In contrast, the medical literature is replete with reports of the effectiveness of specific biomedical interventions that influence the course of particular diseases. John Bunker has gone further and estimated that health services in general account for about half of improvements in health (measured as increases in life expectancy) in the most recent half-century (Bunker, 2001). While his monograph demonstrates the important role of health services, it reinforces the simultaneous importance of other influences.

The effect of social factors on health, and the possibility of their remediation, does not detract from the importance of health services, at least in part because one of the correlates of social factors is differential access to and appropriate use of health and other services. Documentation of the overall effect of services specifically on children’s health is more limited. A 1985 publication on the importance of health services on the incidence, prevalence, and severity of 16 important conditions in childhood (Starfield, 1985b) illustrated the importance of access to health services. However, this study provided no quantitative estimates of the total magnitude of effect of health services on the child population, and it predated numerous new vaccines and other general environmental improvements that have further reduced morbidity and mortality. It was also based on a model of health that was more disease-oriented than the multifaceted conceptualization of health proposed in this report.

In more recent years, it has become clear that the nature of health services, rather than simply their presence, is important. For example, an accumulating number of studies, both in the United States and abroad (as well as international comparative studies) have shown the importance of a strong primary care orientation in health services systems (Starfield et al., 1998). The benefits of a strong primary care orientation are even more salutary for children than for adults (Shi and Starfield, 2002).

Comprehensive, high-quality center-based early education has been demonstrated to improve a range of educational outcomes (National Research Council and Institute of Medicine, 2000). A growing literature supports the ability of early intervention services to intervene and modify developmental health trajectories in children who are at risk of developing developmental, behavioral, and mental health conditions (Ramey et al., 1992; Karoly et al., 1998; Olds and Kitzman, 1993; Olds et al., 1997, 1998, 1999). The availability and configuration of services in a given community can be logically assumed not only to affect a range of children’s health outcomes, but also to create a context for and to affect the range of other influences.

Figure 3-1 presents a theoretical framework modified from Halfon and Lawrence (2003) to illustrate how services can direct or modify a course of healthy development; modify predisease pathways; and minimize the risk of exposures before they occur, thereby actively promoting the development of health capacities. Services can reduce exposure to health-compromising events. For example, there is strong evidence that multiple doses of pneumococcal vaccine lead to



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