Levels Of Health Care Resources Research Articles

Assessing the Relationship Between Resources Availability and COVID19 Mortality Among US Counties

RESEARCH OBJECTIVE: The coronavirus disease of 2019 (COVID-19) which was declared a pandemic by the World Health Organization in March of 2020 has claimed the lives of millions of people around the world. The United States leads all countries worldwide in the number of COVID-19 related deaths. Individual level factors such as preexisting conditions and demographics along with county level factors such as availability of resources have been attributed to increased risk of COVID-19 related death. This study seeks to build on previous studies to assess the relationship between the level of health care resources and COVID-19 mortality among U.S. counties. STUDY DESIGN: We merged 2019 data from the American Hospital Association (AHA) Annual Survey of Hospitals, Area Health Resources Files (AHRF), and USA FACTS. The final sample consisted of 2,395 counties in the United States. The dependent variable was the number of COVID-19-related deaths by county. Independent variables were county level resources which included the number of airborne infection control rooms, average occupancy rate, number of full-time equivalent hospitalists and registered nurses (RN), hospital spending per capita, number of Joint Commission accredited and teaching hospitals, and total skilled nursing facilities beds. We controlled for the percentage of the population 65 years and older. Ordinary least square regression was used to determine the relationship between the level of health care resources and number of COVID-19 deaths. PRINCIPAL FINDINGS: The level of health care resources was significantly associated with COVID-19 related mortality. An increase in FTE Registered Nurses (ß = -0.0002; p<0.001), hospital spending per capita (ß = -0.0001; p<0.001) and teaching hospitals in the county (ß = -0.2063; p<0.001) were associated with a decrease in COVID-19 related deaths. However, an increase in the number of airborne infection control rooms (ß = 0.0071; p<0.001), average occupancy rate (ß = 0.0102; p<0.001), total skilled nursing facilities beds (ß = 0.0003; p<0.001), FTE hospitalists (ß = 0.0204; p<0.001), per capita income (ß = 0.0001; p<0.001), and Joint Commission hospitals in the county (ß = 0.0767; p<0.001) were associated with an increase in COVID-19 related deaths in the county. For each increase in the percentage of population 65 years and older, there was a decrease in the COVID-19 related deaths (ß = -0.0771; p<0.001). CONCLUSION: The availability of resources such as the presence of teaching hospitals, increased spending per capita, and adequate number of nurses to better care for patient may lead to a reduction in COVID-19 related death.

1302-P: Availability and Affordability of WHO Essential Medicines for Diabetes in Low- and Middle-Income Countries—Assessing the Gap and Needs from a Systematic Review

Background: The burden of diabetes is overwhelming worldwide and more important in low- and middle-income countries (LMICs). Preventing cardiovascular morbidity and mortality by providing essential medicines for diabetes and its associated risk factors is a major concern in a context of scarcity of resources and weak health systems. We conducted a systematic review from the recent literature to assess and synthesize the gap and needs for access to essential diabetes medicines in LMICs. Methods: We selected the recently published literature on essential medicines for diabetes in LMICs using the PubMed database. Articles were found using the following keywords: "Diabetes AND Essential Medicines" and "Diabetes AND Access to Insulin." Relevant studies conducted in one or more LMICs, as defined by the World Bank, were selected for analysis. Results: Availability and affordability of essential medicines for diabetes is poor in LMICs. Availability of insulin was as low as 10.3% in low income countries while 63% of households could not afford insulin in the PURE study conducted in 22 countries (18 LMICs). In two national surveys conducted in Uganda and Zambia, none of the heathcare facilities was meeting the WHO Standards for essential tools and medicines in Uganda and few (6 out of 46) in Zambia, with only 11% availability of insulin in rural area. Conclusions: The LMICs include a wide range of countries with varying levels of health care resources and quality. To meet the challenge of access to essential medicines for diabetes and other noncommunicable diseases, it is necessary to categorize needs by region and by country in order to prioritize interventions. Disclosure A.M. Diallo: None. M.K. Ali: None. K. Narayan: None.

Spatio-Temporal Distribution, Spillover Effects and Influences of China's Two Levels of Public Healthcare Resources.

In China, upper-level healthcare (ULHC) and lower-level healthcare (LLHC) provide different public medical and health services. Only when these two levels of healthcare resources are distributed equally and synergistically can the public’s demands for healthcare be met fairly. Despite a number of previous studies having analysed the spatial distribution of healthcare and its determinants, few have evaluated the differences in spatial equity between ULHC and LLHC and investigated their institutional, geographical and socioeconomic influences and spillover effects. This study aims to bridge this gap by analysing panel data on the two levels of healthcare resources in 31 Chinese provinces covering the period 2003–2015 using Moran’s I models and dynamic spatial Durbin panel models (DSDMs). The results indicate that, over the study period, although both levels of healthcare resources improved considerably in all regions, spatial disparities were large. The spatio-temporal characteristics of ULHC and LLHC differed, although both levels were relatively low to the north-west of the Hu Huanyong Line. DSDM analysis revealed direct and indirect effects at both short-and long-term scales for both levels of healthcare resources. Meanwhile, the influencing factors had different impacts on the different levels of healthcare resources. In general, long-term effects were greater for ULHC and short-term effects were greater for LLHC. The spillover effects of ULHC were more significant than those of LLHC. More specifically, industrial structure, traffic accessibility, government expenditure and family healthcare expenditure were the main determinants of ULHC, while industrial structure, urbanisation, topography, traffic accessibility, government expenditure and family healthcare expenditure were the main determinants of LLHC. These findings have important implications for policymakers seeking to optimize the availability of the two levels of healthcare resources.

Provincial and Age Disparity on Chronic Disease Education Among Migrants in China: The Migrants Population Dynamic Monitoring Survey.

Chronic diseases have become serious threats to public health in China; the risk is particularly high for internal migrants. Chronic disease education is a key to the prevention and control of chronic diseases for such population. The national population-based Migrants Population Dynamic Monitoring Survey (MPSMA) was used to examine the current status and delivery methods of chronic disease education among internal migrants, from both provincial level and individual’s level. The study population included 402 587 internal migrants. Multilevel logistic regression was used to investigate factors that were related to chronic diseases education. In total, only 33.9% of the participants received chronic disease education. In the final model, parameter estimates on key variables from both individual and provincial level were significant (P < .001). Participants from provinces with higher level of health care resources and lower density of internal migrants were more likely to receive chronic disease education. The percentage and methods of receiving education varied across different age groups. This study suggests that future chronic disease education in China need to be more focused on areas with high density of internal migrants and younger internal migrants with low level of education and income. Attention should be paid to use tailored education methods to different populations.

Cost-Effectiveness of Transjugular Intrahepatic Portosystemic Shunt versus Large-Volume Paracentesis in Refractory Ascites: Results of a Markov Model Incorporating Individual Patient-Level Meta-Analysis and Nationally Representative Cost Data

PurposeTo compare relative cost-effectiveness of serial large-volume paracentesis (LVP) and transjugular intrahepatic portosystemic shunt (TIPS) creation for treatment of refractory ascites. Materials and MethodsA decisional Markov model was developed to estimate payer cost and quality-adjusted life-ears (QALYs) associated with LVP and TIPS treatment strategies for cirrhotic patients with refractory ascites. Survival estimates were derived from an individual patient-level meta-analysis of prospective randomized clinical trials. Health utilities for potential health states were derived from a prospective study of patients with cirrhosis. Cost data were derived from national representative claims databases (MarketScan and Medicare) and included reimbursement amounts for relevant procedures, hospitalizations, and outpatient pharmaceutical costs. One-way and probabilistic sensitivity analyses were performed. ResultsLVP resulted in 1.72 QALYs gained at a cost of $41,391, whereas TIPS resulted in 2.76 QALYs gained at a cost of $100,538. Incremental cost-effectiveness ratio of TIPS versus LVP was $57,003/QALY. At a willingness-to-pay ratio of $100,000/QALY, TIPS has a 62% probability of being acceptable compared with LVP. ConclusionsThis study suggests that TIPS should be considered cost-effective in a country that places a relatively high value on health improvements but less so in countries with lower levels of health care resources.

The implicit theories of male child sexual offenders residing in a high secure psychiatric hospital

Although the vast majority of individuals with a mental disorder do not commit sexual offences, sexual offenders are a significant group within forensic psychiatric populations and command a high level of healthcare resources. Despite this, there is little published research focusing on the offence-specific cognitive styles (e.g. cognitive distortions and implicit theories) of these individuals, limiting understanding of their assessment and treatment needs. The current study aimed to establish whether evidence for the implicit theories identified by researchers of non-mentally disordered child sexual offenders would also be present among a population of high secure psychiatric male sexual offenders. Analysis of interviews with 12 such individuals indicated that the majority of the cognitive distortions articulated by these men could be categorised within existing implicit theory descriptions. The findings are discussed in relation to clinical practice and suggestions for future research with this specific population are proposed.

Management of colon cancer: resource-stratified guidelines from the Asian Oncology Summit 2012

Colon cancer is seen with increasing frequency in the Asia-Pacific region, and it is one of the most important causes of cancer mortality worldwide. This article reviews the available evidence for optimum management of colon cancer-in particular, with respect to screening and early detection of colon cancer, laparoscopic surgical treatment, adjuvant treatment of individuals with high-risk stage II and stage III cancer, palliative treatment of patients with metastatic disease, and management of resectable and potentially resectable metastases-and how these strategies can be applied in Asian countries with different levels of health-care resources and economic development, stratified by basic, limited, enhanced, and maximum resource levels.

Management of HER2-positive breast cancer in Asia: consensus statement from the Asian Oncology Summit 2009

Patients with breast cancer positive for human epidermal growth-factor receptor type 2 (HER2) are an important subgroup for consideration in the Asian context. Rationally designed, anti-HER2 targeted agents that can substantially improve treatment outcomes have become commercially available, but are still too costly for some groups in developed countries and for underdeveloped and developing nations. This review discusses the available evidence for optimum management of HER2-positive early and advanced breast cancer, and how this evidence can be applied to Asian countries with different levels of health-care resources and economic development--using framework provided by the Breast Health Global Initiative. We provide a brief overview of HER2 testing and discuss management of early and advanced HER2-positive breast cancer, and formulate a consensus statement for the management of breast cancer in the context of basic, limited, enhanced, and maximum health-care resource availability.

Management of T-cell and natural-killer-cell neoplasms in Asia: consensus statement from the Asian Oncology Summit 2009

T-cell and natural-killer (NK)-cell lymphomas are neoplasms with geographical variations in frequencies. T-cell lymphomas are more prevalent in Asia than in Europe and North America, and NK-cell lymphomas occur almost exclusively in Asia and South America. These low frequencies mean that the diagnosis and optimum treatment of patients with T-cell and NK-cell lymphomas have not been studied prospectively in randomised controlled trials. Because T-cell and NK-cell lymphomas are more prevalent in Asia, the establishment of management recommendations by Asian oncologists in collaboration with international experts is pertinent. This review outlines guidelines commensurate with different levels of health-care resources and expertise. Consensus statements were formulated for diagnosis, staging, follow-up, and treatment approaches in patients with T-cell and NK-cell lymphomas--aimed at unifying the design of studies and interpretation of results. For patients not in clinical trials, consensus opinions offer useful guidelines on optimum management.

Contextual effects on health care access among immigrants: Lessons from three ethnic communities in Hawaii

Immigrant health care is the product of the dynamic interaction between societal factors and the individual's socio-economic and cultural characteristics. Our knowledge about immigrant health care, however, has been limited to individual characteristics, without paying attention to the social context in which immigrants reside. This paper explores the effects of social contexts on access to health care among recent immigrants. As a natural experiment, it compares health care experiences of three immigrant groups in Hawaii - Filipinos, Koreans, and Marshallese - who are situated in different social contexts including immigrant health policy, ethnic community, and individual networks. Through household surveys conducted between October 2005 and January 2006, information of 378 recent immigrant adults on health care access, health insurance status, socio-demographic characteristics, linguistic and cultural factors, health status, ethnic community social capital, and social networks was obtained. The results of analyses show that Marshallese respondents have better access to health care than the other two groups, in spite of their lowest socioeconomic status. The high insurance rate of the Marshallese, mainly associated with a state health policy that provides health insurance assistance for the Marshallese, is the major contributor of their greater health care access. While Filipino immigrants do not benefit from state insurance assistance, high levels of health care resources and social capital within the Filipino community enable them to have significantly better health care access than Koreans, who have higher income and educational attainment. Interestingly, the advanced family/kinship networks are associated with better levels of immigrant health care access, while the increase of co-ethnic friend networks is related to lower access to health care. This study implies that restoration of immigrants' eligibility for public health insurance assistance, development of health care resources and social capital within ethnic communities, and mobilization of immigrant networks would be effective starting points to improve health care access among immigrants.

Rethinking equal access: Agency, quality, and norms

In 2005 the Global Health Council convened healthcare providers, community organizers, policymakers and researchers at Health Systems: Putting Pieces Together to discuss health from a systems perspective. Its report and others have established healthcare access and quality as two of the most important issues in health policy today. Still, there is little agreement about what equal access and quality mean for health system development. At the philosophical level, few have sought to understand why differences in healthcare quality are morally so troubling. While there has been considerable work in medical ethics on equal access, these efforts have neglected health agency (individuals’ ability to work toward health goals they value) and health norms, both of which influence individuals’ ability to be healthy. This paper argues for rethinking equal access in terms of an alternative ethical aim: to ensure the social conditions in which all individuals have the capability to be healthy. This perspective requires that we examine injustices not just by the level of healthcare resources, but by the: (1) quality of those resources and their capacity to enable effective health functioning; (2) extent to which society supports health agency so that individuals can convert healthcare resources into health functioning; and (3) nature of health norms, which affect individuals’ efforts to achieve functioning.

Projecting the Number of Patients with End-Stage Renal Disease in the United States to the Year 2015

The size of the prevalent ESRD population in the United States increased dramatically during the 1990s, from 196,000 in 1991 to 382,000 in 2000. Incidence also increased considerably during the same period, from 53,000 to 93,000 per year. If previous trends in ESRD incidence and prevalence continue, then current levels of health care resources that are devoted to the care of these patients will eventually be unable to meet the demand. This study discusses a Markov model developed to predict ESRD incidence, prevalence, and mortality to the year 2015 and incorporating expected changes in age/race distributions, diabetes prevalence, ESRD incidence, and probability of death. The model predicted that by 2015 there will be 136,166 incident ESRD patients per year (lower/upper limits 110,989 to 164,550), 712,290 prevalent patients (595,046 to 842,761), and 107,760 ESRD deaths annually (96,068 to 118,220). Incidence and prevalence counts are expected to increase by 44 and 85%, respectively, from 2000 to 2015 and incidence and prevalence rates per million population by 32 and 70%, respectively. The financial and human resources that will be needed to care for these patients in 2015 will be considerably greater than in 2005.

Hospital Reimbursement for Adult Patients with Severe Sepsis Treated with Drotrecogin Alfa (Activated)

Purpose Patients with severe sepsis are critically ill and use a high level of health care resources. The high resource utilization and lack of a specific diagnosis related group may lead to a significant loss in revenue for health care organizations secondary to inadequate reimbursement. The primary objective of this study is to quantify the difference in total cost and reimbursement in patients with severe sepsis treated with drotrecogin alfa (activated) (DAA) at our institution. Methods All patients between December 2001 and December 2003 diagnosed with severe sepsis and treated with DAA were evaluated. Demographic data, primary payer, diagnosis related group, hospital length of stay, length of medical/surgical stay, length of Intensive Care Unit stay, days on mechanical ventilation, total costs, and total reimbursement were determined by chart review and our institution's information systems. Results Data from a total of 71 patients were included. The total treatment cost was $6,294,590, and the total reimbursement received was $4,295,950. This represents a loss of $1,998,640 or $28,150 per patient. The primary factor contributing to this loss was Intensive Care Unit length of stay (P = 0.011). Conclusion Management of patients with severe sepsis is costly and strains hospital resources. The current reimbursement system does not allow for appropriate compensation. Therefore, in addition to efforts directed toward improved treatment strategies for severe sepsis, health care practitioners must target interventions to reduce hospital length of stay and maximize reimbursement.

Funding Child, Elderly Health Care Gets Widespread Support

Back to table of contents Previous article Next article Health Care EconomicsFull AccessFunding Child, Elderly Health Care Gets Widespread SupportMark MoranMark MoranSearch for more papers by this authorPublished Online:15 Oct 2004https://doi.org/10.1176/pn.39.20.0390016A majority of Americans believe that the health care needs of children and the elderly are not being met, according to a survey published in the online edition of the journal Health Affairs last month.The survey also found that many Americans assume an equal distribution of health care resources among children and the elderly, when in fact there is a significant per capita and aggregate difference favoring the elderly.There is widespread support for a strong government role in providing health care to all children and the elderly, regardless of income level, and this support cut across age groups, gender, and political party affiliation, the results of the survey indicated.According to the survey, 59 percent of adults believe that the health care needs of children are not being met, while 67 percent believe that the health care needs of the elderly are not being met. When questioned about the role government should play in financing health care for these groups, 90 percent thought that government should fund health care for all low-income children and elderly, while almost the same percentage felt that this funding should be available to both age groups, regardless of income.“People want to take care of the poor and people who have needs,” said lead study author Marc Berk, vice president and senior fellow at the National Opinion Research Center (NORC) at the University of Chicago, which conducted the survey. “In an era of likely budget deficits where there is a lot of pressure to look for ways to cut programs, this survey shows that health care is not an area that the public wants to consider cutting.”The survey was funded by the Nemours Foundation and was conducted by telephone from June 4 to 18. Using random-digit dialing, 2,013 respondents from a nationwide sample were interviewed. They were asked a series of questions concerning their views on public funding of health care programs for children and for the elderly.In addition to the survey results, the September Health Affairs offers new data on generational differences in government spending, how children are affected by downturns in the economy, and an analysis of the challenges facing the State Children's Health Insurance Program (SCHIP).At least two-thirds of those surveyed indicated that they believed that children and the elderly were already receiving the same level of health care resources. In fact, however, current per capita public spending on health care for the elderly is far higher than that for children. In 2001, for example, per capita government spending on health care for the elderly was $4,360, compared with $258 for children, the authors of the survey article noted.In an interview with Psychiatric News, Berk explained that the survey question did not specify whether people assumed equal resource allocation in per capita or aggregate terms. Rather, he said, the question was a measure of how people viewed societal priorities; that is, the responses were an indication of a general assumption that the government would not favor one group over the other, he said.“Although governmental spending on the elderly vastly exceeds that for children, most Americans, including those with a college education, do not [believe] this to be the case,” Berk and colleagues stated in their report. “When asked about the relative priority that government should place on the health care needs of children versus those of the elderly, Americans clearly do not want government to choose, with a majority indicating that government should be spending about the same on children as it does on the elderly. In light of the apparent lack of understanding about current spending, the public sentiment that supports equal funding for health care for children and the elderly should probably be interpreted not as a call for an enormous shift of resources from one group to the other but as evidence that the public considers these needs to be of equal and high priority.”A study by researchers at the University of Pennsylvania School of Medicine, also published in the same issue of Health Affairs, shows that the gap in per capita social welfare spending between children and the elderly grew 20 percent in the past two decades. The study indicates that unlike spending on the elderly, spending for children suffers during economic recessions, as evidenced by recent cutbacks in many SCHIP programs stemming from overall state budget cutbacks (see Original article: page 6).The survey report, “Americans' Views About the Adequacy of Health Care for Children and the Elderly,” is posted online at<content.healthaffairs.org/cgi/content/abstract/hlthaff.w4.446>.▪ ISSUES NewArchived

Adenotonsillectomy in children with obstructive sleep apnea syndrome reduces health care utilization.

To investigate health care utilization of children with obstructive sleep apnea syndrome (OSAS) 1 year after adenotonsillectomy (T&A). A longitudinal, case-controlled, prospective study was conducted at Clalit Health Care Services (CHS), a health maintenance organization in the southern region of Israel. We defined 3 groups of children: 1) children who had OSAS and were treated with T&A (n = 130); 2) children who had OSAS and did not undergo surgery (n = 90); and 3) control subjects who were matched by age, sex, and area of residency (n = 520) and randomly selected from the CHS database. OSAS was verified with polysomnography studies in all patients. Indices of health care utilization were analyzed 1 year before and 1 year after T&A. Medical records in the emergency department and during hospitalization were reviewed for diagnosis before the polysomnography diagnosis. Mean age of all children with OSAS was 5.6 +/- 3.6 years. Total annual health care costs were reduced by one third in children who underwent T&A, whereas there was no change in the control and untreated OSAS groups. T&A was associated with a 60% reduction in the number of new admissions, 39% reduction in emergency department visits, 47% reduction in the number of consultations, and 22% reduction in costs for prescribed drugs. In group 2, the total costs were similar in years 1 and 2. T&A significantly reduces health care utilization in children with OSAS. Untreated children with moderate and severe OSAS will continue to consume high levels of health care resources. Increased morbidity among children with OSAS is mainly related to upper respiratory tract infections.

Community characteristics associated with child abuse in Iowa

Problem: Various demographic and community characteristics are associated with child abuse rates in national and urban samples, but similar analyses have not been done within rural areas. This study analyzes the relationships between reported and substantiated rates of child abuse and county demographic, health care resource and social services factors in a predominantly rural state in the US. Methods: County-level data from Iowa between 1984–1993 were analyzed for associations between county characteristics and rates of child abuse using univariate correlations and multivariate stagewise regression analysis. Population-adjusted rates of reported and substantiated child abuse were correlated with rates of children in poverty, single-parent families, marriage and divorce, unemployment, high-school dropouts, median family income, elder abuse, birth and death rates, numbers of physicians and other healthcare providers, hospital, social workers, and number of caseworkers in the Department of Human Services. Results: Rates of single-parent families, divorce and elder abuse were significantly associated with reported and substantiated child abuse in multivariate analysis, while economic and most health care factors were not. Reporting and substantiation rates differed across districts after adjustment for multiple factors including caseworker workload. Conclusions: In this rural state, family structure is more significantly associated with child abuse report and substantiation rates than are socioeconomic factors. The level of health care resources in a county does not appear to affect these rates.

Access to health care and travel for birthing: Native American-white differentials in Montana

The location of medical services critically affects access to health care. We examine the extent to which the spatial distribution of health care resources allows expectant mothers to give birth in the county where they live or forces them to travel elsewhere for obstetrical care. We focus on native American-white differentials in access and travel because little is known about inter-racial differences involving native American Indians. Montana birth records for the period 1980–1989 are used to identify the degree to which women leave the county of residence to give birth. Thirty-seven percent of births to native American mothers involved travel, compared to 19% of births to whites. Sixty-one percent of births to whites were to mothers residing in counties with relatively high levels of obstetrical care (Level II hospitals), while that proportion for native Americans was only 18%. Of women who traveled, 65% of whites gave birth in counties with a Level II hospital, compared to 40% of native Americans. Results of logistic regression suggest that the distribution of health care facilities in the county of residence largely explains travel for birthing. Inter-racial differences in travel turn out to be minimal when the spatial distribution of health care resources is taken into consideration, and both groups act similarly when faced with the same level of health care resources. Suggestions to improve the delivery of health care in rural areas are offered.

Nursing case management: an innovative model of care for hospitalized patients with diabetes.

Cost, access, and quality are among the most pressing concerns facing the delivery of health care services in the 1990s. These issues are of particular concern for individuals with diabetes because of their high consumption level of health care resources. The purpose of this study was to evaluate whether a managed care approach could reduce the hospital stay while creating a balance between cost and quality of care.

An evaluation of subsidized rural primary care programs: II. The environmental contexts.

The placement of subsidized primary care programs in rural communities has been an important aspect of national health policy over the last decade. Using survey and secondary data from programs in over 700 counties in the United States, it was found that while about one-fourth of all counties with some rural populations have been affected by these programs, certain environmental factors are associated with more or less likelihood of placement. High levels of need and low levels of health care resources are positively associated with the presence of a program. States with health policy climates supportive of reimbursement and broader staffing of primary care programs also contained programs in a higher proportion of their rural counties. The effects of decreased federal funding, increased state responsibility, and the precarious market conditions for primary care programs are discussed with emphasis on the mechanisms for developing favorable climates for these programs.

Health insurance policy development in Denmark and Sweden 1860–1950

With a focus on the development of health insurance policy in Denmark and Sweden, the dynamic relationship between the health care system and the socio-political system is empirically studied. The study begins with a critical review of quality criteria for a health insurance program. Four factors are considered important for determining the quality of a health insurance program: 1) the scope of coverage. (2) nature of benefits, (3) mode of financing, and (4) the level of health care resources. Based on this conceptual framework, the development of the Danish and Swedish health insurance programs are analysed. Despite the general assumption that the health insurance systems of these two nations are very similar, significant differential development patterns are discovered. Particular attention is given to an investigation of the reasons why Denmark was able to achieve a well-organized primary health care system while Sweden did not succeed in this, instead developing a hospital-based health care system, and of the socio-political causes for the fact that a national health insurance program was implemented in Sweden as early as 1955, but not in Denmark until 1971. The study suggests that the health care system can be understood more comprehensively when socio-political factors are taken into account. The health care system is a dynamic function of the total social system.