 
meet health need provide a narrower range of healthcare services because price 
signals to reallocate resources within the system are absent. An equity-efficiency 
trade-off occurs and this can create a dash from central decision making to 
localism where the allocation of resources is determined by local decision 
makers. Much of the tension in the balance between efficiency and equity 
however, can be traced to expectations and changes over time in the common 
understanding of what constitutes good health and wellbeing in communities and 
countries. Inevitably, these understandings are related to stage of economic 
development, economic performance and historical Gross National Product 
(GNP).
Some political and philosophical considerations. 
At the heart of the approaches to needs assessment outlined so far is a relatively 
one dimensional idea of need. There is an altogether different approach in the 
philosophical literature which defines need as a dynamic, politically and 
ideologically value-laden idea. In the political and philosophical view, one focus is 
unmet health needs in the form of morbidity in individuals and populations. It is 
argued that unmet need creates unfair deficits in the distribution of health and 
wellbeing among communities and populations - deficits that society should take 
steps to address. In this view, need is described as something that is likely to be 
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dynamic over time as technologies, expectations and availability of services 
change. Measurement of need will therefore vary in different contexts, such as, in 
the clinical setting and at the population level. Needs assessment planning would 
therefore involve considerations of allocative efficiency along with social values 
(McIntyre, Mooney et al 2009). 
Unfortunately, morbidity turns out not to be a good guide to unmet need!  We 
may posit that one person’s need is greater than another’s because there is a 
greater degree of morbidity – they are sicker. This in turn implies that one health 
state is more deserving than another because of the extent of the disease. It also 
assumes we can accurately measure the differences in disease states. This 
however may be a false premise because degrees of illness in a strictly biological 
or pathological sense, even if they can be measured accurately and meaningfully 
compared, tell us nothing about an individual’s quality of life with different 
degrees of morbidity and therefore their needs in a social or psychological sense. 
Some people cope extremely well with illness and have a relatively good quality 
of life while others seem to be rendered incapable of normal social functioning 
with relatively minor ailments. The subjective experience of illness and an 
individual’s response to it significantly affects their expression of need. It is 
difficult to measure need solely by assessing biological morbidity in any absolute 
sense (Anderson and Bury 1988).  
There is a still more difficult issue relating to health differences in populations. All 
health systems, and by definition all health needs assessment, have to confront 
the systematic differences in the pattern of heath in populations. The health of 
individuals varies, and the health of groups of individuals also varies; so men and 
women, age groups and ethnic groups show average differences in life 
expectancy and patterns of disease. The health of one country varies compared 
to other countries; within countries there are differences between individuals and 
groups. These variations occur because of biological inheritance, because of 
differential exposure to factors which cause disease and because health services 
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are not uniformly or equally spread between individuals and populations. In any 
case, individuals make widely different use of available services especially 
preventive ones. Some people die relatively young, while others live to a ripe old 
age. Some people live life with multiple health problems and disabilities, others 
lead lives of a good quality and die peacefully in their beds in their nineties. So as 
a starting point the demands placed on health systems of these different 
individuals and groups vary. If we are trying in some way to meet the health 
needs or demands of various individuals and populations on what basis should 
we do it? 
The straightforward answer at the heart of most approaches to health needs 
assessment is that we should seek to measure the needs of individuals or 
populations and we should allocate provision to meet the need accordingly, as 
that would be the fairest way to do it. But that in turn raises several questions – 
how exactly would we measure need? Could we do so in a way that was 
accurate and precise and more importantly could we do it in a way that was fair? 
And fair exactly to whom? To the people in need or to the people who are not in 
need and whom we might call upon to fund the needs of others in greater need 
than them. But why should those not in need, subsidize those who are in need? 
Is that fair? The answer as to whether one thinks it is fair will be dictated by a 
political preference as well as general ideas about fairness which would in turn 
be influenced by other ideas about ethics, morality, duty, responsibility and liberty 
for example. Is it fair to have one’s income taken away to fund the needs of 
others? Not forgetting that some people’s health needs are in part generated by 
the choices that they themselves have made in how they have lived their lives, 
whether they have chosen to smoke, to excessively consume alcohol and food 
and to take drugs or engage in sexual practices which might expose them to risk 
of infection. These people have health needs, but whose responsibility is it to 
meet those needs? Again the answer will be influenced by other value positions. 
It must also be acknowledged that in response to the international financial crisis 
of 2008 austerity policies have been pursued in many countries. Consequently, 
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the recent economic environmental context is less likely to trigger positive 
change in population health impact and value through strategic needs 
assessment. In response to austerity in England, Local Authorities have 
developed Sustainability and Transformation Plans (STPs) alongside Joint 
Strategic Needs Assessment. These aim to move resources from acute care to 
prevention by targeting those most in need.    
Patterning of health differences 
There is another very important dimension at play here which, we have not so far 
explored in detail; this is the patterning of health differences.  This removes the 
discussion from the level of the individual to the level of the social or population. 
The differences in health experience and health outcomes, the differences in 
access to services, the differences in exposures to risk and the differences in 
activities which are health damaging are not distributed randomly or evenly in the 
population.  Health experience and health outcomes are strongly patterned by 
social position.  On whatever measure used to assess health be it mortality, 
morbidity or self-defined health, the measures follow a social gradient.  Those 
who are better off on average enjoy better health, live longer and make more use 
of available services.  This applies under whatever arrangements for the funding 
of services operate.  
It holds true in market systems like the United States, it holds true in social 
insurance systems as found in much of Western Europe and it holds true in 
societies where care is free at the point of use like the United Kingdom. This is 
called the health gradient - and is one of the most enduring and vexatious 
characteristics of contemporary health systems (Graham and Kelly, 2004).  
Comparative data for the UK and the USA illustrate the gradient. They show 
similar patterns of graded health differences measured by income for, among 
other things, self-assessed health, diabetes, heart disease, and lung disease 
(Banks, Marmot et al 2006).  The gradient is described in many texts, reports and 
papers (Bleich, Jarlenski et al 2012).  The shape of the gradient varies; it tends to 
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be steeper in societies with very heterogeneous populations and rather gentler in 
societies which are more socially homogeneous; but only by degree. Health 
differences linked to social position remain an enduring and structural feature of 
contemporary developed societies. In both developing and low income countries 
the same features of health inequities apply though the shape of the gradient 
tends to be more curvilinear. In some developing and low income countries a 
small affluent elite enjoy good health outcomes and the majority of the population 
are in a less desirable situation (Bonnefoy, Morgan et al 2007).
In broad terms the state of the contemporary world is one where health 
differences, however measured, prevail across all societies and also between 
societies. There are absolute health differences between rich and poor societies 
and between rich and poor people and those not so poor, in all societies (Kelly 
and Doohan, 2012).  So here we encounter a major problem with the apparently 
rational calculus of health needs assessment. Whether health need is expressed 
in terms of health status or outcome, n ed (including subjective expression of 
need) varies systematically across the population and there are considerable 
health inequalities. It can be, and often is argued that the needs of the most or 
the relatively disadvantaged are paramount and therefore resources should be 
deployed in such a way that they meet those needs first. All that would remain to 
be done would be to find a technical solution to the measurement of need. 
In addition to the health gradient there are two other ways of looking at health 
differences called health disadvantage and health gaps (Graham and Kelly 
2004).  Health disadvantage simply focuses on differences, acknowledging that 
there are differences between individuals, distinct segments of the population, or 
between societies. It is a descriptive and non-judgmental approach. The health 
gaps approach, in contrast, focuses on the differences between the worst off and 
everybody else, often inviting the conclusion that those who are not the worst off 
enjoy uniformly good health. The gap approach also invites the conclusion that 
this state of affairs is wrong or unfair. 
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A gap approach and a gradient approach lead to rather different solutions. 
Conceptually, narrowing health gaps look to actions which will improve the health 
of the poorest regardless of the rest of society. Such an approach would be one 
which achieved both an absolute and a relative improvement in the health of the 
poorest groups. The health gradient approach takes, as its starting point in 
contrast, the acknowledgement that the penalties of inequities in health affect the 
whole social hierarchy even though they increase from the top to the bottom. 
Gaps and gradient approaches lead to quite different assessment of need and 
how to meet those needs. It may seem counter intuitive, but if policies or actions 
only attempt to target the needs of people at the bottom of the social hierarchy, 
there will be little or no impact on health inequalities across the rest of society 
(Rose, 1984; 1992). This is because inequities in health will still exist, the social 
determinants continue to exert their malign influence and the health needs of the 
majority of the population remain unatt nded to. The alternative approach 
advocated by the Marmot reviews for example and WHO (Bonnefoy, Morgan et 
al 2007) involves a consideration of the whole gradient in health inequities rather 
than only focusing on the health of the most disadvantaged. An effective policy in 
this regard is one that meets two criteria. It is associated with (a) improvements 
in health (or a positive change in its underlying determinants) for all 
socioeconomic groups up to the highest, and (b) a rate of improvement which 
increases at each step down the socioeconomic ladder. In other words, a 
differential rate of improvement is required: greatest for the poorest groups, with 
the rate of gain progressively decreasing for higher socioeconomic groups. It 
locates the causes of health inequity, not in the disadvantaged circumstances 
and health-damaging behaviours of the poorest groups, but in the systematic 
differences in life chances, living standards and lifestyles associated with 
people’s unequal positions in the socioeconomic hierarchy (Graham, 
2004a,2004b; 2006).  The significant caveat is that where the health gap is both 
large and the population numbers in the extreme circumstances are high, a 
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process of prioritizing action by beginning with the most disadvantaged would be 
the immediate concern.
    
From health inequality to health equity 
The gradient leads to some other questions. Does it matter that there are 
patterns of inequalities in health? Why should we seek to remedy this state of 
affairs? Why use the instruments of health service provision to deal with this 
problem? Why conduct needs assessment to try to change the gradient? After 
all, all societies demonstrate a gradient to some extent. Even though health 
differences are clear, a case may be made that over the last century and a half, 
things have improved for nearly everyone - at least in the developed West. Rates 
of infant mortality are at an historic low and life expectancy has never been 
greater. Furthermore, while average patterns of morbidity and mortality in 
different social groups and populations may be clear, there are wide variations 
between individuals. In short, not all well to do people live to a healthy ripe old 
age, and not everyone who is disadvantaged dies young. To be human is to 
know that we will eventually die and that the manner and timing of our death is in 
almost all circumstances beyond our control whether we are rich or poor. So is it 
the case that patterned average differences in early and largely preventable 
death and suffering are unfair and unjust just because they are theoretically 
preventable – particularly when there is no necessary inevitability that relatively 
disadvantaged people should die earlier than anyone else? There is no 
straightforward answer. 
A number of writers have explored the theme of injustice in this context. The 
World Health Organisation (WHO) has had a long-standing interest in the matter. 
The World Health Organisation’s Commission on the Social Determinants of 
Health used a series of definitions to clarify things which were based on the work 
of Whitehead (Whitehead, 1992; Whitehead and Dahlgren 2006) and Solar and 
Irwin (Solar and 2010).  A distinction is made between health inequality and 
health inequity. Health inequality is defined as health differences which are not 
avoidable or preventable, are not the consequence of human actions and 
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activities, but are based on genetic or constitutional individual differences, age or 
biological sex. These are sometimes also referred to as variations (Kelly, Morgan 
et al 2007).  Health inequity, in contrast, is defined as unfair and avoidable or 
remediable differences. Health equity in turn is defined as the absence of unfair 
and avoidable or remediable differences in health among social groups (Solar 
and Irwin, 2010).  The italics highlight the difference in definitions. It is particularly 
important to note that the difference in definition between inequity and inequality 
is not used universally and many writers and commentators employ the two 
terms as synonyms. Also the distinctions between individual differences which 
are based on human biology and differences arising from interaction between an 
organism and an external man-made hazard are in reality difficult to draw in 
anything other than an analytic sense. Empirically the divides are much fuzzier 
than these definitions suggest. However, as a way of beginning to find some 
clarity the distinction is helpful. Equity and inequity are not products of nature 
they are the products of human actions and, as they are socially, economically 
and/or politically produced they are, th oretically at least, modifiable. The 
defining characteristics of equity are fairness and justice; the defining 
characteristics of inequity are unfairness and injustice (Whitehead and Dahlgren, 
2006)
Fairness and unfairness can be conceptualised as absolutes; something or some 
state of affairs is either fair or unfair – it cannot be both at the same time. But 
thinking like this in absolute terms misses the point that fairness and unfairness 
are not properties, things or states of affairs, but are about relationships between 
people. Fairness and unfairness arise as a consequence of the nature of the 
relationships between people and the ebb and flow of human affairs. So too 
justice is not a simple measure of equitable distribution of resources according to 
need, but is about the nature of relationships in society. 
Justice may be understood in terms of the properties of people, their conduct, the 
rules that govern their affairs and the characteristics of institutions - an absolute 
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definition The alternative is a relational concept of justice which concerns itself 
with the ‘justness’ of relations between people - X is unjust to Y (Pogge. 2010). 
Such relations involve human agency, purpose and motive. From a relational 
point of view justice should not be about fair distribution; it should be about 
seeking to identify the agents responsible for the social arrangements that 
determine the shape of human relationships (Pogge, 2010).  
Health equity may be conceptualised in distributional or relational terms in the 
same way that justice can be. The distributional approach is focussed on the goal 
of equalising good health across society – which is really the underlying value 
position of most health needs assessment and much of the discourse about 
health inequity. The relational view is about the balance between the harms 
inflicted and harms mitigated or prevented. In the relational view social 
institutions and those responsible for them should have more concern to prevent 
and mitigate those things they cause themselves and for which they are 
responsible, rather than those things which are outside of their control (Pogge. 
2010). So the real issue in relational terms, with which equity should be 
concerned, is not the fact that health is differentially distributed, but that social 
systems contribute to the differential distribution of health and disease. Poverty is 
the greatest contributor of all to ill health. Organisi g economic arrangements so 
that they do not generate the conditions of poverty which generate ill health is 
thus, it may be argued, a moral duty. Therefore, focussing on assessing need 
without looking at the wider determinants of the causes of inequity in the first 
place, is misguided. The global economic order is responsible for the generation 
of ill health and health inequities (Pogge, 2010), and the social arrangements that 
have negative effects on health are unjust (Venkatapuram, 2011). 
In a celebrated paper called ‘What is the point of equality?’ Anderson outlined a 
number of the problems associated with the distributional concept of equality. 
She warns against the notion that we can construct institutions to make them 
more equal and fair, not least because this tends towards greater and greater 
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state interference in the lives of the citizenry. She notes that one of the dangers 
associated with egalitarianism and the distributional approach is that it pushes 
the limits of the state further into the lives of ordinary people. This is a particular 
danger if states become concerned with equities of health rather than 
oppressions of the powerful against the powerless. In other words, focusing on 
rearranging health care resources to make the patterning of health more 
equitable is rather like moving deck chairs around on the deck of the Titanic after 
she hit the iceberg - largely irrelevant and pointless when the ship is sinking. 
“Recent egalitarian writing has become dominated by the view that the 
fundamental aim of equality is to compensate people for undeserved bad luck – 
being born with poor native endowments, bad parents and disagreeable 
personalities, [and] suffering from accidents and illnesses” (Anderson, 1999). 
This she says is not really the issue. We should instead be preoccupied with 
ending oppressive social relations rather than trying to ensure that everyone gets 
what they morally deserve. It is about creating a community in which people have 
equality in relationships with one another (Anderson, 1999) – a community built 
on cooperation between members who see themselves as equals. She argues 
for democratic equality which means that all law abiding citizens are allowed 
effective access to the social conditions of their freedom. Anderson criticizes the 
view that the purpose of distributive justice is to compensate people for their 
misfortune. Her argument strikes at the heart of the idea that health inequities are 
simply unfair; her position is that while life may be unfair, bad luck is not at the 
heart of it – it is the relations between people and the way that they treat each 
other that is much more fundamental. 
Anderson draws our attention to the fact that concept of equality can mean a 
number of different things depending on the underlying political value position 
and the epistemological assumptions of the theory. So a utilitarian seeking to 
maximise the greatest happiness of the greatest number would see things 
differently to a Marxist seeking absolute parity in access to wealth for example. 
She demonstrates that equality is a rationalist rather than an empiricist concept, 
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meaning that the discourse about distributional equality and heath equity is 
premised on the manipulation of ideas and the contest between different ideas 
and political philosophies, rather than being something that can be demonstrated 
by empirical methods (Millican, 2007). True, protagonists will appeal to empirical 
evidence about poverty and about wealth to justify their arguments, but in the 
end, much of the discussion about equality is grounded in ideal discussions of 
future desired states and institutions and the manipulation of ideas to justify that 
view, rather than the case being made that empirically things could be changed 
by doing x, y or z. Where x, y or z are suggested, they are selected on the basis 
of ideological preference, not empirical science. 
Bernard Williams argued that the proper grounds for the distribution of health 
care are health need (Williams, 1962). This he saw as a fundamental truth (Wolff, 
2007).  Others have argued that this is not a fundamental truth at all. Nozick has 
suggested that the focus on need, common among egalitarian thinkers, is to 
define people quintessentially as consumers. The task then becomes one of 
finding the best way to ensure the fair distribution of available goods to 
consumers (Nozick, 1974). The problem of course with this approach, is that this 
casts humanity into a fundamentally passive role and it doesn’t consider 
individuals as active producers (Wolff, 2007). Williams also argued that there is 
nothing about need itself intrinsically that should motivate action on equity 
(Williams, 1962). What society decides to do for people, particularly in health 
need, depends upon a moral and ethical stance. 
Another argument is that the goal of fair distribution should be treating the worst 
off as well as possible rather than flat equity (Wolff, 2007).  John Rawls argued 
that difference in the distribution of primary goods such as health is tolerable, so 
long as the welfare of the most disadvantaged is looked after (Rawls, 1971) . 
Dworkin takes this argument a stage further. He suggests that we need to 
determine why the worst off are in that position. Dworkin asserts that some may 
not be able to work because they are unable to find work; but others may decide 
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they do not want to work. Dworkin also notes that some people’s needs are 
greater than others (someone who is severely disabled has greater need than 
someone who is able bodied for example – although as we noted above this is a 
highly questionable first premise). But needs, Dworkin notes, are compounded by 
taste. Some people’s needs are determined by expensive tastes say for drugs or 
wine or jewellery. Dworkin therefore distinguishes between brute bad luck and 
circumstance from optional bad luck involving some degree of culpability for 
being in need. For Dworkin, this distinction is all important, as it is his view that 
the state has a duty to deal with the former, but not the latter (Dworkin, 2000).
Some further philosophical reflections
Health needs assessment is not value neutral it is premised on a number of 
philosophical and political concepts. It is helpful to explore the arguments relating 
to these ideas not least because although they are fundamental to health needs 
assessment the conventional literature about health needs assessment seldom 
considers the underlying assumptions and issues in detail. This is particularly so 
with respect to the central importance of utilitarianism and its contested place in 
the philosophical canon. The discussion is made all the more confusing because 
many of the relevant ideas like justice, equality, fairness and so on are in 
common as well as technical philosophical usage and the meanings attached to 
common sense understanding of the words and the technical vocabulary usage 
are seldom commensurate. 
Another very intriguing characteristic of the literature – a literature after all which 
readily uses terms like justice, fairness, equality, is that with the exception of Sen 
(2009), (more of whom below) the origins of the arguments about justice and 
need are conducted almost entirely without reference to their antecedents in 
Christian or the teachings of the other major world religions. The secular 
attempts to define the equal society, justice and fairness struggle in this regard, 
to find a moral or ethical point of reference. The other very odd thing is that 
conventional political philosophy has, down the years, actually paid scant 
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attention to health and health inequalities and issues of distribution of health care 
resources (Venkatapuram, 2011).  
At the heart of the debates about equity and health inequity in contemporary 
society is, as we saw above, social justice. Health inequities are considered by 
many commentators to be unjust and unfair and this is advanced as a reason for 
allocating resources following needs assessment, more fairly. Just as 
utilitarianism is central to health needs assessment, it has also been central to 
theories of justice too viz. what produced the greatest happiness in the greatest 
number was considered to be socially just (Venkatapuram and Marmot, 2009).  
This absolute or distributional approach to justice was based on a highly 
individualistic model and was premised in turn on the individual as the unit of 
analysis and not the alternative which is the relational conception of social life. 
The solution in the utilitarian view of the world is fair distribution and systems 
which can efficiently distribute resources, a principle at the very heart of health 
needs assessment. The utilitarian argument overlooks, by virtue of its basis in 
the maximisation of utility, not only the fact that humans are motivated by a 
variety of things, not just maximising utility, like love, social conflict, human 
venality, and sheer and utter evil, but also it doesn’t seem have a concept of the 
social (Etzioni, 1988).  In other words, individual utility maximising motivated 
agents are the focus of the argument, not social relations between people. This 
individualistic approach chimes with medicine. 
Medicine has as its principal focus, pathology in the individual human body. This 
means that, with only a few historical exceptions, the intellectual interests have 
been oriented to phenomena located in individual human bodies or minds with 
pathology measurable in ways that reflect the individual and individual variation 
from some notion of what is normal or healthy (Antonovsky, 1985;1987; Carter, 
2003).  This approach received an enormous boost with the rise of germ theory 
and with the fantastic successes of the isolation of pathogenic microbes and then 
antibiotics to combat them (Kelly & Russo, 2018). Of course medicine has other 
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foci too; especially body systems, but the variables and phenomena of particular 
interests are individual. The pathogenic paradigm, in which the fundamental 
rationale is isolating the specific cause (pathogens) of specific outcomes 
(pathologies), reinforces the individualistic approach (Antonovsky, 1987). 
Psychology has likewise made its main focus the individual so measures of 
intelligence, personality, quality of life, all reside in the individual or are 
characteristics or properties of individuals. The approach is about the degree to 
which things go wrong in individual bodies and minds and the preceding causes 
of the pathology. Need as an individual property is an obvious next step in this 
way of thinking. 
Economics and especially health economics has bought into this individualistic 
paradigm in a big way. The QALY and the application of cost utility analysis and 
health technology assessment are deeply infused with an individualistic 
orientation. The greatest happiness of the greatest number is the utilitarian 
philosophical view which sits very comfortably with the individualistic paradigm 
because it conceptualises the notion of the good as the aggregate of lots of 
different individual utilities. The ontological consequence of this – i.e. the 
assumptions made about what constitutes human life and how and why it is the 
way that it is – is the idea that the essence and meaning of human existence can 
be captured by isolating these individual characteristics and seeing how they 
connect to each other. So individual characteristics as different as height, weight, 
blood pressure, bone density, hair colour, IQ, biological sex and size of tumour 
for example can each in turn be linked to the presence of other characteristics in 
the individual like health of mother, poor nutritional status in childhood, genetic 
coding, parental heredity, age, chromosome structure and exposure to tobacco 
smoke. The causal link is from one individual characteristic to another. 
Now all of this is intuitively meaningful – in the modern Western world the 
individual and the individuated self are touchstones of the way we live our lives 
and the way the state regulates our lives - we have for example individual 
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national insurance numbers, passport numbers, birth certificates, tax codes and 
genomic structures. Individual variables seem natural. Further in medical terms 
there have been some remarkable successes in isolating disease mechanisms 
and offering curative technologies using the individual approach– although far 
less than the popular imagination often supposes - using these principles. 
However, there are two fundamental objections which suggest that an additional 
way of viewing things might be helpful. First the individualist approaches 
dehumanise people – people are reduced to some sub-human characteristic – a 
number, a genetic code, a pathological organism, a utility. But second, and more 
importantly, and notwithstanding the advances that have followed in the wake of 
some of the individualistic connections which have been made, above all it 
ignores or relegates the fact that humans live in groups and that those groups 
are in relations with each other and that membership of those groups is a 
defining characteristic of identity and of profound importance to most people – 
one’s family, class, tribe, caste, gender, ethnicity, nationality are all paramount 
social markers in life. Moreover, the relationships within which we live our lives, 
the relations with other people, the relationships within and between different 
groups, shapes the nature of our human selves, our experiences and our 
behaviour (Kriznik et al 2018). The defining characteristic of human life is 
belonging - to be a member of multiple groups and communities. We live our 
lives in a network of interlinked and overlapping relations with others. Knowingly 
or not, the desire to belong has far reaching consequences on the types of 
behaviours that we adopt and the choices that we make. Not surprisingly 
therefore, the effects of social exclusion or isolation from social groups are of 
paramount importance when trying to explain the health of an individual. 
What this makes us pause and reflect on is not that the individual understanding 
of human affairs is unimportant – that would clearly be an absurd position to 
adopt. Rather it is that a full understanding of the human condition requires 
additionally another set of concepts – which capture human relationships – 
relational concepts – in order to develop a rounded account of human life (Kriznik 
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et al 2018). And moreover inequity and injustice are best understood in relational 
not individualistic terms.
Social theorists have grasped the idea of a well-rounded approach very neatly in 
the conception of the dynamic interaction between agency and structure. The 
idea of agency is that we are all unique biological, psychological and physical 
individuals. We all engage in individually motivated actions and behaviours which 
are in part the results of our unique individuality. But the sum of all human 
behaviours is the social structure which is the product of the millions and billions 
of human relationships that are the medium for individual actions. Those 
structures or webs of human relationships are relational and in turn they 
constrain, drive, and facilitate individual human behaviour. So we have individual 
behaviour, the medium for its expression which are human relationships, and 
social structures which are the sum of all those relationships which in turn 
impinge on and delimit the possibilities of individual behaviour (Giddens, 
1979;1984; Elder Vass, 2010)
This rather abstract approach allows us in turn to consider some of the thorny 
problems at the heart of health needs assessment. Thinking of the dynamic 
interaction between agency and structure moves us beyond the methodological 
individualism of traditional epidemiology and therefore of health needs 
assessment and provides an escape from the individual level of explanation 
(Frohlich, Corin et al 2001).  This in turn allows for a fuller understanding of the 
dynamics of the development of health inequalities. (Abel and Frohlich, 2012),
This way of thinking has been linked to what is called capability theory (Sen, 
2009).  Under austerity policies the notion of capabilities has started to enter into 
Joint Strategic Needs Assessment, Health in All Policies (see section above on 
some political and philosophical reflections above). The core characteristic of 
capability theory is its focus on what people are effectively able to do within 
relationships with each other (Abel and Frohlich, 2012). Individuals being able to 
engage effectively in what they really want to do, is the core idea.  These 
engagements include being active, healthy, and being able to work but the list is 
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not limited to these activities. In the capability approach, resources and their fair 
distribution to individuals (the focus of the traditional utilitarian approach) are not 
the central interest. Resources are not ends in themselves they are means to 
ends. And neither are resources reducible to monetary utilities. People’s abilities 
to realize their life goals and plans are the focal point. In the capability approach, 
the issue of justice, fairness and need does not apply to resources per se but to 
the range of options for agency – the capabilities (Abel and Frohlich, 2012).
Sen is a key thinker in relation to these arguments. He makes the case for a 
dynamic approach to social justice. He has argued that to think about justice like 
this is a major shift away from the traditional ways that philosophers have thought 
about justice. This is because they were locked into the utilitarian/ distributional 
tradition (Sen, 2009). This is important in the context of needs assessment which 
is fundamentally utilitarian and implies that through its rationality and market 
allocative efficiency it will be possible to deliver fairness by market redistribution. 
This follows a tradition which goes back, according to Sen, to the Enlightenment. 
The utilitarian position is a rationalist position writ large, i.e. a position which is 
about the manipulation of ideas, rather than the observation of empirical facts 
(Millican, 2007).  The ideas about social justice which are being manipulated are 
that it is possible to design institutional arrangements that will deliver justice and 
this will be the basis of a perfect society. For Sen, justice is a relative concept 
and is about relations between people. Justice is a process, an aspiration; it is 
about advancing justice or reducing injustice. It is not about finding or describing 
the perfectly just society. Because social structures and their properties emerge 
out of human relationships, it means that to try to legislate to change social 
systems to make them more just or fair can only ever be partially effective. In a 
sociological sense justice and injustice are properties of social systems not 
abstract transcendental things that can be made by social actors. Sen’s 
approach is comparative, plural, iterative, dynamic, and acknowledging of 
alternatives. 
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Justice in this view is not a given – a rationally derived static universal principle. It 
is about relations between people and arises as a consequence of social action 
and social structure. Therefore, injustice will also arise socially in social 
interaction and is decided upon morally or metaphysically. The judgement about 
whether the relations between people, such as differences in health, are just or 
unjust is a value judgement. In short, seeking to bring about equality in relation to 
health by the utilitarian redistribution of resources is never likely to work, or to 
produce fairness and justice because justice is not a quality of individuals or 
institutions. Equality is about human relationships and the utilitarian approach at 
the heart of health needs assessment is based on an alternative individualistic 
ontology.
Sen’s argument is that theories of justice major on something; it could be 
happiness as in the case of classical utilitarianism, and it could be resources or 
income. Sen argues that in contrast to these utility-based or resource-based lines 
of thinking, individual advantage is judged in the capability approach by a 
person’s capability to do things they have a reason to value. A person’s 
advantage in terms of opportunities is judged to be lower than that of another if 
they have less capability – less real opportunity – to achieve those things that 
they have reason to value. The focus is on the freedom that a person actually 
has to do this or be that – things that they value doing or being (Sen, 2009).  
Sen’s approach is about human life and the opportunities for living - living as 
against just existing. Justice for Sen cannot be created by social institutions. 
Justice should aim to reduce injustice, i.e. change the nature of the relationships 
between people, rather than aiming to produce a perfectly just society.
Conclusion.
Health needs assessment can be seen as a highly rational and straightforward 
means of identifying health needs, of linking needs to patterns of health 
inequities, of marshalling appropriate resources to match those needs and then 
deploying resources accordingly. And of course that is what it aspires to do. But 
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that aspiration is based on the traditional rationalist approach of utilitarianism and 
in turn on an individualist ontology. Need, as we have shown, is not a static, 
objective thing. It is therefore intrinsically difficult to measure and as soon as one 
starts to try to capture the idea fundamental questions about fairness and justice 
are raised. 
The objective and measurable concept of need is located in an individualist 
ontology. When we think instead in relational terms about equity, justice and 
human capabilities a different perspective is possible. Capabilities theory 
captures the idea of equity in a far more nuanced way than individualistic 
utilitarian accounts. It also offers a more complete way of understanding how we 
might rethink health needs assessment. 
So rather than seeking to measure individualistic objective variables and then 
seeking to apply resources accordingly, the relational capabilities approach bids 
us to think about the relations between service providers and users in a novel 
way. It requires us to not to try to match resources to a completely slippery and 
spuriously objective concept of need, but instead makes us consider the nature 
of the relationships between people and services. 
Maximising health outcomes, a utilitarian fundamental principle, may not be what 
social justice requires and alleviating injustice may require more than maximising 
efficiency (Venkatapuram, 2011).  The argument then hinges on several 
fundamental things: the degree to which the structure and organisation of 
services permits people to meet their own capabilities, the degree to which it 
allows human potentials to be realised, the degree to which the relationships with 
services do not distort or alienate people from themselves or from others. The 
capability approach privileges human functioning, not maximising utility or 
achieving an idealised and biologically improbable disease free state 
(Venkatapuram, 2011).
This means that service design should reflect and respect human dignity; this 
means respect for an individual person, but at the same time acknowledging the 
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limitations which disease and disability genuinely impose on people while 
recognising that there is not a direct cause and effect linear relationship between 
disease state and social functioning. It should acknowledge the fact that illness 
and disease by their very nature tend to exacerbate disconnectedness between 
the person and their normal role responsibilities, their primary social attachments 
and their desired capabilities. The experience of disease and disability can also 
produce a profound separation of the individual from their sense of self or their 
sense of who and what they want to be. The capability approach therefore 
requires us to respect the lifeworlds of ordinary people and work with them to 
build their skills, assets and capabilities (rather than focussing on their deficits 
and trying to correct them via resource redistribution). These skills, assets and 
capabilities allow them to manage their lifeworlds with minimal interference. The 
kinds of skills which enhance capabilities include interpersonal relationships, 
technical skills to manage the routine aspects of social and economic and 
domestic life, skills to develop emotional and psychological resistance (often 
referred to as coping or resilience mechanisms) and an ability to make life seem 
meaningful. These skills enable people to manage the routine travails of ordinary 
living as well as the more significant life events which engulf everybody from time 
to time (Kelly, 2010b).  It also allows people to manage the material lifeworld they 
inhabit. This is important because the material and psychological lifeworlds 
mediate the stressors - physical, psychological and biological - which assault the 
human body periodically. The greater the ability people have to control their life-
worlds, the greater the resilience they will have. Skills to control the life-world are 
quintessentially capabilities. The inability to exert that control forms the basis of 
the patterning of health inequities because the ability to exert control is not 
spread uniformly through the population. Following Sen’s prescription, we should 
seek not to measure need in a potentially spuriously scientific way, but rather 
acknowledge that the total population, all of us, are in need of strengthening our 
capabilities. Further it is relatively easy to predict where the need to develop 
more capabilities and skills is greatest and that is among the poor, the 
disadvantaged, sub-groups and minorities, and people with disabilities. Efforts to 
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develop and build the skills and capabilities should be proportionately, but not 
exclusively, focussed on these groups. The level of self-empowerment to help to 
realise these capabilities needs to be appropriate for the individual. This is an 
important consideration when deciding where to deploy resources. When this 
happens, it almost always involves active public participation to determine what it 
is that people value. 
Moreover, upstream efforts need embrace a public health preventive approach; 
an education in basic skills for living, appropriate role modelling as the basis of 
skills for human interaction, proper deportment, manners, respect for others, 
management of emoti ns and the development of a balanced sense of self and 
identity – are the basics of human socialization. This means that the early years 
are particularly important and that taking the edge off encounters between people 
that are destructive and harmful is paramount. 
While all of this plays out on life’s grand stage, it must also apply to the way 
health services are provided and delivered. If services are organised around 
allocative efficiency alone and neglect the sense of self, the identity, the skills 
required to negotiate the system, and they alienate patients and public from and 
systematically deskill the recipients of care, they meet no one’s needs at all, and 
serve only to make the patterns of inequities worse. They become, in other 
words, a contributor to the problem, rather than a solution to it. Unfortunately, the 
utilitarian approach with its individualistic ontology, and its emphasis on ideal 
rationality, is focused on a question, which on the face of it is not unreasonable, 
of how to match resource deployment to need. This is in fact the wrong question, 
so it often ends up doing exactly the opposite of what it is trying to do and making 
matters worse. A purely deficits approach to health needs assessment may well 
be neat and tidy, however it only tells one side of the story. Widening the 
approach to encompass assets starts to get complex and messy. Where Sen’s 
capability theory is involved there is no ready-to-go formula. Instead of avoiding 
what is hard to do we should embrace the challenge. It is after all, the challenge 
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of understanding what it is to be human. Fortunately, there are many people who 
have risen to this challenge and remarkable things are happening across the 
Globe. Whilst helping people in need is a virtue we mustn’t lose sight of the fact 
that we are all part of the human species and we all live on the same planet.  
None of us are equal until all of us are equal. 
We should understand needs assessment in terms of building assets and 
capabilities rather than focusing on deficits. In the context of the aftermath of the 
global financial crisis, austerity, the ageing population, rising levels of obesity and 
costly healthcare systems there are clear implications for the nature of health 
needs assessment. What is required is greater capacity to harness insight from 
routine digital data, more acceptance of ideas about creating agency among 
those most in need and acknowledging the impact of the structural determinants 
of health on capability. Population approaches, targeting those in greatest need 
allow the harder edge of human existence to be ameliorated. 
It does mean though that the temptation to try to find purely rationalist solutions 
which can only ever work in theory, or indeed in Utopia – nowhere - rather like 
transcendent theories of justice, must be resisted. It must be acknowledged that 
it is about human relationships and allowing those relationships to be as humanly 
meaningful and fulfilling and permitting of enhancing human capabilities as 
possible. The most important task in a good and just society is to prevent the 
erosion of those things which protect and maintain human capabilities. It is to 
protect the virtuous and the virtues and to enhance them where possible and to 
protect them by supporting social arrangements which facilitate that. 
Relationships cannot be legislated for, nor made to happen by complex 
processes of resource allocation. Justice and the social arrangements that 
maintain relationships are in the end the emergent properties of social relations. 
Those relations must be cultivated in a humane, and as far as possible, just way 
that protects and enhances people’s capabilities. This must be the pre-requisite 
for any state wanting to deploy its health care resources in a way that is both 
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effective and meaningful. Building capability into service design is a fundamental 
pre-requisite. 
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