Schell Carl Otto, Reilly Marie, Rosling Hans, Peterson Stefan, Ekström Anna Mia
Department of Public Health Sciences, Division of International Health (IHCAR) Karolinska Institutet, Stockholm, Sweden.
Scand J Public Health. 2007;35(3):288-97. doi: 10.1080/14034940600979171.
To reach the Millennium Development Goals for health, influential international bodies advocate for more resources to be directed to the health sector, in particular medical treatment. Yet, health has many determinants beyond the health sector that are less evident than proximate predictors.
To assess the relative importance of major socioeconomic determinants of population health, measured as infant mortality rate (IMR), at country level.
National-level data from 152 countries based on World Development Indicators 2003 were used for multivariate linear regression analyses of five socioeconomic predictors of IMR: public spending on health, GNI/capita, poverty rate, income equality (Gini index), and young female illiteracy rate. Analyses were performed on a global level and stratified for low-, middle-, and high-income countries.
In order of importance, GNI/capita, young female illiteracy, and income equality predicted 92% of the variation in national IMR whereas public spending on health and poverty rate were non-significant determinants when adjusted for confounding. In low-income countries, female illiteracy was more important than GNI/capita. Income equality (Gini index) was an independent predictor of IMR in middle-income countries only. In high-income countries none of these predictors was significant.
The relative importance of major health determinants varies between income levels, thus extrapolating health policies from high- to low-income countries is problematic. Since the size, per se, of public health spending does not independently predict health outcomes, functioning health systems are necessary to make health investments efficient. Potential health gains from improved female education and economic growth should be considered in low- and middle-income countries.
为实现卫生领域的千年发展目标，有影响力的国际机构主张将更多资源投向卫生部门，尤其是医疗治疗。然而，健康有许多超出卫生部门的决定因素，这些因素不如直接预测因素那么明显。
在国家层面评估以婴儿死亡率（IMR）衡量的人口健康主要社会经济决定因素的相对重要性。
使用基于《2003年世界发展指标》的152个国家的国家级数据，对IMR的五个社会经济预测因素进行多元线性回归分析：卫生公共支出、人均国民总收入、贫困率、收入平等（基尼系数）和年轻女性文盲率。分析在全球层面进行，并按低收入、中等收入和高收入国家分层。
按重要性排序，人均国民总收入、年轻女性文盲率和收入平等预测了国家IMR变化的92%，而在调整混杂因素后，卫生公共支出和贫困率是无显著意义的决定因素。在低收入国家，女性文盲率比人均国民总收入更重要。收入平等（基尼系数）仅是中等收入国家IMR的独立预测因素。在高收入国家，这些预测因素均无显著意义。
主要健康决定因素的相对重要性在不同收入水平之间有所不同，因此将卫生政策从高收入国家推广到低收入国家存在问题。由于卫生公共支出本身的规模并不能独立预测健康结果，因此需要运转良好的卫生系统来提高卫生投资的效率。低收入和中等收入国家应考虑改善女性教育和经济增长可能带来的健康收益。
