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National health policies appear to be at a crossroads in many developed nations due to escalating financial burdens. Overextended welfare states in Europe and (at least until the last year or so) the federal deficit in America are forcing stringent fiscal policies at exactly the time when aging populations are increasing the demands upon these health care systems. Questions concerning how health care systems affect popular health gain a special urgency, therefore, in ongoing attempts to restructure the financing and provision of health care without harming national welfare. This paper seeks to contribute to an understanding of how macro health systems work by comparing three possible sets of influences on national health care outcomes: 1) health care facilities and their presumed link to national affluence, 2) social characteristics which are assumed to promote healthy behavior, and 3) political variables in the form of welfare state development. Our findings bear both optimistic and pessimistic connotations. On the one hand, the somewhat limited importance of the first set of factors shows that good health in a country is not simply the function of high spending levels. However, the surprisingly strong role of "social development" in determining health care outcomes that emerges implies that much more than the direct provision of health care must be manipulated to ensure optimal health for a nation's population.
Model and Hypotheses
Three potential sets of factors that might explain why health care outcomes are better in some societies and communities rather than in others focus, respectively, on economic, social, and political conditions. As Figure 1 which sketches these presumed relationships shows, these explanations appear to be more complementary than competing. Probably the dominant approach at present focuses upon economic factors in what may be termed a "physical quality" model. The logic of this argument regarding health care policy rests on the very simple premise that "newer and bigger are better." Thus, the key to improving the health of a community or society is assumed to be building new facilities, acquiring better technology, and training and recruiting physicians, nurses, technicians, and other health care personnel (Evans, 1990). Consequently, richer societies should have a decided advantage in promoting healthier populations because they can better afford such facilities and personnel, in addition to the better nutrition available to their populations (Donabedian, 1982). While such differences should be especially marked between First World and Third World nations, even developed nations vary significantly in affluence; and many regions and communities within the richer nations face poverty conditions that almost certainly have a negative impact upon their health care systems. The set of strong positive relationships going across the bottom of Figure 1, then, represents this "physical quality" model which assumes the centrality of "economic determinism:" richer countries and communities spend more on health to support better facilities which, in turn, create a healthier population. The provision of health care is not the only factor that affects health care outcomes among the general population. In fact, research has demonstrated that, in addition to health facilities, the "healthy behavior" (i.e., nutrition and diet, exercise, smoking, stress, etc.) of various socioeconomic groups is very important in determining disease and mortality rates (Fuchs, 1986; Mechanic, 1972; Raffel, 1984). Such healthy behavior, in turn, is probably a function of a nation's "social development" as indicated by such factors as the average education and degree of economic inequality in a population.
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The presumed impact of the political variables, though, makes the model more complex and at least partially contradictory. It might be expected that affluence would have at least a weak association with the development and expansion of welfare states. Large welfare states, in turn, should have comparatively high levels of health spending and of social development, …