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instead a harm-reduction agenda. The harm-elimination approach has often been adopted in the United States, but harm-reduction programs are more prevalent in Canada, western Europe, and Australia.

Health care reform has emerged as a prominent issue on the national policy agendas of all industrialized democracies during the 1990s. Most reform efforts have centered on issues of cost containment, efficiency and increasing access, equity, quality, and accountability. Reform efforts within industrialized democracies have taken different shapes and directions owing to differing political, historical, socioeconomic, cultural, and institutional factors. The United States remains one of the only industrialized democracies without universal or near-universal health care access or state-regulated benefit packages and standards, a situation that has strained public and private resources and prompted health care reform efforts.