Medical Care and Health Improvement: The Critical Link

What is the contribution of medical care to health improvement? For decades, this question has occupied and preoccupied countless professionals, researchers, politicians, and members of the public. Health care systems serve many secondary purposes, such as creating jobs or generating profits, but most people would agree that services should be primarily a means toward the end of improved health. However, there is sharp disagreement about the strength of this relation compared with other factors that determine health status. The implications of this discrepancy go beyond academic interest to include key policy matters.

The “In the Balance” papers in this issue deal with one of those matters, probably the most important one: What is the best strategy to reduce persistent inequalities in health? Andrulis [1] and Pincus and colleagues [2] draw up the lines of the debate with clarity. One side maintains that expanded access to medical care is essential to achieve that goal. The key assumption underlying this position is that health services are major determinants of health status, so that inequalities in the latter are largely the result of differential access to the former. The other side claims that medical services have a small effect on health status compared with socioeconomic determinants. Thus, progress in reducing health inequalities will be achieved not so much by increasing access to medical care as by changing the social conditions and lifestyles that account for the persistence of such inequalities.

Clearly, the question that lies at the heart of the discrepancy between the two articles has to do with the weight of medical services compared with other determinants of health status. This debate has a long history in medicine and public health. Throughout the evolution of this debate, two levels of analysis …