Preventive Health Care in Six Countries: Models for Reform?
Chaulk, C. Patrick, Health Care Financing Review
International models have attracted increasing attention from health care reformers in this country. Numerous comparisons have been made with respect to overall health care systems (U.S. General Accounting Office, 1991a; Iglehart 1991a, 1991b, 1988a, 1988b), financing and cost-containment mechanisms (U.S. General Accounting Office, 1991b), and levels of health care spending (Schieber, Poullier, and Greenwald, 1991). However, little has been written about the comparative differences or similarities of specific services within these systems, such as preventive health services directed at children or pregnant women (Williams and Miller, 1991; Starfield, 1991; U.S. General Accounting Office, 1993c).
In this article, I examine the health care systems of six industrialized countries (Canada, Sweden, France, Germany, Japan, and the United Kingdom), compare their basic structures and financing arrangements, and describe how these systems address certain preventive health care needs of children and pregnant women as part of a focus on primary care. Despite wide variations in financing mechanisms, levels of health care spending, and cost-containment strategies among these six systems, each provides comprehensive services to all children and pregnant women. Additionally, access and outcome measures such as insurance coverage, prenatal care, high-risk pregnancy outreach, home visiting, immunization, universal periodic screening for children, infant mortality, and low birth weight are better than those of the United States. The variations in program structure and financing suggest that effective health care programs for this population need not be restricted to any single organizational structure; this should offer flexibility to health care reformers in this country seeking models for expanding preventive services.
Selected health status and health care system characteristics of six industrialized nations described in the 1991 Organization for Economic Cooperation and Development (OECD) Health Data file (Schieber, Poullier, and Greenwald, 1993) were analyzed and supplemented with information from several sources that describe services for children and pregnant women. The OECD data characteristics analyzed included per capita gross domestic product (GDP) and percent of GDP spent on health care, public spending as a percent of health care spending, and number of physicians per capita. Other characteristics derived from supplementary sources include percent of physicians in primary care and, for children and pregnant women, measures of health status infant mortality rates, percent of low-birth-weight infants, maternal mortality rates, and percent of births delivered by cesarean section), preventive services (rates of pediatric immunization, presence of universal periodic preventive screening, home visitation services, high-risk pregnancy outreach, duration of maternity leave, and level of maternity financial support), and access to care (percent of women of childbearing age and children without health insurance).
However, methodological problems exist with most comparative international studies. Health outcomes, for example, are determined by a variety of sociocultural factors that lack sufficient descriptive data. In addition, taxonomy often complicates international comparisons. Recent analysis of international infant mortality rates finds less disparity between the United States and other industrialized countries when adjusting for definitional differences applied to infant mortality (Liu et al., 1992). Despite these limitations, relative, rather than absolute, differences are useful in understanding international health care systems and their services.
HEALTH CARE SYSTEMS
The six countries described reflect a wide diversity in organizational structure for the delivery of health care, in cost containment and financing mechanisms. The organizational structure and decision-making process are represented by single-payer centralized systems (Canada, United Kingdom) and decentralized systems (Sweden). …