title: Determinants of performance of health systems concerning maternal and child health: a global approach.
abstract: OBJECTIVE
  To assess the association of social determinants on the performance of health systems around the world.
  
  
  METHODS
  A transnational ecological study was conducted with an observation level focused on the country. In order to research on the strength of the association between the annual maternal and child mortality in 154 countries and social determinants: corruption, democratization, income inequality and cultural fragmentation, we used a mixed linear regression model for repeated measures with random intercepts and a conglomerate-based geographical analysis, between 2000 and 2010.
  
  
  RESULTS
  Health determinants with a significant association on child mortality(<1year): higher access to water (βa Quartile 4(Q4) vs Quartile 1(Q1) = -6,14; 95%CI: -11,63 to -0,73), sanitation systems, (Q4 vs Q1 = -25,58; 95%CI: -31,91 to -19,25), % measles vaccination coverage (Q4 vs Q1 = -7.35; 95%CI: -10,18 to -4,52), % of births attended by a healthcare professional (Q4 vs Q1 = -7,91; 95%CI: -11,36 to -4,52) and a % of the total health expenditure (Q3 vs Q1 = -2,85; 95%CI: -4,93 to -0,7). Ethnic fragmentation (Q4 vs Q1 = 9,93; 95%CI: -0.03 to 19.89) had a marginal effect. For child mortality<5 years, an association was found for these variables and democratization (not free vs free = 11,23; 95%CI: -0,82 to 23,29), out-of-pocket expenditure (Q1 vs Q4 = 17,71; 95%CI: 5,86 to 29,56). For MMR (Maternal mortality ratio), % of access to water for all the quartiles, % of access to sanitation systems, (Q3 vs Q1 = -171,15; 95%CI: -281,29 to -61), birth attention by a healthcare professional (Q4 vs Q1 = -231,23; 95%CI: -349,32 to -113,15), and having corrupt government (Q3 vs Q1 = 83,05; 95%CI: 33,10 to 133).
  
  
  CONCLUSIONS
  Improving access to water and sanitation systems, decreasing corruption in the health sector must become priorities in health systems. The ethno-linguistic cultural fragmentation and the detriment of democracy turn out to be two factors related to health results.
authors.affiliation: Centre for Research in Health Systems (CISS), Instituto Nacional de Salud Pública de México, Cuernavaca, Mexico.
authors.forename: Carlos Eduardo
authors.initials: CE
authors.lastname: Pinzón-Flórez
authors.affiliation: Information Center for Public Health Decisions (CENIDSP), Instituto Nacional de Salud Pública, Cuernavaca, Mexico.
authors.forename: Julián Alfredo
authors.initials: JA
authors.lastname: Fernández-Niño
authors.affiliation: Department of Public Health, School of Medicine, School of Health, Universidad Industrial de Santander, Bucaramanga, Colombia.
authors.forename: Myriam
authors.initials: M
authors.lastname: Ruiz-Rodríguez
authors.affiliation: Department of Public Health, School of Medicine, School of Health, Universidad Industrial de Santander, Bucaramanga, Colombia.
authors.forename: Álvaro J
authors.initials: ÁJ
authors.lastname: Idrovo
authors.affiliation: Centre for Research in Health Systems (CISS), Instituto Nacional de Salud Pública de México, Cuernavaca, Mexico.
authors.forename: Abel Armando
authors.initials: AA
authors.lastname: Arredondo López
mesh_terms: D002648:Child; D000067576:Child Health / Q000706:statistics & numerical data*; D046688:Child Mortality; D005260:Female; D014943:Global Health / Q000706:statistics & numerical data*; D005102:Health Expenditures / Q000706:statistics & numerical data; D006801:Humans; D016014:Linear Models; D008428:Maternal Mortality
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