title: Policy relevant determinants of health: an international perspective.
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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: 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. bstarfie@jhsph.edu
authors.forename: Barbara
authors.initials: B
authors.lastname: Starfield
authors.forename: Leiyu
authors.initials: L
authors.lastname: Shi
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D003431:Cross-Cultural Comparison; D003695:Delivery of Health Care / Q000145:classification / Q000191:economics / Q000458:organization & administration*; D019049:Developed Countries / Q000706:statistics & numerical data; D005260:Female; D015276:Health Care Rationing / Q000706:statistics & numerical data; D005102:Health Expenditures / Q000706:statistics & numerical data; D006291:Health Policy; D006302:Health Services Research; D006305:Health Status Indicators; D006801:Humans; D007182:Income / Q000706:statistics & numerical data; D007223:Infant; D008297:Male; D008875:Middle Aged; D011320:Primary Health Care / Q000458:organization & administration; D012907:Smoking / Q000453:epidemiology; D012959:Socioeconomic Factors