 PUBLIC HEALTH MATTERS 

Comparing Health Systems in Four Countries:

Lessons for the United States
| Lawrence D. Brown

an excuse for—declining to pursue it. The

The Rekindling Reform initiative examined the health systems of 4 countries: Can-
brightest and best strategies to build a nor-
ada, France, Germany, and Great Britain (United Kingdom). From the 4 country reports
published in this issue of the American Journal of Public Health, 10 crosscutting themes mative case for universal coverage have
emerge: (1) coverage, (2) funding, (3) costs, (4) providers, (5) integration, (6) markets, failed so far, and no one seems to know how
(7) analysis, (8) supply, (9) satisfaction, and (10) leadership. Lessons for the United to change these values, which are, by defini-
States are presented under each point. (Am J Public Health. 2003;93:52–56) tion, fairly durable.

The 4 articles in this issue of the Journal that
explore universal-coverage health care sys-
tems in (1) Canada, (2) France, (3) Germany,
and (4) Great Britain (United Kingdom) are a
sophisticated package of generalization, varia-
tion, and implication that defies easy synthe-
sis and summation. Nonetheless, this rich
cross-national variation yields 10 general
themes.
COVERAGE
All 4 nations entitle almost all their citizens
to health coverage. Health care is not enough;
their images of solidarity, community, and eq-
uity insist that how care is obtained, not
merely that it be somehow obtainable, mat-
ters greatly. Respect for human dignity de-
mands that no one refrain from seeking med-
ical care from fear of the consequences of
doing so, and that no one suffer financial ad-
versity as a result of having sought care. The
moral foundations of universal coverage are
as simple as that.
Although these nations all cover medically
necessary and appropriate services, they also
debate the limits of publicly defined coverage.
In Canada, for example, home health care
and drugs lie outside the public system. In
France, dental and eye care tend to be cov-
ered by supplementary insurance. As medical
innovation advances, discussion intensifies
about how to define baskets of benefits that
distinguish the responsibilities of the national
community from those that individuals and
families ought to bear personally. Although
these deliberations steadily gain prominence
and publicity, so far they proceed mainly at
the margins of comprehensive systems that
show little inclination to cut back covered ser-
vices. The core values of these systems—soli-
darity, community, equity, dignity—remain in-
tact and surprisingly little disturbed by rising
costs and by gloomy forecasts that aging,
technology, and the rest are rendering their
systems unaffordable.
The moral and cultural foundations of uni-
versal coverage are missing in the United
States, as the continuing presence of 40 mil-
lion uninsured would seem to intimate. Cir-
cumstances are not propitious: 85% of the
population has medical coverage, much of it
funded by private employers; the 15% who
lack insurance are not organized, cohesive, or
politically active; sizable redistributive shifts
by national design are not the political sys-
tem’s strongest suit; and the right-of-center
precincts in which that system has lingered
for the past 35 years do nothing to ease the
struggle. Equally important, Americans
“know” that safety net providers care for peo-
ple who lack coverage—a powerful inhibition
to public action in a nation whose welfare
state programs aim less at broad-ranging se-
curity in health and other policy spheres than
at post factum compensation for those who
fall through private-sector cracks. Reformist
appeals based on human dignity (to which
health security is fundamental) resonate very
little here. September 11 and rescued miners
aside, solidarity finds little place in the na-
tional political lexicon. Likewise, in the
United States, community is not a spur to na-
tional action but rather an alternative to—and
FUNDING
In all 4 systems the national government
sets a statutory framework for financing uni-
versal coverage. (In Canada the provinces
must meet centrally defined conditions for
participation in central/provincial fund-shar-
ing arrangements.) How they raise these
monies differs substantially, however: Great
Britain’s National Health Service draws
mainly on general revenues; 70% of Can-
ada’s health bill comes from national and
provincial general revenues; Germany relies
primarily on work-based social insurance con-
tributions; and—the most dramatic evolution-
ary development in this quartet—France in-
creasingly supports its social insurance regime
with general revenues that tap a broad range
of wealth. None of these approaches is plainly
superior to the others; they all “work,” and
they all carry their burden of political and
economic stress. France and Germany also
have various degrees and types of cost shar-
ing by patients.
The good news for the United States is that
in essence any major funding approach will
serve. The bad news is that no such approach
seems close to commanding consensus, and
feuding over the merits of funding strategies
aggravates the chronic righteous strife among
proponents of reform that (given the imposing
strength of the opposition) has heavily dam-
aged reform prospects. One contingent con-
tends that a “single payer” (general revenue—
based) system is best. Another believes that
the success of Social Security and Medicare
validates a social insurance strategy. Whereas
no other nation believes that universal cover-

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age can be won and sustained without candid
debate about taxes, a prominent American re-
form camp wants to build on the private em-
ployer contributions that buy most US health
insurance today. (Indeed the Clinton adminis-
tration’s reform plan of 1993 would have
mandated such employer “premiums” pre-
cisely in order to avoid uttering the dreaded
“t word.”) Meanwhile, the widespread convic-
tion that done right, universal coverage
should require no new monies (tax-derived or
other) beclouds the US reform debate. The
system is said to be replete with waste that
can be intelligently squeezed to yield abun-
dant funds to rechannel resources from exces-
sive use and payments to providers and to-
ward coverage for the uninsured. (This too
was a premise of the Clinton plan.)
This pastiche of theory and ideology lays
down myriad stumbling blocks that reform-
ers must somehow surmount. A workable
coalition probably presupposes avoiding
fierce redistributive battles over how and
where to squeeze and redirect wasteful
spending within the status quo, dismissal of
employer mandates (and the battles with
business they trigger), the political courage to
discuss tax increases that (probably) mingle
social insurance payments with general rev-
enues, and, not least important, willingness
among ardent advocates of diverse financing
strategies to rally behind whatever seems to
stand some chance of passing. Meanwhile,
cost controls can be taken up after the uni-
versal deed is done—a prospect that will of
course be plain to stakeholders who oppose
reform and will take up their political cudgels
accordingly.
COSTS
Although the 4 nations spend a smaller
share of their national resources on health
care than the United States does, cost contain-
ment has long been a preoccupation in each
and all. (Great Britain is arguably a case
apart. There, reorganization and better man-
agement of the National Health Service
have—until recently—been successfully of-
fered as alternatives to the infusions of cash
the Blair government was eventually moved
to promise.) The 4 nations pay their physi-
cians less and provide fewer specialized and
January 2003, Vol 93, No. 1 | American Journal of Public Health
 PUBLIC HEALTH MATTERS 
highly technical services than the United
States does, and all expect that structured ne-
gotiations between payers and providers will
hold the line on costs.
These staples of cost containment seem in-
creasingly insufficient to counter the funda-
mental challenges all nations face—growing
and aging populations, technological progress,
inflation, wage pressures, and rising popular
expectations1—and so in their sundry fash-
ions, the 4 countries try to cap health spend-
ing. In Great Britain and Canada, the public
health care budget is itself a ceiling. In
France, since 1996 Parliament has legislated
a national spending target annually. Germany
has tried to link health spending increases to
the growth of workers’ wages. Only in Great
Britain have these public constraints gener-
ated highly controversial waiting lists, and
these, says Light,2 are mainly limited to elec-
tive referrals to specialists. Waiting lists occa-
sionally appear in Canada, but Deber1 argues
that these vary with place and procedure and
are a minor, albeit well-publicized, concern.
“Rationing” is a nonissue in France and Ger-
many. Containing costs is never easy, but the
4 nations have done it—indeed, in the British
case perhaps too well.
Rising health costs are of course a huge
headache in the United States, and the likeli-
hood that universal coverage would push
them higher and faster is a weighty political
burden on reform. Unlike the 4 nations, the
United States has rejected all talk of publicly
set limits on health spending. Insurers, provid-
ers, business interests, and other opponents of
reform loudly equate all such aggregate con-
straints with “rationing,” and the equation has
dependably terrified public opinion. In 1993,
Bill Clinton proposed to harmonize cost con-
trol with universal coverage by means of
managed competition among health plans,
backstopped by caps on health insurance pre-
miums, should market forces fail to hold them
down. The Clinton plan was rejected, leaving
cost containment to unmanaged competition
among health plans, which (to many reform-
ers’ surprise) proceeded to “work” in the sec-
ond half of the 1990s as cost increases
slowed dramatically. Health spending moved
rapidly upward thereafter, however, leaving
purchasers and policymakers wondering what
to do for an encore.
This strategic tabula rasa may leave the
United States uncommonly receptive to learn-
ing from abroad. On the other hand, public
budgets and caps, which continue to connote
rationing and remain abhorrent to influential
stakeholders, do not seem to be gaining a
constituency. Adopting them would entail
elimination of some politically potent sources
of waste that market forces tolerate or aggra-
vate, namely (to borrow from Deber’s list):
marketing costs, efforts at selective enroll-
ment, stockholders’ profits, executives’ exorbi-
tant salaries, lobbying expenses, and less
widely diffused technology. And if such waste
were gone, the fundamental things—growing
and aging populations and such—would apply
here, as in other nations, as time goes by.
PROVIDERS
Conflict between policymakers (in both
health and financial ministries) and providers
over terms and levels of payment is a persis-
tent fact of political life in all 4 nations.
Within public budgets and fiscal caps, provid-
ers negotiate with the state, the sickness
funds (health insurance institutions), or both.
In Great Britain and Canada, physicians’ or-
ganizations and individual hospitals bargain
directly with government agencies. In Ger-
many, associations of sickness-fund physi-
cians and individual hospitals negotiate with
sickness funds within a framework of public
rules. In France, unions of physicians bargain
separately with the sickness funds as the
state moves back and forth between the side-
lines and the battlefield. In each of the 4,
payers squeeze, providers protest (and some-
times strike), payers relent, costs increase,
payers squeeze, and so it goes. Although
budgetmakers invariably spend more than
they prefer, providers in all 4 nations earn
considerably less than their more specialized
US counterparts.
The US medical profession is more lucra-
tive and entrepreneurial than is the case else-
where. To American providers, collective ne-
gotiations with public payers, which imply
more than tacit consent to a state-run social
enterprise called (or headed toward) national
health insurance, have long been anathema.
The United States has coped politically by
evolving a bifurcated pattern of payer and
Brown | Peer Reviewed | Public Health Matters | 53

provider relations. The main public program,
Medicare, shifted from a payment system that
mimicked the private sector (retrospective
payment of actual hospital costs and usual
and customary physician charges) to prospec-
tive payment models, steered by commissions
in which providers have a voice, and by Con-
gress, which they lobby directly. In the private
sector, purchasers have hoped to discipline
providers by shopping among and signing on
with managed care plans that presumably
contract selectively with “efficient” providers
and apply organizational reviews and con-
straints that enforce efficiencies.
The future of these disparate arrangements
is a key question for health reform. Would a
public system of prospective payment prevail,
and could it coexist with the current private
managed care model? Must reform mean the
end of unmanaged competition among health
plans and a belated biting of the bullet on
managed competition, and if so, what version
of it? As with financing, there appears to be
no one right way, but workable reform will
have to hold the line on provider payments,
and doing so will mean constructing new bar-
gaining machinery with which providers agree
to “live,” however grudgingly. Today, US pro-
viders are more inclined to wish a plague on
the payment practices of both Medicare and
managed care than they are to think construc-
tively about better ways to negotiate collec-
tively with payers. Most American physicians
and hospitals continue to view health insur-
ance as an economic, not a social, enterprise
and organize and strategize accordingly.
INTEGRATION
These 4 nations all voice dissatisfaction
with the organization of their delivery sys-
tems; they all deplore “fragmentation” and
aspire to “integration.” International literature
and their own observations teach that over-
use of services is substantial and that, to coin
a phrase, care ought to be better managed.
Having long allowed physicians and hospitals
to practice medicine largely as they pleased—
a norm crucial to the quid pro quo in which
providers accepted regulation of their pay-
ments—these countries now seek efficiencies
in production that supposedly accompany or-
ganizational innovation. Great Britain’s tools
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 PUBLIC HEALTH MATTERS 
of choice, for example, were fundholding
among general practitioners and hospital
trusts, now giving way to primary care trusts.
Indeed, writes Light,2 the government now
plans to “unite specialty care with primary
care, unite primary care with community
health care, and unite all three with social
services,” yielding “comprehensive, integrated
services that are community based.” The
French are experimenting with “networks of
coordinated care,” notes Rodwin.3 These
countries view reorganization (or redisorgani-
zation, in health economist Alan Maynard’s
term) soberly, as “reforms” worth testing as
possible sources of better value for money
within fundamentally sound systems.
The United States, the esteemed source of
much of the theory and practice of the ser-
vices integration other nations seek to emu-
late, may be ahead of the international curve
but faces integrative challenges of its own.
Both here and abroad, proponents of reform
sometimes divide over whether the achieve-
ment of universal coverage is a necessary and
sufficient policy objective, over whether to in-
sist that such coverage be encased in a prop-
erly designed delivery system. Americans
must decide how far to tie reform to managed
care, the driver of US-style integration, and
increasingly an 800-lb gorilla politically. Will
the new system seek to redeem a fee-for-
service system, follow Medicare’s dubious
lead into some variant of choice between a
fee-for-service system and managed care, or
assume that managed care will be main-
stream and fee-for-service payment an excep-
tion? Beyond decisions about how far to push
managed care lie others on what to do about
managed competition, an issue that has vexed
US health policy since the 1970s. Is integra-
tion—in this case the proliferation of managed
care organizations—a natural institutional re-
ceipt for better efficiency and quality? Or do
these objectives presuppose competition
among integrated entities? Can this competi-
tion stay loosely managed, as now, or would
universal coverage trigger anew the many dis-
putes about managed competition that sunk
the Clinton plan a few years ago? Ironically,
other nations are better equipped to address
integration incrementally than the United
States is: here it invites a host of radical
questions.
American Journal of Public Health | January 2003, Vol 93, No. 1
MARKETS
American reformers who admire the rest of
the West for its refusal to treat health care as
a commodity to be bought and sold in the
marketplace tend to view the growing foreign
fascination with market forces in health care
as a trip down the garden path. This fascina-
tion is unmistakable in all 4 nations, however,
as evidenced by Great Britain’s internal mar-
kets, Germany’s regulated competition,
France’s networks, and Canada’s Community
Care Access Centres. All the same, foreign at-
tachment to health care markets tends to be
clear-eyed and decidedly nonevangelical, is
far from taking national health insurance sys-
tems by storm, and may already be waning
(judging by Light’s account2 of Great Britain,
the most market-friendly of the 4). Other na-
tions recognize that competition is difficult, at
least in a real world populated by real institu-
tions. Besides breaking important political
compacts (for example, that any national
health insurance physician may treat any na-
tional health insurance patient, a settled norm
that pretty much precludes closed panel plans
and selective contracting by payers), competi-
tion requires heroic analytic feats, which
carry no small price tag: better management
information systems, copious consumer infor-
mation, subtle measures of quality, methods
to adjust payments by risk of enrollees, and
more. None of these countries views competi-
tion as a panacea, and none fantasizes that
market forces can supplant the solid regula-
tory machinery now in place. All 4 worry that
even well-designed competition could under-
cut solidarity, community, and equity, and
each wonders candidly whether the market
game is worth the social candle.
Although the United States has embraced
markets and competition as health care “solu-
tions” with a passion puzzling abroad, it hesi-
tates too. For years, 1 school of market re-
formers has predicted that competition
among managed care plans per se will make
the system more efficient, whereas another
has contended that such competition must be
managed (by and within a sophisticated and
extensive framework of public rules) lest it
lapse into such market failures as selection of
preferred risks, underservice, and geographic
segmentation of markets, all of which would

damage the public interest. The slow growth
of health costs in a strong economy in the lat-
ter 1990s cushioned the horns of the
dilemma. Today costs rise faster, the economy
grows more slowly, and the prospect of incor-
porating 40 million uninsured into a new re-
formed system brings competitive disputes to
center stage again. Would a new round of re-
form put managed competition over the polit-
ical goal line at last? Dare reformers view re-
form as the great escape from an imprisoning
competitive mindset? Must they accept it as
part of the strategic furniture they must per-
force rearrange? Having gone to market so
often, the United States may no longer be ca-
pable of a swift, clean U-turn, but if we can-
not live without competition, how will reform-
ers live with it?
ANALYSIS
The 4 countries show a strong and grow-
ing curiosity about how analytic tools—evi-
dence-based medicine, technology assessment,
report cards, and cost-effectiveness analysis,
for example—can help policymakers to assess
the performance of their health systems and
suggest means to improve them. New agen-
cies such as the National Institute for Clinical
Excellence in Great Britain and the ANAES
(Agence nationale d’accréditation et d’evalua-
tion) in France promote and conduct such
evaluative studies. Although foreign policy-
makers have suitably modest expectations for
these tools, their influence might advance by
several different routes—for example, im-
proved performance as measured by analytic
criteria could become a condition for in-
creased pay to providers, and continued docu-
mentation of overuse of services within these
systems might fuel budget makers’ determina-
tion to manage care—that is, providers—more
assertively.
In the United States, the birthplace of many
of these tools, expectations are high, but stub-
born professional resistance to implementa-
tion of practice guidelines and kindred con-
straints and the befuddlement of most private
and some public purchasers over what to do
with analytic findings often leave the evalua-
tive enterprise all dressed up with no place to
go. In this arena, the United States and the 4
nations may well converge. As cost pressures
January 2003, Vol 93, No. 1 | American Journal of Public Health
 PUBLIC HEALTH MATTERS 
build, so too will the impulse to find diag-
noses and recommendations in neutral ex-
pertise and objective evidence. Analytic find-
ings and advice will throw down the gauntlet
to providers, who will respond both by seek-
ing to shoot the messenger and by redoubling
their efforts to document, define, and perhaps
even reconsider their practice patterns. Policy-
makers will reply that the providers offer too
little, too late, and the deployment of analytic
weapons in the unending political conflicts
will escalate.
SUPPLY
The 4 nations all use public authority and
planning to control the number and distribu-
tion of hospitals and physicians. Contrary to
conventional wisdom, such constraints do not
necessarily make the system “smaller” or
harder to access. Rodwin’s Table 2,3 for ex-
ample, shows that on most measures of re-
sources and utilization—for instance, active
physicians per thousand population; total in-
patient hospital beds, physician visits, and
hospital days per capita; admission rates to
and lengths of stay in hospitals—France sur-
passes the United States. These limits do
make the systems less specialist driven and
technology intensive, however, which seems
to be how they register savings for the na-
tions in question.
Notwithstanding such programs as certifi-
cates of need, the United States relies mainly
on a combination of market forces and pro-
fessional preferences to decide what levels of
supply are adequate. The market itself must
challenge the hoary conviction that “health is
a community affair,” meaning in practice a
highly entrepreneurial affair in which local
providers behave as if more is better, often
with the acquiescence of boosterish local
business leaders. Hospitals and physicians
want bigger and better facilities, the latest and
best equipment, deeper market penetration,
and more accessible satellite sites, as do the
communities they serve. Managed care plans
that contract too narrowly risk losing cus-
tomers. Health “planning,” which connotes ra-
tioning, waiting lists, and beneficial services
foregone has largely vanished from the Amer-
ican radar screen. Perhaps, however, the cost
pressures accompanying universal coverage
will so obviously overmatch the disciplinary
powers of market forces that US policymakers
will rethink their options on this controversial
count.
SATISFACTION
In all 4 nations, citizens record high
(though not unreserved or uncritical) satisfac-
tion with their health care systems. No one
views national health insurance as a big mis-
take and wants to start over. The vices of the
US system—40 million uninsured people, an
additional (and sizable) number with inade-
quate coverage, wide disparities in access and
quality—are thought to overwhelm such mod-
est and distinctive virtues as more extensive
integration of services and more advanced
analytic capacity. The foreign systems’ costs
are routinely and rhetorically said to be in
“crisis.” The systems themselves are not.
American public opinion voices no small
dissatisfaction with the US system and consid-
erable support for major, even fundamental,
changes in it. The rub, however, is that this
grousing does not yield a clear mandate for
anything very different from the status quo.
Despite years of intense opinion polling, poli-
cymakers remain unsure precisely what peo-
ple are upset about (beyond the impossibility
of enjoying ready access to fine care at mini-
mal cost) and what they think would work
better. Nor is this so odd after all: the same
political leaders who quietly pushed arcane
payment reforms in public programs have
generally declined to launch searching public
discussions of the big and touchy redistribu-
tive and regulatory issues and tradeoffs on
which health reform turns. Bill Clinton’s un-
availing and politically painful effort to break
the pattern reaffirmed it instead. A perplexed
public has therefore come to view health care
reform as something like shopping for shoes:
“We think we are in the mood to buy a health
care reform today but not that style or fit, so
keep showing us others.” The technical opac-
ity of the debate, not to mention continuing
skepticism of anything “made in Washington,”
inhibit grassroots mobilization, citizen educa-
tion, and other key concomitants of vigorous
pluralist politics. No one seems to have a clue
how to make well-documented dissatisfaction
kindle a political fire under health reform.
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LEADERSHIP
The 4 countries all recognize that strong,
continuing leadership by the central govern-
ment is the sine qua non of affordable univer-
sal coverage. Great Britain is, of course, the
home of “socialized medicine.” Efforts by
France’s famously powerful state to reform
the health care system have multiplied in the
last 2 decades, especially since the Juppe re-
forms of 1996. Germany’s central govern-
ment is a “supervisor, enabler, facilitator,
monitor,”4 and purveyor of national standards
for the health system. Canada’s constitution
reserves health duties for the provinces, but
the central government uses its financial
leverage to enforce on them 5 straightforward
principles that protect solidarity and equity
for Canadian citizens.
None of the 4 countries, however, supposes
that health policy can be run entirely from
London, Paris, Berlin, or Ottawa. Germany
and Canada are federal systems and, as Al-
tenstetter4 and Deber1 explain, a mix of con-
stitutional, political, and informal rules and
norms ensure that states and provinces partic-
ipate extensively in making and running
health policies that affect them. With such
consultation comes conflict and delay, but
federalism and universal coverage are emi-
nently compatible.
Great Britain and France have created new
regional and community bodies—the Primary
Care Trusts in the former and regional hospi-
tal councils and public health conferences in
the latter, for instance—that encourage delib-
eration and coordination closer to the prover-
bial grass roots. All 4 acknowledge that de-
centralization and devolution are goals worth
pursuing, but they also understand that work-
able decentralization presupposes effective
centralization of policy authority.
This latter proposition generally eludes US
health policy. Save on rare occasions—for ex-
ample, the New Deal and the Great Society—
when issues of economic and social justice
dominate the national agenda, fights over the
alleged evils of new central powers quickly
upend debate on the ends of reform, health
or other. At least in the health sphere, actions
may speak louder than words—Medicare,
Medicaid, Children’s Health Insurance Pro-
gram, and other public programs control
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 PUBLIC HEALTH MATTERS 
roughly half the dollars in the health care sys- 2. Light, DW. Universal health care: lessons from the
tem, after all—but political protocol requires British experience. Am J Public Health 2003;93:
25–30.
proclaimed allegiance to an official ideology
3. Rodwin VG. The health care system under
of market forces and less government even as
French National Health Insurance: lessons for health
reformers quietly and incrementally add a reform. Am J Public Health 2003;93:31–37.
new piece of managed care regulation here, 4. Altenstetter, C. Insights from health care in Ger-
expansion of public coverage to another in- many. Am J Public Health 2003;93:38–44.
come category there. Much of this (abundant)
public action originates in the states or
evolves from complex sharing of initiatives,
funds, and powers between the national and
state governments. Fifty states are a more
daunting tableau than 10 provinces, but the
United States might infer from the Canadian
system that universal coverage in a federal
system can be managed by 5 succinct princi-
ples, not 50 volumes of the Federal Register.
Unfortunately American reformers have been
more inclined to admire Canada’s “single-
payer” financing than its much more instruc-
tive central/provincial accommodations.
Where this self-denying activism, this
stealthy state leadership, leads is anyone’s
guess. Perhaps the present pattern—one step
forward, one step back, and the nation count-
ing itself lucky if the number of uninsured
does not exceed 40 million—will persist. Per-
haps incrementalism will proceed and the na-
tion will awake one day to find that enough
programmatic pieces are in place to sustain
near universal coverage if only the money
and leadership can be summoned to add a
few more beneficiary categories and raise in-
come thresholds a few more notches. Perhaps
another 1932 or 1964 waits right around the
corner, and “real” health reform may sud-
denly arrive on waves of social indignation
and political innovation. At this point, how-
ever, cross-national learning disappears into
the depths of national character.
About the Author
The author is with the Mailman School of Public Health,
Columbia University, New York, NY.
Requests for reprints should be sent to Lawrence D.
Brown, Professor of Health Policy and Management,
Mailman School of Public Health, Columbia University,
600 W 168th St, New York, NY 10032 (e-mail: ldb3@
columbia.edu).
This article was accepted September 17, 2002.
References
1. Deber, RA. Rekindling Reform: lessons from Can-
ada. Am J Public Health. 2003;93:20–24.
American Journal of Public Health | January 2003, Vol 93, No. 1