How Healthcare Works in the Five Healthiest Countries
I spend a lot of time frustrated at our healthcare system. After all, we pay more for healthcare than every other nation yet we have a lower life expectancy, spend more of our lives sick, and have the highest rate of avoidable deaths.
Why is it like this? How can we do this better? What can we learn from other countries?
In this article, I’ll dive into the basics on how healthcare works in the five healthiest countries worldwide—Spain, Italy, Iceland, Japan, and Switzerland. By better understanding the healthcare systems of these countries, perhaps we can gain insights into successful models that prioritize the well-being of their people.
🇪🇸 Spain
Life expectancy: 83
Per capita healthcare spend: $2,901
Health expenditure (% of GDP): 9.1%
Obesity rate: 23.8%
Number of doctors per 1,000 inhabitants: 4.4
How healthcare works: Spain offers universal healthcare coverage (via Sistema Nacional de Salud; SNS), meaning everyone is given health insurance paid for with tax dollars. Although approximately 10% of the population opts for private health insurance to enhance their coverage, the vast majority benefits from the publicly funded system.
Out-of-pocket expenses (co-payments for medicines, dental care, and medical devices like hearing aids) amount to 21.8%. Despite this, healthcare accessibility remains exceptional throughout the country. Merely 0.2% of individuals report barriers to medical care due to factors such as cost, distance, or waiting times.
Spain's commitment to the health and well-being of its citizens is evident in its remarkable health outcomes. The nation boasts some of the lowest mortality rates resulting from preventable and treatable causes. And according to the World Economic Forum and to Bloomberg, Spain has the most efficient health system in Europe.
🇮🇹 Italy
Life expectancy: 82.8
Per capita healthcare spend: $3,351
Health expenditure (% of GDP): 8.7%
Obesity rate: 19.9%
Number of doctors per 1,000 inhabitants: 4.1
How healthcare works: Italy, too, stands as a beacon of universal healthcare coverage, demonstrating its commitment to the well-being of its population. Under the system known as the Servizio Sanitario Nazionale (SSN), health insurance is primarily funded through public resources. Each region is responsible for organizing and delivering health services through both public and accredited private hospitals.
There’s a strong culture of health prevention in Italy, surpassing the European Union (EU) average in spending dedicated to preventive measures. As part of the Gaining Health Program, public health campaigns include health promotion activities in schools and nutrition literacy campaigns.
Italy also has remarkably low hospital admission rates for chronic diseases. This reflects the efficacy of the primary care system, where general practitioners serve as gatekeepers. In certain regions, multidisciplinary teams contribute to providing acute and chronic care, as well as preventive services for the entire population.
🇮🇸 Iceland
Life expectancy: 83.12
Per capita healthcare spend: $6,636
Health expenditure (% of GDP): 9.65%
Obesity rate: 21.9%
Number of doctors per 1,000 inhabitants: 4.42
How healthcare works: Iceland's healthcare system is primarily publicly funded, also embodying the core principle of universal coverage for its population. A distinctive characteristic is the integrated purchaser-provider relationship, where the government acts as both the payer and owner of most health service organizations. Approximately 15% of healthcare expenditures come from out-of-pocket payments, predominantly for pharmaceuticals, dental care, and outpatient medical services.
Only about 3% of Icelanders report unmet medical needs. However, like many other healthcare systems, excessive waiting times have been a persistent challenge (e.g. in 2020, half of the patients seeking cataract surgery faced waits of over three months, while two-thirds experienced similar delays for hip replacement procedures).
Surprisingly, preventive care receives relatively less financial investment. Nevertheless, public health efforts in Iceland include nutritional standards in schools, prohibiting food and beverage advertising on TV and radio during times when children are the primary audience, and utilizing the Nordic keyhole nutrition label to promote healthy eating. Like Italy and Spain, Iceland exhibits one of the lowest mortality rates for treatable causes, indicating the effectiveness of its healthcare system in saving lives.
🇯🇵 Japan
Life expectancy: 84.45
Per capita healthcare spend: $4,388
Health expenditure (% of GDP): 10.9%
Obesity rate: 4.3%
Number of doctors per 1,000 inhabitants: 2.4
How healthcare works: Japan's healthcare system operates on a social health insurance model, ensuring that all citizens and residents have access to healthcare. Mandatory health insurance enrollment is required, and the government regulates fees to maintain affordability and accessibility. There is a 30% coinsurance for most services (lower for low-income adults), and there’s an annual household out-of-pocket maximum for health care based on income and age. Approximately 14% of healthcare expenditures come from out-of-pocket payments
At its core, Japan places a strong emphasis on primary care, prevention, and regular health check-ups. Interestingly, there is no institutional or financial distinction between primary care and specialty care in Japan. The vast majority (83%) or providers are privately owned and managed by physicians or by medical corporations, but the government sets the prices.
The government actively promotes preventive care measures to detect diseases early and encourage healthy lifestyles among the population. This commitment to prevention extends to various aspects of public health, including health education and awareness campaigns.
🇨🇭Switzerland
Life expectancy: 83.85
Per capita healthcare spend: $10,309
Health expenditure (% of GDP): 11.8%
Obesity rate: 19.5%
Number of doctors per 1,000 inhabitants: 4.3
How healthcare works: In Switzerland's, residents are required to purchase health insurance from a number of private (non-profit) health insurers that are regulated by the government. To access healthcare services, adults are subject to yearly deductibles and coinsurance, with a cap ($579 USD) on the annual amount paid.
Switzerland's healthcare system features a combination of public and private ownership of healthcare providers. Patients typically begin their healthcare journey with an initial consultation with a family physician acting as the gatekeeper.
While the Swiss benefit from great health outcomes, their healthcare costs are the second-highest in the world, only behind the United States.
Despite our status as one of the world's wealthiest nations, the U.S. grapples with challenges regarding healthcare accessibility, affordability, and health outcomes. By juxtaposing the U.S. system against those of the healthiest countries, we can identify areas for potential improvement and learn from international best practices.
Things that stand out to me:
Universal coverage. All five countries ensure that healthcare services are accessible to all citizens. Our absence of universal coverage and fragmented financing contribute to disparities in healthcare access and quality. (Shockingly, the individual health insurance market in the U.S. is $1.6T, more than the total healthcare expenditures of all five of these countries combined).
Preventable deaths. Compared to peer nations, the U.S. has among the highest number of hospitalizations from preventable causes, and the highest rate of avoidable deaths. Emphasis on primary care and preventive measures serves as a foundation for promoting early detection and disease prevention in these peer countries. (I will give the U.S. a shout-out in terms of flu vaccinations and breast cancer screening, where we outperform peer nations).
The integration of public and private sectors, coupled with effective regulation, creates a balance between effectiveness and equity. We also have fewer doctors than all the countries except Japan. Perhaps that’s why Americans have fewer physician visits than most our peers countries.
The obesity rate in the U.S. is 2-10x higher than these nations. Obesity is a key risk factor for chronic conditions such as diabetes, cardiovascular diseases, and cancer. These five countries invest in promoting public health, and recognize the impact of obesity on overall well-being and chronic disease. Determinants of obesity include unhealthy living environments, less-regulated food and agriculture industries, and socioeconomic and behavioral factors.
What do you think? What else can we learn from these healthcare systems and others?