Key Components of an Ideal Healthcare System

“It is health that is real wealth and not pieces of gold and silver.”

Mohandas K. Gandhi

OBJECTIVES

After completing this chapter, the reader will be able to:

1. Compare and contrast population health statistics for the United States, Sweden, Japan, and the United Kingdom.

2. Compare and contrast the major health issues and healthcare systems of the United States, Sweden, Japan, and the United Kingdom.

3. Relate healthcare disparities within and among the countries of the United States, Sweden, Japan, and the United Kingdom.

4. Discuss the high rates of longevity for residents of Japan and Sweden.

INTRODUCTION

This chapter gives examples of developed countries and their major health issues and trends. Many of the health issues will be reviewed in greater detail within other chapters of this text. These countries were chosen because they vary in terms of their healthcare systems and geographic areas.

Many of the developed countries are currently working on controversial legal, religious, and ethical issues that directly relate to health care and healthcare systems of delivery. Specifically, the following topics are being addressed:

▀ Access to health care for all residents

▀ Issues of funding for nonlegal residents (illegal aliens) and healthcare services provided by government and nongovernment organizations

▀ Options for termination of an unwanted pregnancy

▀ A woman’s right to determine what happens to her body (birth control, abortion, contraception, genital mutilation, sexual assault and/or abuse, sterilization, child molestation, prostitution)

▀ Sex education in schools, clinics, and public health facilities

UNITED STATES

Location

The United States is located in North America, bordering both the Atlantic and Pacific Oceans, between Canada in the north and Mexico in the south. It includes 50 states, the District of Columbia, and several territories and possessions.

Population statistics

The U.S. population as of 2010 was 303,500,000. In 2050, it is projected that the U.S. population will be third largest in the world, after China and India (U.S. Census Bureau, 2010).

Economy

The United States has the largest and most technologically powerful economy in the world, with a per capita gross domestic product (GDP) of $47,000 annually in 2007 ($2.2 trillion in total), ranking tenth in world income (Central Intelligence Agency [CIA], 2009). In this market-oriented economy, 12% of the population lives below the poverty line. The unemployment rates vary among ethnic groups, gender, socioeconomic groups, and geographic locations.

The United States is the leading industrial power of the world, highly diversified and technologically advanced. Its products include steel, petroleum, motor vehicles, aerospace, telecommunications, chemicals, electronics, food processing, consumer goods, lumber, and mining. Products include wheat, corn, other grains, fruits, vegetables, cotton, beef, pork, poultry, dairy products, forest products, and fish.

Health Trends and Issues

Monitoring the health of any country is essential for identifying and prioritizing public health and research needs. It is necessary for identifying important information such as diseases and conditions and for determining new health policy priority areas, funding, and programs. The overall health of the United States is improving because of funding devoted to health education, public health programs, health research, and health care. In 2007, U.S. men could expect to live 3.5 years longer and U.S. women 1.6 years longer than their counterparts in 1990. Longer life expectancies are considered desirable with healthy aging, but aging often is accompanied with an increase in chronic diseases such as hypertension, diabetes, renal disease, cancer, and Alzheimer’s disease and other dementias (Centers for Disease Control and Prevention [CDC], 2009).

In 2007, the U.S. infant mortality rate was 6.77 infant deaths per 1000 live births, 27% lower than 1990. Yet there remains a disparity in infant mortality based on race and ethnicity: Infant mortality was highest among non-Hispanic African Americans, with a rate of 13.63 deaths per 1000 live births (CDC, 2009).

During the past 50 years, many diseases have been eradicated or greatly controlled in the United States. Heart disease deaths have declined because of public health education emphasizing healthy lifestyles, such as decreasing cigarette smoking, lowering cholesterol through medications and diet, and new technology in heart procedures and surgery. Despite the fact that the 1964 U.S. Surgeon General’s report was published more than 45 years ago, 25% of men and 20% of women in the United States continue to smoke. With respect to infectious diseases, HIV/AIDS rates have declined because of the introduction of antiretroviral medications. Home, workplace, and motor vehicle safety have also helped to extend lives by lowering unintentional injuries for adults and children. Rates of acute infectious diseases of children such as measles, mumps, and rubella have decreased due to immunizations (CDC, 2009).

The U.S. healthcare system is not cost-effective given the amount of money spent yearly. The United States spends more on health care than any other developed country ($1.7 trillion annually) in the world—approximately $5267 per person per year. Neither public nor private funding at this level can be sustained indefinitely.

The United States clearly is the leader in healthcare spending as a percentage of GDP. Figure 2-1 shows per capita health expenditures for 2008 in U.S. dollars purchasing power parity. Health spending per capita in the United States is much higher than in other developed country.

In spite of these large expenditures on health care, a growing number of Americans—often referred to as the working poor—are “caught in the middle,” earning too much money to be eligible for Medicaid, not being old enough for Medicare, yet not earning enough to pay for a private healthcare policy. In addition to these cost issues, accessing health care presents a problem in the United States. The life expectancy in the United States is lower than in many other developed countries. For example, the life expectancy in Japan is 82.1 years, the life expectancy in Germany is 79 years, the life expectancy in Switzerland is 81.3 years, and the life expectancy in the United Kingdom is 79 years. By comparison, the life expectancy in the United States is 78 years (Organisation for Economic Co-operation and Development [OECD], 2010).

FIGURE 2-1 Total Health Expenditure per Capita, U.S. and Selected Countries, 2008

Source: Organisation for Economic Co-operation and Development (2010), “OECD Health Data”, OECD Health Statistics (database).

U.S. infant mortality in 2011 was 6.06 deaths per 1000 live births, which is not an especially good rate, considering that other developed countries—such as Sweden, Japan, France, Italy, Spain, Finland, Norway, and many others—have much lower rates (CIA, 2011). The United States also has one of the highest rates of all types of cancers and one of the highest obesity rates. Medical errors injure 1.5 million people annually (Institute of Medicine, 2011).

Population Characteristics

The racial and ethnic composition of the United States has changed in recent decades. Notably, the Hispanic (Latino) population and Asian and Pacific Islander ethnic groups have grown rapidly. In 2012, the Hispanic population became the largest ethnic minority, representing 16.3 % of the total population, and the Asian subpopulation accounted for 5.6% of the total U.S. population. During the past 50 years, the U.S. population of adults age 75 and older grew from 3% to 6%, and by 2050, the older adult population is projected to make up 12% of the total population. In 2002, more than 50% of African American and Hispanic children and those older than 65 years lived at or near poverty levels (CDC, 2004a; Pew Hispanic Center, 2012; U.S. Census Bureau, 2011a).

Health Risk Factors

Obesity increases the risk of heart disease, diabetes, and stroke. Alcohol consumption and illicit drugs increase the risk of disease and injuries, whereas cigarette smoking increases the risk of lung cancer, heart disease, emphysema, and other diseases. Regular exercise can reduce the risk for many diseases and enhance mental health functioning. Nevertheless, the rates of overweight and obesity can be seen to have more than doubled among U.S. school-aged children, 6–11 years, and more than tripled among adolescents, when comparing the periods 1976–1980 and 2005–2006. Also, among adults 20–74 years of age, the obesity rates have more than doubled for similar-year differences (CDC, 2009).

The rates of nonfatal workplace injuries and illnesses were 50% lower in 2007 as compared to the corresponding rates in 1989. In 2007, there were 36,000 new HIV/AIDS cases in the United States. Males 13 years and older accounted for 70% of all cases and African American males accounted for 31% of all new cases; African American females accounted for 17% of all new cases. Adults living below the poverty level were four times more likely to have serious psychological stress as compared to those living at twice the poverty level or higher (CDC, 2009).

Table 2-1 shows the leading U.S. health indicators as indicated by the CDC in its Healthy People 2010 goals (CDC, 2010b). Table 2-2 summarizes the leading causes of death in the United States in 2009 (CDC, 2010c).

TABLE 2-1 Leading U.S. Health Indicators According to Healthy People 2010

1. Physical activity

2. Overweight and obesity

3. Tobacco use

4. Substance abuse

5. Responsible sexual behavior

6. Mental health

7. Injury and violence

8. Immunization

9. Access to health care

Source: CDC, 2010b.

TABLE 2-2 Leading Causes of Death in the United States, 2009

1. Heart disease: 616,067 deaths

2. Cancer: 562,875 deaths

3. Stroke (cerebrovascular diseases): 135,952 deaths

4. Chronic lower respiratory diseases: 127,924 deaths

5. Accidents (unintentional injuries): 123,706 deaths

6. Alzheimer’s disease: 74,632 deaths

7. Diabetes: 71,382 deaths

8. Influenza and pneumonia: 52,717 deaths

9. Nephritis, nephrotic syndrome, and nephrosis: 46,448 deaths

10. Septicemia: 34,828 deaths

Source: CDC, 2010c.

Utilization of Health Care

According to the CDC (2004b), the U.S. healthcare system has undergone a dramatic change over the last decade. New technology, drugs, procedures, and tests have changed the manner in which care is delivered. The growth of ambulatory surgery has been influenced by improvements in noninvasive and minimally invasive techniques. The growth of managed care and limits on payment by insurers and other payers represent an attempt to control healthcare costs, which has also had a major impact on healthcare utilization.

The following are factors that decrease the utilization of health care (CDC, 2004a):

▀ Decreased supply of hospitals and healthcare providers

▀ Improvement in public health and sanitation, such as cleaner water

▀ Better public health education of risk factors and methods to make behavioral changes to reduce risks

▀ New treatments or cures for diseases

▀ Public policy or guidelines that recommend decreased utilization

▀ Shifts of care sites, such as from inpatient to outpatient surgery

▀ Payer pressures to decrease costs

▀ Changes in practice patterns, such as those that emphasize more self-care, alternative sites, or alternative medicine

The following are factors that increase the utilization of health care (CDC, 2004a):

▀ Increased supply of healthcare facilities and providers

▀ Population growth

▀ Aging of the population

▀ New procedures and technologies

▀ Guidelines or policies that recommend increased utilization

▀ New threats, such as HIV or bioterrorism

▀ New drugs

▀ Increased healthcare coverage

▀ More aggressive treatments for patients

▀ Changes in consumer demand, such as for cosmetic surgery and hip replacements

Many types of preventive care or treatment of illnesses are performed at an increasing rate in outpatient clinics or physicians’ offices. For example, the use of prenatal care services, which begins in the first trimester of pregnancy, has been steadily rising. The percentage of children receiving their childhood immunizations is at a high level. The chickenpox vaccine (varicella) has been widely distributed as well. Women are getting Pap smears and mammograms at increasing rates, and older adults are increasingly getting vaccines for influenza and pneumonia (CDC, 2004a).

At the same time, inpatient healthcare utilization has been declining. Admissions and length of hospitalization stays have decreased. Many procedures that were traditionally done within the hospital are now performed in clinics, physicians’ offices, outpatient surgery centers, and rehabilitation centers, leaving more complex procedures and illnesses to be treated within the hospital. Inpatients now have higher acuity levels whereas inpatient mental health treatment has significantly declined (CDC, 2004a).

Healthcare Resources

Use of healthcare resources is partially determined by the quantity of healthcare providers and the infrastructure. Although the number of healthcare providers in the United States has increased, they are unequally distributed, with most often being found in large urban centers rather than isolated rural areas. Proportionately, there were a higher percentage of healthcare specialists in 2006 as compared to 1993. Since 1990, the number of inpatient mental health hospital beds has decreased by 45%, compared to the number available in 2004 (CDC, 2009).

Healthcare Access Disparities

The best health care in the world is meaningless to those who do not have access to health insurance coverage or who cannot afford it. The continued increases in healthcare costs combined with economic changes have caused a number of U.S. residents to go without any health insurance, giving them less access to health care.

A health disparity is a statistically significant difference in health indicators that persists over time, between groups—for example, maternal and infant mortality. A health disparity also comprises an unequal burden of disease morbidity and mortality often found in racial, ethnic, or socioeconomic groups as compared to the dominant group. Examples of U.S. health disparities include the following:

▀ Infant mortality: Mortality rates for African American babies remain nearly 2.5 times higher than the corresponding rates for white babies.

▀ Life expectancy: African American men and women have nearly 10 fewer years of life than their white counterparts.

▀ Death rates attributable to heart disease, stroke, prostate and breast cancer: Rates are significantly higher for the African American population, and diabetes rates are more than 30% higher among Native Americans and Hispanics than among whites (CDC, 2004a, 2010a; Smedley, Stith, & Nelson, 2003; Sridhar, 2005).

Healthcare disparities exist across racial, ethnic, and socioeconomic groups. Racial and ethnic minorities and low-socioeconomic groups tend to receive lower-quality health care than whites, even when insurance status, income, age, and illness severity are comparable. To decrease these healthcare disparities, the United States needs to increase the awareness of the problems among providers, insurers, and policy makers; promote consistency and equity of care; and strengthen the culturally competent healthcare approach and improve diversity of the healthcare workforce to increase patients’ choices for healthcare providers. Measurement of health and healthcare quality includes the following considerations: (1) clinical performance measures of how well healthcare providers deliver specific services; (2) assessment by patients of how well providers meet their healthcare needs; and (3) outcome measures that may be affected by the quality of health care received, such as death rates from cancers preventable by screening (CDC, 2004a, 2010a; Smedley et al., 2003; Sridhar, 2005).

Causes of healthcare disparities in the United States include unequal and inadequate access to insurance coverage. Health insurance directly affects access to health care regardless of race, ethnicity, or socioeconomic status. When they lack insurance, many people will go without medical care because they cannot afford to pay out-of-pocket for care. Minority groups and persons without a regular source of health care are less likely to access care. Low-income and uninsured individuals are particularly unlikely to access health care. Low-income immigrant minorities, in particular, may be unable to obtain health insurance through programs such as Children’s Insurance Program (CHIP).

Physical barriers to accessing health care include inadequate or no transportation to healthcare services and long waiting times for seeing a healthcare provider. Scarcity of healthcare providers and pharmacy services in inner-city and isolated rural areas where there are higher concentrations of minority populations are major issues as well.

Language barriers create additional barriers. Persons with limited or no English speaking and understanding abilities are less likely to be able to set up an appointment for medical care and, therefore, tend to rely on emergency rooms for care when vitally needed (CDC, 2004a, 2010a; Smedley et al., 2003; Sridhar, 2005). Lack of English skills also inhibits comprehension of healthcare advice and contributes to lack of health literacy. Health literacy is the ability to obtain, process, and understand basic health information so as to make appropriate health decisions; it is needed to access healthcare systems. A larger number of minority patients have challenges in health literacy.

Lack of diversity in healthcare providers can also be a problem. Minority patients, when given a choice, tend to be more comfortable with healthcare providers who are more like themselves and know their culture and language, as well as their health beliefs and practices. Collectively, minority groups in the United States represent 25% of the population, yet members of minorities account for less than 9% of nurses, 6% of physicians, and only 5% of dentists (CDC, 2004a, 2010a; Smedley et al., 2003; Sridhar, 2005).

In its 2004 report, the Sullivan Commission noted that racial and ethnic disparities in healthcare delivery are related to differences in treatment by healthcare providers. Minority groups are less likely than whites to be given appropriate cardiac medicines or to undergo cardiac bypass surgery when necessary. Compared to whites, they are less likely to receive renal dialysis or transplants, the best diagnostic tests, treatment for a stroke or cancer, or the best treatment for HIV/AIDS. Moreover, they often distrust healthcare providers (the majority of whom are white), receive care from less adequate health facilities, and are treated by lower-quality (in terms of education and experience) healthcare providers than whites. African Americans are more likely than whites to seek care from hospitals that have fewer resources and up-to-date technology, have higher surgical mortality rates, and have higher neonatal mortality rates. African Americans are also more likely to receive care from physicians with less training, have less access to specialist physicians, have higher rates of breast and prostate cancer due to less screening, and receive later care and have less access to care. Perhaps not surprisingly, the cancer incidence for African Americans is 10% higher than for whites.

The overall health statistics for all ethnic and socioeconomic groups in the United States have, in many cases, improved, yet some health statistics indicate worsening situations. Based on CDC (2010a) data, Table 2-3 compares U.S. health statistics from 2000 (left column) with more recent statistics (middle and right columns) for 2006–2009.

The United States has also been growing more racially and ethnically diverse, and its residents are living longer. The National Center for Health Statistics (CDC, 2004a) has pointed out major areas where disparities exist between race and ethnicity and socioeconomic status. Those residents who live in poverty are more likely to be in poor health and less likely to receive adequate health care. Poor people are four times more likely to have psychological stress. There are large disparities in infant mortality rates and life expectancy rates between those persons living in poverty and the remainder of the population. In addition, adults younger than 64 years who are Latino or Native American (American Indian) are more likely to be uninsured than members of other racial or ethnic groups. Diseases and medical conditions such as diabetes or obesity increase with age and are more likely to occur in non-Hispanic blacks and Latinos than in non-Hispanic whites. Some of these disparities may be the result of differences in socioeconomic status, culture and health practices, stress, environmental exposures, discrimination, and access to health care (CDC, 2004a).

TABLE 2-3 U.S. Health Statistics, 2000 and 2006–2009

Peterson, Wright, and Peterson (2002) studied the utilization of interventional cardiac procedures among African American and Caucasian patients; their findings revealed that African Americans had far fewer cardiac interventions and procedures. Dr. David Satcher (former U.S. Surgeon General) and colleagues (2005) reported that from 1960 to 2000, the United States made progress in decreasing the black–white gap in civil rights, housing, education, and income, but inequality still exists in health care and general health status.

A study conducted by Callahan and Cooper (2005) revealed that young adults, 19–24 years old, are the most likely to be uninsured in the United States. These researchers collected data from 11,866 subjects. Their results indicated that 27% of women and 33% of men had no health insurance. Thus almost one-third of the young adults in the United States are uninsured. Only half of the employers of this group pay any health insurance for their employees. As a consequence, these young adults are more likely to be uninsured—even though they are at the highest risk of all age cohorts for unintended pregnancy, sexually transmitted diseases, substance abuse, injuries, and other chronic medical diseases. Lack of insurance in adults is related to less frequent healthcare screenings, delayed diagnosis of illnesses such as cancer, poor care for chronic diseases, and higher rates of mortality when hospitalized. According to Callahan and Cooper (2005), Latino young adults are more likely to be uninsured than any other ethnic group.

Clearly, there are significant disparities in accessing health care in the United States based on race, ethnicity, and socioeconomic status. Those living in poverty are significantly less likely to access health care and are generally in poorer health than others. In addition, those in poverty are four times more likely to have serious mental health problems. Infant mortality rates and life expectancy rates also differ among racial and ethnic groups (CDC, 2004a). In essence, the United States rations health care by not providing universal coverage to its entire population. Ultimately, the United States provides less access to health care to more people than any other developed country. Those who get charity treatment are most likely to get less than adequate health care (Lamm & Blank, 2005).

Reschovsky and Staiti (2005) conducted a study that addressed both physicians’ and patients’ perspectives on quality of health care in rural America as compared to urban America. Data were collected from 12,406 physicians and 59,725 patients, representing 48 U.S. states. Results of the study indicated that rural areas had far fewer physicians than urban areas, but the overall perception was that health care was adequate for the rural areas. A decreased rural supply of healthcare providers did not necessarily mean lower quality of care. Because of the lower population density and smaller number of physicians available, patients in rural areas often had to travel longer distances for care, wait longer for appointments, and wait longer in doctors’ offices—yet there were no perceived differences in unmet medical needs within the two groups. Nevertheless, physicians in rural areas reported greater difficulty in helping patients (by referral) receive specialty medical care, when needed, owing to a lack of qualified medical specialists in rural areas. Rural residents were also poorer and more likely to lack adequate insurance or be able to pay out-of-pocket expenses for health care (CDC, 2004a).

Healthcare Expenditures

Healthcare expenses in the United States are the highest in the world, and continue to rise, due to both the cost of services and the greater number of services provided, made necessary by the country’s increasingly older population. In 2010, the United States spent 16% of its GDP on health care, compared to 11% of GDP in Switzerland, the second highest spender. Medicaid is funded by federal and state governments to provide medical care for low-income people. In 2007, 36% of health care was paid by private insurance, 14% was paid out-of-pocket, and 45% was covered by public funds (CDC, 2010a).

Overall Quality and Future Needs of u.s. Health Care

The quality of U.S. health care is less than desirable. There is a substantial gap between the best of health care that can be provided to some individuals and that which is routinely delivered to many people. Reports indicate that 95% of hospice patients receive the right amount of pain medications, yet only 8% of alcoholic patients needing treatment receive care in a special facility. The median level of receipt of needed services is 58%. In spite of efforts to focus on effective prevention and chronic illness care, the U.S. health-care system performs better in making patient diagnoses and treating acute illnesses, such as myocardial infarctions (heart attacks), than in providing outpatient treatments for chronic diseases such as cancer and diabetes. For those without health insurance, the healthcare situation is even worse. The median level of receipt of health care for the uninsured is 50% compared to 65% among people with health insurance. Persons 65 years and older are excluded from these statistics because most have Medicare. In addition, the data do not take into account the current recession (CDC, 2010a).

Patient safety remains a major healthcare problem and clearly needs improvement. In 2008, approximately one of every seven hospitalized Medicare patients experienced one or more adverse events. Nosocomial infections (infections acquired during hospital care) are, by far, the most serious problem.

Health care varies not only with types of health insurance, but also with geographic location. There are wide variations in the quality of care provided throughout the country. The upper Midwest and New England regions have the highest quality of health care, while the Southwest and South Central regions of the country tend to have lower-quality health care. Quality of health care appears to be improving, albeit at a very slow rate. Outcome measures related to quality health care are also improving (CDC, 2010a).

Infectious diseases remain a great cause of morbidity and mortality. The numbers of measles and rubella cases have decreased because of an increase in vaccinations, but some communicable diseases such as chlamydia have increased. In addition, the incidence of new infectious diseases such as H1N1, SARS, H5N1, avian influenza, and some drug-resistant bacteria strains, such as methicillin-resistant Staphylococcus aureus (MRSA), has increased. Influenza and pneumonia remain major causes of death, and HIV/AIDS continues to spread (CDC, 2010a).

The removal of barriers to receiving health care is greatly needed in the United States. Lack of health insurance continues to represent the major barrier to quality health care. The Office of Healthcare Reform is leading the government effort to improve healthcare access and quality for all residents of the country. Health information technology is needed to support these quality improvements (CDC, 2010a).

Medication Usage

Utilization of medications differs according to third-party coverage (insurance) and availability. Nearly half of the U.S. population takes at least one prescription medication, and almost one in six takes three or more medications. These medications are predominately prescribed for lowering cholesterol to reduce the risk of heart disease, controlling depression, and/or controlling diabetes. The number of people taking medications and the number of medications taken both increase with age, with five out of six people who are 65 years or older taking at least one medication and nearly half taking three or more (CDC, 2004d).

Fertility

Teenage mothers and their children are more likely to be disadvantaged and have less adequate health status than older mothers and their children. In 2002, birth rates for teenagers declined to 43 births per 1000 women, while birth rates for women aged 35–44 increased. More women are postponing birth for education and careers, and infertility interventions make it more possible for women to give birth at later ages (CDC, 2004a). From 2005 to 2007, however, birth rates rose 5% among teenagers from 40.5 to 42.5 live births per 1000 females (CDC, 2009).

Other trends differ by racial and ethnic groups. In 2002, the birth rates for Hispanic (Latina) women ages 15–44 years was 64% higher than for non-Hispanic white women, with 94.4 births per 1000 Hispanic women as compared to 57.4 births per 1000 white women (CDC, 2004a).

Health Behaviors

Rates of cigarette smoking have declined in the United States, with 22% of men and 17% of women remaining smokers (CDC, 2009). Between 1997 and 2003, the rate of teenage smoking also decreased from 36% to 22%. The rate of smoking during pregnancy, which causes a higher incidence of preterm and low-birth-weight babies, declined from 20% in 1989 to 11% in 2002 for all women, yet teenage smoking during pregnancy for 2002 was higher at 18%. Low-birth-weight babies, who have higher risks for death or disability, have also increased as a proportion of all newborns, from 7% of all births in 1990 to 7.8% in 2002 (CDC, 2004a).

Overweight and obesity have become nationwide problems among children and adults in all age groups. Obesity causes approximately 300,000 deaths per year in the United States and is perhaps second only to smoking as a preventable cause of death. Estimates of deaths from obesity are based on body mass index (BMI), which is defined as weight in kilograms divided by height in meters squared. BMI is correlated with body fat and is the measure recommended by the National Heart, Lung, and Blood Institute for use in clinical practice. Much of the overweight/obesity problem relates to trends toward inactivity and overeating, especially of the high-fat “junk” foods. In 2003, 33.3% of high school students had no moderate or vigorous physical activity, with females reporting less activity than males. Within the adult population 20–74 years of age, obesity increased from 47% in 1976–1980 to 65% in 1999–2002.

Obesity across the life span also varies by race and ethnicity. In 2002, 50% of non-Hispanic African Americans, 39% of Mexican Americans, and 31% of non-Hispanic white adults were obese. From the period 1976–1980 to the period 1999–2002, the rates of overweight and obesity in children, 6–11 years of age, rose from 7% to 16%, and for adolescents 12–19 years, the obesity rate more than tripled from 5% to 16% (CDC, 2004a, 2010a; Flegal, Williamson, Pamuk, & Rosenberg, 2004).

Alcohol use among those 18 years and older is reported by 41% of males and 20% of females, with the most common usage by 18- to 24-year-olds. The rate of illegal drug use among 12- to 17-year-olds was reported to be 12% in 2002. Males 26–34 years had a rate of 222 cocaine-related visits to emergency rooms per 100,000 (CDC, 2004a).

Morbidity and Mortality

Morbidity (disease rate) includes the limitation of activities due to chronic illness. The morbidity rate was 6–7% for U.S. children younger than 18 years during 1997–2002. As adults age, morbidity caused by chronic illness increases. In 2002, 14% of those persons 65 years and older were limited in at least one ADL (CDC, 2004a).

Mortality (death rate) reflects the statistics of life expectancy and infant mortality—the key measures to evaluate the overall health standard of a population. In the United States, there is an upward trend in life expectancy. State variations in infant mortality range from 12.6 deaths per 100,000 live births in Mississippi to 4.9 deaths per 100,000 live births in Massachusetts. Infant mortality rates (IMRs) also differ greatly by race, with highs of 20.9 deaths per 100,000 in non-Hispanic African Americans in Hawaii and 18.5 deaths per 100,000 in the District of Columbia, as compared to 2.7 deaths per 100,000 non-Hispanic whites in Hawaii and 3.2 deaths per 100,000 non-Hispanic whites in the District of Columbia. In Massachusetts, the IMR is 10.3 deaths per 100,000 live births among non-Hispanic whites (Kaiser Family Foundation, 2011).

Despite the fact that Americans smoke less, they have lowered their cholesterol levels, and deaths from heart disease and stroke are declining in the general population, deaths are not declining within specific racial and ethnic groups in the United States. Those groups who have not experienced any positive changes in their health statistics include African Americans, Hispanics (Latinos), persons who are poor, and persons with less than a high school education. African American men and women have the highest rates of hypertension, diabetes, and hospitalizations for stroke. African American women also have higher rates of obesity. Hispanics (Latinos) are most likely to lack health insurance, are less likely to receive influenza or pneumonia vaccines, and have the poorest rates of good health. Native Americans (American Indians) have the highest rates of cigarette smoking and alcohol use. Reasons for these disparities include inadequate access to health care, distrust of the healthcare providers, cultural and language barriers, and genetic predisposition to heart diseases and stroke (CDC, 2008).

American Indians/Alaskan Natives represent 1.5 percent of the total U.S. population. More than 538,000 of American Indian/Alaskan Natives (representing one third of the total American Indian/Alaskan Native population) live on reservations or other trust lands where the climate is challenging, the roads are often impassable, transportation is scarce, and healthcare facilities are difficult to access. In some areas, health services and facilities have not kept up with services and facilities in areas with white populations. In the Navajo area, the numbers of hospital beds have declined steadily; the proportion of doctors and nurses to patients has not kept up with that of the general U.S. population. About 60 percent of American Indians nationwide, rely on the Indian Health Service (IHS) to provide access to health care. Addressing barriers of access to health care is a large part of the overall IHS goal, which strives to assure that comprehensive, culturally acceptable, personal and public health services are available and accessible to American Indian and Alaskan Native persons. Diabetes and liver diseases within this population are greater than twice that of all other adults in the United States. The greatest mortality rates are due to direct and indirect effects of type 2 diabetes despite special federal expenditure programs. Compared with whites, Indians of all cultural groups, have higher levels of obesity, diabetes, and spend less time in doing physical activities than whites. A special Diabetes Program for American Indians has provided funds for prevention and treatment of diabetes, yet rates are still higher than those of whites. Compared with whites, Indians of all cultural groups have higher levels of smoking and heart disease than whites; have higher death rates of fetuses, infants, children, adolescents and young adults than other groups; have higher preterm deaths and fetal alcohol syndrome (FAS) than other groups; and have lower rates of prenatal care. Infant mortality is 1.7 times higher, and they have twice the rate of sudden infant death syndrome compared to all other US population groups. Their rates of sexually transmitted diseases are 5.5 times higher than for non-Hispanic whites. Unintentional injuries are the third leading cause of death for the 1–44 age group. Death rates for unintentional injuries and motor vehicle accidents are 1.7 to 2 times higher than rates for all other groups in the US. Suicide rates are 3 times greater than for whites of similar ages (CDC, 2008).

African-Americans have twice the uninsured rates as non-Hispanic whites. Non-Hispanic African-Americans bear a disproportionate burden of disease, injury, death, and disability. The risk factors, incidence and morbidity rates for diseases and injuries are greater than for non-Hispanic whites. Three of the 10 leading causes of deaths for non-Hispanic African-Americans are not among those listed among the 10 leading causes of deaths for non-Hispanic whites. They are homicide (sixth), HIV virus (seventh) and septicemia (ninth). The infant mortality rate for African-Americans is 13.9 per 1,000 live births as compared to 6.9 per 1,000 live births for non-Hispanic white Americans. Today, an African American baby is 2.5 times more likely to die before reaching one year of age than a non-Hispanic white American baby. Preterm birth is the leading cause of death for African-American infants. Higher pregnancy-related mortalities are found among African-American women compared to white women of similar socioeconomic status including rates of preeclampsia, eclampsia, abruptio placenta, placenta previa, and postpartal hemorrhage, leading to death. Non-Hispanic African-American women are at a higher risk for having low and very low birth weight babies. There are lower numbers of females receiving prenatal care during the first trimester of pregnancy. Compared to white American women, middle class African-American women have access to fewer financial resources, more restricted opportunities for wealth accumulation, are more likely to reside in racially segregated areas, and more are affected by lifelong legacies of childhood poverty and psychological stress due to discrimination (CDC, 2008).

Child Health

Wise (2004) revealed the following about the determinants of child health in the United States. In 2002, approximately 17% of all children and 18.5% of those younger than 6 years lived in poverty—that is, in households with incomes below 100% of the federal poverty level ($14,348 in 2002). Half of those living in poverty live at 50% of the federal poverty level, placing them within the “severely poor” group. Children who are poor disproportionately suffer more problems with low birth weight and overall higher infant and child mortality and morbidity rates. Medicaid eligibility expansion for poor children and the State Children’s Health Insurance Program (SCHIP) for poor children eligible for Medicaid have made a significant difference in facilitating access to health care for poor children.

Almost 60% of all deaths in childhood occur during the first year of life, and 40% of all deaths in childhood occur during the first month of life. Death in newborns is usually from prematurity, low birth weight, congenital anomalies, or other genetic disorders. The United States has increased the survival rates of premature babies mainly through advances in technology and establishment of neonatal intensive care units. In spite of this advanced technology, however, the United States still does not rank among the best in infant mortality rates among developed countries, mainly because of the high rate of premature births in the United States. With the ever-increasing rates of survival of premature babies also comes long-term health problems. African-American babies continue to have at least twice the infant mortality rates as white babies, a difference that is attributed to the higher rates of low-birth-weight and premature babies of African-American women who live in poverty (Wise, 2004).

The U.S. mortality rates for children have fallen sharply during the past few decades. The greatest reduction is attributable to prevention and treatment of acute infectious diseases. Unintentional injury remains the leading cause of childhood death at present in the United States, but children having complex chronic conditions have the second highest death rates. Hospitalization costs for children ages 1–18 are typically related to the following causes (ranked from highest to lowest in cost): asthma, mental disorders, trauma, respiratory infections, ear infections, other infections, epilepsy, diabetes, and congenital anomalies. Mortality rates for African-American male adolescents (15–19) have risen dramatically in recent years, mainly because of homicide and suicide. In addition, African-American children experience significant death rates from sickle cell disease (Wise, 2004).

Child health outcome trends (according to a study by the National Health Interview Survey of 40,000 households) revealed that little changed from the years 1962 to 2000 in terms of the rate of children with acute illnesses (defined as any disease that requires restriction of activity for less than 3 months). For young children, this rate remained stable; it declined slightly for school-aged children. For chronic illnesses such as asthma, type 2 diabetes, and behavioral disorders, an increase in rates has been seen during the past several decades. Obesity is now considered a chronic problem with children, and also causes other problems, such as type 2 diabetes (Wise, 2004).

The CDC reported that more children than ever had health insurance in 2003, but their parents often had less coverage (CDC, 2004c). More than 70% of indigent children younger than 18 years are covered by some form of public insurance, either federal or state. Even so, approximately 3.9 million children did not have any form of health care in 2003. More specifically, 12% of Hispanic (Latino) children, 5% of non-Hispanic African American children, and 3% of Caucasian children had no health care in that year. Also, more than 4 million children aged 2 to 17 years lacked dental care.

Blumberg, Halfon, and Olson (2004) report that the first 3 years of a child’s life are critical for development. Early exposure to malnutrition, viral infections, drugs, and environmental toxins can have harmful consequences for children’s neurological development, resulting in alterations in cognitive and emotional development. These effects are not always recognized immediately and may not be discovered until the child is older. Exposure to a compromised environment may also result in cardiovascular disease or diabetes later in adulthood. Ideally, a child who has a positive caring relationship with parents and other caregivers will have opportunities for learning skills needed throughout the child’s life. Today, however, there are great obstacles that impede many children’s progress toward a safe and healthy life. Children need regular health checkups that include immunizations and treatment for illnesses, intellectual stimulation, good nutrition, and a safe and caring home environment to ensure the best long-term outcomes.

Health Care for Older Adults

According to Lamm and Blank (2005, p. 23), “One of the challenges in America’s future is to retire the baby boomer without bankrupting the country or unduly burdening future generations.” Ways to provide health care and services to the elderly include society (the government) funding of health care or social insurance. The U.S. healthcare retirement system is now unsustainable, in part because healthcare expenditures have grown in the past 40 years at 2.5 times the rate of inflation, which is now greater than 15% of the GDP. Approximately 3 times more funds are spent on health care for the elderly than for children in the United States.

The most rapidly growing segment of the U.S. population during the past decade has been the group of people ages 65 and older. With the increases in life expectancy, more health care is needed for maintaining and improving quality of life. The United States has made progress in vaccinating 90% of children by the time they are 2 years old, but immunization rates for adults 65 years and older range from 23% to 49%, and are characterized by great racial and ethnic disparities. Influenza and pneumonia vaccines can be given in the traditional sites of physician offices or health clinics, as well as in nontraditional sites, such as grocery stores and senior centers. Recommendations from the CDC for immunizations for older adults include the following (Weber, 2004):

▀ Tetanus–diphtheria vaccine: all adults, every 10 years

▀ Influenza vaccine: adults 50 and older, annually

▀ Hepatitis A vaccine: adults at risk

▀ Hepatitis B vaccine: adults at risk

▀ Measles, mumps, and rubella vaccine: susceptible adults

▀ Varicella (chickenpox) vaccine: susceptible adults

▀ Meningococcal polysaccharide vaccine: susceptible adults

For older adults, oral health care is not covered by Medicare, and many have difficulty in accessing this care. The well elderly as well as the chronically ill elderly will need good oral care for routine cleaning, problems with tooth loss, dental caries, and periodontal diseases. Periodontal diseases are chronic and can carry organisms and spread endotoxins that cause other problems, such as systemic infections. At present, there are not enough dentists trained to meet the needs of the elderly in the United States, and many residents do not have sufficient funds to pay for these services on an out-of-pocket basis (CDC, 2004e; Lamster, 2004).

In addition to providing medical care benefits, the federal government operates a federal food and nutrition program for older adults who qualify. The U.S. government appropriates approximately $1 billion annually for all food and nutrition assistance programs for older adults, funded through the Older Americans Act (OAA). OAA nutrition programs, which are run by the U.S. Department of Health and Human Services and the U.S. Department of Agriculture, reach only 6% to 7% of the people who need them, however. By comparison, the federal government’s special Supplemental Nutrition Program for Women, Infants and Children (WIC) is funded at $5 billion and reaches approximately 50% of eligible women, infants, and children; this program began in the 1970s (Friedland, 2005a; Wellman, 2004).

Occupational Health

The total recordable cases of nonfatal occupational injury and illness incidence rate among private industry employers declined in 2010 to 3.5 cases per 100 workers—its lowest level since 2003, when estimates from the Survey of Occupational Injuries and Illnesses were first published. The preliminary count of fatal work injuries in the U.S. in 2010 was 4547. Overall, fatal work injuries are down 22 percent since 2006. Fatal work injuries due to fires and explosions increased by 65% in 2010 (U.S. Department of Labor, 2011).

Overall, much progress has been made in decreasing work-related diseases and deaths. Nevertheless, muscular and skeletal disorders remain the biggest sources of problems reported; these disorders typically come from repetitive motion injuries, which create medical problems such as carpel tunnel syndrome and back injuries. Occupations with the most repetitive motion injuries are as follows (Seminario, 2003):

▀ Truck drivers

▀ Nursing aids, orderlies, and attendants

▀ Laborers, nonconstruction

▀ Assemblers

▀ Janitors

▀ Registered nurses

▀ Stock handlers and baggers

▀ Construction workers

▀ Supervisors, sales jobs

▀ Carpenters

▀ Cashiers

▀ Maids and housemen

▀ Sales workers

▀ Clerks

▀ Welders

▀ Cooks

Vallarejo (2003) reported that of U.S. hired farm workers, who are mostly Mexican immigrants, two-thirds are living in poverty. Very few data have been collected related to their health issues. At least half of these individuals are undocumented immigrants; only 20% have any health insurance either from the government or from their employer. The Federal Migrant Health Program serves approximately 13% of all workers plus their dependent families. Only 10% receive food stamps or WIC benefits, and 13% receive Medicaid services (these federal health benefits are available for those persons deemed eligible because of their low income and number of family members, age younger than 65 years, and ineligibility to receive Medicare). Half of these workers are younger than age 29, 80% are male, and many earn less than $10,000 per year. Most migrant farm workers have only 6 years of education, and the majority have access to health care only when absolutely necessary—for example, by visiting hospital emergency rooms or clinics. Fewer than half of the workers have ever been to a dentist. The infectious diseases most often reported among these individuals typically come from parasites from poor drinking water in work camps, and the rate of tuberculosis in this group is six times greater than the rate in the general U.S. population. In addition, HIV/AIDS and sexually transmitted diseases rates among farm workers are much higher than the rates among the general U.S. population.

Complementary and Alternative Medicine

The CDC (2004f) reports that 158 million people in the United States use complementary and alternative medicine (CAM) medical interventions for health, at a cost of $230 million. One study of 31,000 adults conducted by the CDC (2004f) revealed that 36% of the U.S. adult population uses CAM. If prayer for health is also considered, the percentage rises to 62%.

CAM is defined as a group of diverse medical and healthcare systems, practices, and products that are not at present considered to be part of conventional medicine. When used with conventional medicine, such measures are considered complementary; when used alone or in place of conventional medicine, they are considered alternative. Types of CAM include services offered by providers, such as acupuncture and chiropractic, plus others that do not require a provider, such as yoga, message, special diets, vitamins, herbs, and botanical products. In addition, prayer for health is classified as a type of CAM. CAM interventions are most often used to treat back pain, colds, neck pain, joint pain or stiffness, depression, or anxiety. Fifty-five percent of U.S. residents use CAM with conventional methods, 26% use CAM at the suggestion of their conventional medical care providers, and 13% use CAM because they believe it is less expensive than conventional medicine. In addition, 28% use CAM because they believe that their conventional medicine is not helping them.

The CDC (2004f) has reported that some strong scientific evidence from randomized clinical trials supports the use of acupuncture and some herbal medicines and manual therapies. More research is necessary to prove the safety and efficacy of other practices and medicinal plants. Unregulated or inappropriate use of some CAM (traditional) medicines or practices can sometimes have harmful effects. For example, the herb ephedra (ma huang in Chinese) is traditionally used to treat respiratory congestion in China, but in the United States it has been marketed as a diet additive—a usage that has caused some deaths from heart attacks or strokes. Twenty-five percent of modern medicines are made from plants that were first used in traditional medicine. Many other traditional medicines from plants or herbs are currently being tested for prospective modern use—for example, for malaria, HIV, and sickle cell anemia.

The National Center for Complimentary and Alternative Medicine (NCCAM) of the National Institutes of Health recommends that people who are considering the use of CAM review the following key points:

▀ As an informed consumer, review the scientific studies (published in refereed journals) done of the products that are being considered for use.

▀ Consult a conventional healthcare provider before starting any use.

▀ Learn more about the background and competency of a healthcare provider who is practicing a therapy such as acupuncture.

▀ Check for health insurance coverage before starting treatments or care.

▀ Check about the components or ingredients that make the products and where they come from.

▀ Check about the safety of the manufacturing process. How does the manufacturer avoid contamination?

The U.S. Food and Drug Administration (FDA) does not require testing of dietary supplements. If dietary supplements claim to diagnose, treat, cure, or prevent disease, they are considered “unapproved new drugs” that are being sold illegally.

Payment for Health Care

Healthcare costs have been rising for several years. Expenditures in the United States on health care surpassed $2.3 trillion in 2008, more than three times the $714 billion spent in 1990, and over eight times the $253 billion spent in 1980. Controlling this growth has become a major policy priority, as the government, employers, and consumers increasingly struggle to keep up with healthcare costs (Kaiser Family Foundation, 2011). In 2008, U.S. healthcare spending was about $7,681 per resident and accounted for 16.2% of the nation’s Gross Domestic Product (GDP); this is among the highest of all developed countries. Total healthcare expenditures grew at an annual rate of 4.4 percent in 2008, a slower rate than recent years, yet still outpacing inflation and the growth in national income. Without healthcare reform, there is general agreement that health costs are likely to continue to rise in the foreseeable future. President Obama has made cost control a focus of health reform efforts under way (Kaiser Family Foundation, 2011).

Although Americans benefit from many of the investments in health care, the recent rapid cost growth, coupled with an overall economic slowdown and rising federal deficit, places great strains on the systems used to finance health care, including private employer-sponsored health insurance coverage and public insurance programs such as Medicare and Medicaid. Since 1999, family premiums for employer-sponsored health coverage have increased by 131 percent, placing increasing cost burdens on employers and workers. Workers’ wages growing at a much slower pace than healthcare costs are causing many people to face difficulty in affording out-of-pocket spending (Kaiser Family Foundation, 2011).

Government programs have been growing. For example, Medicare and Medicaid account for a significant share of healthcare spending, but have increased at a slower rate than private insurance. Medicare per capita spending has grown at a slightly lower rate, on average, than private health insurance spending, at about 6.8 vs. 7.1% annually respectively between 1998 and 2008. Medicaid expenditures, similarly, have grown at a slower rate than private spending, though enrollment in the program has increased during the current economic recession, which may result in increased Medicaid spending figures soon (Kaiser Family Foundation, 2011).

Methods to control healthcare expenditures are needed. Factors driving the growth in spending are:

▀ Technology and prescription drugs—New medical technology and prescription drugs are leading contributors to the increase in overall health spending. Some analysts state that the availability of more expensive, state-of-the-art technological services and new drugs fuel healthcare spending not only because the development costs of these products must be recouped by industry, but also because they generate consumer demand for more intense, costly services even if they are not necessarily cost-effective.

▀ Chronic disease—Health care in the United States has changed dramatically over the past century with longer life spans and greater chronic illnesses causing increased demands on the healthcare system, particularly treatment of ongoing illnesses and long-term care services such as nursing homes; it is estimated that healthcare costs for chronic disease treatment account for over 75% of national health expenditures.

▀ Aging of the population—Health expenses have increased as the baby boomers began qualifying for Medicare in 2011 and many of the costs are shifted to the public sector. Yet the aging of the population contributes minimally to the high growth rate of healthcare spending.

▀ Administrative costs—It is estimated that at least 7% of healthcare expenditures are for administrative costs (e.g., marketing, billing) and this portion is much lower in the Medicare program (<2%), which is operated by the federal government. The mixed public-private system creates overhead costs and large profits that are causing increases in healthcare spending.

(Kaiser Family Foundation, 2011)

Four major factors make up the healthcare system: (1) healthcare purchasers, which include employers, governments, and individuals; (2) medical insurance groups, which receive money from the purchasers and reimburse the providers; (3) governments, which are both insurers and purchasers through the Medicare and Medicaid programs; and (4) payers, which are both purchasers and insurers. Healthcare providers include physicians, nurses, and other healthcare professionals, along with hospitals, nursing homes, home care agencies, and pharmacies. Healthcare suppliers include the pharmaceutical, medical suppliers, and computer industries. Each dollar spent on healthcare services is an expense to payers and a source of income to providers and suppliers. Payers would like to reduce healthcare costs, whereas providers and suppliers generally resist cost containment (Bodenheimer, 2005).

Seventy-five percent of people in the United States who are younger than age 65 have private health insurance, which is mainly obtained through their place of work. Health insurance is usually provided through a managed care organization such as a health maintenance organization (HMO), preferred provider organization (PPO), or point-of-service plan (POS). For those persons who are older than 65 years, and for those who are disabled, Medicare—a federally funded program—provides health care. Medicaid—a program jointly funded by federal and state governments—provides health care for low-income individuals and families (CDC, 2004a). In 2010, the percentage of people without health insurance was 16.3 percent of the total U.S. population. Among the non-elderly, 18.4% of individuals were uninsured in 2010. During 2010, 49.9 million people were without insurance. Young adults are the age group least likely to have health insurance. However, 18–24 year olds were the only age group to experience a significant increase in the percentage with health insurance over the past year, from 70.7% in 2009 to 72.8% in 2010. This is a two percentage point increase in the share of adults 18–24 with coverage and represents 500,000 more young adults with health insurance. The Affordable Care Act allows children to remain on their parents’ plans until age 26, and this policy took effect for insurance plan renewals beginning on September 23,2010. The percentage of children under age 18 without health insurance in 2010 was 9.8%. The uninsured rate for children has decreased significantly from 12.0% in 1999, due to the substantial expansion of coverage in response to the Children’s Health Insurance Program (CHIP). Employer-sponsored insurance continues to be the largest source of health insurance coverage in 2010, covering 55.3% of the population, a decline from 56.1% in 2009 and 64.1% in 1999. Uninsured rates for Hispanics (30.7%) and blacks (20.8%) are higher than for non-Hispanic whites (11.7%) (U.S. Census Bureau, 2011b).

SWEDEN

The kingdom of Sweden is a Nordic country in Scandinavia, in Northern Europe. The present king is Carl XVI Gustaf, and the prime minister is Goran Persson. This country, having a subarctic climate, has light all summer, but very little light during the winter. It is divided into 21 different counties, each with a county administration board and a county council. Each council, in turn, is divided into many municipalities. In 2004, there were 290 municipalities in Sweden. Sweden has a very high standard of living because of its high-tech capitalism and an extensive social welfare system (Government Offices of Sweden, Ministry of Health and Social Affairs, 2004).

Sweden has one of the highest levels of health care in the world, a very low infant mortality rate, and a high average life expectancy. Those in the population who have chronic illnesses have a good quality of life due to the country’s excellent health care. Death rates from diseases such as diabetes and heart disease are declining. The older adult population is growing, and more people are able to live a higher quality of life than in previous years (Government Offices of Sweden, Ministry of Health and Social Affairs, 2004).

Healthcare System

The goal of the Swedish healthcare system is for the entire population to have equal access to good health care, which is provided to all citizens based on need, and funded by the Swedish government. The government health welfare system includes health and medical care, care of the elderly, pharmaceutical care, psychiatric care, and dental care. The healthcare system is directed by the Medical Responsibility Board, the Pharmaceutical Benefits Board, the Medical Products Agency, the National Board of Health and Welfare, the Swedish Council on Technology Assessment in Health Care, and the state-owned National Corporation of Swedish Pharmacies (Government Offices of Sweden, Ministry of Health and Social Affairs, 2004).

Health care is administered by 21 different county councils throughout the country. Eighty-nine percent of the councils’ budgets is used for health and dental care. Municipalities are responsible for care of the elderly and psychiatric care. For those needing psychiatric care, the municipalities also take care of their housing, employment, and financial support. Healthcare agencies within Sweden consist of 9 regional hospitals, 70 county and provincial hospitals, and 1000 health centers. Expenditures on health care amount to 9.1% of the GDP, which is equal to $196.8 billion. The out-of-pocket costs paid by patients represent 15% of the total healthcare expenditures (Government Offices of Sweden, Ministry of Health and Social Affairs, 2004).

There are different categories of charges for health care within the Swedish healthcare system:

▀ Outpatient healthcare charges. Charges are applied to visits to a district nurse, doctor, or specialist. Costs vary among the different councils and depend on the type of healthcare provider used. The maximum that any one person pays for health visits per year is 900 SEK ($115); this maximum cost also includes children younger than age 18 within the same family.

▀ Pharmaceutical charges. The maximum cost per year for medications is 1800 SEK ($230). After this cost is reached, a free pass is given, which is good for 12 months from the date of the first purchase.

▀ Charges for a portion of dental treatments. These charges vary depending on the type of treatment and materials used. This category also includes orthodontia work.

▀ Costs for inpatient care. When a patient is admitted to a hospital, the local council can charge the patient a maximum of 80 SEK ($10.24) per day (Government Offices of Sweden, Ministry of Health and Social Affairs, 2004).

Sweden has an extensive social welfare system in which the government pays for child care, maternity and paternity leave, healthcare costs above a ceiling amount, retirement pensions, and sick leave. Parents get 480 days paid leave of absence from their jobs from the time of the birth of a child to his or her eighth year. Child care is free and guaranteed for all children 1–5 years old. For the aging adult, the Swedish Social Security Insurance Agency provides an old-age pension. It also provides for loss of income if a person is unable to work because of illness or because of caring for a child (Government Offices of Sweden, Ministry of Health and Social Affairs, 2004).

During the 1990s, Sweden’s welfare state was in crisis due to economic challenges and lack of political support. Some spending cuts and reforms were made, but the healthcare system was left mostly intact. For the first time, however, the private healthcare sector competed with the public healthcare providers. The new private healthcare services (which represent 5% to 15% of all health care) began to somewhat undermine the egalitarian system of equal quality health care for all the citizens. At present there are choices of health services, and wealthier citizens often use private healthcare services while lower-income individuals use the public health services (Government Offices of Sweden, Ministry of Health and Social Affairs, 2004).

Statistics

The country of Sweden has a population of 9.5 million people. Its gross national product per capita is $27,271, which is ranked as the 26th highest in the world. Life expectancy at birth is 78 years for males and 83 years for females. Healthy life expectancy is 71.9 years for men and 74.8 years for females. The infant mortality rate (prior to 12 months of age) is 3 deaths per 100,000 live births, which is among the lowest in the world. The child mortality rate (prior to 5 years of age) is 5 deaths per 100,000 males and 3 deaths per 100,000 females. Total health expenditures per capita amount to $2512. The total fertility rate is 1.6. Because Sweden has socialized medicine, the government pays 85.3% of the total health expenditures incurred by the country’s citizens. The remaining 14.7% of healthcare expenditures is paid privately in the form of out-of-pocket payments. Approximately 23% of the Swedish population is 60 years old or older (WHO, 2005).

Dental Care

The dental health of Sweden has improved considerably for all age groups over the last few decades. The number of children who need tooth fillings has declined, as has the number of older adults who need total tooth extractions. Many differences persist in the level of dental care among county councils, however. The criteria for good dental care are as follows:

▀ Having high standards with a particular emphasis on preventive care

▀ Satisfying safety concerns

▀ Being easily accessible

▀ Respecting patients’ rights

▀ Having good communication between patients and dental healthcare personnel (WHO, 2005)

Mental Health

The Swedish government takes responsibility for providing mental health care as a part of basic health and medical care. Patients with slight or moderate mental health needs can get care from primary care healthcare providers. Compulsory mental health care is regulated by the Compulsory Mental Care Act. Under this act, patients with serious mental health problems are treated in a special psychiatric care setting, even if they refuse care. This is especially true if the individual threatens the personal safety, physical safety, or mental health of others. Forensic mental health care includes care for people who have committed serious crimes and for those who suffer from mental illness (Government Offices of Sweden, Ministry of Health and Social Affairs, 2004).

Sex Education

Sweden is a pioneer country in terms of family planning. In Sweden, attitudes toward teenage sex education are considered liberal. Sex education is a high priority and has been taught in schools since the 1950s. Since 1975, abortion has been free and given on demand. Contraceptive counseling is free, and Planned Parenthood services are available in youth clinics. Screening for sexually transmitted diseases is included in these services as well. Contraception and emergency contraception are low in cost and sold over the counter. Teenage pregnancy is rare. Since the 1990s, however, the Swedish economy has been stagnant and rates of teen abortions, sexually transmitted diseases, smoking, and drug use have increased (Edgargth, 2002).

JAPAN

Background

Japan (also known as “Nippon”) is an island-nation, made up of four main islands and 4000 smaller islands located in the Pacific Ocean, east of the Sea of Japan, China, North Korea, South Korea, and Russia, and north of Taiwan. The four largest islands—Honshu, Hokkaido, Kyushu, and Shikoku—account for 97% of Japan’s area. Most of the islands are mountainous, and many are volcanic. Approximately 70% to 80% of the country is covered with forests and mountains and, therefore, is unsuitable for agriculture, industry, or residential use; as a consequence, the habitable areas, which are mainly located on the coasts, have very high population density. The population of Japan exceeds 127 million—making Japan home to the world’s tenth largest population. Tokyo, the capital city, in combination with its surrounding smaller cities, has a population of more than 30 million, making it the largest metropolitan area in the world.

Japan is organized into 47 prefectures, each of which is overseen by an elected governor, legislature, and administrative bureaucracy. Each prefecture is divided into cities, towns, and villages. Japan has a constitutional monarchy with very little power, and an elected parliament, called the Diet. The prime minister of Japan is the head of state.

Until recently, Japan had the world’s second largest economy, but China has now taken its place in the number 2 spot, making Japan the third largest economy. (The United States remains the largest economy.) Japan is the world’s fourth largest exporter and fifth largest importer. It is the only Asian country in the G8 (Group of Eight) and currently serves as a nonpermanent member of the UN Security Council. Japan officially renounced its right to declare war but still maintains a large military for peacekeeping and self-defense purposes. It is a developed country with a very high standard of living.

Japan has the world’s highest life expectancy and the third lowest infant mortality rate. The country’s unemployment rate is at 4%, and Japan’s workers get the highest salary per hour in the world. Some of the largest businesses in Japan include Toyota, Nintendo, Canon, Honda, Sony Panasonic, Sharp, and Japan Oil. In addition, Japan is one of the world’s leaders in scientific research, including technology, machinery and biomedical research.

Population

Within Japan’s population of 127.3 million, the largest group comprises the Yamoto people, the main ethnic groups are the Ainu and Ryukyuan peoples, and the main social ethnic group is the Burakumin.

Today many young Japanese choose not to marry and have children, and the population is expected to drop to 100 million by 2050. As of 2008, Japan’s per capita GDP was $34,200. Approximately 84% to 96% of the population practice both Buddhism and Shintoism; a small minority practice Christianity, Taoism, Confucianism, or Buddhism. Most people speak Japanese, and most children today learn both Japanese and English in school. Approximately 75.9% of Japanese children finish high school and attend a university or trade school. The educational system is very competitive, particularly for entrance into universities (CIA, 2010; WHO, 2010).

Health and Health Care

Japan has the highest life expectancy rates in the world: 79 years for males and 86 years for females. The leading cause of death in people younger than age 30 is suicide; in 2009, the number of suicides in Japan exceeded 30,000 for the twelfth straight year. The infant mortality rate is 2.8 deaths per 1000 live births, also one of the lowest rates in the world. The number of physicians per 10,000 people is 21.

Government health expenditures represent 17.9% of total government expenditures. In 2006, total per capita expenditures for health amounted to $2514, compared to a gross national income per capita of $32,840. Mandatory universal healthcare coverage is provided to all residents by a national, employer-based insurance system. Medical care is based on cost sharing, but is free for those on welfare support and living below the poverty line. Long-term care for everyone older than age 65 covers home care, respite care, or institutional care, which is financed by public and private buyers, with premiums based on income and ability to pay. Cash payments are given to mothers to cover pregnancy care because there is no maternity care health insurance coverage.

Japan provides universal coverage to all residents through three broad categories of insurance: employer-based insurance, national insurance, and insurance for the elderly. These programs are financed primarily by the national government, private employers, and individual coinsurance payments, but the services are delivered through a mostly privately operated hospital and clinic system. All programs cover a broad range of services, including inpatient and outpatient care, dental care, and some pharmaceuticals. The programs cover little preventive care, however. All programs place a cap on the amount of out-of-pocket spending health consumers may incur in a year (CIA, 2010; NationMaster.com, 2010; WHO, 2010).

Healthcare System

Japan’s healthcare system is characterized by universal coverage; free choice of healthcare providers for patients; a multi-payer, employment-based system of financing; and a predominant role for private hospitals and fee-for-service practices. Virtually all residents of Japan are covered without regard to any medical problems; that is, predisposing conditions or risks for illnesses do not affect coverage. Premiums are based on income and ability to pay. Control of the delivery of care is left largely to medical professionals, and there appears to be no public concern about healthcare rationing (CIA, 2010; WHO, 2010).

The healthcare system in Japan provides healthcare services, including screening examinations for particular diseases. Patients pay 30% of the cost of prenatal care and infectious disease control, and the government pays the remaining 70%. Payment for personal medical services is offered through a universal healthcare insurance system that provides relative equality of access, with fees set by a government committee. People who do not have insurance through their employers can participate in a national health insurance program administered by local governments. Patients are free to select physicians or facilities of their choice and cannot be denied coverage. Hospitals, by law, must be run as nonprofit entities and be managed by physicians (CIA, 2010; WHO, 2010).

Japan has 15.8 inpatient hospital beds per 1000 persons. In contrast to the high number of hospital beds, the country has only 21 physicians per 10,000 people. In 2007, Japan had 95 nurses per 10,000 people. The country has a low rate of hospital admissions; once hospitalized, however, patients tend to spend comparatively long periods of time in the hospital, notwithstanding low hospital staffing ratios. In Japan, the average hospital stay is 36 nights, compared to 6 nights in the United States (CIA, 2010; WHO, 2010).

All residents of Japan are required to be enrolled in one of the Japanese insurance programs. In contrast, foreigners living in Japan are recommended to join the national health scheme but are not forced to do so. There are a total of eight health insurance systems divided into two categories, Employee Health Insurance and National Health Insurance. National Health Insurance is generally reserved for self-employed people and students, whereas social insurance is normally for corporate employees. National Health Insurance can be broken down into two groups: National Health Insurance for each city, town, or village, and the National Health Insurance Union (CIA, 2010).

Services are provided either through regional/national public hospitals or through private hospitals/clinics, and patients have universal access to any facility, although hospitals tend to charge higher fees to those patients who arrive without a referral. Compared to the United States, Japan has about three times as many hospitals per capita. Japanese patients visit the hospital 14 times per year, on average, more than four times as often as Americans do. Due to large numbers of people visiting hospitals and doctors for relativity minor problems, space can be an issue in some regions (CIA, 2010).

Japan Nuclear Concerns

According WHO (2011), radiation-related health consequences remain a serious concern for the Japanese people. These health risks are dependent upon exposure, which takes into account factors such as amount and type of radiation, weather conditions, proximity to nuclear power plants, and amount of time spent in irradiated areas. The Fukushima Daiichi nuclear power plant experienced serious leakage from the tsunami and earthquake of March 11,2011. Those persons living between 20 and 30 kilometers from the plant were asked to evacuate the area, and risks of exposure included food contamination (WHO, 2011).

UNITED KINGDOM

The United Kingdom of Great Britain and Northern Ireland is a country located in Western Europe. A member of the European Union, the nation is usually known as the United Kingdom, or inaccurately known as Great Britain, Britain, or England. The United Kingdom has four parts consisting of England, Wales, and Scotland (all located on the Island of Great Britain) and Northern Ireland (located on the island of Ireland). The capital and largest city is London. As of January 2012, England’s government was headed by Prime Minister David Cameron (the leader of the Conservative Party) and Queen Elizabeth II. The queen’s role is mainly ceremonial; the U.K. government is a constitutional monarchy with executive power given to the prime minister.

Population

In 2010, the population of the United Kingdom totaled approximately 63 million. Life expectancy is 78 years for men and 82 years for females. Total expenditures on health as a percentage of the GDP amounted to 9.3% in 2009. On a per capita basis, $3399 is spent on health care annually.

The United Kingdom is a leading world financial power and trading center, with a capitalist economy. The country’s economy is ranked fourth largest in the world, with a per capita income of $36,240. During the past 20 years, the government has decreased private ownership and has continued the growth in the direction of a welfare state. The United Kingdom produces 60% of its food and needs through the efforts of only 1% of its labor force. It has coal, natural gas, and oil supplies available from domestic sources. Insurance, banking, and other business services provides for the high per capita incomes in the country. The United Kingdom is Europe’s largest manufacturer of cars, armaments, computers, petroleum products, televisions, and mobile phones. It is ranked sixth in the world for tourism. Languages spoken are mainly English, but other indigenous languages include Welsh, Scottish Gaelic, Irish Gaelic, Cornish, Lowland Scots, Romany, and British Sign Language.

Healthcare System

The National Health System (NHS) was established in 1948 to provide free health care for all residents of the United Kingdom. It was designed to be free at the point of need, meaning that every time a resident needs to go to the doctor or receive inpatient hospital treatment, it is provided free of charge. This system is funded by federal taxation and run by the Department of Health. In addition, private healthcare providers are available; people pay for such services either through their insurance or as out-of-pocket expenses at the time of use (BBC, 2005).

Funding for health care comes from direct taxation. The 2008–2009 budget equated to £1980 ($3.11) for every person in the United Kingdom (NHS, 2009). As of 2009, the prescription charge for medication in England was £7.20 ($11.31); the equivalent charge was £4 ($6.28) in Scotland, and prescription medications in Wales and Northern Ireland were free. All people older than 60 years; children 16 years or younger, or younger than 19 years if in a full-time educational program; those who have certain medical conditions; and those who are considered very low income are exempt from all healthcare payments. NHS dental services had been reduced as of 2008. Optical exams are free for everyone and there are vouchers for free glasses for those who qualify (NHS, 2009).

The basic concepts underlying the U.K. healthcare system are as follows (Light, 2003):

▀ Health care should be “free at the point of service.” No copayments are needed for services.

▀ Health care is funded through income taxes. The U.K. people believe that income taxes are more equitable and cost-effective than insurance-based health care as in the United States.

▀ A strong primary healthcare base should be established for the NHS. Every U.K. resident should be able to choose a physician or healthcare service. The system also provides general practitioners (physicians) with incentives to practice in underserved areas.

▀ Reductions in the inequalities of health care have been made. Areas that have greater health problems and are poorer are now getting more funding.

▀ Bonuses are given to general practitioners who reach population-based targets for health prevention.

▀ All subspecialists are paid on the same salary scale.

▀ Basic prescription drugs are price controlled, while research that produces new drugs is rewarded. The government works out an agreement with the private pharmaceutical companies to create price controls for drugs.

In October 2006, the number of primary healthcare trusts (PCTs) in the United Kingdom was reduced from 303 to 152 in an attempt to bring services closer together and cut costs. PCTs oversee 29,000 general practitioners and 18,000 NHS dentists, and they control 80% of the total NHS budget. As of April 2008, every adult in the United Kingdom was eligible for a free health screening to check for heart disease, stroke, diabetes, and kidney disease under a new government plan (NHS, 2009).

During the last few years, the private sector has funded some of the buildings and structures within the NHS, and in addition some local communities are currently making some of their own healthcare decisions. Since 1997, a change in philosophy toward healthcare management has emphasized more partnerships and comprehensive planning. Although there are differences in the healthcare system within each country in the United Kingdom, there is a single secretary of state for health, who must answer to the U.K. parliament. The Department of Health is responsible for local planning, regulation, inspection, and policy development. There are also 28 strategic health authorities who manage the health care of their respective regions and are considered the link between the Department of Health and the NHS (BBC, 2005).

Healthcare services are classified as either primary or secondary, and are managed by the local NHS organizations called trusts. The primary trusts are often outsourced to private companies. Primary care is delivered by local general practitioners, surgeons, dentists, and opticians (i.e., PCTs). The PCTs, who decide the amount and quality of services provided by hospitals, receive approximately 75% of the overall NHS budget. In addition, the PCTs control hospital funding. Hospitals and specialized services, such as mental health, are managed by organizations called acute trusts. Usually, outpatient services such as surgery and ophthalmology have long waiting lists.

Private health care offers similar services, and patients who use this system of care generally pay through private health insurance. Insurance premiums are paid by either employers or individuals who pay out of pocket by themselves. There are more than 300 private hospitals in the United Kingdom (BBC, 2005).

The U.K. healthcare system is currently far from ideal. Regarding the current situation of the NHS, Light (2003) reports that the current system is no longer sustainable and no longer affordable. If services were limited to only emergency and welfare service, however, the NHS approach would be economically feasible. In the future, specialty care services are likely to be united with primary care services. Muller (2002) states that the system is failing to meet expectations because of underfunding and the fact that it is centrally controlled.

Stevens (2004) reports that the NHS operates with outdated old buildings and inadequate equipment. Health professionals are in short supply, with 2 physicians available per 1000 people in the United Kingdom, as compared to 2.8 in the United States and 3.3 in France and Germany. Long waiting lists are the norm for routine surgery.

In 2003, U.K. taxes increased and policy makers began to pay more attention to improving the health-care system. Recently some especially pressing issues were identified, and the following changes were made as a result (Stevens, 2004):

▀ The supply of physicians and nurses was increased by 55%.

▀ The infrastructure was modernized. Hospitals were rebuilt and record keeping, prescriptions, and scheduling were transferred to an electronic system.

▀ In-service learning help for doctors, nurses, and other health professionals was increased, leading to great improvements in the new knowledge and technology of healthcare delivery.

▀ National standards were developed for the types of care given to patients. Goals were set to improve health statistics for specific illnesses, such as reductions in rates of heart and cancer disease, increased access to care for all residents, and reductions in infant mortality rates.

▀ Physicians are now subject to mandatory relicensing every five years. Quality assurance is used to upgrade standards of care.

▀ Healthcare providers are individually rated by performance and the results are published as public information.

▀ Financial bonuses are given to healthcare providers who are doing an excellent job.

▀ Healthcare funding now goes to PCTs directly, which purchase some managed care for patient care.

▀ Patients are given a choice of any provider, which may be public, private, or not for profit.

▀ The NHS has begun using the diagnosis-related group (DRGs) system to regulate pricing for services.

▀ The NHS is being held accountable to local citizens for its budget, spending, and services.

Medicines are the most frequently and widely used NHS treatment and account for more than 12% of total NHS expenditures. A pilot program involving half of the PCTs in England is testing out individual budgets for health care, including medications. In this program, patients are offered more choice and control over their health care through the country’s first direct payment scheme. Direct payments for health care are given to individual patients to allow them to purchase the care they need (NHS, 2009).

Health Issues

Within the United Kingdom, there is a persistent disparity in health care and health issues. Scotland has the lowest life expectancy among the U.K. countries, at 74.6 years for men and 77.2 years for women, compared with 77.2 years for men and 81.5 years for women in England. The rate of hospital inpatient admissions varies from 205 per 1000 population in Northern Ireland, to 135 per 1000 population in Scotland. The death rate from heart disease is highest in Scotland and lowest in England. From 1996 to 2006, smoking rates among teens and young adults dropped 18% in England, 15% in Scotland, and 12% in Wales. A greater number of women are breastfeeding, with the highest rates (77%) seen in England and Wales; in contrast, only 64% of women breastfeed their children in Northern Ireland. The infant mortality rate in the United Kingdom is 1.8 deaths per 1000 live births, which is higher than the IMR in many countries in the European Union, yet lower than the rate in the United States. The HIV rate within the general population is 2 cases per 1000 adults (13–49 years) (NHS, 2009).

Within the United Kingdom, the major health issues are cancer, coronary heart disease, stroke, accidents, and mental illness. Newer health problems include HIV/AIDs and Creutzfeldt-Jacob disease (Sproston & Primatesta, 2003). Cardiovascular disease (CVD) and stroke are two of the major causes of death or disability on an annual basis.

A goal was set to reduce CVD and stroke death rates for people younger than age 75 by two-fifths by 2010. In a study conducted by the U.K. government, 13.6% of males and 13% of females reported a CVD or stroke diagnosis. Incidence increased as household income decreased (poorer people had greater incidence).

Heart attack deaths have decreased by 50% in less than a decade, according to a major study of over 800,000 patients in England. The research has been extensively reported, with news sources suggesting a range of possible reasons, such as better treatments and a reduction in numbers of people smoking. A recent study found that in England the death rate from heart attacks halved between 2002 and 2010. The researchers calculated that just over half this decline was caused by fewer people having heart attacks and just under half by more people who had heart attacks surviving (NHS, 2012).

Deaths from heart and circulatory disease are falling, but it remains the UK’s biggest killer. In 2009, over 180,000 people died from cardiovascular disease (CVD) in the UK—one in three of all deaths. Twenty-eight percent of premature deaths in men and almost 20% of premature deaths in women were from CVD in 2009.(British Heart Foundation, 2010).

Stroke is the single largest cause of severe disability and the third most common cause of death in the United Kingdom. Each year 11,000 people die of stroke in England and Wales. Most people diagnosed with CVD or stroke take aspirin and lipid-reducing medications (Sproston & Primatesta, 2003; Youman, Wilson, Harraf, & Kalra, 2003).

There are 2.6 million people who have been diagnosed with diabetes in the UK (2009). By 2025, there will be more than four million people with diabetes in the UK. It is estimated that there are up to half a million more people in the UK who have diabetes, but have not been diagnosed. This gives a UK average prevalence of 4%. The rate is also increasing in children. There are over 22,000 people under the age of 17 with diabetes in England with 97% having type 1 diabetes, 1.5 percent have type 2 and 1.5 percent have another type of diabetes (Diabetes in the UK, 2010).

Hypertension (high blood pressure) was diagnosed in those people with a systolic blood pressure of 140 mm Hg or greater and a diastolic blood pressure of 90 mm Hg or more. Uncontrolled hypertension is the greatest cause of stroke (Sproston & Primatesta, 2003). Lloyd, Schmieder, and Marchant (2003) report that in the United Kingdom approximately 5.7 million adults, or 12% of the population older than age 16 years, have a blood pressure exceeding 160/95 mm Hg. In addition, 10.3 million (21%) have a blood pressure of 140/90 mm Hg. An estimated 58,000 cardiovascular problems occur in these patients because of hypertension, which would not exist if their blood pressure were within normal limits. Failure to control blood pressure contributes to huge monetary costs to the NHS for treating cardiovascular problems.

Cancer causes problems for one in four people, with the most common form (one third) being lung cancer. Eighty percent to 90% of all lung cancers are attributable to smoking. In women, 20% of all cancer cases involve breast cancer: England has one of the highest rates of breast cancer in all of Western Europe. Cancer in the United Kingdom is one of the three leading causes of death for people of all ages, except for preschool children. Cancer causes approximately 62,000 deaths per year (Sproston & Primatesta, 2003).

Smoking has been identified as the single greatest preventable cause of illness and premature death in the United Kingdom. In this country, the overall smoking rates for all ages are 27% of men and 24% of women, though these rates are higher among younger adults and lower among persons 75 years or older. Cigarette smoking in the United Kingdom has been found to increase as household income decreases (Sproston & Primatesta, 2003).

Alcohol consumption has been reported by 42% of men and 26% of women in the United Kingdom, who stated that they consumed alcohol at least three days per week. Statistics on alcohol reveal that in 2002, 47% of men drank more than four units of alcohol at least one day in the previous week, and 22% of women drank at least three units of alcohol one day in the past week. Total expenditures on alcohol amounted to 5.7% of family income in 2003 (Sproston & Primatesta, 2003).

Overweight and obesity have been diagnosed in 65.4% of men and 55.5% of women in the United Kingdom. Overweight is defined as 25 kg/mm2 and obesity as more than 30 kg/mm2. Obesity rates are higher in lower-income households (Sproston & Primatesta, 2003).

Accidents account for 10,000 deaths per year in England. England has lower death rates from car accidents than anywhere else in Europe, but rates of death of children from pedestrian accidents are among the highest in Europe. Road accident rates are higher in rural areas than in larger cities. Older adults are at risk for death and disability from falls. Osteoporosis affects more women and contributes to the number of broken bones, especially wrists and hips, incurred by this population (Sproston & Primatesta, 2003).

Infant and Child Health

In 2010 the infant mortality rate was 4.2 deaths per 1000 live births, the lowest ever recorded for England and Wales. Infant mortality rates were high among babies of mothers aged under 20 years and over 40 years at 5.6 and 5.8 deaths per 1000 live births respectively. Perinatal mortality rates were also higher for mothers in the “under 20” and “40 and over” age groups, at 8.3 and 10.2 deaths per 1000 live births respectively. Very low birthweight babies (under 1500 grams) had the highest infant and perinatal mortality rates, at 164.7 and 250.9 deaths per 1000 live births respectively. Infant mortality rates were highest for babies registered jointly by parents living at different addresses and those registered solely by their mother, at 5.5 and 5.4 deaths per 1000 live births respectively (Office of National Statistics UK, 2011).

Herbal supplements Use by Adults

The use of herbal extracts in the United Kingdom, especially by older adults, has been increasing. A recent survey found that 15% of those persons older than 65 years used over-the-counter herbal medicine during the last 12 months. The herbs are used to treat existing health problems, prevent illness, and promote general health. Older adults should report the use of herbs to their doctors, of course, and doctors should have good information about potential herb and drug interactions (Canter & Ernst, 2004).

CONCLUSION

Table 2-4 compares population and health statistics for Japan, Sweden, the United Kingdom, and the United States (Kaiser Family Foundation, 2011).

TABLE 2-4 Healthcare Statistics for Japan, Sweden, the United Kingdom, and the United States

Date/Date

Data

Indicator

Range

Data Type

Japan

Sweden

United Kingdom

United States

Demography and Population

Population

2011

Number

126,475,664

9,088,728

62,698,362

313,232,044

Adult sex ratio

2011

Number

1.02

1.02

1.03

1.00

Median age

2011

Number

44.8

42.0

40.0

36.9

Population younger

2010

%

13%

17%

18%

20%

  than age 15

Urban population

2010

%

86%

84%

80%

79%

Birth rate

2011

Rate per 1000

7.31

10.18

12.29

13.83

Total fertility rate

2011

Number

1.21

1.67

1.91

2.06

Contraceptive

2000–

%

54.3%

NA

84.0%

78.6%

  prevalence rate

2010

Death rate

2011

Rate per 1000

10.09

10.20

9.33

8.38

Infant mortality

2011

Rate per 1000

2.78

2.74

4.62

6.06

  rate

Female infant

2011

Rate per 1000

2.58

2.57

4.15

5.37

  mortality rate

Male infant

2011

Rate per 1000

2.98

2.90

5.07

6.72

  mortality rate

Under-five

2009

Rate per 1000

3

3

6

8

  mortality rate

Maternal mortality

2008

Rate per 100,000

6

5

12

24

  ratio

Life expectancy:

2009

Number

86

83

82

81

  female

Life expectancy:

2009

Number

80

79

78

76

  male

Population

2011

%

-0.28%

0.16%

0.56%

0.96%

  growth rate

Income and the Economy

GDP per capita

2009

U.S. dollars

$32,418

$37,377

$35,155

$45,989

GNI per capita

2009

U.S. dollars

$33,440

$38,050

$35,860

$45,640

Country income

As of

Text

High

High

High

High

  classification

July 2011

income

income

income

income

HIV/AIDS

People living with HIV/AIDS

Data from most recent year available

Number

8100

8100

85,000

1,200,000

Adults living with HIV/AIDS

2009

Number

8100

8100

85,000

1,200,000

Adult HIV/AIDS

2009

%

0.1%

0.1%

0.2%

0.6%

  prevalence rate

Women living with HIV/AIDS

Number of women living with HIV/AIDS and women as a percentage of adults living with HIV/AIDS, 2009

%

33%

31%

31%

26%

Men living with HIV/AIDS

Number of men living with HIV/AIDS and men as a percentage of adults living with HIV/AIDS, 2009

%

65%

69%

69%

77%

Children living with HIV/AIDS

2009

Number

NA

NA

NA

NA

AIDS deaths

2009

Number

100

100

1000

17,000

AIDS orphans

2009

Number

NA

NA

NA

NA

Tuberculosis

New TB cases

2009

Number

26,000

580

7400

13,000

People living with TB

2009

Number

33,000

750

9100

14,000

TB prevalence rate

2009

Rate per

26

8

15

5

100,000

TB death rate

2009

Rate per

1

0

1

0

100,000

TB incidence in HIV+ people

2009

Number

110

14

260

1300

TB incidence in HIV+ people per 100,000 population

2009

Rate per

0

0

0

0

100,000

HIV prevalence in incident TB cases

2009

%

0.4%

2.4%

3.5%

10.0%

Other Diseases, Conditions, and Risk Indicators

DTP3 immunization coverage rate

2009

%

98%

98%

93%

95%

Percent with water

2008

%

100%

100%

100%

99%

Access to sanitation

2008

%

100%

100%

100%

100%

Population undernourished

2005–2007

%

NA

NA

NA

NA

Low-birth-weight babies

2000–2009

%

8%

NA

8%

8%

Child malnutrition

2000–2009

%

NA

NA

NA

1.3%

Female prevalence of obesity

2005

%

2%

11%

24%

42%

Male prevalence of obesity

2005

%

2%

12%

22%

37%

Female prevalence of smoking

2006

%

13%

23%

24%

19%

Male prevalence of smoking

2006

%

42.4%

17.3%

26.1%

25.4%

Programs, Funding, and Financing

Health expenditures per capita

2008

$ $2817

$3622

$3222

$7164

Total expenditures on health

2008

%

8.3%

9.4%

8.7%

15.2%

Government health expenditures as a percentage of total government expenditures

2008

%

17.9%

13.8%

15.1%

18.7%

Government health expenditures as a percentage of total health expenditures

2008

%

80.5%

78.1%

82.6%

47.8%

Social security expenditures on health

2008

%

81.5%

0.0%

0.0%

27.8%

Out-of-pocket expenditures on health

2008

%

80.6%

92.8%

63.7%

24.4%

Health Workforce and Capacity

Physicians

2000–2010

Rate per

21

36

27

27

10,000

Nurses and midwives

2000–2010

Rate per

41

116

103

98

10,000

Community health workers

2000–2010

Rate per

NA

NA

NA

NA

10,000

Births attended by skilled health personnel

2000–2010

%

100%

NA

NA

99%

Hospital beds

2000–2009

Rate per

139

NA

39

31

10,000

This chapter has examined the health and health care of the countries of the United States, Sweden, Japan, and the United Kingdom. Included in this comparison were population statistics, types of government healthcare programs, economics and healthcare spending, and healthcare personnel.

STUDY QUESTIONS

1. Why do you think that the United States has the world’s highest rate of obesity? How does this problem relate to chronic health diseases such as cardiovascular disease, hypertension, and diabetes?

2. In spite of the country having the highest level of per capita expenditures, why does the United States still have a relatively high rate of infant mortality as compared to other developed countries?

3. What are some reasons that contribute to Japan and Sweden having the world’s best longevity rates? Even though it spends the most dollars per capita on health care, why is the United States so far behind in terms of longevity?

4. What are some health disparities within the United Kingdom, and how might they be solved?

CASE STUDY

The mortality rate for American Indians, which includes Alaskan Natives (Native Americans), has increased primarily due to the effects of type 2 diabetes. The U.S. Department of Indian Health Service has provided a Special Diabetes Program for Indians resulting in increased spending for health care, however, the rate for age-adjusted deaths has increased as compared to white Americans.

Infectious diseases are decreasing while chronic diseases, such as type 2 diabetes are increasing in this population. Data collected was mainly from Navaho Indians living in the western part of the United States. Other major health issues include obesity, cardiovascular diseases, smoking, and hypertension. Also discussed was the high rate of sedentary lifestyles as compared to historically much greater daily physical activities.

Reference

Kunitz, S. (2008). Changing patterns of mortality among American Indians. American Journal of Public Health, 98(3), 404–411.

Case Study Questions

1. Create a culturally congruent plan for reduction of exceptionally high levels of type 2 diabetes among American Indians/Alaskan Natives.

2. Why do American Indians have higher levels of increased smoking, obesity, and sedentary life styles, which contribute to the type 2 diabetes rates than whites?

3. Why is the Indian Health Service an important part of health care that is historically “owed” to American Indians/Alaskan Natives?

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Holtz, Carol. Global Health Care: Issues and Policies, 2nd Edition. Jones & Bartlett Learning, 05/2012. Vital Book file.

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