Policy relevant determinants of health: an international perspective
Introduction
An international comparison using data from the mid and late 1980s [1] showed that western industrialized countries differed with regard to the strength of their primary care infrastructure and suggested that this was one reason for differences in various aspects of the health of their populations and costs of health care. Relatively recent comparisons of countries (although with older data) have added a focus on socioeconomic characteristics, and have suggested that poorer health follows greater disparities in income [2] or cultural and behavioral characteristics of populations [3]. The purpose of the current research was to determine the robustness of the findings in the light of the passage of 5–10 years, the addition of two more countries, and the findings of other research on the possible importance of other determinants of country health levels.
Data from the early and mid 1990s were used to determine the robustness of the original findings on the importance of primary care outcomes to a variety of health outcomes as well as costs of care, in the face of some evidence on other characteristics of the countries (income inequality and smoking). The original comparison was limited to western industrialized nations with populations over 5 million, for which comparable data were available. The current study added two countries: France and Japan. For the former, data are now available whereas they were not previously. Japan, even though not a ‘western’ nation, was added because of interest in its reportedly good performance on most common health indicators. Data on income inequality were also added because of recent findings concerning its possible salience to overall health levels, and the behavioral characteristic of smoking was included as a potential major explanatory factor for differences in overall health.
Section snippets
Methods
Data were sought to enable the characterization of countries according to the strength of their primary care, considering both those characteristics of health system policy that are conducive to primary care, as well as characteristics of practice that reflect good primary care.
Health system characteristics include the extent to which the system regulates the distribution of resources throughout the country; the mode of financing of primary care services; the modal type of primary care
Results
Table 1 provides the primary care scores for the countries. Three groups emerge according to the strength of primary care infrastructure: those with poor primary care infrastructure (with total primary care score less than 10), those in the middle (with primary care score between 10 and 20), and those with strong primary care (with primary care score greater than 20). The ranking of scores for practice characteristics was highly related to those for system characteristics, thus indicating the
Discussion
Within the past 15 years, almost all countries have undergone some type of health care reform, mostly directed at conserving costs. Existing international comparisons [10], [11] have provided descriptive data on some important aspects of these health systems, but these have lacked information on both socio-economic characteristics or primary care characteristics that could be related to differences in population health levels. Except for the general finding that there is little association
Acknowledgments
The authors acknowledge the support of the Bureau of Primary Health Care, Health Resources and Services Administration, Department of Health and Human Services, and the Johns Hopkins University Primary Care Policy Center.
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