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

^a Department of Pediatrics, Mattel Children’s Hospital at UCLA, Los Angeles, California
^b UCLA School of Public Health, Los Angeles, California
^c Commonwealth Fund, New York, New York

	ABSTRACT

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BACKGROUND. The increasing scope of health supervision recommendations challenges well-child care delivery in the United States. Comparison of the United States with other countries’ delivery systems may highlight different assumptions as well as structural approaches for consideration.

OBJECTIVE. Our goal was to describe the process of well-child care delivery in industrialized nations and compare it to the US model of child health care.

METHODS. Literature reviews and international experts were used to identify 10 countries with unique features of well-child care delivery for comparison to the United States. Key-informant interviews using a structured protocol were held with child health experts in 10 countries to delineate the structural and practice features of their systems. Site visits produced additional key informant data from 5 countries (Netherlands, England, Australia, Sweden, and France).

RESULTS. A primary care framework was adapted to analyze structural and practice features of well-child care in the 10 countries. Although well-child care content is similar, there are marked differences in the definitions of well-child care and the scope of practice of primary care professionals and pediatricians specifically who provide this care across the 10 countries. In contrast to the United States, none of the countries place all well-child care components under the responsibility of a single primary care provider. Well-child care services and care for acute, chronic, and behavioral/developmental problems are often provided by different clinicians and within different service systems.

CONCLUSIONS. Despite some similarities, well-child care models from other countries differ from the United States in key structural features on the basis of broad financing differences as well as specific visions for effective well-child care services. Features of these models can inform child health policy makers and providers in rethinking how desired improvements in US well-child care delivery might be sought.

Key Words: developmental care • preventive services • preventive health care visits

Abbreviations: AAP—American Academy of Pediatrics • MCH—maternal and child health • PMI—Protection Maternelle et Infantile

Well-child care is the cornerstone of US preventive pediatrics, combining elements of health supervision, anticipatory guidance, growth/development monitoring, and immunizations to promote children’s health and development.¹ The goal of well-child care is to ensure that children are on an optimal trajectory for growth and development by identifying influences that can negatively affect their health outcomes. Although primary care has traditionally been a vehicle for delivering immunizations, well-child care services provide an opportunity for providing preventive or early intervention services for the many prevalent developmental and behavioral problems that are of concern to parents.²

Reflection on the goals of pediatric health promotion has increased from historical efforts to prevent negative outcomes for children, such as injury or disability, to the potential for optimizing their developmental potential over the life course. The 2004 Institute of Medicine report Children’s Health, the Nation’s Wealth defines children’s health as "the extent to which individual children or groups of children are able to or enabled to (a) develop and realize their potential, (b) satisfy their needs, and (c) develop the capacities that allow them to interact successfully with their biological, physical and social environments."³ This new definition of children’s health highlights how the potential to be healthy is intimately intertwined with the process of human development and the relationship that multiple interacting influences have on both health and development.⁴

Bright Futures, initiated by the Maternal and Child Health Bureau more than a decade ago, is dedicated to the principle that optimal child health involves a trusting relationship among the health professional, the child, the family, and the community. Expanding professional recommendations for practice such as those from Bright Futures and the American Academy of Pediatrics (AAP) reflect the pediatric profession’s efforts to respond to the wide range of environmental and family issues that influence children’s safety and health. The AAP and Bright Futures guidelines emphasize that an important task for pediatricians is to identify and address family psychosocial, developmental, and behavioral issues during routine well-child care.⁵ Yet, as these recommendations have expanded, studies have documented some gaps in care⁶ and significant barriers to the achievement of these aspects of care.⁷ Barriers reported by pediatricians in addressing psychosocial issues and developmental assessments during well-child visits include the inability to bill or be reimbursed separately for assessments and well-child care, unfamiliarity with instruments, lack of available specialists for diagnosis/treatment, lack of time, lack of training, and lack of referral options for children identified with possible developmental problems.^7,8

As the scope of well-child care evolves to match the expanding paradigm of children’s health, self-reflection on both practice capacity and the structural and financial barriers to optimal well-child care delivery in the United States is occurring. The length of a well-child visit is an average of 17 minutes, which makes it difficult for pediatricians to cover many anticipatory-guidance topics.⁷ As additional content becomes valued, there is tension between the schedule of visits and the scope (as well as timing) of counseling.^2,6 New information on parent preference and unmet well-child care needs increase attention to how US well-child care can better achieve its vision.⁶

In light of these tensions in US well-child care, our goal for this study was to identify different structures and practices of pediatric well-child care internationally and to explore promising practices that might inform the debate in the United States on improving our well-child care system.

	METHODS

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We used a multistage approach to identify features of well-child care practice in 10 countries. Institutional review board approval obtained at the University of California, Los Angeles before data collection.

Definition of Well-Child Care
The construct of well-child care has many terms and meanings in the pediatric literature. Using the AAP’s Guidelines for Health Supervision III,⁹ the Bright Futures guidelines,⁵ 2nd edition, and the Early Periodic Screening, Diagnosis, and Treatment recommendations,¹⁰ we defined well-child care as preventive care for children that includes:

• health supervision (including anticipatory guidance on nutrition, elimination, sleep, discipline, injury prevention, etc);
  
• developmental surveillance and milestones and school performance;
  
• child and family psychosocial assessment;
  
• care coordination (ie, oversight of referrals to needed community-based resources/services); and
  
• immunization(s), physical examination, and additional screening (height, weight, lead level, hemoglobin level, vision, hearing, etc).
  

We defined well-child care as a subcomponent of primary care for children that includes well-child care, acute and chronic care, and coordination and follow-up for developmental problems.

Conceptual Framework
To analyze structural and practice features that influence well-child care delivery, we adapted the conceptual framework of Starfield.¹¹ The method for profiling primary care systems in multiple international comparison studies comes from Macinko et al¹² (Table 1). Among the 4 structural features, "regulation and governance" refers to the degree of centralization of the organization and provision of well-child care in the country as well as the geographic distribution of primary care providers; "financing" refers to universality and the relative use of public and private financing of care; "health care professional" refers to the training type and level of professionals providing well-child care as defined for this study; and "accessibility" refers to the extent of cost sharing required (ie, financial accessibility).

Advisory Board
To identify the countries to be studied, we convened an advisory board composed of internationally recognized experts in child health from the United States, Australia, England, and Japan. Advisory board members were identified by referral from national child health experts in the United States as well as from reviewing editorial boards from international child health journals. Members reviewed the study framework and provided input on the domains for study.

Literature Review
We performed a literature review of international child health, early childhood development, pediatrics, developmental screening tests, child primary care, and health services topics to identify articles about the basic organization and delivery of child health practices in the 20 developed countries with the lowest infant mortality rates. The following search terms were used: "international child health," "early childhood development," "developmental screening tests," "pediatric primary care," "well-child care," and "international health services." This literature review revealed that most developed countries had basic similarities in their approach to child health with periodic visits and anticipatory guidance.

Selection of Potential Target Countries
In consultation with the advisory board, 4 selection criteria were chosen for identifying the final 10 study countries. These criteria were set to optimize comparisons and adoptability/adaptability of practices in the United States. The inclusion criteria included that the countries (1) be a developed country, (2) have a population size of more than 5 million people, (3) have available and comparable country data on general health indicators, and (4) appear in the published literature on early childhood developmental services and interventions. In addition, innovative programs or practices in well-child care or delivery of preventive child health services were considered for country selection. The final 10 study countries identified were Australia, Canada, Denmark, England, France, Germany, Japan, Netherlands, Spain, and Sweden. All are members of the Organization of Economic Cooperation and Development.

Using data from our literature review, a country summary document was generated for each of the 10 countries in the study. These documents outlined the structural characteristics and practice features of each country’s well-child care system and served as the basis for the key informant interviews.

Key Informant Interviews
Using the advisory board’s network of international child health contacts, a snowball sampling strategy was used to identify the most knowledgeable within-country informants in child health from each of the 10 countries. Two key informants in each country were contacted for potential participation in the study and agreed to participate in telephone interviews. In 60-minute telephone interviews with the key informants we confirmed the structural and practice features of well-child health service delivery. From these interviews we also delineated emerging policies/trends and identified practices of well-child care in their respective countries that differed from those in the United States. Each of the 20 key informant interviews were audiotaped and transcribed. Four independent reviewers read the key informant interview transcripts to identify broad themes and trends.

Site Visits
To gain further insight into these countries’ systems, site visits by US pediatricians were made. Resource constraints allowed visits to 5 countries. On the basis of information gathered during the key informant interviews, the 5 countries with the most innovative well-child care practices were selected for site visits. We visited the Netherlands, England, Australia, Sweden, and France for 3 to 4 days each. The visits included face-to-face meetings with the key informants and child health policy leaders as well as observations of child health providers at local clinics. Data from the site visits were collected through field notes and semistructured qualitative interviews (Dr Kuo visited all 5 countries, Dr Samson visited 3 countries, and Dr Lotstein visited 2 countries).

	RESULTS

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A key distinction between the United States and each of the countries we studied is that outside of the United States, the 5 components of well-child care are not included within the scope of a single provider. Instead, they are spread among the practices of multiple health care professionals, frequently with different funding sources.

Structural Features
Table 2 displays the 4 structural features that influence well-child care across the 10 countries analyzed.

Financing
All 10 countries in this study have universal health care financing for citizens that is funded primarily through taxation, either directly to the government or through employer or payroll taxes. Spain and England both have a national health service in which the federal government is the single payer and provider of health care for most citizens. For the most part, care is funded by national bodies in virtually all countries and delivered privately (except Spain, Sweden, and Denmark). Several countries (eg, Sweden, France, Australia) use separate, public nurse-based MCH systems to provide immunizations and/or well-child care elements of prevention, guidance, and counseling. In these countries, well-child care is largely publicly financed with virtually no cost sharing (eg, premiums, deductibles, or copayments). In France, maternal and child preventive health care, education, and social and financial support are encompassed in the Protection Maternelle et Infantile (PMI). The PMI started after World War II to combat infant mortality and morbidity by providing "protection for all" and offering preventive health care with no cost to all children younger than 6 years. Parents who choose not to receive these services through the PMI may pay some costs for this care in the private sector.

Health Care Professionals
In nearly all of the 10 countries, well-child care as defined in the United States is either divided between physicians and nurses or is provided exclusively by MCH nurses. Some countries such as Sweden and England have interdisciplinary child health care "teams" that provide some components of well-child care. The state of Victoria has the most developed MCH system in Australia, and virtually all well-child care including immunizations, anticipatory guidance and counseling, and developmental surveillance is delivered by nurses in geographically based maternal and child health centers. Home nursing services supplement the MCH nurse activities offered through these centers. Pediatricians serve a specialty role and provide some developmental screening for children identified by the MCH nurses or a child’s general-practice physician (providing acute and chronic care) with a specific concern. Examples of countries with distinct responsibilities for well-child care among MCH nurses and physicians include France and the Netherlands. In Japan, some prefectures use public health nurses to provide well-child care, whereas in other prefectures it is a responsibility of general practice physicians. In contrast, well-child care is provided by general practice physicians and pediatricians in Germany and general practice physicians in Canada. Although French PMIs offer preventive services universally, most children see private practice pediatricians for preventive care; PMIs provide preventive services largely to children in lower-income households. In France, public preschools (école maternelle) provide an additional site of health care for young children; 4-year-olds receive their physicals in these locations.

Accessibility
All 10 countries have universal access to medical care and publicly financed MCH services for their citizens. There is no cost sharing for preventive health examinations and immunizations in all countries except France and Japan. In France, parents may pay a share of cost if well-child care is received from private physicians. In Japan, there is variable cost sharing depending on the scope of employer coverage. Cost sharing for nonpreventive primary care varies by country. Whereas no costs apply to primary care in England, Sweden, Germany, and Spain, some cost sharing may apply to acute and chronic primary care services in Australia and France depending on the nature of the child’s medical insurance and in Australia on whether the parent selects a private plan to supplement publicly financed services for their child. Coverage of outpatient services varies subtly between provinces in Canada because the Canada Health Act requires provincial plans to cover medically necessary outpatient care for all eligible residents.

Practice Features
First Contact
In contrast to typical US well-child care in which health-supervision/anticipatory guidance, immunization, and developmental screening are provided by a single "first-contact" person and/or setting, in these 10 countries the first contact professional differs depending on the component of well-child care (Table 3). Nurses (MCH nurses, public health nurses, or health visitors) are the most common first point of contact for all components of well-child care. These individuals provide age-appropriate counseling on health-promotion topics (often using standardized lists of topics based on a national early childhood health record), respond to parent questions about development and other preventive topics, and usually administer immunizations. The Australian system is a good example: MCH nurses provide first-contact care for well-child care, general practice physicians are the first-contact providers for primary medical care associated with acute and chronic conditions, and pediatricians are specialists to which a parent and child gain access only after referral by the general practice physician (not the MCH nurse) regardless of whether the issue is developmental or medical in nature. In most of the countries studied, pediatricians serve exclusively as specialists for developmental/behavioral and/or for specific chronic pediatric conditions.

In nearly all of the 10 countries, general practice physicians are the first point of contact for primary medical care associated with acute or chronic conditions and act as gatekeepers to the rest of the health system. Although a general practitioner is not the mandated referral source in Australia, its Medicare system reimburses specialist consultation fees at a significantly higher rate if the patient was referred by a general practitioner. In Canada, a similar process of referral/reimbursement occurs in several provinces. Germany differs from most of the other countries in that both pediatricians and general-practice physicians provide primary care for young children (<6 years old).

Coordination
Countries that separate preventive from acute and chronic care responsibilities among providers differ in the extent and nature of coordination. In Australia there is little coordination between MCH nurses providing anticipatory guidance and pediatricians serving as specialists in behavioral/developmental and/or in medical conditions. Instead, parents seek such referrals when needed from the child’s general practice physician. In contrast, French national guidelines promote some coordination by directing the examining physician to forward health certificates for 3 health-supervision visits from the carnet de santé to the local PMI agency. The PMI agency reviews these certificates for social and/or medical risk factors and offers targeted assistance as needed to families with young children, including home visitors (puéricultrices) to monitor the health of local mothers and children through the first few months of a child’s life. Sweden differs by co-locating preventive care professionals with pediatricians in geographically-based centers. Given their relatively small size and the fact that all children within a specified area attend that single site, coordination is less formal but more systematic. Nurses with a developmental concern can provide the medical chart to a pediatrician personally and have a face-to-face conversation, and they can directly schedule parents for pediatrician visits. Notably, most countries seem to assign little value to coordination between different care providers (eg, between developmental, preventive, and/or acute and chronic care providers. In the United States, the medical-home approach embraced by the AAP recognizes that coordination among providers is an important part of delivering quality health care.¹³

Countries without a separate preventive care system give gatekeeping responsibilities to either general practice physicians who manage access to pediatricians for specialty consultations (eg, Australia, Denmark) or to the physician sector generally in which parents choose general practice or pediatric physicians. Although most countries use physicians as gatekeepers for specialty medical care, some countries permit greater parent self-referral (eg, France, Germany) than others. The scope of specialized services that require gatekeeper referral is greater in Canada and England and occurs to a lesser extent in Denmark, where otolaryngology and ophthalmology require no referral.

Comprehensive Care
The extent to which well-child care is provided in an integrated fashion with acute, chronic, and behavioral/developmental care ranges in the 10 countries from a completely separate system with little or no integration (Australia) to a highly integrated, co-located system of child health services (Sweden, Spain). In several other countries, the extent to which care is comprehensive (provided by a single individual and/or setting) depends on the characteristics of the child and family. In these countries, care for higher-income households is provided by a single professional, whereas children in lower-income households and/or who have a chronic medical condition receive care through both a public health system (eg, supplemental immunization and MCH counseling programs in Canada) or an MCH system (eg, France). Sweden’s system is distinguished from all of the other systems by the "horizontal" integration in many regions in which universal, geographically based pediatric centers co-locate public health nurses, primary care pediatricians, social workers, and public health services targeting individuals and families. In a limited but increasing number of centers, early care and education professionals provide child care and preschool services and model ideal parenting practices for families.

Longitudinality
Continuity with a clinical setting is required for primary care and well-child care in several countries and optional in others. For primary care, Australia and France provide flexibility in both setting and provider; in Australia, parents may consult more than 1 general practitioner because there is no requirement to stay with a single provider. Germany provides a particularly high degree of individual choice and flexibility in primary care, and families do not have to sign up for a specific setting or individual provider. Because Germany does not institutionalize a relationship between a child and an ongoing source of primary care, no regular examination of children’s health is guaranteed. Japan differs from the other 9 countries in placing little value on continuity with a specific clinician.

Continuity of setting is more frequent in well-child care than in other primary care services in the 10 countries because they are geographically based. Unlike medical care for acute and chronic conditions, the PMI centers in France and MCH centers in Sweden and Australia serve specific communities and neighborhoods. Although children visit a consistent location for well-child care in these countries, parents have flexibility to choose a nurse health visitor or MCH nurse within the centers.

The use of child health records that are maintained by parents and brought to well-child visits to promote longitudinal care is common across the 10 countries. For example, a defining feature of the French system is the carnet de santé, a uniform, 80-page health notebook issued to each child at birth. It explains parental responsibilities to promote their child’s health, including compliance with preventive health examinations and vaccinations. The carnet de santé acts as a parent-held medical chart in which physicians record observations, diagnosis, and treatments. In Japan, the boshi techo is a parent-held medical chart that includes coupons that can be redeemed to cover certain well-child visit.

Family Centered
Countries differ markedly in the extent to which they institutionalize a 2-generation model of care. Regarding perinatal care, most countries provide some type of MCH services (separate from medical care) that address infant health and maternal health as well as family social issues during a specific postnatal period. Regarding health care for the family in Denmark, general practitioners often care for all members of a family and, as a result, may have greater insight into family functioning and potential for long-term doctor-patient relationships. In contrast, almost all localities in Sweden operate completely separate systems for pediatric care, prenatal/maternal care, and adult screening services/acute care/chronic care. However, despite operating 3 completely separate delivery systems, Sweden uses the most explicitly 2-generational approach for behavioral/developmental issues and for social issues specifically (eg, income-related needs, maternal depression) among the 10 countries.

Community Oriented
Several countries can be distinguished by the extent of universal, geographically based health centers that cater to specific neighborhoods and plan their services around the unique needs of their populations. In Australia, MCH centers are located at a neighborhood level with an adequate supply to allow all served families to be within walking distance of their assigned center. Sweden also has pediatric centers that are geographically based/assigned and have autonomy for prioritizing and planning health-related interventions depending on the sociodemographics and identified health care needs of their communities. France and the Netherlands offer geographically-based services with a community orientation that generally either serve a less-than-universal population (eg, France in which the PMIs serve more lower-income than higher-income families) or limit their services to a particular age group (eg, the perinatal period in the Netherlands). Most of the other countries have national systems with limited local authority (eg, England, although this seems to be changing with primary care trusts) or have decentralized private systems with minimal structural features that would mandate geographically oriented services (eg, Germany).

	DISCUSSION

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Increasing reflection in the United States and internationally on the potential for well-child care to not only screen for and address problems but also promote health and optimize development raises the question of how innovative practices and programs have developed within local and national systems to provide well-child care. In addressing this issue, our comparison of how well-child services are structured and delivered in 10 industrialized countries shows variability in organization and, more fundamentally, in the scope of care of various providers.

The key finding emerging from our analysis is that well-child care as conceptualized in the United States and defined by the AAP and Bright Futures does not translate directly into practice elsewhere. In most of the countries, health promotion is usually separate from acute care, so the notions of a primary care provider and medical home as conceptualized in the United States (providing preventive, developmental, acute, and chronic care) does not exist. In most countries studied here, responsibilities for well-child care are divided among various professionals, each with different health care training and responsibilities for care. Usually there is little effort to coordinate or integrate the preventive, developmental, acute, and chronic care despite having 2 or 3 professionals being responsible for different well-child care components. Sweden is a unique case in which responsibilities are divided among 2 or more types of professionals but often integrates some of these activities through co-location in community-based centers with intentional coordination for children with a developmental or chronic problem. England is the only other country that uses a team concept for nurse-delivered preventive care and physician-delivered care, but it does not occur in all regions.

The provider of well-child care in the 10 countries studied is often not a physician, and the various aspects of well-child care are typically divided among multiple providers. One model of care occurs in the Netherlands, in which child health doctors provide only well-child care and other physicians (general practitioners, pediatricians) provide other aspects of primary care. Another model of physicians providing well-child care is one in which general practitioners provide primary care and pediatricians generally act as "specialists," focusing on developmental and psychosocial problems and management of chronic illnesses but having no responsibility for other aspects of well-child care. It is interesting to note that these 2 models parallel the models proposed by the Future of Pediatric Education II (FOPE II) report in 2000, in which general pediatrics in the United States would undergo possible shifts in scope of work in the future.¹⁴ The FOPE II report stated that general pediatrics in the United States could possibly evolve in the future into 1 of 2 extremes: one in which the pediatric generalist performed only well-child care and basic ambulatory problems (similar to the process in the Netherlands) or one in which the generalist "specialized" in the developmental and chronic-illness needs (including lower-acuity subspecialty problems) of children (such as is done in England or Australia).

The division of responsibility seen internationally provides a stark contrast to the United States, in which general pediatricians are increasingly expected to provide a broad range of services including well-child care, acute care, and management of chronic illness. As well-child care becomes more complex with the need to address psychosocial and family issues, a question for the US system is whether it would be more effective for a pediatric "specialist" to focus only on well-child care or whether the general pediatrician should be more comprehensive.

In deciding which, if any, of the principles and features of well-child care seen abroad can be adapted for use in the United States, differences in the social and cultural histories would need to be considered. Although an in-depth discussion of this topic is beyond the scope of this article, it follows that one country’s system may have some features that are not easily exported to another. For example, features such as geographically based centers with MCH nurses providing preventive care (eg, France, Australia) are possible because of a greater national role in designing and/or regulating the organization of health services. Some features are facilitated by characteristics that differ markedly from the underlying cultural values in other systems/countries. The Swedish system of assigning children to particular settings based on geography and the Japanese approach that does not value longitudinality in the parent-child-provider relationship reflect underlying values and assumptions that differ from the prevailing US approaches and professional policy statements about well-child care. Some of the greatest differences are seen by comparing the US system to that of Sweden, given that privatization and choice have been historically valued in the United States, whereas equal access and active health promotion characterize Swedish health policy. Yet, key elements of the Swedish system, such as co-location of care, a team-based approach, and specific assigned well-child services according to professional training, are also seen in recent US health care innovations such as the Healthy Steps intervention.¹⁵ This suggests that certain elements from abroad could be exported more feasibly to the United States; however, making these changes universal would require significant policy change. Professional viewpoints on development may also differ, with Swedish health care professionals assigning less value to developmental screening and preferring to actively promote the development and learning of all Swedish children in lieu of a deficit-based "case-finding" strategy that has been prevalent in the traditional medical model of child health in the United States, for example.

Our findings suggest that although sociopolitical features of the countries studied differ from those of the United States (such as government-organized and/or -financed health care, universal coverage, value of community-based planning, and less focus on individual responsibility and choice), some elements are analogous to emerging principles for care in the United States. These principles have been expressed in AAP policy statements for coordination of medical care with social and educational support, co-location, and in emerging initiatives using multidisciplinary teams to provide early childhood care (eg, Healthy Steps). In the United States, particular attention has been paid to children with special health care needs and the challenges that face providers of well-child care to these children.¹⁶ For example, the AAP’s Medical Home initiative is a community-based change strategy to help pediatricians understand their role in the multiple systems from which a child with special health care needs can receive services. This initiative has stimulated discussion in the profession about the role of the general pediatric office in helping to coordinate the care for children with special health care needs.

Finally, we found that the well-child care systems for young children in the 10 countries studied are dynamic, with child health experts in most of the countries actively reflecting on and seeking improvements to the provision of well-child care, just as pediatricians reflect on these issues in the United States. Recent landmark reports on well-child care and developmental screening in England¹⁷ and Australia¹⁸ show that questions of surveillance/screening efficiency and scope and models of health supervision/anticipatory guidance are being considered internationally with the ongoing epidemiologic shifts that affect health promotion for young children.

	LIMITATIONS

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This survey focused on current systems as documented in the literature and reported by key informants. The complexity of health systems limits the ability of all features to be described. The findings from these countries may not generalize to other European and industrialized countries. It is also unknown how different systems of care or differences in process (ie, screening methods) affect health and developmental outcomes or how the systems or processes may influence intermediate outcomes such as early identification of developmental concerns/problems or early literacy. Immunization rates are available for comparison across countries, but few other well-child care service rates and quality can be compared because of the absence of data. Finally, our findings focus on well-child care delivery to children aged 0 to 5 years. Several of the countries studied provide well-child care for school-aged children via school-based services. Thus, an assessment of well-child care delivery for school-aged children across these countries would yield different results in areas of primary care practice such as coordination and integration.

	CONCLUSIONS

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An international comparison of well-child care services across 10 different industrialized countries shows that a range of models are in use. The primary care framework is useful for comparing and contrasting systems and raises the question of whether the implicit values within the model, such as the desirability of a single first-contact professional for primary care, is required for the scope of well-child care services. Although the approach to well-child care may have differed among the countries, all countries studied are considering how to achieve optimal early childhood development most efficiently in light of epidemiologic changes.

	ACKNOWLEDGMENTS

 
This study was funded by a grant from the Commonwealth Fund.

Our Advisory Board Members included Dr Frank Oberklaid (Centre for Community Child Health, Royal Children’s Hospital, Melbourne, Victoria, Australia); Dr Frances Glascoe (Vanderbilt University, Nashville, TN); Dr Sheila Kamerman (Columbia University, New York, NY); Dr Robert J. Haggerty (University of Rochester Medical Center, Rochester, NY); Dr T. Berry Brazelton (the Brazelton Institute, Boston, MA); Dr Barbara Starfield (Johns Hopkins Bloomberg School of Public Health, Baltimore, MD); Dr John Takayama (National Center for Child Health and Development, Tokyo, Japan); and Dr David M. Hall (Royal College of Paediatrics and Child Health, London, England). We acknowledge the guidance given by our project advisors during this study.

We also thank Greg Stevens for helping to convene the advisory board, Rachel Mitchell for organizing the international site visits, and Molly Maidenberg for assistance preparing this manuscript.

Our key informants (by country) included: Australia: Drs Frank Oberklaid and Sharon Goldfeld (Centre for Community Child Health, Royal Children’s Hospital, Melbourne, Victoria); Canada: Dr William Mahoney (Developmental/Chedoke Child and Family Centre, McMaster Children’s Hospital, McMaster University, Hamilton, Ontario) and Dr Robert Armstrong (British Columbia Research Institute for Child and Family Health, University of British Columbia, Vancouver, British Columbia); Denmark: Drs Kristen Lykke and Ole Andersen (Hillerød County Hospital, Hillerød); France: Prof Marc Brodin (Faculté de Médecine Xavier Bichat, Santé Publique, Paris) and Dr Marie-Paule Martin (Direction Enfance et Famille Conseil General, Chartres); Germany: Prof Hubertus von Voss (Institut für Soziale Pädiatrie und Jugendmedizin, Ludwig-Maximilians-Universität München, München) and PD Dr med. Ute Thyen (Klinik für Kinder und Jugendmedizin, Universitätsklinikum Schleswig-Holstein, Lübeck); Japan: Drs John Ichiro Takayama and Makiko Okuyama (National Center for Child Health and Development, Tokyo); Netherlands: Prof Dr Pauline Verloove-Vanhorick (TNO Prevention and Health, Leiden) and Dr Robert A. Holl (Leiden University Medical Center, Leiden); Spain: Dr Luis Rajmil (Catalan Agency for Health Technology Assessment and Research, Agència d’Avaluació de Tecnologia i Recerca Mèdiques, Barcelona) and Dr Conxa Bugié (Centres de Desenvolupament Infantil i Atenció Precoç, Servei d’Estimulació Precoç, Sant Cugat, Barcelona); Sweden: Dr Claes Sundelin (Uppsala University Hospital, Uppsala) and Dr Jan Johansson (Chief Child Health Care Officer, Barnhälsovårdsöverläkare, Centrala Barnhälsovården, Borås); and England: Dr Mitch Blair (Imperial College, Northwick Park Hospital, Harrow) and Dr Sir David Hall (Royal College of Paediatrics and Child Health). We also gratefully acknowledge all of the international participants in this project. Study participants included advisory board members, key informants, and site hosts.

	FOOTNOTES

 
Accepted May 23, 2006.

Address correspondence to Alice Kuo, MD, PhD, University of California Los Angeles, 1100 Glendon Ave, Suite 850, Los Angeles, CA 90024. E-mail: akuo{at}mednet.ucla.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.

	REFERENCES

TOP ABSTRACT METHODS RESULTS DISCUSSION LIMITATIONS CONCLUSIONS REFERENCES

 

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