In 1883, the German Reichstag changed the course of human history when it passed the first modern health insurance law. While modest in scope by our standards, this piece of legislation was the first in a series of laws that ushered in the modern welfare state.
Its original architect, Otto von Bismarck, was no friend of the working class. Quite the opposite, in fact. The Iron Chancellor, as Bismarck was known, believed that these reform measures would inoculate the working class against the radicalism of the socialist forces that had been gathering strength in rapidly industrializing Germany following its formal founding as a nation-state in 1871.
By denuding, or least moderating, the genuine existentialist anxieties of workers labouring in the unsafe and dangerous factories of the late 19th Century, Bismarck hoped to channel their revolutionary ambitions into a safe harbour.
Whatever Bismarck’s motivations might have been, his agenda radically altered the relationship between the state and its citizens — and their expectations of governance. First, groups previously antagonistic towards one another were forced to co-operate. Bismarckian laws required shared contributions and sacrifices through collective institutions, which might eventually become objects of national pride, with similar binding effects like national railways or other large-scale projects.
The emerging welfare state also changed the role of the state. Whereas previous prevailing theories tasked the state with nothing more than protecting citizens from internal and external threats, the state started to assume new obligations in areas of human development that exceeded its previous mandate. More subtly, Bismarck created expectations and measures by which the performance of government could be assessed.
Health, once largely a private concern, was becoming a subject of public discourse and political decision-making. Accordingly, governments were increasingly judged by their ability to deliver public health services in an effective manner, both in terms of outcomes and costs.
This list of Top 10 healthiest countries is one such measure. Each has devoted considerable resources to an extensive health-care system — with the results to prove it, according to the 2012 Bloomberg Health Rankings (whose sources were the World Health Organization, the United Nations and the World Bank.) This, of course, is not the only reason the citizens of these countries rank among the healthiest in the world.
Other factors (including personal behaviour, dietary choices and cultural norms) also play a role in shaping public health outcomes. So it would be a mistake to reduce the “health” of a society to mere measures of utility. On the other hand, any attempts to broaden the definition of a healthy society can quickly lead into difficult, even dark corners. This said, a look at the very bottom of the Bloomberg Rankings highlights many of the conditions that characterize unhealthy societies: corruption, the absence of basic infrastructure and the very internal strife Bismarck was striving to prevent.
1. Singapore
Ten years ago, this tiny state found itself in the middle of one of the worst global epidemics of recent memory when the virus responsible for severe acute respiratory syndrome (SARS) infected 238 people, killing 33.
Besides this human loss, SARS rattled a society that reveres order. Schools closed for weeks and the government implemented sweeping measures designed to contain this disease, which ultimately claimed 238 lives from 8,096 reported cases worldwide. These measures, while ultimately successful, also temporarily crippled the economy of Singapore. Tourism and transport-related industries suffered major downturns. But this crisis also revealed the organizational talents and resourcefulness of Singapore.
It comes as no surprise then that Singapore ranks as the healthiest country in the world. Singapore’s government, however, does not appear to be content with this status, as it finds itself in the midst of developing a Healthcare 2020 Masterplan designed to “keep Singaporeans healthy and give them greater peace of mind.” Singapore’s health-care problems today or in the near future are considerable — including an aging and increasingly sedentary society and a shortage of medical professionals. But if past performance predicts future success, Singapore appears poised to meet the challenge.
Mediterranean diet, perhaps?
2. Italy
Internationally, practitioners of medicine marvel at the country’s major achievement: to build one of the most accessible, affordable and accomplished health-care systems in the world. This finding may force some to readjust their prejudices against Italy as an unproductive and indifferent society. Not surprisingly, Italy consistently ranks at or near the top of many health outcome categories, as tracked by various international agencies, such as the OECD. It notes that Italy’s life expectancy at birth almost reaches 83 years, exceeding the average for all OECD countries of 80 years. But this figure also points to one of the central concerns facing the Italian health-care system and the state generally: its society is aging rapidly due to one of the lowest birth rates in the world. If the German poet Johann Wolfgang von Goethe experienced Italy “like a youthful dream” during his famed sojourn in the late 18th Century, modern travellers are more likely to encounter a geriatric society.
3. Australia
It has become tradition among Canadian social scientists to seek ideas and inspiration from developments in the Land of Down Under.
Both countries share a colonial history with the United Kingdom. And both mix the British parliamentary system, ostensibly designed for a unitary system, with federalism. And both nations’ elites confront the challenges of governing a relatively small, but diverse population spread across continent-spanning countries.
These similarities invite obvious comparisons. “Australia is the country most like Canada and, as such, the best country against which to benchmark ourselves,” wrote Globe and Mail columnist Jeffrey Simpson three years ago. Mr. Simpson finds the Australian public health-care system outperforms its Canadian counterpart on a number of scores, by allowing some private competition.
Other, more comprehensive assessments have reached comparable conclusions. While the nature of the health-care system is only one factor among many that determine the overall health of a population, it clearly has served Australia well, to the point that several western countries have tried to recommend changes in their respective jurisdictions along lines of the Australian model.
This commentary does not mean to downplay the reported deficits within the Australian health-care system (growing concerns about exploding costs and social inequity.) Nor does it mean to ignore larger health issues in Australia (the disparity in health outcomes between Australia’s aboriginal and non-aboriginal population and the tripling of obesity rates through the last three decades.) Contrary to popular perceptions, Australia reports physical activity levels on par with the United States, the perceived paragon of sloth. It is clear, though, that Australia has managed to keep health-care costs in line without sacrificing quality, and has somehow maintained a relatively healthy population, at justifiable costs.
According to the OECD, Australians can expect to live 82 years, two years longer than the OECD average. At the same time, the OECD notes that health spending in Australia accounts for 9.1 percent of total GDP, below the 9.5 percent average for all OECD countries. This said, Australia ranks above the OECD average in terms of total health spending per person at US$3,670, compared to US$3,268. In other words, things are going well now, but the need for reform is apparent.
4. Switzerland
If money spent on health care could guarantee a “healthy” society, the United States would top the rankings. No other country in the western world spends more than the U.S.
This disconnect between input and output is a central reason the Obama administration passed the Affordable Health Care For America Act, a health-care scheme very much modelled along the Swiss system.
According to an OECD survey, combined public and private health expenditures in the U.S. topped US$8,233 per capita in 2010, a figure more than $3,000 higher than second-place Norway. Yet, the U.S. ranks well below its OECD counterparts in many health categories.
Unlike its European neighbours, Switzerland does not offer a “public option” to use the parlance of the U.S. debate. It instead achieves universal coverage by mandating individuals to purchase private insurance, as Obamacare insists. But if the two countries share an instinct for profit and free enterprise in the provision of health care, Switzerland has been far more effective in regulating the worst excesses of this approach while achieving top health outcomes. It has one of the lowest child mortality rates in the world (202nd) and highest life expectancies (eighth), according to the CIA World Factbook. And if we accept the OECD Better Life Index as a measure of mental health, the Swiss were the happiest people in 2013.
Health care is not cheap in Switzerland. The country ranks behind the United States and Norway in terms of per-capita health spending ($5,270). But it is far more effective, with the results to prove it. According to a 2010 OECD survey, Switzerland had the lowest potential for finding additional savings in its health-care system among the 30 survey countries. The United States? Sixth.
5. Japan
Japan’s finance minister, Taro Aso, stepped into it earlier this year when he urged the elderly to get on with dying. “Heaven forbid if you are forced to live on when you want to die,” he said. “I would wake up feeling increasingly bad knowing that [treatment] was all being paid for by the government. The problem won’t be solved unless you let them hurry up and die.”
Of course, one wonders whether this appeal from one of Japan’s senior politicians included an element of self-loathing because Aso — who eventually apologized — belongs to the very group he offended. Almost a quarter of Japan’s 128 million citizens are over the age of 60 and their demographic share will only rise.
Japan is already home to the second-largest number of centenarians in the world after the U.S. This phenomenon has inspired an impressive volume of scholarship into the actual causes and potential consequences of Japan’s aging society. The former include genetics, diet and social practices, such as religious worship and communal activities. The latter, still emerging, focus on reduced economic productivity, labour shortages and inter-generational strife.
However, it is appropriate to already draw one tentative conclusion: The aging of Japan reveals a prosperous society, able to dedicate substantial resources to the care of its most vulnerable (and by implication valued) citizens. This commitment — which runs counter to the economic utilitarianism so prominently promoted by Aso — is an accomplishment worth celebrating. If nothing else, it suggests a “healthy” society, at peace with others and itself, at least for the time being.
6. Israel
You would not expect Riki Cohen, a 37-year-old married mother of three children from Hedera to relish the attention she received when Israel’s finance minister, Yair Lapid, mentioned her name in a column he posted on his Facebook page. You see, according to Lapid, Mrs. Cohen, who, with her husband, earns a little more than NIS 20,000 a month [$5,800 Cdn], is the very definition of middle class.
“We sit here, day after day and talk about balancing the budget. But our job is not to balance Excel spreadsheets, but to help Mrs. Cohen,” Lapid lectured his civil servants.
As touching as this account might appear, it features a fatal flaw: Mrs. Cohen is a fictitious character, conjured up by the political imagination of Lapid. Reactions to Lapid’s creativity were swift and devastating, but also distracted from a larger issue: the health of the Israeli health-care system, which according to Lapid, “is collapsing around (Cohen).”
The genuine facts, of course, tell a different, far more complex story — one that reflects larger tensions within Israel. On one hand, a recent run of strikes by doctors and nurses speaks to growing economic tensions. Yet the overall quality of the health-care system also reflects the country’s high degree of livability. The most recent Life Index released by the OECD ranks Israel fifth with an 8.8 out of 10 rating on health issues, ahead of the U.S., Britain, France, Japan and Germany. Average life expectancy almost tops 80 years and nearly eight out of 10 Israelis say their health is good or very good.
But figures of this sort only tell part of the story. While Israelis can access some of the world’s best neighbourhood medical clinics, many dread extended hospital stays, as the country ranks near the bottom of the OECD (27th out of 30) in terms of availability of general hospital beds with only 1.93 spaces per 1,000. Not surprisingly, Israel has the highest hospital occupancy in the OECD (98.8 percent). These infrastructure problems co-exist with certain societal inequities. According to a 2012 OECD review of health-care quality in Israel, recent immigrants, the poor and Arabs are getting worse care and living shorter lives than other groups, certainties that only hint at the larger complexities within Israel.
7. Spain
Five years into the worst economic crisis since the Great Depression and three years into the Euro crisis, the toll of human greed and government corruption is becoming more and more apparent in countries around the world, including those in the Mediterranean, where Greece is experiencing nothing less than a public-health crisis. According to statistics published in 2012, more than 2,500 people have taken their own lives in Greece since 2010, with the actual figure suspected to be higher. And Greek officials are warning that the worst might be still to come as the state continues to cut medical services in an effort to meet austerity measures.
Other countries in the region are facing comparable prospects, including Spain. While Spain easily ranks among the Top 10 in OECD’s Better Life Index in terms of health (8th) and work-life balance (5th), its economic problems could undermine these standings. New research published by the London School of Hygiene and Tropical Disease this summer warned that ongoing austerity measures could effectively dismantle large parts of the country’s health-care system. Warnings of this sort are difficult to judge, but the Greek experience should give Spaniards pause.
transport for adults and children.
8. Netherlands
It is said that good things take time. Case in point: recent reforms to the Dutch health-care system. Following nearly two decades of discussion, Holland introduced a comprehensive reform package in 2006 that responded to a long list of deficiencies. They included health inequalities, some caused by a rigid two-tier system of private health insurance for the rich and state insurance for everyone else. They also dealt with extensive (not to mention expensive) bureaucratic rationing of state-supplied services and few incentives for private insurers to compete for business, with a corresponding lack of patient focus.
The much-discussed reforms ended the two-tier system by creating a compulsory social health-insurance scheme. But if the government serves as the legal regulator, the insurance market itself is private. Insurers must offer a basic package of minimum health insurance, covering “essential health care” (the nature of which the government determines) at a “reasonable cost.” According to government regulations, insurers cannot deny coverage to individuals deemed high-risk.
With a minimum level of care established, the Dutch government then allows insurance companies to compete against one another in setting premiums and service levels. This system ensures universality, but also grants individuals considerable choice. The results have been impressive. Voted the best health-care system by the Euro Health Consumer Index in 2008 and 2009, the Dutch system has since become an inspiration for reform in the United Kingdom and elsewhere. While Holland still lags behind the OECD average in the provision of some medical services, it scores higher in areas that measure access.
9. Sweden
Sweden — like its Nordic neighbours — possesses one of the most generous welfare systems anywhere in the developed world. Accordingly, Sweden commits significant resources to ensuring the health of its citizens.
Consider the following numbers. In 2010, 3.9 physicians cared for 1,000 citizens in Sweden, well above the OECD average of 3.2 per 1,000. This commitment is even more apparent when we consider the number of nurses per 1,000 — 11.1, well above the OECD average of 8.7. Sweden, not surprisingly, exceeds the OECD’s average life expectancy of 80.1 years by almost two years (81.9).
Statistics of this sort, however, do not tell the whole story. Sweden’s decentralized delivery of health care ensures local accountability and a measure of competition. Swedish citizens have also done their part in placing Sweden on this list. Encouraged by extensive educational campaigns, Swedes have significantly cut back on smoking. While 32 percent of Swedes smoked daily in 1980, slightly more than 13 percent did so in 2011, a figure well below the OECD average of 20.9 and the lowest among all OECD countries.
Swedish obesity rates, while doubling from 5.5 percent in 1989 to 11 percent in 2011, also remain lower than the OECD average of 15 and well below reported rates in the United States (28.5 per cent). This said, aspects of the Swedish model leave room for improvement. Based on 2011 figures, Sweden has fewer hospital beds per 1,000 than the OECD average of 4.8 beds. Rising obesity rates also suggest that health care will continue to absorb a growing share of Sweden’s GDP. As of 2011, that share stood at 9.5 percent, above the overall OECD average of 9.3 percent.
Palace Canal. Germany’s health-care model is among the most advanced in the world.
10. Germany
Notwithstanding local variations, health-care models tend to fall into four categories: the out-of-pocket model (people pay for medical services as needed); the “Beveridge” model (named after former British labour minister William Beveridge) that sees the state monopolize the delivery of health care; the “Bismarck” model, named after Germany’s Iron Chancellor, that aims for universal coverage supplied by a combination of public and private insurers; and the National Health Insurance model, that mixes elements of the Beveridge and Bismarck models.
Germany, of course, has invented and subsequently refined the Bismarck model to an impressive (but also costly) level of complexity, constantly seeming in need of reforms. On one hand, the German health-care model ranks among the most advanced in the world, capable of delivering a level of care largely unmatched. On the other hand, it also ranks among the most expensive, partly because it is very bureaucratic. Deficits of this sort are compounded by demographic realities. Germany’s society is aging and Germans themselves do not always make the healthiest dietary and lifestyle choices. Obesity rates are among the highest in Europe and public acceptance of smoking is generally higher than in North America.
Wolfgang Depner is a doctoral candidate at the University of British Columbia-Okanagan and the co-editor of Readings in Political Idealogies since the Rise of Modern Science, published by Oxford University Press.
Top five unhealthiest countries
Mozambique: First, the good news. The HIV/AIDS epidemic that ravaged this southeastern African country has levelled off. Here comes the bad news: HIV/AIDS remains a defining fact of life in the country, as more than 1.4 million of its 24 million people live with the disease, the fifth-highest total in the world.
Chad: Located in the heart of the Sahel zone, the cross-continent strip that reaches from Senegal eastward to Sudan, this country arguably optimizes the struggles of the larger region. They include environmental decline, internal strife and political corruption and a host of related health problems. Women and their children face particularly grim odds. According to the CIA World Factbook, the country ranks sixth in infant mortality (almost 92 deaths per 1,000 live births) and second in terms of maternal mortality, the annual number of female deaths per 100,000 live births from any cause related to or aggravated by pregnancy, with 1,100 deaths per 100,000 live-births. Only the recently created South Sudan has a higher rate with 2,054 deaths per 100,000 live-births.
Democratic Republic of Congo: Ravaged by decades of war, Africa’s fourth most populous country continues to chart an uncertain future. The governing challenges that confront the current government of Joseph Kabila appear immense. They include a nearly non-existent medical infrastructure — the DRC has 0.11 physicians (2004 figure) and 0.8 hospital beds per 1,000 people (2006 figure) — and a high rate of infectious diseases. Ongoing conflicts with various armed groups, some sponsored by foreign powers, continue to ravage the country and its people.
Lesotho: Totally surrounded by its neighbour, South Africa, this enclave struggles to meet the most basic needs of its citizens. Almost 75 percent of its 1.9 million residents lack access to improved sanitation facilities and almost 24 percent of its adult population suffers from HIV/AIDS, the third-highest rate in the world.
Swaziland: Neighboured by Mozambique and South Africa, land locked Swaziland has a population of just 1.4 million. Of its adults, more than 26 percent suffer from HIV/AIDS, the worst rate in the world, according to the CIA World Factbook. Not surprisingly, the average life expectancy in Swaziland is just over 50 years.