Education determines a nation's health, but what determines educational outcomes? A cross-national comparative analysis.

This study is premised on the notion that public health policy should address not only health itself, but also primary determinants of health. We examined the effect of national policies on educational outcomes, in particular, on adolescent reading literacy (ARL). We compared the effect of traditional policy indicators--national income and educational spending--with income inequality, a measure of redistributive policies. We used Organization for Economic Cooperation and Development (OECD) data that provide a rare opportunity to test policy effects after accounting for competing individual-, school-, and country-level explanations. Our sample consisted of 119,814 students, 5126 schools, and 24 countries. Multilevel/Hierarchical regression findings were striking: GDP had a significant, but negligible effect on ARL scores (β=0.002, SE=0.0008), while educational spending had no significant effect. By contrast, income inequality exhibited a larger inverse association (β=-1.15, SE=0.57). Among the wealthy nations in OECD, additional economic prosperity and educational spending is trumped by distribution of income for its effect on ARL. Our study yielded a striking result about education, a major determinant of health. Not only is income inequality a significant determinant of ARL scores, but direct spending on education and overall national economic prosperity are not.