Starfield Barbara, Shi Leiyu
Department of Health Policy and Management, School of Hygiene and Public Health, Johns Hopkins University, Room 452, 624 North Broadway, Baltimore, MD 21205-1996, USA.
Health Policy. 2002 Jun;60(3):201-18. doi: 10.1016/s0168-8510(01)00208-1.
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.
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.
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.
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.
国际比较能够为理解一些与政策相关的重要健康决定因素提供线索，包括那些与医疗服务提供相关的因素。一项早期研究表明，卫生服务系统的初级保健基础设施的实力可能与卫生服务的总体成本有关。当前研究的目的是根据5至10年的时间推移、新增的两个国家以及其他关于国家健康水平其他决定因素可能重要性的研究结果，来确定这些发现的稳健性。
利用国际数据集和国家信息提供者，对13个工业化国家（所有国家人口至少500万）进行了特征描述，这些特征包括其初级保健基础设施的相对实力、国民收入不平等程度以及一种可通过政策干预改变的健康行为决定因素（吸烟）的主要表现。根据预先设定的标准对卫生系统和初级保健实践特征进行判断。将主要健康指标以及医疗保健成本用作因变量。
初级保健越强，成本越低。初级保健基础设施非常薄弱的国家在健康的主要方面表现较差。虽然初级保健实力处于中等水平的国家总体健康水平通常至少与初级保健水平高的国家一样好，但在生命早期并非如此，此时强大的初级保健影响最大。一组特征（资源公平分配、具有公共问责制的全民医保覆盖、低成本分担、综合服务以及以家庭为导向的服务）区分了各年龄段总体健康状况良好的国家和健康状况较差的国家。收入不平等和吸烟状况均无法准确识别那些在健康指标方面表现一直良好或一直较差的国家。
即使存在强大的初级保健基础设施，可能也需要一定水平的医疗保健支出才能实现总体良好的健康水平。成本过低可能会妨碍实现良好的健康状况，尤其是在老年时，尽管成本过高可能表明存在过度且可能损害健康的医疗服务。五个与政策相关的特征似乎与更好的人群健康水平相关。在不同年龄组中，收入不平等、吸烟与通过各种健康指标衡量的健康水平之间不存在一致的关系。
