Elsevier

Health Policy

Volume 60, Issue 3, June 2002, Pages 201-218
Health Policy

Policy relevant determinants of health: an international perspective

https://doi.org/10.1016/S0168-8510(01)00208-1Get rights and content

Abstract

Background: International comparisons can provide clues to understanding some of the important policy-related determinants of health, including those related to the provision of health care services. An earlier study indicated that the strength of the primary care infrastructure of a health services system might be related to overall costs of health services. 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. Methods: Thirteen industrialized countries, all with populations of at least 5 million, were characterized by the relative strength of their primary care infrastructure, the degree of national income inequality, and a major manifestation of a behavioral determinant of health that is amenable to policy intervention (smoking), using international data sets and national informants. Health system and primary care practice characteristics were judged according to pre-set criteria. Major indicators of health were used as dependent variables, as were health care costs. Findings: The stronger the primary care, the lower the costs. Countries with very weak primary care infrastructures have poorer performance on major aspects of health. Although countries that are intermediate in the strength of their primary care generally have levels of health at least as good as those with high levels of primary care, this is not the case in early life, when the impact of strong primary care is greatest. A subset of characteristics (equitable distribution of resources, publicly accountable universal financial coverage, low cost sharing, comprehensive services, and family-oriented services) distinguishes countries with overall good health from those with poor health at all ages. Neither income inequality nor smoking status accurately identified those countries with either consistently high or consistently poor performance on the health indicators. Interpretation: A certain level of health care expenditures may be required to achieve overall good health levels, even in the presence of strong primary care infrastructures. Very low costs may interfere with achievement of good health, particularly at older ages, although very high levels of costs may signal excessive and potentially health-compromising care. Five policy-relevant characteristics appear to be related to better population health levels. There is no consistent relationship between income inequality, smoking, and health levels as measured by various indicators of health in different age groups.

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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