4.1 Relative and absolute need

This learning object investigates the concept of health care as a basic human need and lack of health care as a form of poverty. In particular, it explores the distinction between relative and absolute poverty. Health care planning is variously concerned with meeting absolute and relative needs and it is therefore necessary to understand the context of need and the policies with which it may be addressed.

Fundamentally, need describes the prevalence of health conditions that should be addressed by health care services

(Cromley and McLafferty, 2002: 238)

 

Basic human needs are widely expressed in terms of clean water, sanitation, shelter, education, information, food and health. Absolute poverty can be defined as the absence of the resources necessary to meet these basic needs. Relative poverty is the lack of resources when compared to an average level, and can entail the inability to engage in activities that might be accepted as normal in a particular societal context. It can be argued that poverty, rather than specific behaviours or diseases is  the single greatest cause of world mortality.

Gordon (2004) makes clear the contrast between the developed and developing worlds and the relative contributions of absolute and relative poverty in the understanding of their health needs, particularly highlighting the stark pattern of childhood mortality in the developing world that can be attributed to widespread absolute poverty. The vast majority of child deaths could be prevented at very low cost. Gordon suggests that 30% of the world’s children suffer from absolute poverty in terms of lacking two or more of the basic human needs identified above, of which the greatest proportion are in Africa. This situation reflects a massive inequality in the distribution of wealth between nations, whereby the poorest 20% of the world’s population have just 1.4% of world income, compared to the richest 20% who have 82.7%. When we start to consider the distribution of resources between countries and within the developed world then we move further up this spectrum of inequality, where relatively few are suffering from absolute poverty, but many are affected by relative poverty, both of which have important impacts on health and thus on need for health care. Of those lacking the basic human need of “health”, this generally means no effective provision of health care services: approximately 13% of the world’s children have never come into contact with medical services. In addressing these needs, there is often greater political will to address provision of health care and education than some of the other infrastructural aspects such as water or sanitation.

Haines and Smith (1997) argue that wealth is the single most important driver of health worldwide – more important than, for example, smoking. They note (p. 529) that “in developed countries, relative poverty (having an income substantially below the mean for that society) is a more important influence on health than absolute poverty (lacking the basic means to live)”. This issue is of growing importance because in many countries the gap between the rich and poor is widening, and national mortality rates tend to be lowest in countries that have smaller internal income differentials, and hence lower levels of relative deprivation (Wilkinson, 1997). Repeated studies have shown that gross national product per capita is a poor predictor of life expectancy, but that internal variations in the distribution of wealth can have big impacts on health. Gakidou and King (2002) provide an example of a study which seeks to incorporate measures of the variation in health risk across individuals as well as across large groups.

Although there are many regions in the world which struggle to provide even the basic human needs universally, the majority of health care systems are more often concerned with issues of relative need. In this setting the needs of one group are generally set against the needs of others but it becomes very hard to separate need for health care from the characteristics of the health care system. Discussion of relative need turns to considerations of equity and equality: different health care systems may aim for equality of health care expenditure, equality of the value of health care actually used or equality of health outcomes. Each of these conceptualizations will result in different assessments of relative need, and thus different priorities for marginal adjustments to the health care system.

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