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Rethinking Well-Child Care in the United States: An International Comparison

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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.

Practice-Level Features
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

CountryFirst Contact—
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
Family Centered—
Focus on Family and two-generational model of care
AustraliaCommunity-based MCH nurses for well-child care; general-practice physicians for all other primary careLittle coordination between MCH nurses and GPsAssigned to MCH center; usually the same nurse over time; choice of GPCommunity-based MCH nurses provide social support to all families in districts (greater in Victoria than other states)
EnglandTargeted risk assessment by health visitors or nurses for developmental screening; GP linked to health visitorCoordination of preventive and primary care between GP and health visitors attached to the general practitioner's office who observed the family settingPatient choice of general-practice physicianHealth visitors linked to general-practice physicians visit families with indentified psychosocial needs
FranceNurse at PMI for health supervision; pediatrician for developmental screenings using a nationally mandated toolPortable medical chart enables physicians and local PMI agency to share information about care and concernsPatient choice if opt for private sector; same location and usually same provider in PMIPMI provides prenatal and postnatal care, psychosocial assessment, and support for families
NetherlandsChild health doctors conduc pediatric developmental screenings using a nationally mandated toolGeneral practitioners and nurses provide preventive health servicesSame health center location and nurse; limited use of the same physicianMinimal explicit family orientation
SwedenCommunity-based public health nurses provide well-child care; general practitioners provide the rest of primary care servicesPublic health nurses and general practitioners provide preventative health services including well-child careSame health center location and usually the same nurseA direct two-generational approach for behavioral
and social issues is usedPMI = Protection maternelle et Infantile (national agency that covers maternal and child health care); MCH = maternal and child health
Source: Adapted from A. Kuo et al.

Publication Details

Editor: Alice Kuo
Citation: Pediatrics