Healthcare is a costly item in national budgets, but who gets the best value for money, and who the best outcomes? We compare the systems in some of the world’s leading countries for healthcare.
Upfront payments: yes
Data: France scores highly on GP numbers and on spending as a percentage of GDP, but it comes off badly in the Commonwealth Fund’s international comparison reports, ranking only ninth out of 11 in the latest assessment.
Under France’s state-run equivalent of the NHS, the majority of patients must pay the doctor or practitioner upfront. The state then reimburses them in part or in full. The patient has freedom to choose which doctor or service to visit.
All health transactions centre on a smartcard, the Carte Vitale. A GP visit costs €23 (£17), the Carte Vitale is swiped and the money is paid back into the patient’s bank account within five days. In general, the state reimbursement rate is between 70% and 100%. The poorest people and the long-term sick are covered 100%.
Most people are signed up to a mutuelle, a semi-private insurance body, often related to their job, which tops up the remaining amount to be paid. If a patient is taken to the emergency department of a hospital, for example, they would provide their Carte Vitale, and depending on the health issue, could be reimbursed fully by the state. However, from November 2017 doctors such as GPs will have to waive the upfront fees for all patients, and instead the state and themutuelle companies will pay doctors direct. At pharmacies, the patient pays upfront but swipes their Carte Vitale. A large number of prescribed medicines are reimbursed between 15% and 100%.
Upfront payments: yes
Data: Ireland has more nurses than any other rich country, but its other metrics are distinctly average.
A GP visit in Ireland typically costs €40-€60. However, in 2015 the Irish government abolished charges for children under six while people with a medical card or GP visit card also receive free GP care.
In most cases individuals pay for prescriptions from pharmacies capped at €144 per month under the Drugs Payment Scheme. Medical cardholders do not pay for medication but do pay a prescription charge of €2.50 per item (capped at €25 per month per person/family).
Patients are usually referred for secondary treatment by their GP unless they have entered the health system directly through an emergency department. Those attending emergency departments without being referred by a GP are charged €100 (with some exemptions). You are not charged if you are subsequently admitted as an inpatient but may be liable for hospital charges. The charge for an overnight stay in a public bed in a public hospital is €75 per day up to a maximum of €750 in 12 consecutive months.
As of the end of September, 46% of the population had health insurance, meaning they could be treated as a private patient in the public system or in a private hospital. Public patients who receive treatment in private hospitals pay for their own care.
Upfront payments: yes
Data: Sweden is ranked third by the Commonwealth Fund, with a high proportion of doctors, above-average healthcare spending, and relatively low prescriptions of drugs.
Patients wishing to see a doctor pay a fee that varies depending on where they live, but usually about 100-200 kronor (£8-£16) for adults. Children pay only if they go to emergency rooms, about 120 kronor. For a visit to a specialist you pay up to 400 kronor and for emergency about 400 kronor. A hospital stay costs 100 kronor a day. You usually pay the same whether you choose a private or public clinic or hospital, as long as the private clinic is connected to the general healthcare system. And most are.
There is a limit to how much you pay for healthcare within a 12-month period. In most regions that is 1,100 kronor, but there are regions where the limit is just 900 kronor. Everything is free after that. Prescriptions are subsidised and you never pay more than 2,200 kronor in a 12-month period.
If you are referred to an expert, you pay a lower fee of about 100 kronor. If there are recurring visits you pay each time, but only up to 1,100 kronor within a 12-month period. Some regions charge small fees for the cost of an ambulance, about 150 kronor.
Only about 600,000 Swedes have a private health insurance – usually paid for by employers. It gives them the ability to skip the queue for procedures and operations, and to get to a doctor more quickly.
Upfront payments: yes, but low
Data: China scores poorly on just about every healthcare metric, apart from the growth in how much it spends each year on public health – a sign that it is trying to catch up.
Hundreds of millions of Chinese citizens lost the right to free public healthcare after the Communist party launched its economic reforms drive in the late 1970s.
Today, the cost of a hospital consultation is still relatively low. For those with blue government “social insurance” cards, for example, a trip to Beijing’s Friendship hospital can cost as little 2 yuan (20p). It costs about 100 yuan to be admitted to A&E while a night in a ward sets a patient back about the same.
Patients on beds overflowing into the corridors of a hospital in central China’s Anhui province. Photograph: AFP
But the often exorbitant cost of medicine and treatment can be enough to ruin a Chinese family.
Government officials say they hope to provide affordable healthcare to every Chinese citizen by 2020 and claim 95% of the population now boasts some kind of medical insurance. But in reality even those who do have insurance find it often fails to cover their bills.
Poorly paid doctors are notorious for overcharging patients for unnecessary prescriptions while even an ambulance ride to the hospital can set you back several hundred yuan.
Discontent over this state of affairs has made medicine a dangerous profession in China with a surge in verbal and physical attacks, including murders, against doctors in recent years.
Upfront payments: yes
Data: the US scores poorly on many fronts, ranked 11th out of 11 in the Commonwealth Fund 2014 list. And yet it far outstrips all its peers in terms of the amount it spends on healthcare – a whopping 17% of GDP.
US healthcare is not quite the Darwinian lottery imagined by foreigners. Hospitals are duty-bound to treat emergency cases. Government spending pays for a surprising share of visits to the doctor and drugs through a patchwork of public programmes: Medicare for the old, Medicaid for the poor and Chip for children. Since Obama’s insurance reforms, the percentage of people who have no cover has fallen to “only” 10% – a mere 33 million people.
For the rest, standards are generally high, sometimes among the best in the world. But no matter how good the insurance policy, few Americans can escape the crushing weight of payments bureaucracy, or the risk-averse medical practices that flow from a fear of lawsuits.
Almost all visits to the doctor (often a specialist, rather than general practitioner) will generate “co-pays” for the patient and revenue streams for the physician that some fear encourages excessive testing and intervention: a consumer, rather than care-led, culture.
Preventive medicine and public health are harder to incentivise. Patchy access to insurance can leave emergency rooms clogged with chronic conditions. Obesity and mental illness often go entirely untreated.
Though the system fosters excellence and innovation in places, the messy combination of underinsurance and overinsurance has left the US with the highest healthcare costs in the developed world and some of the worst overall health outcomes.
Upfront payments: no
Data: Japan spends a sharply rising proportion of GDP on healthcare but falls down on the amount of time people spend in hospital, which is one of the highest among rich countries.
Every resident of Japan is required, in principle, to take out public health insurance. Regular employees are typically covered by a work scheme, and are required to pay 20% of their total medical costs at the point of delivery.
Those not covered by their employer – mainly the self-employed and unemployed – must join the national health insurance scheme. Premiums are based on salary, value of property and the number of dependants, and members pay 30% of the cost of inpatient or outpatient treatment – including emergencies – with the government paying the remainder. People over 70 pay 10% of costs.
Medical fees above a certain ceiling – calculated depending on income and age – are paid in full by the government. Fees are waived for uninsured people on low incomes who receive government support.
Both public insurance plans cover a range of services, including hospital care, mental health care, prescription drugs, physiotherapy and, significantly, most dental care.
A radiation specialist and a patient at Yamanashi University Hospital in Chuo city, Japan. Photograph: Everett Kennedy Brown/epa/Corbis
The role of the state in providing healthcare services outstrips many other developed countries. In 2012, 82% of health spending was publicly funded, compared with an OECD average of 72%.
Universal health coverage has been credited with contributing to Japan’s impressive longevity statistics, but the growing elderly population is adding to healthcare costs. Lengths of hospital stays are almost twice as long as in other countries.
Japan spent 8.6% of GDP on healthcare in 2008, according to OECD figures. By 2013 that had risen to 10.3%, largely because of the ballooning cost of caring for older people.
Upfront payments: no
Data: Spain has a relatively high number of doctors – and a low number of nurses – proportionate to its population, but the amount it spends on healthcare has started to fall amid the economic crisis.
Spain offers free, universal healthcare to anyone resident, legally or illegally, in the country, as well as to tourists and other visitors. Since 2012, undocumented foreigners have been entitled only to emergency care. Some 90% of Spaniards use the system, with about 18% signing up to private healthcare schemes, including many public sector workers who are given the option of free, private care. Most dental and eye care is carried out in the private sector.
The system is decentralised across the country’s 17 autonomous regions and so the quality of care, and in particular access to specialist procedures or units, varies. This leads to a degree of internal health tourism. In a recent poll, medical professionals, said nine out of 10 of the best hospitals were in either Madrid or Barcelona. Some regions, notably Catalonia, have implemented deeper spending cuts than others, leading to longer waiting lists and some migration towards the private sector.
Upfront payments: in some cases
Data: high doctor ratios, high numbers of pharmaceutical prescriptions.
In Italy, the national health service, Servizio Sanitario Nazionale, offers universal health coverage that is free or low cost at the point of delivery and covers the vast majority of drugs.
It is recognised by independent experts as offering affordable and high quality care, though there are regional differences in the standard of some state-run hospitals, with facilities in northern Italy being considered better than those in the south. Citizens can also buy private insurance, which some do to avoid waiting times for doctors’ visits.
The national insurance scheme is offered to all European citizens, and includes full coverage – paid for by general taxes – of inpatient treatments, tests, medications, surgery, emergency care, paediatrics and access to a family doctor. According to Italy’s health ministry, the list of pharmaceuticals that are covered by national insurance is the most complete in Europe, with patients having to pay for only products that treat minor disorders.
The ministry said Italy is also the only country in Europe that allows families to choose a paediatrician for children until age 14 at no charge.
Upfront payments: no
Data: middle of the pack. Germany was positioned fifth in the latest Commonwealth Fund rankings, spending more than the EU average on healthcare – but its lengths of stay in hospital tend to be higher than in other countries.
In Germany’s healthcare system, which goes back to Otto von Bismarck’s social security programme of the 1880s, anyone residing in the country is required to take out a health insurance scheme.
About 85% of the population do this by taking out insurance with one of the country’s 124 non-profit Krankenkassen or “sickness funds”: public insurers, many of whom are small and linked to trade unions. Membership rates are about 15% of monthly salary, half of which is paid by employers.
Those who earn more than €4,350 (£3,300) a month can take out insurance with a private company, an option that is mainly popular with freelancers and the self-employed. For welfare recipients, health insurance membership is covered by local authorities.
Doctors tend to patients at the UKB hospital in Marzahn district in Berlin, Germany. Photograph: Theo Heimann/Getty Images
Membership covers GP and registered specialists as well as basic dental care. If you are taken to hospital, your public health insurance kicks in once you are charged more than €10 a day, covering inpatient care with the doctor on duty at your nearest hospital.
It doesn’t cover private doctors or private rooms at a hospital, homeopathic treatment or more advanced dental treatment. Patients pay for 10% of prescription drugs, with a minimum of €5 and a limit of €10 per medication per prescription.
Since 2013, patients in Germany no longer have to pay a consultation fee of €10 when seeing a doctor. They can now also go straight to a specialist, rather than waiting to be referred by a GP.
Upfront payments: no
Data: Russia has a relatively large number of doctors, but its healthcare spending is low and outcomes are generally poor.
On paper, the Russian health service is free to all. In practice, a complex compulsory medical insurance system plus low wages for doctors and nurses means that without substantial bribes, gaining a decent level of care outside the better private clinics is almost impossible. The horrific case in December in which a doctor in Belgorod punched a patient in the face, who fell to the floor and subsequently died, put the spotlight on the poor care many Russians receive.
There are many efficient and modern private clinics in Moscow, but in the regions ageing Soviet infrastructure and outdated medical practices are widespread. Medicine is widely available, and many drugs that are prescription-only in Britain are available over the counter. The Russian tendency to overprescribe means that Russians often spend huge amounts on medicines.
A tuberculosis patient having his blood pressure measured in eastern Siberia. Photograph: Alamy
Emergency care is also free in theory, but private ambulances often arrive much quicker than state-provided ones, and there are also reports of ambulance crews demanding money to take patients to hospital. Most middle-class Russians have private health insurance, or simply pay upfront at private clinics when required.
Upfront payments: yes
Data: Australia scores well in comparative datasets, ranking fourth in the Commonwealth Fund table, with high numbers of doctors and average amounts of national wealth devoted to healthcare.
Most people pay to see a GP, which costs about $50-$80 (£24-£38). About half of this is reclaimable via a nationwide Medicare insurance scheme.
Some GP surgeries offer “bulk-billing”, which means they only charge the reclaimable fee, so patients do not have to pay anything to see the doctor. Low-income earners and pensioners who have a government-issued healthcare card are always bulk-billed.
Most prescriptions are subsidised through the Pharmaceutical Benefits Scheme (PBS).
Treatment in public hospitals is completely covered by Medicare, though people with private health insurance often elect to use private hospitals.
Ambulances are not covered by Medicare. Some states fund ambulances through an annual levy, though others charge $300-$2,000 (£150-£950) for an emergency ambulance callout. This goes up to $10,220 (£5,000) for an emergency callout of a helicopter in Victoria. Many people have ambulance cover as part of their health insurance.
In 2011-12, 57% of adult Australians had private health insurance, particularly older people, high earners and women in their 20s and 30s who use it for maternity care.
Upfront payments: no
Data: the UK came first in the latest Commonwealth Fund assessment of healthcare systems around the rich world, but other surveys such as a European one earlier this month are not so flattering. Healthcare spending as a proportion of GDP is falling behind international averages, and an elderly demographic, the obesity epidemic and alcohol bingeing are all taking their toll. The UK also has the worst cancer outcomes of any rich country.
A mission statement set in 1948 for a universal service free at the point of use is under strain like never before. People are still able to see a GP free of charge – though booking an appointment is becoming harder. It will cost nothing to call out an ambulance and go through A&E, to undergo chemotherapy or major surgery. And yet about 11% of the population prefer to pay for private health insurance.