We find Steven Lewis's concern about the sustainability of healthcare to be refreshing. However, Mr. Lewis seems to have missed the central point of our article. The nature of demand for healthcare has evolved. The demand is now fundamentally different from when publicly funded medicare was introduced in the 1960s. There is a significant and growing part of the demand (or need) for healthcare that involves helping people get more enjoyment out of life. There is ample evidence of this in the growing consumer demand for sports medicine, cosmetic surgery, cosmetic dentistry, therapies to enhance sexual performance and complementary therapies and alternative medicine - such as homeopathy, naturopathy, chiropractic medicine, laser therapy, massage therapy, herbal therapy and many others (Statistics Canada, Health Services Division 1995; York University Centre for Health Studies 1999). We also see the increasing medicalization of responses to conditions associated with lifestyle, for example, gastric bypass surgery to address obesity and pharmacology to ward off type 2 diabetes (DREAM Trial Investigators 2006; Fonseca and Kahn 2006; Gerstein 2007). We illustrate this in Figure 1, which indicates how, over time and as our society has become more affluent, the higher levels of the hierarchy of healthcare needs have grown in importance.

[Figure 1]

We do not question the validity of these top-of-the-hierarchy needs. In fact, it is encouraging that more people are taking a proactive interest in optimizing their health. But we do ask whether - in a time of increasing concern about the sustainability of healthcare spending and, particularly, the taxpayer-funded portion of the spending pie - we should not be looking to focus public spending more on the lower and middle levels of the hierarchy. We also raise this question at a time when other basic human needs traditionally financed by government - notably, social housing and welfare support - promise to be trampled to extinction by the healthcare elephant (Taylor 2006). Seen in this light, turning a blind eye to this phenomenon is to impose a heavy burden on the poorest echelons of society, who most depend on government for essential services beyond health.

Lewis raises good questions about how efficiently we produce and deliver health services. We largely agree with the points he has made. In fact, in another report, we have gone to some length to argue that we must find ways to get greater value from our healthcare system (IBM Institute for Business Value 2006). We discuss the challenges that the health sector has faced in articulating and measuring value and achieving a dynamic that rewards value. Healthcare lags behind most other sectors of our economy in this regard. However, in this paper, we have chosen to focus on the issue of needs and demand, and how we have to give this issue due consideration as we look for ways to make our healthcare system sustainable.  

There has been some very instructive policy analysis recently on how we manage the demand for healthcare (Wong et al. 2005). However, it has failed to take account of the different types and changing nature of demand (or need). We suggest that Adams's hierarchy of healthcare needs provides a useful framework for advancing this discussion.


DREAM Trial Investigators. 2006. "Effect of Rosiglitazone on the Frequency of Diabetes in Patients with Impaired Glucose Tolerance or Impaired Fasting Glucose: A Randomised Controlled Trial." The Lancet. Retrieved October 3, 2006. http://www.thelancet.com/webfiles/images/ clusters/thelancet/dream_article.pdf

Fonseca, V.A. and S.E. Kahn. 2006. "Of Hopes and DREAMS: The Quest to Prevent Type 2 Diabetes." Journal of Clinical Endocrinology and Metabolism 91: 4762-63.

Gerstein, H.C. 2007. "Point: If It Is Important to Prevent Type 2 Diabetes, It Is Important to Consider All Proven Therapies within a Comprehensive Approach." Diabetes Care 30: 432-34.

IBM Institute for Business Value. 2006. Health Care 2015: Win-Win or Lose-Lose? A Portrait and a Path to Successful Transformation. Somers, NY: Author.

Statistics Canada, Health Services Division. 1995. National Population Health Survey Overview 1994-1995. Ottawa: Minister of Industry.  

Taylor, C. 2006. BC Economic and Fiscal Update. Victoria: BC Ministry of Finance. Retrieved September 15, 2006. http://www.fin.gov.bc.ca/qrt-rpt/qr06/Q1powerpoint.pdf

Wong, J., H. Beglaryan, L. Kilburn and P. Orovan. 2005. Turning the Tide on Demand for Health Care. Toronto: The Change Foundation.

York University Centre for Health Studies. 1999. Complementary and Alternative Health Practices and Therapies: A Canadian Overview. Ottawa: Health Canada.