The changing context The goals of improving access to care and achieving equity are set in a rapidly changing medical and social context. Innovations in health technology over the past 30 years include major advances in surgery such as successful hip and knee replacements; the introduction of coronary by-pass surgery, and kidney, heart, lung and other transplant operations; new investigative procedures; and high-cost drug treatments such as antiretroviral therapies for AIDS. The overall effect of new possibilities for treatment is an expansion ofmedical needs and the potential for health care. Needs for services are further increased by the advancing age of the population and the success of medicine in extending the lives ofpatients with chronic conditions. A larger proportion ofthe population now experiences chronic or degenerative conditions that will benefit from treatment to improve functioning, reduce pain and enhance the quality of life. Costly procedures that were initially evaluated on younger patients often diffuse into health care for the elderly, thus further increasing demands for services (Dozet et al. 2002). The scope ofpreventive activities has also expanded through developments in antenatal and newborn screening, child health checks and immunisations, cancer screening techniques and new preventive measures such as cholesterol screening and regular health checks for elderly people.