Preventive Health Care in Six Countries: Models for Reform? C. Patrick Chaulk, M.D., M.P.H. International systems are frequently In this article, I examine the health care offered as models for health care reform. This systems of six industrialized countries study, focusing on preventive services for chil­ (Canada, Sweden, France, Germany, Japan, dren and pregnant women in six industrial­ and the United Kingdom), compare their ized countries, finds that a broad range of basic structures and financing arrange­ preventive services can be provided through ments, and describe how these systems health care systems with divergent financing address certain preventive health care and cost containment, utilizing multiple needs of children and pregnant women as entry points into the health care system, and part of a focus on primary care. Despite empioying targeted programs for high-risk wide variations in financing mechanisms, patients. Despite variability in form and levels of health care spending, and cost­ financing, health outcomes are not compro­ containment strategies among these six mised, suggesting that health care reformers systems, each provides comprehensive in this country need not be restricted to any services to all children and pregnant single model to strengthen preventive health women. Additionally, access and outcome care for children and pregnant women. measures such as insurance coverage, pre­ natal care, high-risk pregnancy outreach, INTRODUCTION home visiting, immunization, universal periodic screening for children, infant mor­ International models have attracted tality, and low birth weight are better than increasing attention from health care those of the United States. The variations reformers in this coWltry. Numerous com­ in program structure and financing sug­ parisons have been made with respect to gest that effective health care programs for overall health care systems (U.S. General this population need not be restricted to Accounting Office, 1991a; Iglehar~ 1991a, any single organizational structure; this 1991b, 1988a, 1988b), financing and cost­ should offer flexibility to health care containment mechanisms (U.S, General Accounting Office, 1991b), and levels of reformers in this country seeking models for expanding preventive services. health care spending (Schieber, Poullier, and Greenwald, 1991). However, little has been METIIODS written about the comparative differences or similarities of specific services within these Selected health status and health care sys­ systems, such as preventive health services tem characteristics of six industrialized directed at children or pregnant women nations described in the 1991 Organization (Williams and Miller, 1991; Starfield, 1991; for Economic Cooperation and Development U.S. General Accounting Office, 1993c). (OECD) Health Data ffie (Schieber, Poullier, and Greenwald, 1993) were analyzed and The author is with The Johns Hopkins School of Hygiene and Public Health. The opinions expressed in this article are those of supplemented with information from several the author and do not necessarily reflect the opinions of The sources that describe services for children Johns Hopkins School ofHygieneand Public Health or the Health Care Financing Administration. and pregnant women. The OECD data HEALTII CARE FINANCING REVIEW/Summer 1994/Volume 15. Number4 7 characteristics analyzed included per capita single-payer centralized systems (Canada, gross domestic product (GDP) and percent United Kingdom) and decentralized sys­ of GDP spent on health care, public spend­ tems (Sweden). Other countries rely ing as a percent of health care spending, on quasi-public, employer-based sickness and number of physicians per capita. Other funds with variable coverage through pub­ characteristics derived from supplementary lic insurance (Germany, Japan, France). sources include percent of physicians in pri­ Private health insurance plays only a mary care and, for children and pregnant minor, supplementary role in all the for­ women, measures of health status (infant eign countries. By contrast, in the United mortality rates, percent of low-birth-weight States, the health care system is very infants, maternal mortality rates, and per­ decentralized and based predominantly on cent of births delivered by cesarean a system of private health insurance. Public section), preventive services (rates of programs generally serve the elderly and pediatric inununization, presence of universal certain categorical groups of poor women periodic preventive screening, home visita­ and children. None of these countries, tion services, high-risk pregnancy out­ except the United States, contains any sig­ reach, duration of maternity leave, and level nificant percentage of uninsured children of maternity financial support), and access or women of childbearing age. to care (percent of women of childbearing In 1991, per capita spending and percent age and children without health insurance). of GDP spent on health care were all sub­ However, methodological problems exist stantially less than in the United States with most comparative international stud­ (Figure 1). The country with the next-high­ ies. Health outcomes, for example, are est spending per capita on health care was determined by a variety of sociocultural Canada. The United States spent roughly factors that lack sufficient descriptive data. 50 percent more per capita on health care In addition, taxonomy often complicates than Canada, and some 175 percent more international comparisons. Recent analysis than the United Kingdom. The percent of of international infant mortality rates finds GDP spent on health care reflects a similar less disparity between the United States pattern (fable 1). The United States spent and other industrialized countries when 13.2 percent of its GDP on health in 1991, adjusting for definitional differences compared with 6.6-10.0 percent for the six applied to infant mortality (Ilu eta!., 1992). other countries. Although only 42 percent Despite these limitations, relative, rather of health care spending in the United than absolute, differences are useful in States is publicly funded, well over 70 per­ understanding international health care cent is publicly funded in the six countries. systems and their services. Partially because of the substantial pub­ lic funding of health care, all six countries HEALTH CARE SYSTEMS implement significant national cost-control measures (Chaulk and Bialek, 1993), The six countries described reflect a including systemwide global budgets wide diversity in organizational structure (Canada, United Kingdom) (U.S. General for the delivery of health care, in cost con­ Accounting Office, 199la), expenditure tar­ tainment and financing mechanisms. The gets or global budgets for hospitals and/ or organizational structure and decision­ office-based physicians (France, Sweden, making process are represented by Germany) (Rodwin eta!., 1990; U.S. General 8 HEAL1H CARE FINANCING REVIEW/Summer 1994/Volume 15, Number4 Figure 1 Per C&plta HeaHh Spandlng lor Selected Industrialized Countries: 1991 "'''';~,;; Per Capita Health Spending Percent by Which U.S. Spending • United States $2,868 ~~!;! Exceeds Other Countries canada $1,915 50 percent Gennany $1,659 73 percent France $1,650 74 percent Sweden $1,443 99 percent Japan $1,307 119 percent United Kingdom $1,043 175 percent NOTE: Spending Is In u.s. dollars. SOURCE: (Schieber, Poullier, and Greenwald, 1993). Accounting Office, 1991b, 1993b), provider the other countries, which have predomi­ fee schedules (Germany, Japan, Sweden, nantly primary care physicians (53-63 per­ France) (lkegami, 1990; Brenner and Rublee, cent) (Chaulk and Bialek, 1993; Rodwin et 1992) or capitated fees (United Kingdom) al., 1990; Fielding and Pierre-Jean, 1993; (Ham, 1988), prolnbitions on balance billing McAuley, 1992). (Japan, Sweden), and limitations on medical malpractice (Canada, Japan) (Coyte, Dewees, PRENATAL CARE AND MATERNAL and Trebilock, 1991; Employee Benefits DISABIUIY Research Institute, 1990a). By contrast, cost contaimnent in the United States is less com­ In all six countries, prenatal care is com­ prehensive and generally limited to hospital prehensive, accessible, and either free and provider fees under certain public pro­ or accompanied by .financial assistance. grams such as Medicare and Medicaid, Pregnant women are not excluded from patient cost sharing, and varying managed­ prenatal care based on insurance status or care arrangements. income. Public prenatal clinics often coor­ In terms of physician supply, four of the dinate maternity services and prenatal care six countries have 2.2-3.1 physicians per for women (Goodwin, 1990). capita, and the other two (Japan, United For example, in Japan, prenatal care is Kingdom) have roughly 1.5 physicians per not a routine health insurance benefit. capita This compares with 2.3 per capita in Instead, comprehensive maternity services the United States. However, the specialty are provided through public programs; distribution of physicians is strikingly dif­ however, complications occurring during ferent between the United States and the pregnancy are covered by health insurance. other countries. In the United States, only Japan's focus on prenatal care and chil­ about 33 percent of all physicians declare dren's health began following World War II themselves to be primary care physicians as part of its national reconstruction effort. (Politzer et al., 1991). This contrasts with By the late 1950s, national guidelines