Methodology: How We Compiled the 2024 World Index of Healthcare Innovation

The 2024 FREOPP World Index of Healthcare Innovation (WIHI) is an ambitious attempt to assess healthcare performance in the modern world over a wide selection of measures. The Index uses a data-driven approach to identify leading healthcare systems in 32 countries based on four equally weighted dimensions: Quality, Choice, Science & Technology, and Fiscal Sustainability.

Each element, consisting of measures derived from various data sources, is weighted and aggregated to produce scores for each of the four dimensions, and in turn, an overall score and ranking in the Index. All measures, elements, and dimensions use a standardized scale of 0–100 to grade each country’s performance relative to others.

Below, we begin with an update on what’s new in the 2024 version of WIHI. Then, we describe the formulas used to calculate the Index’s standardized scores. Finally, we describe in detail every measure that goes into the Index and the sources we used.

The World Index of Healthcare Innovation evaluates the healthcare systems of several high-income countries. Four dimensions look at each system broadly, while elements and measures look at each system’s specific features with increasing granularity. The higher level dimensions of Quality, Choice, Science & Technology, and Fiscal Sustainability occupy the center ring in the diagram. Each dimension is composed of 3 to 4 elements that occupy the middle ring, while the outside ring contains each of the Index’s 37 measures. Together, each measure, element, and dimension are weighted to produce the standardized scores used to rank the 32 countries in the Index.

What’s New for 2024

Summary of Major Changes

In response to internal study of the Index’s methodology and feedback from stakeholders, we have made changes large and small since the Index’s original release in 2020. Notably, the overall methodology of the 2024 Index retains much of the same methodology as 2022, with a few key exceptions:

• New measures for pandemic preparedness and response. As the COVID-19 pandemic recedes into the past, we looked back at each country’s performance while introducing new measures that look forward to judge how prepared countries will be to take on the next pandemic. We therefore introduced three measures to the element: 1) “prevent, detect, and respond,” 2) “health system resilience,” and 3) “good governance.” These measures are meant to capture the readiness of countries in tackling the next pandemic, learning the lessons of COVID-19 while also preparing for other pathogenic threats that may require different policy responses than for SARS-CoV-2. We also reweighted the measures, downgrading COVID-19 performance to 20 percent of the element’s scoring and weighting 25-30 percent for the other measures. These changes are further described later in this report.
• Projected data. Due to the complexity of the data we collect for WIHI, data typically lags by a year or more. For almost all measures, data can be obtained through 2022, but often, we can only obtain data from earlier years. For consistency, we therefore projected data for each country forward to 2022 whenever possible. We did so by taking into account up to five years of past data, and estimating a 2022 value based on a linear trend of the past data. In future versions of WIHI, we will consider alternative statistical methods to estimate current data based on past trends.

Updated Sources

Occasionally, we used different sources than prior years of the Index to improve data collection and calculate more precise estimates. Sources were updated for the following measures: treatable mortality, pandemic measures (prevent, detect, and respond; health system resilience; and good governance), transparency, health insurance cost, insurance uptake, catastrophic health spending, provider choice, new drugs available, generic drug market share, biosimilars available, new drugs approved, research and development (R&D) spending, and electronic health records (EHR) adoption.

Standardized scoring

We used two formulas to calculate all standardized scores for each measure. For measures where a larger value indicates better performance (e.g., cancer survival), we used the following formula:

Where measure(x) represents the original data for the country, measure(max) and measure(min) represent the upper and lower bounds for the data set, and stdscore(x) represents the computed measure score for the country.

For the most part, the above equation serves as the method to score each measure, element, and dimension in the Index. However, occasionally a lower value for a measure indicates better performance in the underlying data (e.g., debt-to-GDP ratio). When this is the case, we subtracted 100 from the previously calculated formula to obtain a standardized score as follows:

We used the following measures, weights, and sources to compute each of the 13 elements of healthcare performance.

Dimension: Quality

Element 1: Disease Prevention (40%)

The disease prevention element assesses the extent to which healthcare systems do what they are meant to do: cure disease and restore human function. The measures do not include the effects of factors such as diet and daily activity on the country’s overall health and well-being. Rather, the element relies on a mix of measures designed to isolate health outcomes amenable to the healthcare system itself.

The scores for this element were derived by computing the weighted average score of five measures, with accompanying weights:

• hospital admissions (20 percent),
• cardiovascular survival (10 percent),
• cancer survival (15 percent),
• treatable mortality (35 percent) and
• GDP growth (20 percent).

Hospital admissions. This measure examines hospital admissions for a variety of conditions, including asthma, chronic obstructive pulmonary disease (COPD), cardiac heart failure, hypertension, diabetes, and admissions where the comorbidity pairings of asthma/COPD and cardiac heart failure/hypertension occur. The measure controls for the overall prevalence of each condition in the population, and calculates standardized scores for admissions for each condition. The scores are then averaged to obtain the overall standardized score for the measure.

Cardiovascular survival. This measure is based on the mortality rate up to 30 days following a hospital admission. It measures the degree to which hospital care is curative. When possible, we use linked (person-identifying) rather than unlinked (episode of care) data for mortality rates due to the overestimation of incidence in unlinked data. For countries where linked data was missing, estimates were obtained based on the average difference between linked and unlinked data among countries where both linked and unlinked data were reported. In a departure from prior versions of the Index, a standardized score for acute care episodes involving acute myocardial infarction (AMI), hemorrhagic stroke (HS), and ischemic stroke (IS) were calculated by applying a weight to each condition based on each condition’s relative risk in the population: 60 percent for AMI, 5 percent for HS, and 35 percent for IS. The standardized score based on these weights is then adjusted to the 0–100 scale to obtain the final standardized score.

Cancer survival. For 2024, this measure contains two components: the survival rates for various cancers up to five years following diagnosis, and the cumulative mortality risk for all cancers for the population ages 15 or older. The types of cancer included in the five-year survival rates include esophageal, stomach, colon, rectal, liver, pancreatic, lung, skin (melanoma), breast, cervical, ovarian, prostate, brain, myeloma, and lymphoma. The average of these rates comprise a weight of 70 percent of the measure’s final standardized score. Where adult survival rates were not available, we used child survival rates or the rates in neighboring countries with similar characteristics. Cumulative mortality risk comprised the remaining 30 percent of the score.

Treatable Mortality. For this measure, we aggregated age-standardized mortality rates for ages 0–74 to determine mortality that is treatable by the healthcare system. This stands in contrast to measures of “amenable mortality,” which includes mortality that is also preventable, often through non-medical interventions. For example, we included mortality due to breast cancer because while it is often not preventable, it is often treatable. However, we did not include mortality due to lung cancer, since it is almost entirely preventable by not smoking. 

GDP growth. This measure predicts countries that produce higher quality health outcomes based on positive economic growth on a purchasing-power parity basis over the last 10 years, and is expressed as a percentage. 

Sources: Hospital admissions and acute care survival data from the Organisation for Economic Cooperation and Development (OECD) database; cancer survival data from the CONCORD programme of global cancer survival rates and cumulative mortality risk for all cancers from the WHO International Agency for Research on Cancer; age-adjusted treatable mortality rates from the Global Health Data Exchange’s Global Burden of Disease dataset; and PPP-adjusted GDP data from the International Monetary Fund. Missing acute care, hospital admission, and cancer survival data from various country-level studies and reports from 2005–2024.

Element 2: Pandemic Preparedness (25%)

No event in recent memory has so dramatically affected the world than the coronavirus pandemic. For WIHI 2021, the Index elevated the pandemic preparedness and response to its own separate element, rather than a single component within the measures of preventable disease element. 

This year, the element keeps the 2022 results on COVID-19 performance, including the original weights for vaccination rates, lockdown stringency, fatality rate, and degree of economic isolation. However, these measures are combined into one composite measure, and given a weight of 20 percent for the pandemic preparedness and response element. We then added measures assessing each country’s preparedness for the next pandemic that accounts for various phases of required response. 

The scores for this element were derived by computing the weighted average score of four measures, with accompanying weights:

• COVID-19 performance (20 percent),
• Prevent, detect, and respond (25 percent),
• Health system resilience (25 percent), and
• good governance (30 percent).

COVID-19 performance. This measure captures the response to the COVID pandemic in four ways: 1) COVID vaccination rate, as measured by the number of doses administered per 100 people; 2)lockdown stringency, measuring whether countries pursue a strict lockdown strategy or allow larger segments of society to continue daily activities, with data obtained from the University of Oxford’s COVID-19 Government Response Tracker; COVID fatality rate, measured as the number of fatalities per million residents, through September 5, 2022; and economic isolation, which accounts for countries that have fewer international entry points and experience lighter domestic air travel having a built-in advantage in preventing the spread of respiratory diseases. 

On this final component, the economic isolation measure is derived from both international and domestic travel volumes. The Index also considers how much to weigh raw travel volume versus. the population size of each country. For example, the United States has the most travel volume in our survey, but is also the largest country by population. The exponential nature of COVID-19 transmission argues for overweighting raw volume relative to population; that is, all it takes is one infectious person to transmit the disease to dozens of his acquaintances. Therefore, the Index employs the following formula to calculate the economic isolation score:

where Vol(x) represents the combined average of the international and domestic travel volume standardized scores for country x, and Pop(x) is the population of country x.

Prevent, detect, and respond. We derived this measure from the Global Health Security Index, which assigns point values on a host of values based on whether a country can prevent pathogenic spread, detect outbreaks, and mount a cohesive response to potential pandemics. However, we removed certain measures we determined were of little or no importance based on the global experience with the COVID pandemic.

Health system resilience. Similar to prevent, detect, and respond, this measure derives from the Global Health Security Index, which assigns point values on a host of values based on whether a country’s health system can withstand a surge in demand. Again, we removed certain measures that were of little or no importance based on the global experience with the COVID pandemic.

Good governance. The COVID-19 pandemic exposed weaknesses in political stability, the willingness of officials and scientists to allow open debate, and the strength of institutions to implement existing pandemic plans in a responsible and effective way. Therefore, the good governance measure, derived from the World Bank’s Worldwide Governance Indicators, seeks to assess each country in the areas of voice and accountability, political stability and absence of violence, government effectiveness, regulatory quality, rule of law, and control of corruption. 

Sources: COVID-19 performance data: COVID vaccination rate data from Our World in Data COVID-19 vaccine tracker, lockdown stringency data from the Oxford Government Response Stringency Index, COVID fatality rate data from the Our World in Data COVID-19 tracker, and economic isolation data from the World Tourism Organization’s 2019 International Tourism Highlights report and the International Air Transport Association’s 2019 World Air Transport Statistics; prevent, detect, and respond data and health system resilience data from the Global Health Security Index (2021); and good governance data from the World Bank’s Worldwide Governance Indicators. 

Element 3: Patient-centered Care (20%)

To provide the best and most effective care, a health system must fulfill the Hippocratic Oath to do no harm, be responsive to the patient’s needs, and provide timely access to care so that minor health problems do not become life-threatening. The patient-centered care element measures the extent to which patients get the care they need when they need it, and whether patients and doctors operate in a collaborative environment.

The scores for this element were derived by computing the average score of three measures, all weighted equally:

• transparency (33.3 percent),
• patient safety (33.3 percent), and
• consultation time (33.3 percent).

Transparency. Consumers can make better decisions on their own health when equipped with the right information that is easily accessible. We scored the availability of different types of information as indicated in the following table:

To reach the final score, each component was summed for each country.

Patient safety. When patients receive medical care, they expect to receive it in a safe environment with every precaution taken to avoid adverse outcomes. The patient safety measure includes two sub-measures for the incidence of adverse effects due to medical treatment, weighted as follows: 75 percent for the age standardized death rate and 25 percent for disability-adjusted life years. A standardized score for each incidence measure is obtained, and then weighted as previously described to obtain a final standardized score.

Consultation time. While shorter consultation times may or may not indicate efficiency, longer consultation times almost always represent physicians taking time with patients to discuss needs, provide guidance, and adequately answer patient questions. The consultation time measure is represented as the average minutes spent per appointment with a primary care doctor. 

Sources: Transparency data from KPMG report on international healthcare transparency; patient safety data from the Global Health Data Exchange’s Global Burden of Disease dataset; and primary care consultation time from the British Medical Journal, International variations in primary care consultation time: a systematic review of 67 countries. Missing transparency, patient safety, and consultation time data from various country-level reports from 2010–2024, or imputed based on average rates from similar countries.

Element 4: Infrastructure (15%)

Countries rely on an adequate supply of healthcare personnel as well as physical resources so that patients can obtain care. Countries that score well on the infrastructure element provide the right amount of resources attuned to the population’s needs, is timely, and can respond quickly to a surge in demand.

Prior to the COVID-19 pandemic, hospital administrators were in general agreement that maintaining 85 percent hospital bed occupancy balances efficient use of resources with the need to reserve capacity for emergencies. However, the coronavirus pandemic highlights the need to guard against operating near capacity, which strains hospitals’ ability to triage patients effectively.

The scores for this element were derived by computing the average score of three measures, all weighted equally:

• primary care physicians (33.3 percent),
• nurses (33.3 percent), and
• hospital occupancy (33.3 percent).

Primary care physicians. This measure indicates the concentration of primary care doctors per capita in the population and indicates the level of access patients have to care, as well as signal the importance of primary care in a country’s healthcare strategy. From this measure the standardized score is obtained.

Nurses. This measure indicates the concentration of nurses per capita in the population and indicates the level of access patients have to care, as well as the degree to which countries save money by allowing nurses to perform more healthcare tasks. From this measure the standardized score is obtained.

Hospital occupancy. This measure is based on data for the average hospital bed occupancy percentage in each country. Prior to the COVID pandemic, an 85 percent occupancy rate was considered the consensus optimal rate, balancing the efficient use of resources while protecting against overcrowding caused by a surge in patients. In light of the pandemic, we adjusted the ideal occupancy level to 80 percent. Once the occupancy rate for each country is obtained, the Index calculates the deviation under or over 80 percent, with the lowest deviations considered best.

If the country’s occupancy rate exceeds 80 percent, the Index subtracts 80 from the actual rate to obtain the deviation from optimal, upon which a standardized score is calculated. If the country’s occupancy is below 80 percent, the percentage point deviation is reduced by 50 percent, reducing the penalty for systems that are under capacity versus those that are over capacity:

meaning if county x has a hospital occupancy rate less than 80 percent, then the deviation from the ideal 80 percent occupancy (denoted as occupancydev(x)) is calculated as the absolute value of occupancy(x) minus 80, multiplied by 50 percent. If country x has a hospital occupancy rate more than 80 percent, then the deviation from the ideal 80 percent occupancy is simply calculated as occupancy(x) minus 80. 

Reducing the deviation from the ideal if occupancy is less than 80 percent acknowledges that, while hospitals that have excess capacity are less efficient, hospitals that are over capacity present a greater threat to patient safety and care quality because they have less surge capacity for emergencies like respiratory pandemics or even seasonal flu.

Sources: Primary care doctors, nurses, and acute care hospital bed occupancy data from the OECD database. Acute care bed occupancy data also from Eurostat. Missing primary care physician data from various country-level reports in Hong Kong and Taiwan, the World Bank for Singapore and the United Arab Emirates, and Statista for Saudi Arabia. Missing nurses data from country-level reports in Hong Kong, Singapore, Taiwan, and the United Arab Emirates, and from the World Bank for Saudi Arabia. Missing acute care bed occupancy data calculated using curative care occupancy days from the OECD database for Australia, Denmark, Finland, Greece, New Zealand, Poland, South Korea, and Sweden, and from various country-specific reports for Hong Kong, Singapore, Taiwan, the United Arab Emirates, and the United Kingdom.

Dimension: Choice

Element 5: Affordability of Health Coverage (35%)

Healthcare policy often focuses most on helping residents obtain quality affordable health insurance. Whether through single-payer models or free market insurance and health savings account schemes, the countries of the Index employ various methods to reach the same goal: ensuring its residents can pay for the care they need.

The Affordability of Health Insurance element shows that countries with single-payer models do not always pay the least for health insurance, and that often, those systems that seek to shield residents from out-of-pocket costs ultimately drive up the cost of insurance.

The scores for this element were derived by computing the average score of three measures, all weighted roughly equally:

• health insurance cost (25 percent),
• household out-of-pocket spending (25 percent), and
• insurance uptake (25 percent), and
• catastrophic health spending (25 percent).

Health insurance cost. This measure captures the total cost of health insurance, expressed as the purchasing power parity (PPP)-adjusted amount per capita, before any government subsidies are applied. From this key measure of healthcare affordability a standardized score is obtained.

Household out-of-pocket spending. This measure indicates the degree to which individuals are exposed to out-of-pocket costs for healthcare services. The percentage is calculated by dividing the PPP-adjusted out-of-pocket spending per capita by the PPP-adjusted GDP per capita. 

Insurance uptake. This measure indicates the degree to which healthcare systems protect individuals from unexpected healthcare costs, expressed as a percentage of the country’s legal residents who are insured. 

Catastrophic health spending. This measure indicates how many households experience especially high healthcare spending that could lead to financial ruin. The measure is expressed as the percentage of the population with healthcare spending at 25 percent or more of household income. 

Sources: Health insurance cost data from the OECD database and the World Health Organization (WHO) Global Health Expenditure Database. Missing health insurance cost data for Singapore from the Ministry of Health, and for the United States from the Kaiser Family Foundation, 2019 Individual Market Performance, 2019 Individual Market Enrollment, 2021 Employer Health Benefits Survey, and Medicare Advantage Local Benchmarks data; and from Centers for Medicare and Medicaid Services (CMS) Medicare Enrollment and Medicaid Enrollment data. Out-of-pocket spending data from the WHO Global Health Expenditure Database, with missing data for Hong Kong from the Food and Health Bureau, for Japan from the Director-General for Statistics and Information Policy, and Taiwan from the Ministry of Health and Welfare. Insurance uptake data from the OECD database, with missing data for the United Arab Emirates from the UAE National Health Survey Report (2017–2018) and for Saudi Arabia from the World Health Survey Saudi Arabia (2019). Undocumented resident data for the United States from the Migration Policy Institute.

Element 6: Freedom to Choose Healthcare Services (45%)

The freedom to choose healthcare services element measures the degree to which patients are in control of the major facets of their journey through the healthcare system. Countries that encourage personal choice have patients that are more engaged in their care and actively participate in health activities that yield positive health outcomes while conserving financial resources. In fact, the mere idea of patient empowerment may  help achieve better health outcomes because patients benefit from the positive psychological effect of feeling a sense of control in the face of a disease or ailment.

The scores for this element were derived by computing the weighted average score of three measures, with accompanying weights:

• choice of insurance (40 percent),
• choice of providers (30 percent), and
• national out-of-pocket spending (30 percent).

Choice of insurance. This measure assesses an individual’s choice of health insurance products based on three factors: the average number of plans available to purchase in any given location; the number of unique health insurance companies to purchase from; and the variation in plan benefit design, expressed on a scale of 1–5, with 5 being the highest plan variation. Standardized scores are calculated for each factor and averaged to obtain an overall standardized score for this measure.

Choice of providers. This measure assesses an individual’s ability to freely choose healthcare services based on three factors with weights as follows: freedom to select any primary care doctor (40 percent), number of months before switching primary care providers is permitted (20 percent), and freedom to choose any specialist (40 percent). Scores are calculated for each factor and the weighted average of the three factors forms the overall standardized score.

National out-of-pocket spending. This measure examines the effect of out-of-pocket spending on the choices individuals make within a healthcare system. As opposed to measuring out-of-pocket spending as a percentage of a household’s income, this measure divides out-of-pocket spending by national health expenditures. Higher out-of-pocket spending on a national level indicates that individuals are empowered to choose care to fit his or her budget. 

Sources: Insurance and provider data from various country-specific reports from the European Observatory on Health Systems and Policies’ Health System Reviews. Additional data on insurance products from health insurance comparison websites for various countries, including Australia, Germany, Hong Kong, Ireland, the Netherlands, and Switzerland. United States Exchange-based insurance plan data from CMS and Kaiser Family Foundation. Missing provider data from various country-specific studies and reports for Hong Kong, Saudi Arabia, Singapore, Sweden, Taiwan, and United Arab Emirates. Out-of-pocket spending data from the WHO Global Health Expenditure Database, with missing data for Hong Kong from the Food and Health Bureau, for Japan from the Director-General for Statistics and Information Policy, and Taiwan from the Ministry of Health and Welfare.

Element 7: Access to New Treatments (20%)

Approval by regulatory authorities is the first step to introducing new drugs, affordable generics, and biosimilars to market. However, approval does not mean a pharmaceutical company will market the drug in a particular country. The access to new treatments element tracks whether countries prioritize timely access to both innovative and affordable drugs for their residents. Countries that score well in this element are effective in balancing the need to introduce new and innovative therapies quickly while also providing the regulatory environment that allows affordable options to reach the greatest number of patients.

The score for this element was derived by computing the score of four measures weighted as follows:

• new drugs available (25 percent),
• generic drug market share (30 percent),
• biosimilar access (25 percent), and
• coverage of essential care (20 percent).

New drugs available. This measure assesses a country’s readiness to quickly introduce new therapies to market following regulatory approval. Drugs in the analysis include only those designated “novel” or have unique molecular structures and were approved at any time from June 1, 2022–May 31, 2024. For each country, the number of these drugs that have launched within two years of approval count toward its total. 

Generic drug market share. Health systems that encourage the development and sale of generic medications generally feature competitive pharmaceutical markets that provide more value to the largest number of patients possible. This measure is the percentage of the prescription drug market that are sold as generics, by volume dispensed. 

Biosimilar access. Biosimilars introduce competition against high-priced biologic medicines in the same way that generic drugs introduce competition against branded small molecule drugs. Countries with liberal access to biosimilars combine the best of both worlds: cutting-edge therapies at a more affordable price. This measure examines how many biosimilars are available for sale in each country’s pharmaceutical market. 

Coverage of essential care. This measure assesses the degree to which countries make essential healthcare services available to patients. The World Health Organization measures this through its Universal Health Coverage (UHC) Index. This index is the geometric mean of 14 tracer indicators of health coverage. The tracer indicators fall into one of four components of service coverage: 1) reproductive, maternal, newborn, and child health; 2) infectious diseases; 3) noncommunicable diseases; and 4) service capacity and access. 

Sources: Drug approval data from the U.S. Food and Drug Administration (FDA), New Drug Therapy Approvals; the European Medicines Agency (EMA), Human Medicines Highlights for 2020, 2021, and 2022; and Japan’s Pharmaceuticals and Medical Devices Agency (PMDA), List of Approved Products. Data on launch dates and locations of new drugs marketed by pharmaceutical companies from Symphony Health Pharmaceutical Data, accessed through Bloomberg Terminal, and various country-specific websites. Generic drug market data obtained and analyzed from IQVIA, with missing data collected from The International Generic and Biosimilar Association for for Australia,, Japan, Taiwan, and the United States, and from various sources for Denmark, Hong Kong, Israel, New Zealand, Singapore, South Korea, and the United Arab Emirates. Data on marketed biosimilars obtained from country-specific websites.

Dimension: Science & Technology

Element 8: Medical Advances (35%)

Countries around the world rely on medical advances to address the healthcare challenges of today and tomorrow. This reality came into sharp focus during the coronavirus pandemic, as nations and private industry scrambled to roll out test kits while treatments and vaccines proceeded through clinical trials at an unprecedented pace.

The medical advances element seeks to identify countries that invest in developing new drugs, devices, and treatment protocols that extend and increase quality of life. Though some countries have high-performing health systems while investing little in medical advances, these countries and their citizens nevertheless rely on and benefit from high-innovation countries for life-saving and life-altering treatments.

The scores for this element were derived by computing the average score of three measures, all weighted equally:

• healthcare patents (33.3 percent),
• new drugs approved (33.3 percent), and
• R&D expenditures (33.3 percent).

Healthcare patents. This measure assesses each country’s development of intellectual property in three categories: medical technology, biotechnology, and pharmaceuticals. The total patents granted by an applicant’s country of origin are summed and divided by that country’s population to obtain the number of patents per 1,000 people. 

New drugs approved. This measure focuses on drugs considered novel or whose unique molecular structures were first approved globally during the two-year period from June 1, 2022-May 31, 2024. Each country is then assessed for whether it has approved the drug within two years of the first global approval date and assigned a point value on a sliding scale, with approvals closer to the first global approval date being higher, as follows: first to approve (1 point), approval within six months of first global approval (0.75 points), approval within one year (0.5 points), and approval within two years (0.25 points).

R&D expenditures. This measure shows the degree to which a country supports the regulatory environment, intellectual capital, and capital markets necessary for the private sector to innovate. The combined business enterprise research and development spending for each country in the categories of pharmaceuticals, electromedical equipment, medical and dental instruments, and human health activities research is divided by population to obtain the country’s R&D spending per capita. 

Sources: Healthcare patents data from the World Intellectual Property Organization, WIPO IP Statistics Data Center. Drug approval data from the U.S. FDA, Novel Drug Approvals at FDA for 2020-2022; the EMA, Human Medicines Highlights for 2020, 2021, and 2022; Japan’s PMDA, List of Approved Products; and data assembled from various sources, accessible through Bloomberg Terminal. Private sector research and development spending from the OECD database, with missing data for Hong Kong and United Arab Emirates estimated from UNESCO Institute for Statistics data sets and country profiles.

Element 9: Scientific Discoveries (45%)

At the heart of innovation is intellectual capital. The scientific discoveries element captures the extent to which a country’s best minds influence the science that leads to discovery and invention of new cures and improvements in the treatment and management of disease.

Countries with little to no scientific infrastructure may still have high-performing healthcare systems. Still, they rely on other countries for new treatment discoveries, and they may be slow to adopt new drugs and therapies,especially for rare conditions.

The scores for this element were derived by computing the average score of two measures, weighted equally:

• Nobel laureates (50 percent), and
• scientific citations (50 percent).

Nobel laureates. This measure accounts for a country’s intellectual capital as the basis for future innovation. First, the number of Nobel laureates in medicine and chemistry for the last 20 years are counted separately by both nationality and the country where the laureates made their principal discoveries. The number of laureates obtained for each country is then divided by the total for all 32 countries. From this percentage we calculate a standardized score for both nationality and institution location, which in turn we average to obtain an overall standardized score.

Scientific citations. This measure captures the strength of a country’s academic research, which serves as another building block to future innovative breakthroughs. Data are recorded on the average number of times scientific papers are cited in other research from 2003–2022 in the fields of biochemistry, genetics, and molecular biology for each country.

Sources: The list of Nobel Prize winners and their nationalities from The Nobel Prize website. Country locations for research institutions where Nobel laureates made principal discoveries from various sources, including university websites and news articles. Citation data from the Scimago Journal & Country Rank in the fields of Biochemistry, Genetics, and Molecular Biology (2003–2022).

Element 10: Health Digitization (20%)

Despite the rapid pace of digital advancement in the modern world over decades, digitization of health records has historically lagged. Privacy concerns, legacy record-keeping systems, and resistance from some providers have made electronic health record adoption challenging. The health digitization element evaluates a country’s ability to overcome these headwinds to adopt EHR across a variety of healthcare providers while also measuring a country’s underlying digital infrastructure as a precursor to widespread and effective EHR implementation.

In the hands of patients and providers, the free-flow exchange of medical information made possible by health record digitization can streamline care, and even save lives; the use of national digital records in some countries built robust tracing programs to prevent the spread of SARS-CoV-2.

The scores for this element were derived by computing the average score of two measures, weighted equally:

• EHR adoption (50 percent), and
• Information technology and communications (IT and comms) development (50 percent).

EHR adoption rate. This measure indicates the degree to which primary care physicians, specialists, and hospitals have adopted electronic health records, expressed as a percentage of providers in each type that have adopted their use. These percentages are averaged, from which a standardized score is obtained.

IT and comms development. A widely developed internet and communications system is the foundation upon which EHR is built. This measure examines the degree to which society is digitally connected, based on three factors weighted equally: mobile broadband subscriptions per 100 residents, fixed broadband subscriptions per 100 residents, and percentage of residents using the internet. From the average of these factors a standardized score is obtained.

Sources: OECD Report and statistical figures on EHR adoption. Missing EHR data for Australia, Belgium, France, Hong Kong, Hungary, Italy, Japan, the Netherlands, Saudi Arabia, and Switzerland, as well as hospital and physician rates for the United States from country-specific studies and reports from various sources, including the WHO and the European Commission. Data for IT and comms development obtained from the International Telecommunications Union.

Dimension: Fiscal Sustainability

Element 11: National Solvency (40%)

Countries with heavy debt burdens are less able to adequately fund numerous priorities, including healthcare. Heavy debt also weighs on economic growth, further driving countries into debt. A country’s solvency is further threatened as populations age if fewer young workers exist to support the healthcare needs of the aged.

On the other hand, low amounts of debt relative to a country’s gross domestic product strengthens the country’s ability to meet its priorities, especially during economic downturns. Low debt is also a sign that a country is fiscally disciplined, is unlikely to spend wastefully, and relies on private sector elements to provide healthcare that is high quality, patient-centered, and flexible. The national solvency element identifies countries that are financially ready to meet the challenges of sweeping pandemics, growing chronic disease burdens, and aging populations.

The score for this element was derived by computing the score of two measures weighted as follows:

• debt-to-GDP ratio (60 percent), and
• demographic ratio (40 percent).

Debt-to-GDP ratio. This measure indicates how reliable a country would be in repaying their debts, and whether it can maintain public health spending without crowding out other priorities. 

Demographic ratio. This measure predicts the capacity of the generations that have newly entered the workforce, or will enter the workforce in the near future, to cover the higher healthcare costs of the aged. The score is computed as the ratio of the population 30 and under to the population aged 65 or older. 

Sources: Debt-to-GDP figures obtained from the International Monetary Fund (IMF), General Government Debt Datamapper (2020). Population figures for those 30 and under and 65 and older from the U.S. Census Bureau, International Database.

Element 12: Public Healthcare Spending (40%)

While all modern countries spend at least some government funds on healthcare, those that spend a larger amount per person may struggle to fund other priorities, have high tax burdens, or both. A large central role of government in paying for healthcare may also result in systems that are less responsive to individual needs and choice.

Some governments that spend less on healthcare allow the private sector to develop innovative and cost-effective treatments for patients. Other countries may be able to limit public spending through greater bargaining power afforded by a single-payer system. However it occurs, the public healthcare spending element identifies which countries rely on the public sector to provide healthcare.

The score for this element was derived by computing the score of one measure:

• public healthcare spending (100 percent).

Public healthcare spending. This measure indicates how much countries rely on the public sector to provide healthcare, and is calculated by dividing total national public health spending by the country’s PPP-adjusted GDP. 

Sources: GDP figures from the IMF. Public health spending data from the OECD database. Population figures used to calculate on a per capita basis from the U.S. Census Bureau, International Database. Public health spending data for Hong Kong, Singapore, and United Arab Emirates calculated from the WHO Global Health Expenditure Database. Data for Hong Kong obtained from the Food and Health Bureau. Data for Taiwan obtained from the Ministry of Health and Welfare, Health Statistical Trends 2019.

Element 13: Growth in Public Healthcare Spending (20%)

Countries with accelerating public healthcare spending may be at greater risk of not meeting healthcare obligations in the future. Rapidly rising healthcare spending often signals that the government is not serious about reining in healthcare costs to provide a stable source of security for future generations. Countries that struggle on this element may also be in economic distress, as revenues fall and healthcare spending becomes an ever-increasing share of total government spending.

Countries that show a consistent level or reduction in public health spending demonstrate fiscal discipline and a commitment to preserving a robust healthcare system for future generations, especially as aging populations demand more healthcare services. Countries that perform well on the growth in public healthcare spending element may also have overhauled their budgets in response to the 2008 economic crisis, and have cut healthcare spending dramatically to achieve sustainable levels.

The score for this element was derived by computing the score of one measure:

• growth in public healthcare spending (100 percent).

Growth in public healthcare spending. The measure is calculated by subtracting the public healthcare spending per capita as a percentage of GDP from the latest year from public health spending per capita from 10 years prior, thus obtaining the percentage point increase or decrease in public healthcare spending. 

Sources: GDP figures from the IMF. Public healthcare spending data from the OECD database. Population figures used to calculate on a per capita basis from the U.S. Census Bureau, International Database. Public healthcare spending data for Hong Kong, Singapore, and United Arab Emirates calculated from the WHO Global Health Expenditure Database. Data for Hong Kong obtained from the Food and Health Bureau. Data for Taiwan obtained from the Ministry of Health and Welfare, Health Statistical Trends.