Additional policy efforts to help CHOs' development are needed. Recent government investments in public health and primary care alone are not sufficient and could not be sustainable. It will not until long-term self-sustaining mechanisms to relieve an omnipotent government are established, including competent community doctors (GP) system, supportive social insurance reimbursement, appropriate financial incentives to providers, better transparency and accountability, as well as a more regulated referral system, a legitimate, sustainable and quality community health system could be attained.

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Based on a comparison of discharges for avoidable hospital conditions (AHCs), we find that Paris provides greater access to primary care than Manhattan. Ageadjusted AHC rates are more than 2.5 times as high in Manhattan as in Paris. In contrast, the difference in rates of hospital discharge for "marker conditions" are only about 20 percent higher in Manhattan. Rates of discharges for AHCs are higher among residents of low-income neighborhoods in both cities, but the disparity among high-and low-income neighborhoods is more than twice as great in Manhattan. Our analysis highlights the consequences of access barriers to care in Manhattan, particularly among vulnerable residents. A n i m m e n s e l i t e r at u r e c o m pa r e s national health care systems and attempts to assess their performance and derive "lessons" from countries' experiences.1 Although there are major differences between countries, the focus on national aggregates masks important variations within countries.2 In contrast, the World Cities Project examines cities that share characteristics and problems; this approach provides notable advantages for more refined comparisons and cross-national learning. 3Here we analyze avoidable hospital conditions (AHCs), an indicator of access to primary health care, in Manhattan and Paris, cities that are more alike than their respective countries are (Exhibit 1). The selection of AHCs is only one dimension of health system performance. But in thinking about how health systems can assure access through a combination of health insurance coverage and the 5 1 0 M a r c h /A p r i l 2 0 0 6 D a t a W a t c h

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