Generating Evidence for Action

August 2016
David Vlahov

While I will miss many aspects of serving this School as its dean, I am also excited to return to my research and other pursuits full-time. Among those pursuits is serving as co-director, along with UC San Francisco School of Medicine’s Nancy Adler, of Evidence for Action (E4A), a national program of the Robert Wood Johnson Foundation administered by UC San Francisco, which provides funding of investigator-initiated research to build a culture of health. I believe building that culture is one of the great, under-recognized needs in public health.

Consider that a visitor from Finland once commented about our country, “It’s amazing how little you are able to do with so much.” This is not a surprising critique coming from someone from Finland, where health care expenditures are significantly lower (9.6 percent of their gross domestic product [GDP], or $3,984 per capita) compared with the United States (16.9 percent of our GDP, or $9,451 per capita), while their life expectancies at birth are higher by 2.3 years (81.1 years in Finland compared with 78.8 years in the US).[i],[ii]

In fact, the US spends a much higher percentage of our GDP on health care than any other Organisation for Economic Co-operation and Development (OECD) nation (47 percent more than the next-highest spender), while we’re ranked only 27th of 38 OECD nations in life expectancy.[iii],[iv]  On average, our life expectancy is one year below the OECD average. In addition, according to the results of a U.S. News & World Report survey, we rank 14th of 60 countries evaluated for Quality of Life.[v]

So, what strategies are they using in Finland and the rest of the OECD countries that we aren’t?

One thing to consider is that while the US and Finland spend about the same percentage on health care and social spending combined (36.1 percent and 40.6 percent of GDP, respectively), Finland spends 31.0 percent of their GDP on social services, while we spend only 19.2 percent.[vi] This seems to support the premise that social spending could be a key factor in better health; and in fact, an analysis within the US by Bradley et al. (2011) found that a higher ratio of state “social expenditures to health expenditures was significantly associated with better outcomes in infant mortality, life expectancy and increased potential life years lost.”[vii],[viii] 

Moreover, the US is ranked ninth on the OECD Better Life Index, an aggregate scoring system based on 11 factors ranging from housing and income to work-life balance and life satisfaction that are all contributors to overall well-being. These aggregate values allow us to compare national well-being between the US and the other OECD nations. When we compare the US to the eight countries ranked ahead of us (which include Finland), we score significantly higher than average when it comes to housing and income, but below average when it comes to community, environment, life satisfaction, safety and work-life balance.  

Yet another consideration is that even though the US is ranked highest of the OECD nations when it comes to income, we’re ranked 33rd for social inequality within that category. The story is similar when we look at social and gender inequities in health, jobs, education, civic engagement and safety.

Given these numbers, one could deduce that improving US life expectancies and overall well-being depends at least in part on spending a higher portion of our GDP on social services and programs that reduce inequities and address social determinants upstream before they become health problems. That money could be put toward improving community building, environmental conditions, life satisfaction, safety and work-life balance for all Americans, with a particular focus on disadvantaged populations.

However, for the specifics, it’s not enough to look at strategies that work in Finland or any other country, because, of course, such strategies are not guaranteed to improve health outcomes in the US. The question then becomes: What investments in social services and other interventions that target social determinants will work to improve health outcomes of US populations?

Finding the answers to that question is one of the reasons I joined E4A. We’re funding research about the health outcomes of policies, programs and other types of interventions both within and outside of the health care sector, in order to build the evidence base to determine the best strategies to improve health equity, population health and well-being.  We’re particularly interested in evaluating the impact of interventions designed to address upstream social determinants of health. 

So far, we’ve funded 13 research projects with a wide range of foci – from food bank decentralization to a low-income housing redevelopment project and intervening on the economic determinants of health. You can learn more about our funded projects by visiting our Grantees Page.

What do you think are the most promising approaches to improving population health, well-being and equity? We’d like to hear your ideas. Apply for a grant today!




[i] OECD data: health spending. OECD website. Accessed August 24, 2016.

[ii] Health. OECD Better Life Index website. Accessed August 24, 2016.

[iii] OECD data: health spending. OECD website.

[iv] Health. OECD Better Life Index website.

[v] Best countries: quality of life rankings. U.S. News & World Report website. Accessed August 24, 2016.

[vi] OECD data: social spending. OECD website. Accessed August 24, 2016.

[vii] Bradley EH, Elkins BR, Herrin J, Elbel B. Health and social services expenditures: associations with health outcomes. BMJ Qual Saf. 2011;20(10):826-831. Published March 29, 2011. Accessed August 24, 2016.

[viii] Bradley EH, Taylor LA. Culture of health: how social spending affects health outcomes. Robert Wood Johnson Foundation website. Published August 17, 2016. Accessed August 24, 2016.