general accounting office , 1991a ; iglehart , 1991a , 1991b , 1988a , 1988b ) , financing and cost - containment mechanisms ( u.s . general accounting office , 1991b ) , and levels of health care spending ( schieber , poullier , and greenwald , 1991 ) . however , little has been written about the comparative differences or similarities of specific services within these systems , such as preventive health services directed at children or pregnant women ( williams and miller , 1991 ; starfield , 1991 ; u.s . , i examine the health care systems of six industrialized countries ( canada , sweden , france , germany , japan , and the united kingdom ) , compare their basic structures and financing arrangements , and describe how these systems address certain preventive health care needs of children and pregnant women as part of a focus on primary care . despite wide variations in financing mechanisms , levels of health care spending , and cost - containment strategies among these six systems , additionally , access and outcome measures such as insurance coverage , prenatal care , high - risk pregnancy outreach , home visiting , immunization , universal periodic screening for children , infant mortality , and low birth weight are better than those of the united states . the variations in program structure and financing suggest that effective health care programs for this population need not be restricted to any single organizational structure ; this should offer flexibility to health care reformers in this country seeking models for expanding preventive services . selected health status and health care system characteristics of six industrialized nations described in the 1991 organization for economic cooperation and development ( oecd ) health data file ( schieber , poullier , and greenwald , 1993 ) were analyzed and supplemented with information from several sources that describe services for children and pregnant women . the oecd data characteristics analyzed included per capita gross domestic product ( gdp ) and percent of gdp spent on health care , public spending as a percent of health care spending , and number of physicians per capita . other characteristics derived from supplementary sources include percent of physicians in primary care and , for children and pregnant women , measures of health status ( infant mortality rates , percent of low - birth - weight infants , maternal mortality rates , and percent of births delivered by cesarean section ) , preventive services ( rates of pediatric immunization , presence of universal periodic preventive screening , home visitation services , high - risk pregnancy outreach , duration of maternity leave , and level of maternity financial support ) , and access to care ( percent of women of childbearing age and children without health insurance ) . however , methodological problems exist with most comparative international studies . health outcomes , for example , are determined by a variety of sociocultural factors that lack sufficient descriptive data . recent analysis of international infant mortality rates finds less disparity between the united states and other industrialized countries when adjusting for definitional differences applied to infant mortality ( liu et al . , 1992 ) . despite these limitations , relative , rather than absolute , differences are useful in understanding international health care systems and their services . the six countries described reflect a wide diversity in organizational structure for the delivery of health care , in cost containment and financing mechanisms . the organizational structure and decision - making process are represented by single - payer centralized systems ( canada , united kingdom ) and decentralized systems ( sweden ) . other countries rely on quasi - public , employer - based sickness funds with variable coverage through public insurance ( germany , japan , france ) . private health insurance plays only a minor , supplementary role in all the foreign countries . by contrast , in the united states , the health care system is very decentralized and based predominantly on a system of private health insurance . public programs generally serve the elderly and certain categorical groups of poor women and children . none of these countries , except the united states , contains any significant percentage of uninsured children or women of childbearing age . in 1991 , per capita spending and percent of gdp spent on health care were all substantially less than in the united states ( figure 1 ) . the country with the next - highest spending per capita on health care was canada . the united states spent roughly 50 percent more per capita on health care than canada , and some 175 percent more than the united kingdom . the percent of gdp spent on health care reflects a similar pattern ( table 1 ) . the united states spent 13.2 percent of its gdp on health in 1991 , compared with 6.6 - 10.0 percent for the six other countries . although only 42 percent of health care spending in the united states is publicly funded , well over 70 percent is publicly funded in the six countries . partially because of the substantial public funding of health care , all six countries implement significant national cost - control measures ( chaulk and bialek , 1993 ) , including systemwide global budgets ( canada , united kingdom ) ( u.s . general accounting office , 1991a ) , expenditure targets or global budgets for hospitals and/or office - based physicians ( france , sweden , germany ) ( rodwin et al . general accounting office , 1991b , 1993b ) , provider fee schedules ( germany , japan , sweden , france ) ( ikegami , 1990 ; brenner and rublee , 1992 ) or capitated fees ( united kingdom ) ( ham , 1988 ) , prohibitions on balance billing ( japan , sweden ) , and limitations on medical malpractice ( canada , japan ) ( coyte , dewees , and trebilock , 1991 ; employee benefits research institute , 1990a ) . by contrast , cost containment in the united states is less comprehensive and generally limited to hospital and provider fees under certain public programs such as medicare and medicaid , patient cost sharing , and varying managed - care arrangements . in terms of physician supply , four of the six countries have 2.2 - 3.1 physicians per capita , and the other two ( japan , united kingdom ) have roughly 1.5 physicians per capita . however , the specialty distribution of physicians is strikingly different between the united states and the other countries . in the united states , only about 33 percent of all physicians declare themselves to be primary care physicians ( politzer et al . , 1991 ) . this contrasts with the other countries , which have predominantly primary care physicians ( 53 - 63 percent ) ( chaulk and bialek , 1993 ; rodwin et al . , 1990 ; fielding and pierre - jean , 1993 ; mcauley , 1992 ) . in all six countries , prenatal care is comprehensive , accessible , and either free or accompanied by financial assistance . public prenatal clinics often coordinate maternity services and prenatal care for women ( goodwin , 1990 ) . for example , in japan , prenatal care is not a routine health insurance benefit . instead , comprehensive maternity services are provided through public programs ; however , complications occurring during pregnancy are covered by health insurance . japan 's focus on prenatal care and children 's health began following world war ii as part of its national reconstruction effort . by the late 1950s , national guidelines led to the establishment of maternal and child health clinics throughout the country . by 1965 , when these guidelines were enacted as the maternal and child health law , there were more than 400 such clinics nationwide . during this period of systemic focus on maternal services , japan experienced a progressive lowering of its infant mortality rate per 1,000 live births from 60.1 in 1950 to 30.1 in 1960 , 13.1 in 1970 , 7.5 in 1980 , and finally 4.6 in 1990 ( mother 's and children 's health organization , 1992 ) . in the six countries , non - physicians provide varying amounts of prenatal care , although they do so to a greater extent than do non - physicians in the united states . for example , in some countries prenatal care is provided predominantly by midwives ( sweden , united kingdom ) with obstetricians and family physicians providing specialty care ( kohler and jakobsson , 1987 ; blondel , pusch , and schmidt , 1986 ) . in france , prenatal care is shared more equally by midwives and physicians ( mostly obstetricians ) . however , in japan , although physicians share the provision of prenatal care with midwives ( of which there were 22,918 in 1990 ) ( mother 's and children 's health organization , 1992 ) , labor and delivery remain the province primarily of physicians . many of the six countries use outreach programs for high - risk pregnant women and for postpartum care . home visiting nurses usually provide this service ( sweden , france , germany ) ( blondel , pusch , and schmidt , 1986 ; ierodiaconou , 1986 ) , although community midwives and nurses provide postpartum evaluation to women following delivery ( united kingdom , japan ) ( williams and miller , 1991 ; chaulk and bialek , 1993 ) . these programs may contribute to the lower infant mortality rates ( 4.59 - 8.42 per 1,000 live births ) and fewer low - birth - weight infants ( 4 - 7 percent ) in these countries than in the united states ( 9.8 and 7 percent , respectively ) ( national commission to prevent infant mortality , 1992 ) . in addition to lower infant mortality rates , four of the six countries have maternal mortality rates below those of the united states ( abouzahr and royston , 1991 ) ( table 2 ) . cesarean - section deliveries of infants , generally indicative of pregnancy complications , occur far less frequently in these countries than in the united states ( notzon , 1990 ) . in all six countries , pregnancy benefits ( referred to as maternal disability benefits ) are comprehensive , financially generous , and extend for relatively long periods of time ( employee benefits research institute , 1990b ) . to encourage early prenatal care , pregnant women are offered financial incentives , such as stipends and maternity bonuses or grants , to seek early prenatal care and help defray medical expenses associated with pregnancy ( germany , japan ) ( ierodiaconou , 1986 ) . for high - risk women and women with prenatal complications , visiting nurses routinely perform prenatal evaluations and screening and ensure that women obtain full prenatal services ( france , germany , united kingdom , sweden ) ( williams and miller , 1991 ; blondel , pusch , and schmidt , 1986 ; ierodiaconou , 1986 ; miller , 1988 ) . visiting nurses also provide periodic postpartum visits ( united kingdom ) ( williams and miller , 1991 ) . other incentives , such as maternal and child health handbooks and prenatal care certificates , entitle pregnant women to a variety of benefits , including free prenatal visits , pharmaceuticals , and home - visiting services when the patient is confined to bed . family - planning services and free pharmaceuticals are otherwise provided in public prenatal clinics ( united kingdom ) ( goodwin , 1990 ) . these targeted incentives encourage early and periodic prenatal care and routine infant examinations ( u.s . because of the accessibility to services and the absence of financial barriers , prenatal care appears to be readily used in all six foreign countries ( blondel , pusch , and schmidt , 1986 ) . in these countries , maternal benefits are treated much like disability benefits . however , in the united states , maternity and parental leave were not statutorily protected under federal law until 1993 . during the 102nd congress , the family and medical leave act ( 1993 ) was passed , requiring businesses with more than 50 employees to give 12 weeks unpaid leave for family illness or maternity reasons . in contrast , maternal disability in the other six industrialized countries has been an established benefit , with protected leave ranging from 14 weeks ( germany , japan ) to 25 weeks ( canada ) . financial support under maternal disability is also more generous than in the united states , which does not guarantee cash maternity benefits . during each pregnancy , all six countries provide periodic payments based on existing disability benefit programs ( canada , japan , sweden ) or under distinct cash maternity - disability - benefit plans ( france , germany , united kingdom ) . japan also provides pregnant women with a maternity grant sufficient to cover most maternity - related expenses ( employee benefits research institute , 1990a ) . in the six industrialized countries , the approach to children 's health reflects a common theme : accessible , comprehensive , preventive services beginning at birth and extending into preschool and school health programs . the multiplicity of locations for preventive care is one key feature of this approach ( miller , 1990 ) . japan , for example , where pediatricians constitute some 4.8 percent of all physicians , relies on a system of more than 850 public health centers and 590 maternal and child health centers to provide a wide range of preventive services to newborns , infants , and older children ( japan research institute on child welfare , inc . , services include : ( 1 ) screening for metabolic diseases , hypothyroidism , hepatitis b , and neuroblastoma ; ( 2 ) providing all routine childhood vaccinations ; ( 3 ) conducting hearing , vision , and speech screening ; and ( 4 ) providing special services for low - birth - weight children with disabilities and children with chronic conditions ( approximately 95,000 ) , including malignant neoplasms , diabetes mellitus , and birth defects ( japan international cooperative agency , 1990 ) . public health nurses also make home visits to provide preventive services to high - risk children . as part of an extensive school program in france for preschool children , a health care team , including a physician , nurse , child psychologist , and social worker , provides language and psychomotor skills assessment , hearing and vision screening , and physical examinations ( u.s . house of representatives , 1990 ) . these children also may receive preventive care from public maternal and child health centers or from a private provider . when a medical problem is identified , the child is referred to the patient 's physician for further evaluation and treatment . when children enter the elementary school system , a health care team continues to provide periodic evaluation and screening of students . school health services are coordinated with other school services to address health education and counseling issues such as nutrition . sweden employs a system of child health centers throughout the country that performs health and developmental assessments for infants and children . these centers also provide free immunizations for preschool children and conduct vision , hearing , and speech screening ( kohler and jakobsson , 1991 ) . school health programs provide continued screening and assessment and also provide health education directed at alcohol and tobacco use ( kohler and jakobsson , 1987 ) . this screening program involved counseling on oral hygiene , diet , and fluoride supplements , and was associated with a decline in the percent of children with dental caries ( from 65 percent in 1973 to 30 percent in 1983 ) ( kohler and jakobsson , 1991 ) . most pediatric care in the united kingdom is provided through general practitioners who , under the british national health service , receive annual bonuses for achieving high immunization rates among their pediatric patients . parents may obtain preventive services for their children from their general practitioner or from 1 of more than 3,000 community clinics . utilization of well - child examinations is estimated to be greater than 95 percent for infants under 1 year of age and approximately 70 percent for children 1 - 5 years of age ( williams and miller , 1991 ) . in addition , the home visiting service ( hvs ) provides preventive services and health promotion at home to high - risk children or children without ready access to a physician . the hvs , which dates back to the late 1800s , has generally focused on maternal and child health , drawing upon the skills of registered nurses who frequently have additional training in public health . hvs nurses provide screening , counseling , and health education services in order to identify existing or potential problems . these nurses provide regular home visits to newborns and preventive counseling on breastfeeding , injury prevention , childhood immunizations , and health care . hvs services for children usually include one prenatal visit and five visits from birth to 5 years of age . although all british citizens are eligible for hvs services , frequent limitations on resources have focused services on children , especially high - risk children , or children in certain catchment areas ( u.s . studies evaluating the efficacy of the hvs program suggest that it has been successful in teaching health promotion and disease prevention , increasing rates of immunization , and reducing hospitalizations for infants and children ( select committee on children , youth , and families , 1990 ) . germany , with roughly 6 percent of all physicians identified as pediatricians ( compared with roughly 7 percent in the united states ) , provides most pediatric care through private , rather than public , health clinics ( williams and miller , 1991 ; federal ministry for youth , family affairs , women and health , 1988 ) . routine newborn screening includes hypothyroidism , phenylketonuria , and galactosemia ( williams and miller , 1991 ) . ( in the united states , only the first two are routinely screened . ) in germany , infants and preschool children are entitled to a predetermined number of free comprehensive examinations . public clinics provide limited preventive services , such as immunizations , primarily to poor families or those without insurance ( such as immigrant families ) ( u.s . canada , although it has not established a governmental agency formally charged with responsibility for maternal and child health issues , provides comprehensive pediatric services under its universal system of health insurance . many provinces have developed an extensive network of community health centers that deliver a wide range of preventive services , including well - baby care , postpartum care , and immunizations ( pless , 1990 ) . the canadian task force on the periodic health examination in 1979 released the first national recommendations for periodic preventive services . these include recommendations on the content and timing of well - baby preventive services ( canadian task force on the periodic health examination , 1979 ; gilbert et al . , 1984 ; rourke and rourke , 1985 ) . for many provinces , these well - baby services  screening , counseling , and immunizations  are provided through community health agencies using community health nurses and physicians in addition to office - based care ( hemmelgarn et al . , 1992 ) . some communities have established regionalized special programs , such as for high - risk perinatal care . although health insurance benefits may vary somewhat among canada 's provinces , utilization of children 's services does not involve cost sharing . other measures of preventive health services and access to preventive care for infants and children include rates of childhood immunization and percent of children without health insurance ( table 3 ) . for all six foreign countries , immunization rates for children under 2 years of age are 70 - 95 percent for the diphtheria - pertussis - tetanus ( dpt ) and oral polio vaccines . with respect to measles vaccination , three of these countries have achieved immunization rates of greater than 85 percent ( united nations international children 's emergency fund , 1991 ) . measles immunization rates are lower for children in germany , japan , and france , and appear to be related to timing of vaccine approval and provider concerns over vaccine side effects ( u.s . this compares with estimated immunization rates over the past decade of roughly 57 percent for this same age group in the united states ( u.s . however , data from the 1992 national health interview survey suggest that immunization rates may be increasing in the united states ( dpt , 83.0 percent ; oral polio , 72.4 percent ; and measles , 82.5 percent ) , although underimmunization continues to remain a problem for low - income children and children of races other than white ( centers for disease control and prevention , 1994 ) . by providing comprehensive services using a combination of public clinics , school - based programs , and private office - based care , children in these countries have a broad range of entry points into the health care system . this compares with the roughly 12.9 percent of children under 19 years of age in the united states who do not have health insurance ( employee benefits research institute , 1993 ) . the six foreign industrialized countries in this study reflect a wide range of health care systems ( single - payer , multipayer , mixed private and public insurance , centralized and decentralized ) , differing financing arrangements ( employer - based sickness funds , payroll- and personal - income - tax - financed ) , and broad cost - containment strategies ( global budgets , provider fee schedules , and utilization controls ) . despite spending considerably less than the united states , these countries have health outcomes , reflected in rates of infant and maternal mortality , low birth weight , and childhood immunization , that do not appear to be compromised and generally surpass those of the united states . to achieve these outcomes , these six countries offer various models of health care programs for children and pregnant women . a recurrent theme among them , however , is the high priority given to preventive services . prenatal care is comprehensive and readily accessible and does not involve financial barriers such as cost sharing or demonstration of insurance status as a prerequisite to care . by contrast , some 16.2 percent of all women of childbearing age in the united states are without health insurance ( employee benefits research institute , 1993 ) , a factor that has been associated with more frequent adverse natal outcomes in this country ( braverman et al . , 1989 ) . in the six countries , when necessary , as in the case of high - risk pregnancies , prenatal care may also include outreach services provided through visiting nurses . prenatal care and childbirth involve a wide range of providers , frequently including non - physicians . for mothers working outside the home , maternity benefits are financially comparable to earned income and extend for periods well beyond the time allotted in the united states . these focused and comprehensive approaches likely contribute to the improved infant status and pregnancy outcomes seen in the six countries . with respect to children 's services , all six countries provide accessible and comprehensive infant and pediatric programs beginning at birth . children receive a full range of preventive services that have been recommended in this country as clinically effective ( u.s . department of health and human services , 1993 ) , including metabolic screening , vision , hearing and speech evaluation , early childhood immunization , dental care , and preventive counseling ( injury prevention , tobacco and substance abuse , nutrition , and fitness ) . services are delivered through private providers in office - based settings , as well as through a system of public clinics that are later supplanted by school - based programs . in some countries , providers and parents are given financial incentives to increase the number of children receiving certain preventive services , such as immunizations . as a result , the vast majority of infants ( 80 - 97 percent ) in most of these countries ( japan , france , germany , united kingdom ) receive a broad range of recommended preventive services ( u.s . more than 50 percent of preschoolers appear to receive preventive care , compared with 42 percent or less in the united states ( short and lefkowitz , 1992 ; newacheck and halfon , 1988 ; u.s . this compares with 14.5 percent of children under 18 years of age without health insurance in the united states . the international models in this study provide evidence that a wide range of health care systems based on differing financing and delivery mechanisms and cost - containment strategies can avoid creating significant numbers of uninsured , provide a wide range of preventive services , and avoid compromising health outcomes .