Which countries get the best - and worst - value healthcare?

As the world's attention turns to Davos, many people will remark on the Swiss knack for well-functioning services. It’s something I’ve often observed in their health system, which is one of the best I have ever encountered across the world.

You might expect that, considering how much the Swiss pay for healthcare - $9,276 per person, according to the World Bank, or around 11.5% of their total GDP. What fascinates me are those countries that seem to get the same results for a quarter or even less of that cost. For example, Hong Kong ($1,716 per person, 6% GDP), Israel ($2599 per person, 7.2% GDP) and Singapore ($2,507, 4.6% GDP) all of which, like Switzerland, enjoy life expectancies of between 82 and 83 years.

So why is it that some health systems are getting so much more for their money than others?

Although factors like diet and active lifestyles have an influence, it’s also clear that the huge differences in the way different healthcare systems are set up plays a major role too. Why else would we see similar variation in the outcomes of people who undergo certain treatments?

Having worked in sixty countries’ health systems over the past six years, I’ve gained first-hand experience of healthcare in many of these ‘outlier’ countries (both the highly efficient and the highly inefficient). While it’s impossible to say that any one country is best, a look beneath the statistics reveals some of the things most likely to produce more health for less cost.

A strong primary care system is one of the most important factors. Nowhere is this better evidenced than Israel, which has made easy access to family physicians in the community a cornerstone of its services. This is then ingeniously aligned by having the same four health maintenance organisations pay for and provide all types of healthcare – so there are strong incentives to keep patients well and at home, rather than create ever larger hospitals.

Use of technology to contain cost is another feature of highly efficient health systems, as it speeds up activity, increases accuracy and allows for the kinds of big data analysis that can actually predict which patients are most likely to need follow-up care. Singapore is years ahead of most other countries in this regard - in a international comparison of technological ‘connectedness’ in healthcare, it scored top on every indicator. Increasingly, all hospitals, clinics and care homes in the city-state are linked up to a single, unified records system – to which patients also have access. This enables providers to get a far more holistic view of their patients, rather than the episodic approach in most countries where patients are invisible until they return to the same organisation again.

India offers another example. While no one would wish to receive the care available to most Indians, there are pockets of spectacular efficiency in some of the emerging hospital chains there. As documented in the Harvard Business Review among others, organisations like Narayana, Apollo, Fortis and Aravind are performing surgeries with very nearly the same outcomes as Western hospitals at a tenth or less of the cost. Having seen these organisations develop over some years, the keys to this ability are a combination of specialisation of the kind made famous in car manufacturing assembly lines (Aravind doctors perform up to 1,400 eye surgeries each every year, compared to 400 for comparable physicians in the US) and an absolute intolerance of waste – be that spending too much on a product they could make themselves, or performing unnecessary tests and treatments that don’t improve outcomes.

Looking at those countries on the opposite end of the scale – high care spending for underwhelming health – one feature in particular seems to unite them. Such low outliers include South Africa (8.9% of GDP for 56.7 years), Russia (6.5% for 71 years) and the USA (17.2% for 79). The shared feature of systems like these is that resources are misallocated – either to a particular section of society (leaving another section without) or to particular kinds of service (usually hospitals) sucking up the funding that would be better spent elsewhere.

Looking more broadly though, examples of mis-spent resources are everywhere and in every health system, albeit to varying degrees. For the past year, the World Economic Forum’s Global Agenda Council on the Future of the Health Sector, of which I am a member, has been looking at how misalignments between different payers, providers, patients, pharma companies and others are at the root of many of the persistent problems that hold back the world’s potential for better health at a sustainable cost.

Examples of ‘misalignment’ have been flooding in, but so too have case studies of how systems have turned things around. These have included broadening the incentives of providers so they’re paid for the quality rather than the quantity of their care (so-called ‘value based contracting’), fixing power imbalances that keep patients and consumers disengaged or encouraged to pursue unhealthy behaviours, and creating fora for organisations across healthcare, retail, telecoms and others to work together towards a more health-creating society.

Our findings will be discussed with delegates at Davos later this week, with a final report launched in the coming months. I hope that it will inspire people to look up and out from their own countries, see what there is to learn from other approaches and be inspired to believe that a more effective way of doing healthcare is possible.

Author: Mark Britnell is Chairman and Senior Partner for the Global Health Practice at KPMG. His new book 'In Search of the Perfect Health System' is published by Palgrave Macmillan.