How We Compiled the 2021 FREOPP World Index of Healthcare Innovation
The dimensions, elements, & measures we used to rank 31 high-income national health care systems.
The FREOPP World Index of Healthcare Innovation is an ambitious attempt to assess health care performance in the modern world over a wide selection of measures. The Index uses a data-driven approach to identify leading health care systems in 31 countries based on four equally-weighted dimensions: Quality, Choice, Science & Technology, and Fiscal Sustainability.
Upon these dimensions are 13 elements that serve as foundational building blocks for a vibrant system that heals and empowers patients by harnessing the latest medical advancements in a financially responsible way.
Each element, comprised of measures derived from various data sources, are 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 scoring method, on a 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 2021 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 used to derive each measure.
What’s New for 2021
Following release of the original World Index of Healthcare Innovation in 2020, we evaluated the Index’s methodology as well as received feedback from various stakeholders. After examining available data, we made a few key changes for 2021, described below.
We introduced these changes for three reasons:
- New Data. As data becomes available, we can capture a clearer picture of each country’s performance. One example was including the COVID-19 vaccination rate measure, which tracks a key aspect of ending the pandemic that was not available in WIHI’s first iteration.
- Weighting adjustments. With the addition of new data, sometimes it is necessary to re-weight certain measures and elements. For example, when the Pandemic Preparedness and Response measure was given greater weight as its own element, other elements in the Quality dimension had to be re-weighted to make room for the new element, as the following diagram shows:
- New standards. As health care evolves globally, the standard of excellence may also change. For example, the Index recognized 85% acute care hospital bed occupancy as optimal given health care standards prior to the COVID-19 pandemic. However, given the pandemic strained many hospital to the brink, we adjusted the optimal capacity to 80%. Countries were then evaluated on how much they deviated from this new standard.
The following is a list of all changes made to WIHI 2021, including new measures, weights, and standards.
Pandemic Preparedness and Response. Previously, pandemic preparedness and response was one measure, comprised of three sub-measures (fatality rate, lockdown stringency, and travel volume) relating to COVID-19 response and mitigation. The measure was included with four other measures to comprise the Measures of Preventable Disease element.
For WIHI 2021, the pandemic preparedness and response measure will instead be an additional element in the Index under the Quality dimension. We also added another measure to this new element: COVID-19 vaccination rate.
These changes ensure that handling of COVID-19 for all countries in the Index will take on added significance and contribute more toward their overall score.
Acute Care Hospital Bed Occupancy. Prior to the COVID-19 pandemic, industry experts widely agreed that 85% occupancy of acute care hospital beds was optimal; low enough to prepare for surges in need, while high enough to be considered an efficient use of resources. This perception changed in 2020–21, such that a greater value was placed on having enough capacity to withstand a tidal wave of patients suffering from the worst pandemic in a century. Therefore, WIHI 2021 measures country performance based on deviation from a new optimal capacity of 80%.
Choice elements. Last year, the elements that comprised the Choice dimension were weighted as follows: Affordability of Health Insurance (30%), Freedom to Choose Health Care Services (40%), and Access to New Treatments (30%).
This year, the Index reweighted the elements within the Choice dimension, such that Affordability of Health Insurance and Freedom to Choose Health Care Services each increased by five percentage points (35% and 45% respectively), recognizing these two elements affect virtually everyone that interfaces with the health care system. In contrast, Access to New Treatments decreased by 10 percentage points to 20%, given that fewer people need the latest treatments to maintain good health.
Access to New Treatments. Prior to this year’s version of the Index, the Access to New Treatments element was comprised of only one measure: the number of new drugs available from among the world’s latest novel drug treatments within one year of the first global approval. For 2021, two more measures were added: generic drug market share and access to biosimilars. Both new measures reflect societies with innovative pharmaceutical markets because they provide more value to the largest number of patients possible, not simply provide the newest treatments.
Additionally, the new drugs available measure expands the list of new molecular entities from which all countries are compared by incorporating drugs receiving first global approval by Japan’s Pharmaceuticals and Medical Devices Agency (PMDA).
Finally, the scoring for this measure was adjusted to account for the fact that relatively few people are in need of the latest treatments for the most common ailments across the world. The effect of this change was to decrease the effect of outlier countries on the measure’s standardized scoring.
New Drugs Approved. In addition to incorporating new molecular entities approved by Japan’s PMDA, the Index used a new scoring system to reflect each country’s timing in approving new drugs. Last year, the Index awarded the same point value to each country for each drug approved as long as it was approved within one year of the drug’s first global approval. This year, the Index uses a sliding scale to reward countries that not only are the first to approve, but to assign values that increase the closer its approval is to the first global approval.
Health Digitization. Originally, the Health Digitization element was comprised of three measures: the electronic health record (EHR) adoption rate for primary care, specialists, and hospitals. For WIHI 2021, these EHR adoption rates were averaged into one combined rate, with information and communications technology development included as one additional measure for the Health Digitization element. This measure examines factors such as mobile and fixed broadband use to predict which societies are best equipped to implement and use EHR.
Standardized scoring
Two formulas were used to calculate all standardized scores for each measure. For measures where a larger value indicates better performance (e.g., 5-year cancer survival rate), the following formula was used:
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, 100 was subtracted from the previously calculated formula to obtain a standardized score as follows:
The following describes the measures, weights, and sources used to compute each of the 13 elements of health care performance.
Dimension: Quality
Element 1: Measures of Preventable Disease (35%)
The Measures of Preventable Disease element assesses the extent to which health care 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 wellbeing. Rather, the element relies on a mix of measures designed to isolate health outcomes amenable to the health care system itself.
The scores for this element were derived by computing the weighted average score of four measures, with accompanying weights:
- Hospital admissions (30%),
- Acute care survival (20%),
- 5-year cancer survival (20%), and
- PPP-adjusted GDP growth (30%).
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.
Acute care 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, linked data (person-identifying) for mortality rates are used rather than unlinked data (episode of care) due to 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. Standardized scores for acute care episodes involving acute myocardial infarction, hemorrhagic stroke, and ischemic stroke were averaged to obtain the overall standardized score for the measure.
5-year cancer survival. This measure obtains the survival rates for various cancers up to 5 years following diagnosis. Types of cancer included in the analysis include esophageal, stomach, colon, rectal, liver, pancreatic, lung, skin (melanoma), breast, cervical, ovarian, prostate, brain, myeloma, and lymphoma. Where adult survival rates were not available, rates were estimated based on child survival rates or neighboring countries with similar characteristics. Standardized scores were calculated for survival of each type of cancer, then averaged to obtain an overall standardized score.
PPP-adjusted 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. From this growth percentage a standardized score is obtained.
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 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 2004–2013.
Element 2: Pandemic Preparedness and Response (25%)
No event in recent memory has so dramatically impacted the world than the coronavirus pandemic. For WIHI 2021, the Index has elevated the Pandemic Preparedness and Response to its own separate element, rather than a single component within the Measures of Preventable Disease element. This element evaluates each country’s performance in protecting citizens from COVID-19 — including how well each country has vaccinated the population — while also minimizing the economic harm caused by strict lockdowns. The Index also accounts for whether a country can easily restrict travel to self-isolate and limit viral transmission, a feature unique to WIHI’s rankings.
The scores for this element were derived by computing the weighted average score of four measures, with accompanying weights:
- COVID vaccination rate (20%),
- Lockdown stringency (25%),
- COVID fatality rate (35%), and
- Economic isolation (20%).
COVID Vaccination Rate. This measure compares vaccination rates against SARS-CoV-2 as of May 19, 2021. The vaccination rate is measured as the number of doses administered per 100 people; given that many vaccine regimens require more than one dose, the vaccination rate may exceed 100. From the vaccination rate a standardized score is obtained.
Lockdown stringency. While governments are focused on preventing the spread and deaths caused by the virus, strict lockdowns have brought with them their own set of unintended consequences to health and economic wellbeing, especially among those who are poor but are still less susceptible to severe illness from the virus. The lockdown stringency measure examines whether countries pursue a strict lockdown strategy or allows larger segments of society to continue daily activities. The University of Oxford’s COVID-19 Government Response Tracker calculates a stringency score daily on a scale of 0–100, with a score of 100 representing the most stringent. To calculate a cumulative stringency score from April 2020 through May 2021, the Index first selects the stringency score on the same day each month, and sums them. The cumulative score is then standardized on a scale of 0–100, with lower scores (less stringent lockdowns) being preferable.
COVID fatality rate. Often cited as the primary means to compare countries on COVID-19 response, the COVID fatality rate measures the number of fatalities per million residents, through May 19, 2021. From these figures a standardized score is obtained.
Economic isolation. Countries that have fewer international entry points and experience lighter domestic air travel have a built-in advantage in preventing the spread of respiratory diseases. The Index accounts for this through the economic isolation measure, derived from both international and domestic travel volumes. The Index also considers how much to weight raw travel volume vs. the population size of each country. For example, the U.S. 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 combined average of the international and domestic travel volume standardized scores for country x, and Pop(x) is the population of country x.
Sources: 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.
Element 3: Patient-centered Care (25%)
To provide the best and most effective care, a health system must 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 patient’s voices are heard in an atmosphere of collaboration with their doctors.
The scores for this element were derived by computing the average score of three measures, all weighted roughly equally:
- Medical appointment wait times (34%),
- Patients receiving easy-to-understand explanations (33%), and
- Patients being involved in decisions about care (33%).
Medical appointment wait times. This measure uses a variety of ways to assess wait times, including median days from specialist assessment to treatment, age-standardized rate of patients who wait greater than 4 weeks for a specialist appointment, and the percentage of survey respondents who have unmet medical needs due to wait times. Standardized scores are calculated for each method and averaged to obtain an overall standardized score.
Patients receiving easy-to-understand explanations. This measure indicates the percentage of survey respondents that report receiving clear explanations from a primary care physician. For countries that do not report such data, the average percentage is calculated from countries that report data, with a 10% penalty for lack of reporting. From this percentage a standardized score is obtained.
Patients being involved in decisions about care. This measure indicates the percentage of survey respondents that report collaborating on care or treatment with a primary care physician. For countries that do not report such data, the average percentage is calculated from countries that report data, with a 10% penalty for lack of reporting. From this percentage a standardized score is obtained.
Sources: Wait time and patient experience data from the OECD database. Missing wait time data gathered from a variety of sources, including the European Union Statistics on Income and Living Conditions; the U.S. Center for Disease Control and Prevention, 2018 Behavioral Risk Factor Surveillance System; the Hong Kong Hospital Authority; and scientific studies on wait times and unmet medical needs in South Korea and Singapore.
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% 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 roughly equally:
- Primary care doctors per capita (34%),
- Nurses per capita (33%), and
- Acute care hospital bed occupancy (33%).
Primary care doctors per capita. This measure indicates the concentration of primary care doctors 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 health care strategy. From this measure the standardized score is obtained.
Nurses per capita. This measure indicates the concentration of nurses 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 health care tasks. From this measure the standardized score is obtained.
Acute care hospital bed occupancy. This measure is based on data for the average hospital bed occupancy percentage in each country. Prior to the COVID pandemic, an 85% 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, the Index adjusted the ideal occupancy level to 80%. Once the occupancy rate for each country is obtained, the Index calculates the deviation under or over 80%, with the lowest deviations considered best.
If the country’s occupancy is above 80%, 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%, the percentage point deviation is reduced by 50%, 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%, then the deviation from the ideal 80% occupancy (denoted as occupancydev(x))is calculated as the absolute value of occupancy(x) minus 80, multiplied by 50%. If county x has a hospital occupancy rate more than 80%, then the deviation from the ideal 80% occupancy is simply calculated as occupancy(x) minus 80. Once occupancydev(x) for each country is calculated, standardized scores are obtained.
Reducing the deviation from the ideal if occupancy is less than 80% 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 acute care bed occupancy data calculated using curative care occupancy days from the OECD database for Australia, Finland, New Zealand, Poland, Singapore, and Sweden, and from various country-specific reports for Hong Kong, Taiwan, and the United Arab Emirates.
Dimension: Choice
Element 5: Affordability of Health Insurance (35%)
Health care 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:
- Gross cost of health insurance (34%),
- Out-of-pocket spending (as percentage of per capita income) (33%), and
- Legal residents insured (33%).
Gross cost of health insurance. This measure captures the total cost of health insurance, expressed as the PPP-adjusted amount per capita, before any government subsidies are applied. From this key measure of health care affordability a standardized score is obtained.
Out-of-pocket spending (as percentage of per capita income). This measure indicates the degree to which individuals are exposed to out-of-pocket costs for health care services. The percentage is calculated by dividing the PPP-adjusted out-of-pocket spending per capita by the PPP-adjusted GDP per capita. From this percentage a standardized score is obtained.
Legal residents insured. This measure indicates the degree to which health care systems protect individuals from unexpected health care costs, expressed a percentage of the country’s legal residents who are insured. From this percentage a standardized score is obtained.
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, 2018 Employer Health Benefits Survey, and Medicare Advantage Local Benchmarks data; and from Centers for Medicare and Medicaid Services (CMS) Medicare 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, and Taiwan from the Ministry of Health and Welfare. Health insurance uptake data from the OECD database, with missing data for United Arab Emirates from the UAE National Health Survey Report (2017–2018). Undocumented resident data for the United States from the Pew Research Center (February, 2019).
Element 6: Freedom to Choose Health Care Services (45%)
The Freedom to Choose Health Care Services element measures the degree to which patients are in control of the major facets of their journey through the health care system. Countries that encourage personal choice have patients that are more engaged in their care, and actively participate in health activities and interventions that yield positive health outcomes while conserving financial resources. In fact, the mere idea of patient empowerment may in and of itself help achieve better health outcomes because of a 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 products (40%),
- Choice of providers (30%), and
- Out-of-pocket spending (as percentage of total national health expenditures) (30%).
Choice of insurance products. 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 health care services based on three factors with weights as follows: freedom to select any primary care doctor (40%), number of months before switching primary care providers is permitted (20%), and freedom to choose any specialist (40%). Scores are calculated for each factor and the weighted average of the three factors is calculated to obtain an overall standardized score.
Out-of-pocket spending (as percentage of total national health expenditures). This measure examines out-of-pocket spending’s effect on choices individuals make within a health care system. As opposed to measuring out-of-pocket spending as a percentage of a person’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. From the out-of-pocket percentage a standardized score is obtained.
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. Missing provider data from various country-specific studies and reports for Hong Kong, Singapore, 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, 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 a new drug as well as 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 three measures weighted as follows:
- New drugs available (30%),
- Generic drug market share (40%), and
- Access to biosimilars (30%).
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 in 2019. For each country, the number of these drugs that have since launched for sale count toward its total. Finally, each country’s score is adjusted to reduce the effect of outliers. From this adjusted score a standardized score is obtained.
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 based on the percentage of the prescription drug market that are sold as generics, by volume dispensed. From this percentage a standardized score is obtained.
Access to biosimilars. 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. From this count a standardized score is obtained.
Sources: Drug approval data from the U.S. Food and Drug Administration (FDA), 2019 New Drug Therapy Approvals; the European Medicines Agency (EMA), Human Medicines Highlights 2019; 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. Generic drug market data obtained and analyzed from IQVIA, with missing data collected from various sources for Australia, Denmark, Hong Kong, Israel, Japan, New Zealand, Singapore, South Korea, Taiwan, 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 health care 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 roughly equally:
- Health care patents (33%),
- New drugs approved (34%), and
- R&D Expenditures (33%).
Health care patents. This measure assesses each country’s development of intellectual property in three categories: medical technology, biotechnology, and pharmaceuticals. The total patents granted by applicant’s country of origin are summed and divided by that country’s population to obtain the number of patents per 1,000 people. From this calculation a standardized score is obtained.
New drugs approved. This measure focuses on drugs considered novel or have unique molecular structures first approved globally in 2019. Each country is then assessed for whether it has approved the drug within one year of the first global approval date and assessed a point value on a sliding scale, with approvals closer to the first global approval date being higher.
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 pharmaceutical sector to innovate. Business enterprise research and development (R&D) spending for each country is divided by population to obtain the country’s R&D spending per capita. From this amount a standardized score is obtained.
Sources: Health care patents data from the World Intellectual Property Organization, WIPO IP Statistics Data Center. Drug approval data from the U.S. FDA, 2019 New Drug Therapy Approvals; the EMA, Human Medicines Highlights 2019; 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 health care 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 in medicine or chemistry (50%), and
- Average number of citations to research documents (50%).
Nobel laureates in medicine or chemistry. 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 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 31 countries. From this percentage a standardized score is obtained for both nationality and institution location, which are averaged to obtain an overall standardized score.
Average number of citations to research documents. 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 1996–2019 in the fields of biochemistry, genetics, and molecular biology for each country, from which a standardized score is obtained.
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 (1996–2019).
Element 10: Health digitization (20%)
Despite the rapid pace of digital advancement in the modern world spanning 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 electronic health records (EHR) across a variety of health care 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 possible with health record digitization can streamline care, and even save lives; witness the use of national digital records in some countries to build 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:
- Electronic health record adoption rate (50%), and
- Information and communication technology (ICT) development (50%).
Electronic health record 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.
Information and communication technology (ICT) development. A widely developed ICT system is the foundation upon which widespread use of EHR is built. This measure examines the degree to which society is digitally connected, based on three factors weighted as follows: mobile broadband subscriptions per 100 residents (40%), fixed broadband subscriptions per 100 residents (40%), and percentage of residents using the internet (20%). From the weighted average of these factors a standardized score is obtained.
Sources: OECD Report on EHR adoption. Missing EHR data for Belgium, Hong Kong, Hungary, and the Netherlands from country-specific studies and reports from various sources, including the WHO and the European Commission. Data for ICT development obtained from the International Telecommunications Union.
Dimension: Fiscal Sustainability
Element 11: National Solvency (40%)
Countries with heavy debt burdens risk the ability to adequately fund numerous priorities, including health care. Heavy debt also weighs on economic growth, further driving countries into debt.
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 health care 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 one measure:
- Debt-to-GDP ratio (100%).
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. From this ratio a standardized score is obtained.
Sources: Debt-to-GDP figures obtained from the International Monetary Fund (IMF), General Government Debt Datamapper (2019).
Element 12: Public Health Care Spending (40%)
While all modern countries spend at least some government funds on health care, 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 provisioning health care may also result in systems that are less responsive to individual needs and choice.
Some governments that spend less on health care 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 Health Care Spending element identifies which countries rely on the public sector to provide health care.
The score for this element was derived by computing the score of one measure:
- Public health care spending (as share of GDP) (100%).
Public health spending as a share of GDP. This measure indicates how much countries rely on the public sector to provide health care, and is calculated by dividing total national public health spending by the country’s PPP-adjusted GDP. From this percentage a standardized score is calculated.
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 UN World Population Prospects 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 Health Care Spending (20%)
Countries with accelerating public health care spending may be at greater risk of not meeting health care obligations in the future. Rapidly rising health care spending is often a sign that the government is not serious about reigning in health care costs to provide a stable source of security for future generations. Countries that struggle on this element may also indicate a country is in economic distress as revenues fall and health care spending remains.
Countries that show a consistent level or reduction in public health spending demonstrate fiscal discipline and a commitment to preserving a robust health care system for future generations, especially as aging populations demand more health care services. Countries that perform well on the Growth in Public Health Care Spending element may also have overhauled their budgets in response to the 2008 economic crisis, and have cut health care spending dramatically to achieve sustainable levels.
The score for this element was derived by computing the score of one measure:
- Growth in public health care spending (as share of GDP) (100%).
Growth in public health care spending (as share of GDP). This measure shows whether governments have taken steps to control their health care spending so that future generations may benefit. The measure is calculated by subtracting the public health care spending per capita from the latest year from public health spending per capita from 10 years prior, thus obtaining the percentage point increase or decrease in public health care spending. From this percentage-point change a standardized score is obtained.
Sources: GDP figures from the IMF. Public health care spending data from the OECD database. Population figures used to calculate on a per capita basis from the UN World Population Prospects database. Public health care 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.
