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1. The poverty rate 16.3% under age 18.

2. Government Supports: SNAP, Earned Income Credit, Child Care Assistance Program, Medicaid, Head Start. FMLA-Guarantees 12 weeks unpaid.

3. Brick and Mortar K-12, Generally age 5-19 . By law required 6-18(depending on state.) No Child Left Behind Act .

4. Attend School 180 Days.

5. 2/3 attend early childhood education, health, nutrition, and parent involvement services. HEAD START. Opportunities for learning, socializing,.

6. About 51% attend preschool programs.

7. Child led, Discovery, structured , science based, centers,

8. Curriculum can be set by the state if public or you create and adopt one for private.

9. Preschool teachers need to have BA for a state approved program. Specific training is required for EX development, safety, regulations.

10. HEAD START Federally funded Need to meet guidelines.

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Quality of health care is on the national agenda. In September 1996, President Clinton established the Advisory Commission on Consumer Protection and Quality in the Health Care Industry, which has released its final report on how to define, measure, and promote quality of health care ( President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry 1998).

Much of the interest in quality of care has developed in response to the dramatic transformation of the health care system in recent years. New organizational structures and reimbursement strategies have created incentives that may affect quality of care. Although some of the systems are likely to improve quality, concerns about potentially negative consequences have prompted a movement to assure that quality will not be sacrificed to control costs.

The concern about quality arises more from fear and anecdote than from facts; there is little systematic evidence about quality of care in the United States. We have no mandatory national system and few local systems to track the quality of care delivered to the American people. More information is available on the quality of airlines, restaurants, cars, and VCRs than on the quality of health care.

We have conducted a review of the academic literature for articles on quality of care in the United States, and we summarize our findings in this article. In the absence of a national quality tracking system, we believe such a summary is the best way to provide an overview of the quality of care delivered in the United States. We provide examples to illustrate quality in diverse settings, for diverse conditions, and for diverse demographic groups, and to offer insight into the quality that exists nationwide.

Methods

Definitions

The Institute of Medicine has defined quality as "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge" ( Lohr 1990). Good quality means providing patients with appropriate services in a technically competent manner, with good communication, shared decision making, and cultural sensitivity. In practical terms, poor quality can mean too much care (e.g., providing unnecessary tests, medications, and procedures, with associated risks and side effects), too little care (e.g., not providing an indicated diagnostic test or a lifesaving surgical procedure), or the wrong care (e.g., prescribing medicines that should not be given together, using poor surgical technique).

Quality can be evaluated based on structure, process, and outcomes ( Donabedian 1980). Structural quality evaluates health system characteristics, process quality assesses interactions between clinicians and patients, and outcomes offer evidence about changes in patients' health status. All three dimensions can provide valuable information for measuring quality, but the published quality-of-care literature reveals that there is more experience with measuring processes of care. Two particular techniques, which measure a type of process quality called "technical process quality," dominate the literature.

Technical process quality refers to whether care is provided skillfully and whether the right choices are made in diagnosing and treating the patient. The latter (making the correct choices) is generally measured by assessing appropriateness or adherence to professional standards.

An intervention or service (e.g., a lab test, procedure, medication) is considered appropriate if, for individuals with particular clinical and personal characteristics, its expected health benefits (e.g., increased life expectancy, pain relief, decreased anxiety, improved functional capacity) exceed its expected health risks (e.g., mortality, morbidity, anxiety anticipating the intervention, pain caused by the intervention, inaccurate diagnoses) by a wide enough margin to make the intervention or service worth doing ( Brook et al. 1986). A subset of appropriate care is necessary or crucial care. Care is considered necessary if there is a reasonable chance of a nontrivial benefit to the patient and if it would be improper not to provide the care. In other words, it might be considered ethically unacceptable not to provide this care ( Kahan et al. 1994; Laouri et al. 1997). Appropriateness criteria and necessity criteria can be used, respectively, to measure overuse of care, which is a problem because of treatment complications and wasted resources, and underuse of care, which means that people are not getting care expected to improve their health.

Another way to measure process quality is to determine whether care meets professional standards. This assessment can be done by creating a list of quality indicators that describe a process of care that should occur for a particular type of patient or clinical circumstance and then evaluating whether patients' care is consistent with the indicators. Quality indicators are based on standards of care, which are either found in the research literature and in statements of professional medical organizations or determined by an expert panel. Current performance can be compared against a physician's or plan's own prior performance, against the performance of other physicians and plans, or with reference to a benchmark that establishes a goal. Indicators can cover a specific condition (e.g., children with sickle cell disease should be prescribed daily penicillin prophylaxis from at least six months of age until at least five years of age), or they can cover general aspects of care regardless of condition (e.g., patients prescribed a medication should be asked about medication allergies).

Literature Review

Our review is based on a search of articles in the National Library of Medicine's Medline Plus system (1993 to present) conducted in June 1997 and on studies identified from the bibliographies of these articles. We excluded articles published before 1987. We did not aim to be exhaustive but, rather, to find examples that cover a broad range of conditions and settings. We report data only from large or diverse populations, such as the nation, an entire state, an entire city, or several hospitals. We do not include data from studies that covered only a single hospital or clinic.

Categorization

Our review of quality in the United States is divided into three categories based on type of care: preventive ( Table 1 ), acute ( Table 2 ), and chronic ( Table 3 ). We have chosen this categorization because there are differences in the way these types of care are delivered that could affect quality. Preventive care is typically initiated on a routine basis by the clinician rather than on an episodic basis by a patient coming to the clinician with symptoms, and it is generally not covered as well by insurance. The need for acute care is typically identified by the patient, and the care is often delivered during a single encounter. Chronic care is more likely than acute care to be delivered by a clinician who has an ongoing relationship with the patient, and good chronic care is also more likely to involve good follow-up. The tables describe the health care service for which quality is reported, the sample on which the report is based, the data source for the sample, the findings, and the reference for the findings. We report on data from 48 articles covering about one-half million people.

TABLE 1

Health Care Servicea

Sample Description

Data Source

Quality of Care

Referenceb

IMMUNIZATIONS

Routine childhood vaccines (1995 schedule)

Influenza vaccine (adult)

Pneumococcal vaccine (adult)

CANCER SCREENING

Breast cancer: clinical breast examination (CBE) and mammography

Cervical cancer: Papanicolaou (Pap) smear

Colon cancer: fecal occult blood testing (FOBT) and sigmoidoscopy

Colon cancer: FOBT and sigmoidoscopy

CARDIAC RISK FACTORS

Smoking cessation counseling

Blood cholesterol testing

Blood cholesterol testing

GENERAL PREVENTIVE CARE

Well-child care

The American Academy of Pediatrics recommends routine history, physical examination, screening tests, and anticipatory guidance throughout childhood ( American Academy of Pediatrics 1988).

All children who had their second birthday during the first half of the study year, and all 2-year-olds with otitis media or asthma, from a sample of 2,024 patients of 135 providers

Medical records from physicians' offices, community health centers, and hospital outpatient facilities sampled from Maryland Medicaid claims data, 1988

For each type of clinical setting, the study reports the average percentage of technical quality indicators for well-child care that were not met. Each average was located in the 35%-65% range.

( Starfield et al. 1994)

Well-adult care

Patients should have preventive health visits every 1-3 years when 19-64 years old and every year when ≥65 years old ( U.S. Preventive Services Task Force 1989).

All adults with asthma, hypertension, and diabetes from a sample of 2,024 patients of 135 providers

Same as above

For each type of clinical setting, the study reports the average percentage of technical quality indicators for well-adult care that were not met. Each average was located in the 45%-55% range.

( Starfield et al. 1994)

TABLE 2

Health Care Servicea

Sample Description

Data Source

Quality of Care

Referencea

ANTIBIOTIC USE

Common cold

Upper respiratory tract infection

Pharyngitis, nasal congestion, common cold, and other upper respiratory tract infection

RESPIRATORY ILLNESS

Pneumonia: hospital care

Pneumonia

Bronchitis/asthma

OTITIS MEDIA

Treatment

Use of tympanostomy tubes

HIP FRACTURES

Hip fracture: hospital are

PRENATAL CARE

Medical history

Physical examination

Laboratory tests (hemoglobin blood test and urine test)

Medical history, physical examination, and laboratory tests

Counseling about nutrition and weight gain

Counseling about alcohol, tobacco, and illicit drugs

Counseling about breastfeeding

Counseling about nutrition, weight gain, alcohol, tobacco, illicit drugs, and breastfeeding

Routine prenatal screening tests

Other routine prenatal care

Care for complications of pregnancy

Screening and follow-up for proteinuria (protein in urine)

Recording of gestational age

Assessment of fetal heart tones after 18 weeks of gestation

Follow-up for low hematocrit

Follow-up for high blood pressure

TABLE 3

Health Care Servicea

Sample Description

Data Source

Quality of Care

Referencea

ASTHMA

Adult asthma

Childhood asthma

DIABETES MELLITUS

Dilated eye examination to screen for retinopathy

Any eye examination (including nondilated) to screen for retinopathy

Eye exam by ophthalmologist

Hemoglobin A1C

Cholesterol screening

Diabetes mellitus

HYPERTENSION

Treatment for hypertension

Treatment for hypertension

Treatment for hypertension

Treatment for hypertension

DEPRESSION

Depression: treatment

Depression: treatment

Depression: admission

Depression: admission assessment

Depression: diagnosis and treatment

MENTAL/ADDICTIVE DISORDER

Mental or addicitve disorder

HYSTERECTOMY

Hysterectomy

BREAST CANCER

Breast cancer: treatment

CARDIAC DISEASE

Coronary artery disease: coronary angiography

Coronary artery disease: coronary angiography

Coronary artery disease: coronary angiography

Coronary artery disease: coronary artery bypass graft (CABG)

Coronary artery disease: CABG

Coronary artery disease: CABG

Coronary artery disease: percutaneous transluminal coronary angioplasty (PTCA)

Heart attack: treatment with aspirin

Heart attack: treatment with aspirin

Heart attack: treatment with aspirin

Heart attack: treatment with aspirin

Heart attack: treatment with thrombolytics

Heart attack: treatment with thrombolytics

Heart attack: treatment with heparin

Heart attack: treatment with intravenous nitroglycerin

Heart attack: avoidance of calcium channel blockers for patients with a contraindication

Heart attack: smoking cessation advice for smokers

Heart attack: treatment with angiotensin-converting enzyme (ACE) inhibitors

Heart attack: beta blocker therapy

Heart attack: beta blocker therapy

Heart attack: beta blocker therapy

Heart attack: permanent cardiac pacemaker

Heart attack: hospital care

Congestive heart failure: hospital care

Stroke: hospital care

CAROTID ARTERIES

Carotid endarterectomy

GASTROINTESTINAL DISEASE

Upper gastrointestinal tract endoscopy

CATARACTS

Cataract surgery

HIV/AIDS

Relation between hospital experience and mortality from AIDS

300 patients diagnosed with acquired immunodeficiency syndrome (AIDS)

Case records of the Massachusetts AIDS Surveillance Program and billing records from 40 hospitals, medical records for patients from 22 of the 40 hospitals, and data tapes from the Massachusetts Rate Setting Commission, 1/1/87-12/31/88

Patients in low-experience hospitals were 2.16 times more likely to die (2.92 when controlling for characteristics potentially associated with mortality) during an AIDS admission, compared with those in high-experience hospitals.

Relation between physician experience and mortality from AIDS

NEONATAL MORTALITY

Relation between physician experience and neonatal mortality

53,229 births classified as likely neonatal intensive care unit (NICU) admissions from a sample of 473,209 births (singletons only) in 1990

California birth certificate and infant death file for all nonfederal hospitals, California Office of Statewide Health Planning and Development (OSHPD) discharge abstracts, California Perinatal Dispatch Centers' neonatal transport data, and OSHPD hospital data, 1990

Infants born in hospitals with an average NICU census ≥20 patients per day had lower risk-adjusted mortality than those born in hospitals without an NICU (odds ratio = 0.74; confidence interval = 0.58-0.95; P= .02).

( Phibbs et al. 1996)

PREVENTABLE DEATHS

Evaluation of preventable deaths

ADVERSE EVENTS

Adverse events

Adverse drug events

Quality of Care in the United States

Perhaps the most striking revelation to emerge from this review is the surprisingly small amount of systematic knowledge available on the quality of health care delivered in the United States. Even though health care is a huge industry that affects the lives of most Americans, we have only snapshots of information about particular conditions, types of surgery, and locations of care.

The dominant finding of our review is that there are large gaps between the care people should receive and the care they do receive. This is true for all three types of care-preventive, acute, and chronic-whether one goes for a check-up, a sore throat, or diabetic care. It is true whether one looks at overuse or underuse. It is true in different types of health care facilities and for different types of health insurance. It is true for all age groups, from children to the elderly. And it is true whether one is looking at the whole country or a single city.

It is difficult to provide a numerical summary of the findings presented in these tables, but we offer some simple averages as a rough summary. However, we must emphasize that these studies cover different populations, time periods, and methodologies, and so the averages only give a ballpark idea of the quality of care people are receiving.

For acute and chronic care studies, data are mostly reported as the percentage of people who received recommended care (care that should have been delivered was delivered) or contraindicated care (care that should not have been delivered was delivered). For the few studies that reported the percentage of people who did not receive recommended care (care that should have been delivered was not delivered), we subtract the value from 100 percent to convert to the percentage who received recommended care. We also omit a few studies from the averaging process because they did not report a percentage of people receiving good or bad care. (Some studies, for example, showed an association between care of a particular condition delivered by more experienced clinicians and better clinical outcomes for the condition.) Finally, when there is a range of values for a single item, we use the value that indicates highest quality.

A simple average of the findings of the preventive care studies shows that about 50 percent of people received recommended care. (None of the studies reported a percentage of people receiving contraindicated preventive care.) An average of 70 percent of patients received recommended acute care, and 30 percent received contraindicated acute care. For chronic conditions, 60 percent received recommended care and 20 percent received contraindicated care. These values do not indicate exact levels of quality in the United States, but they do provide a quantitative sense of how much could be done in all areas to identify and eliminate overuse and underuse of care. To provide more precise percentages, we would need to take into account the methodologies of the studies, the sample sizes, the prevalence of conditions, and the impact each type of care has in promoting health.

A few examples emphasize this point. An annual influenza vaccine is recommended as a preventive measure for all adults 65 years or older, a group at especially high risk for complications and death from influenza ( U.S. Preventive Services Task Force 1989, 1996). However, in 1993, 52 percent of people in this age group in the United States received the vaccine; among people who had been to the doctor at least once that year, the percentage was slightly higher at 56 percent ( Centers for Disease Control and Prevention [CDC] 1995b).

A major issue in acute care is the overuse of antibiotics, which has led to the development of strains of bacteria that are resistant to available antibiotics ( Begley 1994; Centers for Disease Control and Prevention 1994a). Antibiotics are almost never an appropriate treatment for people with a common cold because almost all colds are caused by a virus, for which antibiotics are not effective. However, in a study of Medicaid beneficiaries diagnosed with a cold in Kentucky during a one-year period from 1993 to 1994, 60 percent filled a prescription for an antibiotic ( Mainous et al. 1996).

Other types of medications are also not always used in the most appropriate manner. Among hospitalized elderly patients with depression who were discharged on antidepressant medication, 33 percent were on a dose below the recommended level ( Wells et al. 1994b). In a study of 634 patients with depression or depressive symptoms in Boston, Chicago, and Los Angeles, 19 percent were treated with minor tranquilizers and no antidepressants ( Wells et al. 1994a), despite the lack of evidence that tranquilizers work for depression and the risk that they will cause side effects or addiction ( Depression Guideline Panel 1993).

Patients with chronic conditions, for which certain routine examinations and tests are crucial in order to prevent complications, do not all get the care they need. Diabetes mellitus causes several complications that are less likely to occur with good care. One complication is an eye condition called diabetic retinopathy, which is the leading cause of new blindness among persons aged 20 to 74 in the United States. It is recommended that patients with insulin-dependent diabetes mellitus have an annual dilated eye examination (the clinician uses drops to enlarge the pupil to see behind it more easily) starting five years after diagnosis and that patients with non-insulin-dependent diabetes mellitus have the exam annually starting at the time of diagnosis. In a national study in 1989, 49 percent of adults with either type of diabetes had undergone a dilated eye examination in the past year (66 percent in the past two years), and 61 percent had undergone any type of eye exam in the past year (79 percent in the past two years). Twenty percent of diabetics had no eye exam in the past two years. Among diabetics who were at particularly high risk for vision loss because they already had retinopathy or because they had had diabetes for a long time, 61 percent and 57 percent, respectively, had a dilated examination in the past year ( Brechner et al. 1993).

Sometimes surgery is performed on people who do not need it. A study of seven managed care organizations revealed that about 16 percent of hysterectomies performed during a one-year period from 1989 to 1990 were carried out for inappropriate reasons. An additional 25 percent were done for reasons of uncertain clinical benefit ( Bernstein et al. 1993b). There are also examples of patients who need surgery but do not receive it. In a study of four hospitals, 43 percent of patients with a positive exercise stress test demonstrating the need for coronary angiography had received it within 3 months; 56 percent had received it within 12 months ( Laouri et al. 1997).

Adverse events are injuries caused by medical management of a disease rather than by the disease itself. A review in New York State in 1984 found that 1.0 percent of hospitalizations had an adverse event due to negligence ( Brennan et al. 1991). A study of two Boston hospitals found an adjusted rate of preventable adverse drug events of 1.8 per 100 hospital admissions; 20 percent of these events were life-threatening ( Bates et al. 1995).

Not all studies have found such poor quality. In a study of patients who had cataract surgery, 2 percent had the surgery for inappropriate reasons ( Tobacman et al. 1996). In a study of patients who underwent coronary artery bypass graft (CABG) surgery, 1.6 percent had surgery for inappropriate reasons ( Leape et al. 1996). Nonetheless, the majority of studies described in the tables show much room for improvement of quality.

Many have been quick to conclude that managed care is responsible for much of the poor quality that is found in the American health care system. Studies published in the research literature have neither clearly confirmed nor refuted this conclusion. Some studies find that managed care organizations provide better care than fee-for-service (FFS), some find that FFS provides better care, and others find that the care is about the same ( Miller and Luft 1993, 1994). Results vary depending on the setting, the type of care assessed, and the methodology. This topic is complicated by the research approach, which has generally lumped together managed care organizations without distinguishing them either by type (e.g., group- and staff-model health maintenance organizations, independent practice associations, preferred provider organizations, point-of-service plans) or by features (e.g., comprehensiveness of the benefits package, nonprofit versus for-profit status). It would be more useful to look at the impact of specific characteristics of managed care organizations. For example, inclusion of immunizations in the benefits package may have a larger impact on immunization rates than whether the care is offered by a managed care organization or a fee-for-service provider. Finally, managed care is changing so rapidly ( Landon et al. 1998) that most currently available studies are already out of date. Our ongoing quality measurement system is not large enough to enable timely assessment of the rapid changes occurring in the health care marketplace. Even the most widely used systems (e.g., the Health Plan Employer Data and Information Set, described below) are far from universal and do not cover both managed care and fee-for-service.

In this article, we have described reports of quality that have appeared in the research literature. There are also some systems that measure quality in select sectors of the United States, most notably the National Committee for Quality Assurance's (NCQA) Health Plan Employer Data and Information Set (HEDIS). HEDIS is a performance measurement tool designed to assist purchasers and consumers in evaluating managed care plans and to hold plans accountable for the quality of their services. In 1996, more than 330 plans-over half the U.S. plans representing more than three-quarters of all commercial managed care enrollees-were reporting HEDIS measures on their commercial enrollees. Average adherence rates for select indicators made publicly available by NCQA fell primarily in the 60 to 70 percent range, with the extremes at 38 percent for diabetic eye exams (past year) and 84 percent for initiation of prenatal care in the first trimester ( Thompson et al. 1998). Thus, HEDIS's findings are consistent with those of the studies we have reported. Whether assessing quality as part of a research study or as part of a marketplace tool, the evidence repeatedly shows that quality falls short of standards.

Although NCQA, other organizations, and government bodies are doing work to measure quality of care, most of this activity has begun during the past decade. The rapid development of the field is encouraging, but it is confined to organizations that cover specific sections of the country or restrict themselves to certain segments of the health care marketplace. Their work, as well as the findings of individual studies, such as those listed in the tables, provide some evidence of the situation throughout the country. However, there is no system in the United States to provide a comprehensive assessment of quality of care for the nation-including how quality varies by population subgroups (e.g., gender, age, race/ethnicity, income, region of country, size of community) and how quality is changing over time. Efforts like HEDIS could eventually lead to development of a more comprehensive, national quality assessment system, but such a system may not develop rapidly unless there is an organized effort to ensure that it does.

Conclusions

The quality of health care provided in the United States varies among hospitals, cities, and states. Whether the care is preventive, acute, or chronic, it frequently does not meet professional standards. We can do much better. The solution is not simply a matter of spending more money on health care. A large part of our quality problem is the amount of inappropriate care provided in this country. Elimination of such non-beneficial and potentially harmful care would lead to a large savings in human and financial costs. However, there are also many examples of people who receive either too little or technically poor care; fixing these problems may increase expenditures.

Some have assumed that all care delivered in the United States is outstanding. There is good reason to be proud of our health care system, and the evidence from international studies does not show consistent superiority elsewhere in the world ( Gray et al. 1990; Pilpel et al. 1992; McGlynn et al. 1994; Froehlich et al. 1997; Meijler et al. 1997; Tamblyn et al. 1997; Wong et al. 1997). The United States is responsible for many important advances in health care technology, and state-of-the-art care is available in both large and small communities throughout the country. Just because outstanding care is available, however, does not mean that it is always provided or that everyone has access to such care. Most people in the studies reported here did receive excellent care-what is notable is that many also did not.

Some people might conclude that quality is good enough based on the evidence we have presented in this article-in other words, that the standards used in the various studies are too high. We would disagree with such a conclusion.

For those who want to improve our health care system, techniques exist to measure and change the delivery of care. Clinicians and health plans can use information on quality to determine where to focus their efforts to provide better care. If this information is made available regularly and in an interpretable form, consumers and large purchasers can also use it to make informed decisions when choosing among clinicians and plans, which will, in turn, give providers an added incentive to improve quality.

Policy makers can also use information about quality of care to determine the impact of public and private changes in the health care marketplace. We are currently experiencing a dramatic shift in the organization and financing of health services delivery in the United States. The private sector has been the driving force behind this transformation, but the public sector is beginning to use its market power as well. Incentives to move Medicaid and Medicare beneficiaries into managed care represent one of many examples of public sector reform. Changes are occurring faster than evaluations of these changes can be performed. Much of the information concerning the relation between the organization of the health care system and the quality of care is already outdated. At present, we have only a patchwork of systems that measure quality, with little uniformity, breadth, or ability to produce rapid results. Furthermore, these systems do not yet assess most providers of health care in the United States.

The United States cannot afford to let this situation continue. A systematic strategy for routine monitoring and reporting on quality, as well as the information systems needed to support such activities, will be essential if we are to preserve the best of the American health care system while striving to improve the efficiency with which high-quality services are provided.

This strategy could be organized by the federal government, the private sector, or a public-private partnership. It could involve coordination among all three. Regardless, the strategy will need to cover the aspects of quality that patients, purchasers, and providers care about; it will need to collect data in a way that is manageable, reasonable, and affordable; and it will need to produce information in a format that is useful for making a variety of decisions.

The United States is capable of setting up a quality measurement system that can provide the multiple participants in the health care system with the information they need to ensure delivery of high-quality care. In light of the changes that the health care system has been experiencing, a strategy to measure and consequently to improve quality is needed now.

Acknowledgments

Partial funding was provided by the National Coalition on Health Care. We are indebted to Allison L. Diamant, MD, MSPH, Molla Donaldson, PhD, Rachel Spilka, PhD, and Joseph H. Triebwasser, MD, for comments on drafts of this paper. We are also indebted to Lauren N. Nguyen, MPH, Cung B. Pham, Yuko Sano, and Sinaroth Sor, MD, for research assistance.

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Articles from The Milbank Quarterly are provided here courtesy of Milbank Memorial Fund

# data[].attributes.attachment_link.title
How Good Is the Quality of Health Care in the United States?

# data[].attributes.attachment_link.description
Quality of health care is on the national agenda. In September 1996, President Clinton established the Advisory Commission on Consumer Protection and Quality in the Health Care Industry, which has released its final report on how to define, measure, and promote quality of health care ( President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry 1998).

# data[].attributes.body
1. Compared to the United States, Chinese citizens can walk into a doctor's office without making an appointment. Chinese citizens have a highly understaffed and underpaid health care system. The Chinese health system is divided between “tickets” - where healthcare is divided between how much the patient wants to pay. 19% of China’s children fall below the poverty line, according to a survey from 2018.

(https://thechinaproject.com/2017/03/28/healthcare-us-compare-china/)

https://www.unicef.cn/media/22026/file/Child%20Multidimensional%20Poverty%20in%20China.pdf

2. Maternity leave: minimum is 98 days paid, however some can be from anywhere to 128 days to 190 days. There is also child support, school aid in meals, and tax breaks. The support in China is somewhat similar to the United States, but the United States is a bit more established in terms of support for children.

3. In China, they focus more on collectivism instead of individualism. In the United States, individuals are concerned about themselves, whereas China is concerned about the collected community. Unlike in the United States, where you can choose which high school you want to go to, in China the children are required to take a test to enter a specific school. They go to school 5 days a week, similar to United States students, and have similar hours as well.

4. In China, there is a strong divide between the public and private schools for children. Education is split between two categories, depending on age. Early childhood education is dedicated to children from 0 to 3 years old, while kindergarten 4 to 6 years old. Many parents in China are concerned that they will not have access to proper or affordable childcare, such as daycare, nurseries, or schooling for their children. 87.8% of children were able to attend government funded kindergartens.

https://eastasiaforum.org/2023/03/03/insufficient-preschool-education-in-china-needs-reform/

5. Most preschool programs are in suburban and developed areas, their systems are broken into two groups - three and younger go to a nursery, and three through six go to a kindergarten. Children that attend kindergarten are separated into three different categories, juniors, middles, and seniors. The curriculum is defined into a national standard. Teachers are required to have a bachelor's degree in any subject, a clear background check, Teaching English as a Foreign Language (TEFL) certification, and a preferred background in teaching.

6. Yes, education in China is primarily managed by the state run public education system which falls under the ministry of education. Citizens must attend school for a minimum of nine years. Education in China is funded by the government. Primary public schools are tuition-free. They attend primary schools in their neighborhoods, and parents pay little for textbooks and other expenses. In 2020, there was an increase of 34.4 million students entering compulsory education.

Hunter, Katelyn, Alyssa, Gurjit Sanghera

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1. The poverty overall in Canada is 7.4%

2. Employment and Social Development Canada (ESDC) offers various programs to support single mothers in accessing government grants. One such program is the Canada Child Benefit (CCB), which provides monthly financial assistance to eligible families based on their income and number of children.

3. In the US, schools are very competitive, with good grades highly prioritized. In Canada, however, schools view each child individually and combine their complete performance as a student to evaluate how well they are doing.Here are some differences between the education systems in Canada and the United States:

Standardized tests

The US uses standardized tests at the end of each grade, while Canada does not.

High school length

In the US, high school is typically four years, while in Canada it's generally three years.

Extracurricular activities

In Canada, there's less pressure to participate in extracurricular activities to get into university.

School lunches

In Canada, school lunches are more like a restaurant, where you can order from a selection of food.

Tuition fees

In general, tuition fees in the United States tend to be higher than in Canada.

Student visas

To study in the U.S., international students need to obtain a student visa. In Canada, international students need to acquire a Study Permit.

4. In Canada, preschool is generally considered a better choice than the American approach. Canadian preschools focus on critical thinking, exploration, and discovery. They also emphasize early learning and preparing children emotionally, intellectually, and socially for higher grades.According to a 2022 survey, 31% of Canadian children under age 6 attended daycare centers, preschools, and centers de la petite enfance (CPEs) in early 2022.

5. In Canada, it usually also precedes kindergarten (both JK and SK). Preschool thus includes all education before compulsory schooling starts (usually between the ages of four or five). While this includes infant and toddler preschool, most private preschools are geared for children from the ages of three to five.

While they can have different teaching and learning approaches, most preschools cover similar ground. They normally teach math, literacy, science, creative arts, and social skills, among other subjects and skills. There are also some common preschool learning activities in these and other areas.The Ministry of Education is responsible for developing curriculum, while school boards and schools manage the implementation. Having province-wide curriculum and assessment policies provides for consistent planning, implementation, evaluation and reporting of student learning and achievement across school boards.

Licensing requirements for preschool teachers in Canada vary by province and territory. In general, licensing is required in all provinces and territories, while certification is required in British Columbia.

To become an early childhood educator (ECE) in Canada, you typically need to:

Complete secondary school

Have experience in child care

Complete an ECE program or post-secondary courses in ECE

Have a college diploma in ECE or a bachelor's degree

Have current first aid and CPR certifications

Pass a criminal record and background check

Have licensing or certification by a provincial or territorial association

Job Bank

Early Childhood Educator (ECE) in Canada | Job requirements - Job Bank

Windmill Microlending

How to Become an Early Childhood Educator in Canada

Nov 10, 2023 — You must have successfully passed a criminal record and background check, demonstrating that you are eligible to work with young children. Licensing or certification by a provincial or territorial association is a key step.

6. Canadian Social Security and Social Assistance. Canada uses "social security" as a generic term referring to a wide range of programs dealing with health, education, unemployment, and family and child assistance, as well as old age, disability, and survivors' benefits.

Services and information

Employment Insurance benefits and leave. Temporary benefits for workers, sickness, fishing and family-related benefits. ...

Dental coverage. ...

Family and caregiving benefits. ...

Public pensions. ...

Grants and funding opportunities. ...

Student aid and education planning. ...

Housing benefits. ...

Disability benefits.

Its similar to USA , however. Preschool in Canada is generally considered a better choice due to its emphasis on early learning and preparing children emotionally, intellectually, and socially for higher grades. Canadian preschools focus on critical thinking, exploration, and discovery, whereas the American approach to preschool is more relaxed.

Klarissa Hernandez , Sophia Macias

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1. 9.4 percent of individuals in Italy were living below the poverty line.

2. Cash maternity allowance is equal to 80% of pay and is payable for 5 months. (2 prior to and 3 after the date of birth or 1 month prior to and 4 after).

3. Fathers are also obligated to take a ten-day paid leave of absence from work during the five months of maternity leave. The mother has the option to extend the father's paternal leave if she transfers one of her maternity days to him.

4. Italy's healthcare system is consistently ranked among the best in the world. Life expectancy is the 4th highest among OECD countries (83.4 years in 2018)

3. Universal Child Benefit and Single Universal Allowance. Percents with young children 1(50-75E) 2 (100-350E). Single parents: offers an additional 20E per child.

4. The preschool year in Italy begins in September. Preschool is optional in Italy unlike school for children over the age of 6, which is mandatory.

5. 95% of the children attend some kind of nursery. These programs are viewed as one of the best programs in the world. They have a plan-based approach a focus on social skills, emotional development, communication and verbal exchange.

6. Preschool includes some Montessori and Reggio Emilia elements, they are play based, learn by doing in an informal setting which communication and verbal exchange is encouraged focuses on social skills and emotional development in order to develop.

7. As of 2022, Italy offers a single and Universal Allowance for Dependent Children. Is assigned monthly, the amount ranges from a minimum of €30 to a maximum of €217.80 per child. This covers preschool expenses, costs of raising children.

8. Public education is free.

What is an Italian Preschool like? - Scuola Italiana di Portland

Teaching and learning in general lower secondary education (europa.eu)

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Teaching and learning in general lower secondary education

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Curriculum, subjects, number of hours At lower secondary level, the curriculum is defined through National Guidelines for the curriculum (Indicazioni nazionali per il curricolo) issued with the Ministerial Decree 254/2012.

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1. The poverty rate is 21.6% under age 18.

2. Healthcare costs the same no matter the illness in Germany

3. Parental allowance for up to 12 months. Child benefits for each child for 250 euros per month until the age of 18, and in some cases 25. Paid maternity leave is available for 6 weeks prior to birth, and 8 weeks after

https://ec.europa.eu/social/main.jsp?catId=1111&langId=en&intPageId=4546#:~:text=Maternity%20allowance%20is%20paid%20for,for%20the%20day%20of%20childbirth.

4. Germany has two primary school education systems. One is a 5-day week with 188 days per year. The other is a 6-day week with 208 days per year. Children start being graded in grade 2 based on their knowledge and their scores range from 1 (very good) and 6 (very poor). They study German, math, general studies, foreign language, handicrafts, art, music, sport, ethics, religion

https://www.studying-in-germany.org/german-education-system/#primary-education

5. Pre-school is not compulsory and it is not free. It is run by public administrations, but public funding and services have expanded in recent years. 91.7% of children are in pre-school from 3-6

https://www.destatis.de/EN/Themes/Society-Environment/Social-Statistics/Day-Care Children/_node.html

6. German pre-schools don't have a formal education. Kids typically engage in activities such as educational play. They may be introduced to letters, numbers, values and good behaviors. Teachers are required to complete 3-4 years of training within a pre-school in Germany. You need at least a secondary school diploma

https://en.life-in-germany.de/become-a-kindergarten-teacher-in-germany/#:~:text=First%20you%20have%20to%20complete,and%20attend%20a%20training%20center.

7. Pre-school may be partially subsidized by the state.

https://www.expatica.com/de/living/family/finding-childcare-in-germany-106276/

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1. Africa has 431 million of 1.4 billion people living below EXTREME poverty. Poor and middle class rely on under funded public health facilities.

2. Government programs for single parents, 41% living with only mother, 3% living with only father can receive child support grant, care dependency grant, social grant and maternity leave. Receipt of grants fall under 1% due to travel time to welfare offices.

3. Students attend school for 200 days a year, 20% between 6-11 years old are out of school followed by 33% being 12-14 years old.

4. Preschool education is neglected. 75% of children do not attend any form of preschool. 20% of children enroll in “pre-primary” education and attend.

5. Public pre-primary in this country is the least developed with ill trained or untrained educators. Access has increased over recent decades, but enrollment and attendance is low. Curriculum is centered around cultural principles and laws.

6. Scholarships and sponsorships make it possible for bright young children (mainly girls) to stay in school. Funds help cover tuition, books, after school lessons and tutoring, supplies, uniforms and other school related costs. This compares with the US, by law children are required to attend school until graduation or 18 compared to 15 in some parts of Africa.

Rosa, Alyssa, Kaylin, Hadie

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1. July 2023 child poverty was 11.5 %. Japan healthcare maintains a low cost compared to developed countries, while also being affordable it is universal coverage. Average cost of insurance in Japan is 300- 350 USD. National Health insurance and social health insurance are available for children. Insurance will pay 70% of total medical care cost and parents must pay the rest. Although parents can apply for a Free Medical Certificate to which the remaining 30% can be provided by the city but is not valid for ages 15 and older.

2. In Japan, there is private and public daycare and kindergarten. Public kindergarten prioritizes families who need childcare the most. They use a point system to determine how high of a priority you are: If the parents are working more than 7 hours a day (40+ points), whether the parent is on maternity leave (+10 points), if a grandparent is living with them (-6 points), and whether or not the family lives near the facility they are applying to. They are cheaper than public facilities and can run families 10,000 yen a month to 70,000 yen a month depending on their income. In the United States, childcare is also not free, however there are some programs that pay the tuition of the daycare if the family qualifies for it.

3. In Japan they take six classes a day, when we take eight. Unlike most schools in the US, the academic curriculum in Japan includes programming, home economics, and moral education. Japanese students put in 240 days a year at school, a whole 60 days more than Americans. Usually, students take midterm exams in 5 subjects: English, math, Japanese, science, and social studies. During final exams, the students are tested on those 5 subjects plus 4 more: health and physical fitness, home economics, music, and art.

4. - Japanese preschool education is child-centered and based upon the principle of “whole person education”, which focuses on social and emotional development, friendship, and responsibility.

- More than 70% of 3 year olds, more than 80% of 4 year olds, and more than 90% of 5 year olds attend either preschool/kindergarten or nursery school.

5. There are 2 types of early childhood education kindergarten schools (yochien) and daycare schools (hoikuen). Parents have the choice to enroll in before elementary school. Curriculum for both include the teaching of respect for the school, importance of group interaction, language skills, and to have teamwork to reach a common goal. The Ministry of Education and Science must approve the curriculum of a well-balanced time for playing and learning. As far as a preschool teacher they need a bachelor’s degree with training in teaching to kids, basic qualifications depend on the establishment.

6. In Japan, preschool and childcare were made free as of October 1, 2019. This was put into effect to help take away the financial burden from families to help increase the birthrate. The Japanese government also provides other childcare allowances and scholarships for college to help with the low birthrate. Compared to the United States, some schools are free but private school with tuition is an option. The U.S. does provide programs like CCS, scholarships/grants, along with head start that is free to low-income families.

Maternity leave in Japan consist of 14 weeks of leave is available for all working parents, full or part time jobs, there are 6 weeks before your due date and 8 weeks after birth. When you are under your empolyer's insurance your maybe be entitled to childbirth allowance. For women the allowance is 2/3 of their normal monthly allowance. No money is given if you are self-empolyed and covered by national health insurance .

Jaquelynn, Angeni, Gabriella, Chiara

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1. The poverty overall for Australia is 13.4%.

2. Australia has a highly developed health care system which covers all its citizens as well as other permanent residents.Provides safe and affordable health care. Australians enjoy one of the best health care systems around the world, which translates to good health for the majority.

3. Australia provides “Parenting Payments” to help families who have recently had a child or have adopted one raise them based on the gross income of both parents. Maternal leave is eligible up to 18-20 weeks for both parents with the addition of parent payments. Australia also provides parents and children, who are ages 0-5 years old, access to advice and Universal Healthcare support by providing little to no costs on healthcare for either children or their parents. The Australian government also pays the child care subsidy directly to the approved childcare service of the parents choice to reduce the costs and fees that the parent pays.

4.The way how the educational systems of Australia and the United States compare is in the US children aged 6 years old attend elementary school which is primary school in australia. After that is secondary school in both systems , but Americans divided it into middle school and high school. After they graduate they get a diploma and in Australia secondary school spans four years 7th or 8th to 10th grade. Senior secondary school is 11th and 12th grade. After they finish secondary school they receive a SSCE (Senior Secondary certificate of education).

5. Preschool education in Australia is generally seen as important for early childhood development. A significant percent of children, around 85% attend preschool programs before starting formal schooling. It’s valued for its role in preparing children socially and academically for primary school.

6. In Australia, preschool programs usually focus on play-based learning to foster social, emotional, and cognitive development in children aged 3 to 5. The curriculum is often set by state or territory education departments, with input from early childhood education experts. Preschool teachers are typically required to be licensed by the government, and they undergo training in early childhood education, which may include completing a Certificate III or Diploma in Early Childhood Education and Care.

7. Yes, the Australian government provides financial support for preschool through the childcare subsidy. Other initiatives include the early learning payment and the preschool funding program. In the United States, financial support for preschool varies by state and is typically provided through programs like Head start and state funded preschool initiatives.

8. Maternity Leave: The Federal Government's paid parental leave scheme provides up to 18 weeks of paid leave if you are having or adopting a child. If eligible for this payment, you will be paid the minimum wage whole on this scheme, not your usual salary.

Gavin, Savannah, Ameris, Faris

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1. 6.6% poverty overall in Russia.

2. The healthcare system is 58th best out of 89 countries. Healthcare is funded through obligatory medical insurance (OMI).

Employers pay 2-3% of salaries to help fund. Going citizens/residents a right to free healthcare.

3. 140 fully paid days maternity leave. Childcare monetary benefit for families with income below minimum subsistence level

($15.7 thous and--- $171.60 US). Parents receive a large package containing necessary baby items when they have a child.

4. The US school system is designed for individual education, students pick their own subjects and study what they are genuinely

interested in. In Russia all students study the same courses and have clearly defined hours for subjects. Russian students

complete 4 years of primary school, 5 year of secondary school and 2 years of upper secondary school within a 11-year framework. www.alberta.ca

5. The first stage of education in Russia is preschool, and all children ages 3-7 must attend preschool to develop and have improvement in learning.

Children across Russia tend preschool program in education enrollment percentage rate reaches 74%

6. Preschools accept children that are 2 1/2 years old. The Russian Ministry of Education sets the study programs for schools and teachers

follow their designated curriculums. Teachers have to get a bachelor's degree in education or go through teacher trainings for at least 4 to 5 years,

then the government gives teachers their license of education. https://www.russia-education.info/career-options/preschool-teachers

7. Russia requires children ages 3-7 to attend preschool for free. The Social Insurance Fund (SIF) give parents with a child (under ages of 8)

100% of average earnings and up to 74.001 rubles per mont ($808.83 US currency). In the US free preschool is only given to low-income families (depending on the region). The child tax credit is $2000 to $3000 for children under 6 and $300 for children under 18.