In the Literature
In the United States, providers of pediatric preventive care contend with numerous barriers, including financing and reimbursement issues, lack of time and training, and a shortage of referral options for young children with possible developmental problems. Meanwhile, many parents report dissatisfaction with their child's care, unanswered questions, and unmet needs.
For the Commonwealth Fund–supported study, "Rethinking Well-Child Care in the United States: An International Comparison" (Pediatrics, Oct. 2006), researchers compared well-child care processes across 10 countries to identify practices that might be transferable to the U.S. A key finding is that unlike the U.S., where physicians provide the lion's share of a child's health care, most countries divide responsibilities among several professionals, each with specific training and expertise and funded through a variety of sources.
The research team, led by Alice Kuo, M.D., Ph.D., of UCLA's Mattel Children's Hospital, conducted literature reviews, interviews, and site visits to compare well-child care in Australia, Canada, Denmark, England, France, Germany, Japan, the Netherlands, Spain, and Sweden.
Regulation and Financing
In most of the countries, government is responsible for oversight and planning for key well-child care resources, usually on a local level—a departure from U.S. practice. All the countries, moreover, have universal health care financing for citizens, funded primarily through employer or payroll taxes.
There is no cost-sharing for preventive health examinations and immunizations in any of the countries, except France (where parents may pay a share of costs if they use private physicians) and Japan (where there is variable cost-sharing depending on the scope of employer coverage). In nearly all 10 countries, the provision of well-child care is either divided between physicians and nurses or provided exclusively by maternal and child health (MCH) nurses.
In the U.S., a single, "first-contact" clinician provides health supervision and anticipatory guidance, immunizations, and developmental screening. But in the other 10 countries, the first-contact professional varies depending on the component of care. MCH nurses, public health nurses, or health visitors are the most common first point of contact, with pediatricians serving mainly as specialists for developmental or behavioral issues and chronic conditions.
Most countries, the authors note, assign little value to coordination among care providers, in sharp contrast to the U.S. ideal of a "medical home" for coordinating the spectrum of services provided. Certain countries, like Sweden and Spain, provide an element of coordination through co-location in community-based centers. But in many countries, continuity in care is largely the responsibility of parents, who maintain their child's health record and bring it with them to office visits. In France, each child at birth is issued a health notebook that explains parents' responsibilities, like compliance with examination and vaccination schedules. Physicians also use them to record observations, diagnoses, and treatments.
Most countries provide some services that address maternal health and family social issues during the postnatal period. In Denmark, general practitioners often care for all members of a family; consequently, they may have greater insight into family functioning. Australia has health centers that cater to neighborhoods and plan services around the particular needs of specific populations.
Certain features of well-child care from abroad could be feasibly exported to the U.S., the researchers say. Chief among them are co-location of care and a team-based approach. Other features, meanwhile, may clash with long-held American values of privatization and choice.
Selected Well-Child Practice Features in Five Countries
Professional responsible for well-child care and other primary health care
Degree of coordination in elements of well-child care and primary care
Same location and/or provider of care over time
Focus on Family and two-generational model of care
|Australia||Community-based MCH nurses for well-child care; general-practice physicians for all other primary care||Little coordination between MCH nurses and GPs||Assigned to MCH center; usually the same nurse over time; choice of GP||Community-based MCH nurses provide social support to all families in districts (greater in Victoria than other states)|
|England||Targeted risk assessment by health visitors or nurses for developmental screening; GP linked to health visitor||Coordination of preventive and primary care between GP and health visitors attached to the general practitioner's office who observed the family setting||Patient choice of general-practice physician||Health visitors linked to general-practice physicians visit families with indentified psychosocial needs|
|France||Nurse at PMI for health supervision; pediatrician for developmental screenings using a nationally mandated tool||Portable medical chart enables physicians and local PMI agency to share information about care and concerns||Patient choice if opt for private sector; same location and usually same provider in PMI||PMI provides prenatal and postnatal care, psychosocial assessment, and support for families|
|Netherlands||Child health doctors conduc pediatric developmental screenings using a nationally mandated tool||General practitioners and nurses provide preventive health services||Same health center location and nurse; limited use of the same physician||Minimal explicit family orientation|
|Sweden||Community-based public health nurses provide well-child care; general practitioners provide the rest of primary care services||Public health nurses and general practitioners provide preventative health services including well-child care||Same health center location and usually the same nurse||A direct two-generational approach for behavioral|
Source: Adapted from A. Kuo et al.