Exploring models for the roles of health systems' responsiveness and social determinants in explaining universal health coverage and health outcomes.

backgroundIntersectoral perspectives of health are present in the rhetoric of the sustainable development goals. Yet its descriptions of systematic approaches for an intersectoral monitoring vision, joining determinants of health, and barriers or facilitators to accessing healthcare services are lacking.

objectiveTo explore models of associations between health outcomes and health service coverage, and health determinants and health systems responsiveness, and thereby to contribute to monitoring, analysis, and assessment approaches informed by an intersectoral vision of health.

designThe study is designed as a series of ecological, cross-country regression analyses, covering between 23 and 57 countries with dependent health variables concentrated on the years 2002-2003. Countries cover a range of development contexts. Health outcome and health service coverage dependent variables were derived from World Health Organization (WHO) information sources. Predictor variables representing determinants are derived from the WHO and World Bank databases; variables used for health systems' responsiveness are derived from the WHO World Health Survey. Responsiveness is a measure of acceptability of health services to the population, complementing financial health protection.

resultsHealth determinants' indicators - access to improved drinking sources, accountability, and average years of schooling - were statistically significant in particular health outcome regressions. Statistically significant coefficients were more common for mortality rate regressions than for coverage rate regressions. Responsiveness was systematically associated with poorer health and health service coverage. With respect to levels of inequality in health, the indicator of responsiveness problems experienced by the unhealthy poor groups in the population was statistically significant for regressions on measles vaccination inequalities between rich and poor. For the broader determinants, the Gini mattered most for inequalities in child mortality; education mattered more for inequalities in births attended by skilled personnel.

conclusionsThis paper adds to the literature on comparative health systems research. National and international health monitoring frameworks need to incorporate indicators on trends in and impacts of other policy sectors on health. This will empower the health sector to carry out public health practices that promote health and health equity.