The US, South Africa and India have at least one thing in common. In all three the States or Provinces have great influence on health care and public health. Granting or leaving significant State power was a key element in the political compromises that enabled each of these countries to be created in their current form.

States in the US assumed primary responsibility for health from the start. Federal involvement, especially in financing health centers and partnering in Medicaid financing is relatively new and the Supreme Court reinforced the power of the States to say “No” when it slapped down the mandatory Medicaid expansion in the Affordable Care Act.

In South Africa and India primary responsibility for health care and public health were assigned to the existing states or provinces or tribal strongholds. The South African national government provides general per capita grants that are used in part to fund province level care and also provides restricted grants for specific programs such as HIV testing and care. The Indian national government also provides earmarked funds for specific national priorities but the individual States carry a greater total burden for financing health care.

As a result, national population health outcome measures are almost useless as indicators of health system performance or guides for national policy action. It is health outcomes at the State level that really tell the stories. In each of these countries the rates vary dramatically from State to State (Province to Province).(Note to readers: When I am not on the road I will create a chart showing the range of population outcomes in each country as a starting point for more detailed examination of reasons for differences.)

In all three countries there are important State/Province level differences in total population and geography, current income and wealth distribution, education, gender inequality, political leadership, ethnic diversity and religion. The quantity and quality of trained personnel varies greatly by State/Province as does the infrastructure for public health and healthcare. However, listing the differences is only a starting point  from which I will need to pursue answers when time and access to more material allows. However, it is going to become clear pretty fast that explanations for the differences are likely to found upstream in social and economic factors. The question will become why social and economic inequity persists among the States in these countries.