Mirror, Mirror on the Wall, which is the best Health System of them all?

I have a confession to make.?

I started writing this article last year but never really thought I’d finish it.?

I don’t know if it was the sheer volume of research or that I didn’t know how to start or end this narrative. This is one of the few times I faced writer’s block. However, I also knew this article was important because every health system will have a treasure trove of insights. I am all for that. I write these articles primarily because they present me with immense learning opportunities, so it was hard to pass this one up.?

While living in the US for over half a decade, I got the opportunity to experience the US health system first-hand. Growing up in India, I experienced the Indian health system much more. The differences I experienced between the US and Indian health systems led me on my writing journey to understand health systems around the world. I deep-dived into Estonia, France, Israel and the like. I could see commonalities and clear areas of difference between all these health systems. Because comparison tables are bang for your buck, I considered putting together a comparison table across various parameters of these health systems. This would be a table with all data points that could objectively help me assess health systems worldwide, is what I thought. But which parameters? Which health systems? Where can you look up all this information?

That’s when my mind went into overdrive.?

I decided to take a break.?

I moved away from my laptop.?

Luckily, I had a distraction in the form of my 4-year-old niece, who was visiting us from the US along with her parents. She loved Snow White, so we gifted her a storybook with Snow White and the Seven Dwarfs. She was elated but couldn’t read yet, so she prodded me to narrate the story.?

I did.?

There were some complex concepts to translate from the real world into the 4-year-old world, but I managed to help her understand the overall narrative.?

But I was beginning to zone out. My niece could tell I was physically present but mentally absent. She was right.?

The health systems comparison table was playing on my mind. I had several unanswered questions. I was exhausted. So, like one of the dwarfs in the story, I thought, “If only I could get some sleep, I could find all the answers.”?

Sleep, I did.?

That’s when it all came together.?

But Healthcare Ain’t a Fairytale

No, it isn’t.?

Healthcare is where policy meets technology meets human needs. Or that should roughly be the case.?

In healthcare, heroes don't wear capes; they wear scrubs and stethoscopes.?

They navigate legislation and logistics to deliver care. Their world is super complex, which is why we must explore it. ?

But before we do that, we need to zoom out a bit.?

Broadly speaking, there are 4 care delivery models when it comes to how nations manage their healthcare. These models reflect the nation’s cultural values, economic structure, political ideologies, and social priorities. They encapsulate something more profound than just the mechanics of care delivery. These models are blueprints for achieving public health goals, ensuring equity, and managing resources efficiently.

• The Beveridge Model: Named after Sir William Beveridge, this model embraces the principle that healthcare should be provided as a public service, funded through taxation and accessible to all citizens free at the point of use. United Kingdom's National Health Service (NHS) and the healthcare systems in Spain and New Zealand are examples of this model where the government is the primary provider of healthcare services.
• The Bismarck Model: Inspired by the policy framework of German Chancellor Otto von Bismarck, this system relies on a network of insurance funds to which employers and employees contribute. Healthcare providers remain largely private in this model. Countries like Germany, Japan, and France are examples of this model.?
• The National Health Insurance Model: This model blends elements of both Beveridge and Bismarck, featuring universal coverage through a single-payer system—typically the government—funded through taxation. However, unlike the Beveridge model, providers may be private. Canada and Taiwan are examples of this model, showcasing efficient, universal care with a government as the insurer.
• The Out-of-Pocket Model: This model is predominantly seen in many low—and middle-income countries and is characterised by individuals’ direct payment of services at the point of care. Although things are changing as I write this article, most private health care in India is a perfect example of this.

Comparing these models across different nations highlights their unique features and outcomes that could inform future reforms and innovations in global healthcare.

And because I am all about tables, here you go.

Instead of defining a single dimension of healthcare, these models offer a lens through which the complexities of healthcare delivery, financing, and administration can be analysed. In essence, these models are the building blocks of health systems, guiding principles rather than strict blueprints, allowing for innovation and adaptation to meet evolving healthcare needs.

All health systems have structure, and structure is everything.

The structure of health systems serves as the backbone, guiding how care is delivered, financed, and accessed. This structure embodies a nation's commitment to the health and well-being of its citizens. It shapes the pathways through which care is provided, how resources are allocated, and the ease with which innovations are adopted. First step towards exploring & assessing health systems is to understand these structures.?

And no better place to begin than my homeland.?

INDIA

India’s health system combines centralised directives with state-level adaptation. The public and private sectors play significant roles, and several ministries and departments are involved in health policy formulation and implementation.

Here are my key takeaways from analysing India’s health system.

• Centralised Oversight with Decentralized Implementation: The Ministry of Health & Family Welfare is the primary governmental body at the federal level. However, state-specific entities tailor policies to the needs of individual states, which could be both a strength in terms of local responsiveness and a challenge in ensuring uniformity across the nation.
• Inclusive Approach to Traditional Medicine: The Ministry of AYUSH (Ayurveda, Yoga, Unani, Siddha, Homeopathy) is an inclusive approach to healthcare, recognising and integrating traditional and alternative medicine practices alongside allopathic medicine.
• Disease-Specific Programs: India has multiple focused initiatives for disease control, such as vector-borne diseases and tuberculosis, reflecting a prioritised and programmatic approach to public health challenges.
• Regulatory Frameworks: The structure reveals a robust regulatory framework involving the Central Drugs Standard Control Organization and various acts, such as the Drugs and Cosmetics Act, emphasising the country’s commitment to maintaining quality and safety in healthcare services and products.
• Private Sector Engagement: Multiple acts and regulations govern the relationship between public directives and private sector involvement, suggesting a controlled yet significant role for the private sector in healthcare delivery.
• Innovation and Technology: The mention of e-health and telemedicine indicates a push towards digital health solutions, which could improve healthcare accessibility, particularly in remote areas.
• Focus on Health Intelligence and Safety: Entities like the Central Bureau of Health Intelligence and the Food Safety & Standards Authority of India emphasise health data analytics and food safety, which are crucial for preventive healthcare.

The complexity and diversity of India’s health system point towards the challenges of managing healthcare in a vast and heterogeneous country. It underscores the need for coordination between various health authorities and the private sector to achieve health objectives. Moreover, the structure shows India’s efforts to balance modern healthcare demands with traditional practices and to harness technology for better health outcomes.

Let’s move west.?

UNITED STATES

The United States health system seems more evolved. However, even here, there is a complex interplay between public and private entities, involving multiple layers of financing and provision.?

Here are my key takeaways from analysing the health system of the USA.

• Dual Financing Streams: The U.S. health system has distinct public and private financing streams. Public financing includes federal programs like Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and other government insurance programs for veterans and the military (TRICARE). Private financing comes from employers, marketplaces (which could be federal or state-level), and privately insured individuals.
• Diverse Regulatory Environment: The health system is governed by a diverse regulatory environment that involves federal, state, and local government oversight. This multi-tiered structure suggests robust control and potential for policy implementation and compliance complexity.
• Role of Federal and State Governments: Both levels of government play crucial roles. The Department of Health and Human Services (HHS) at the federal level oversees national health policies. At the same time, state governments have their own state insurance commissioners and health departments that manage state-specific health issues.
• Providers and Payers: Healthcare providers in the U.S. include a broad spectrum of entities, such as hospitals, physicians, long-term care institutions, and mental health institutions. Payers include government programs, private insurance companies, and managed care organisations. This diversity of payers and providers contributes to the system's complexity and the variety of care delivery options available.
• Private Insurance Market: The presence of private insurance and managed care organisations indicates a significant role for the private sector in both financing and managing health services. The interaction between public programs and private insurance is a defining feature of the U.S. system, contributing to its complexity and heterogeneity.
• Managed Care Influence: Managed care organisations play a significant role in structuring healthcare delivery and payment. They often function as intermediaries between providers, payers, and patients and attempt to balance cost control with quality of care.
• Decentralised Nature: The variety of players and regulatory bodies suggests a decentralised approach to health system management, which may contribute to variations in healthcare access, quality, and cost across different regions and states.
• Non-Governmental Organizations: The system also involves non-governmental scientific and professional organisations (e.g., the Institute of Medicine and American Medical Association), which can influence healthcare quality, standards, and practices through guidelines and recommendations.

The U.S. health system reflects the broader American value system, which emphasises individual choice, market competition, and innovation but also grapples with the goals of universality, equity, and cost control. This results from historical evolution and leads to ongoing policy debates about the best ways to provide and finance healthcare for all citizens.

Moving back to our neighbours.?

CHINA

China's health system structure is more central. It is characterised by a top-down flow of authority and responsibility, with the central government exerting considerable influence over policy-making and administration through several state bodies.

Here are my key takeaways from analysing China’s health system.

• Centralised Leadership: The organisation chart shows the leading role of high-level state bodies in guiding the health system, indicating that health policies are closely aligned with the country’s broader political and economic strategies.
• Multi-Layered Administration: China's health system demonstrates a multi-layered administrative structure that includes the State Council, National Health Commission, and other state ministries, down to provincial governments. This suggests a degree of decentralisation in implementing health policies while maintaining centralised control.
• Comprehensive Coverage: The inclusion of urban employment-based medical insurance, urban resident basic medical insurance, rural cooperative medical insurance, and maternity insurance indicates an extensive network designed to provide healthcare coverage for various population segments.
• Integration of Traditional Medicine: The State Administration of Traditional Chinese Medicine within the system underscores the country's commitment to integrating traditional medical practices with modern healthcare, promoting a holistic approach to health and wellness.
• Quality and Regulation: Entities such as the China Drug Administration and the Department of Health Care Quality suggest a strong emphasis on the regulation and quality control of medical services and pharmaceuticals, which is crucial for ensuring the safety and effectiveness of healthcare delivery.
• Research and Disease Control: The presence of organisations like the Chinese Academy of Medical Science and the Chinese Center for Disease Control and Prevention reflects China's focus on medical research, innovation, and the management of public health issues.
• Education and Professional Development: The inclusion of the Ministry of Education and the relationship with national universities suggests an integrated approach to health education, professional development, and research, likely contributing to the ongoing development of medical knowledge and practices.

Overall, China's health system shows a well-organized, centralised model that aims to ensure comprehensive coverage and maintain high standards of care. However, such centralisation also presents challenges in terms of flexibility and responsiveness to local health needs. The structure reflects China's approach to providing a uniform health system across a vast and populous nation, balancing traditional practices with modern medical advancements.

Now, let’s look at the land of the rising sun.?

JAPAN

Japan's health system reflects a highly coordinated structure integrating regulation, provision, and oversight within a universal healthcare coverage framework.?

Here are my key takeaways from analysing Japan’s health system.

• Centralised Oversight with Decentralized Execution: The central government, through the Ministry of Health, Welfare and Labour, provides the overarching direction and establishes legal frameworks like the Medical Care Act and Health Insurance Act. However, local governments (prefectures and municipalities) play a significant role in the planning and delivering health services, suggesting a blend of national standards with local adaptation.
• Universal Coverage: The structure shows the operation of statutory health insurance by municipalities and the central social insurance medical council. This indicates that Japan aims to ensure universal coverage through government-managed and employment-based health insurance schemes.
• Involvement of Multiple Stakeholders: The inclusion of payer representatives, provider representatives, and experts, particularly in the Central Social Insurance Medical Council, points to a participatory approach to decision-making for health policy and payment rules.
• Quality Assurance and Fair Competition: Entities like the Japan Council for Quality Health Care and the Japan Fair Trade Commission reflect a commitment to maintaining quality of care and ensuring fair competition among providers, which are crucial for cost control and high standards in service delivery.
• Integration of Health and Social Security Policy: The presence of the Social Security Council and the Health Science Council suggests that health policy in Japan is closely linked with broader social security policy, aligning healthcare objectives with other social welfare goals.
• National and Local Coordination: A sophisticated coordination mechanism exists between the national government and local authorities, ensuring the consistency of healthcare delivery while allowing for regional variations and specialised services.
• Innovation and Regulation of Pharmaceuticals: The Pharmaceutical and Medical Devices Agency's role in establishing regulations underscores Japan's focus on fostering medical innovation while ensuring safety and efficacy.
• Financial Administration: The Ministry of Finance's involvement indicates that healthcare financing is key to Japan's fiscal policy, ensuring that healthcare delivery is sustainable and aligned with the country's economic planning.

The Japanese health system is designed to provide comprehensive, universal access to healthcare services. It combines rigorous quality control, stakeholder participation, and a balance of centralised policy with local implementation. This system demonstrates Japan's methodical approach to ensuring that all residents access necessary healthcare services, focusing on maintaining high quality and controlling healthcare costs.

Ah, I smell coffee - do you??

BRAZIL

The Coffee Pot of the World depicts a simple yet effective health system indicating the interaction between various levels of government—federal, state, and municipal—and other health-related entities.?

Here are my key takeaways from analysing Brazil’s health system.

• Decentralised Structure: The system is decentralised, with responsibilities shared across different levels of government, which may enhance responsiveness to local health needs but also requires effective coordination to ensure consistency and quality across regions.
• Tripartite Management: The Tripartite Inter-Management Committee (CIT) and Bipartite Inter-Management Committee (CIB) clearly take a collaborative approach, indicating a structure in which federal, state, and municipal authorities collaborate on national and regional health negotiations and policies.
• Comprehensive Public Health Policy: The presence of a National Health Council and conferences at all government levels strongly emphasises public participation and comprehensive policy-making in health.
• Focus on Local Systems: Municipal governments have a role in health surveillance and direct delivery of health services, emphasising the importance of local health systems and the delivery of strategic medicines and technologies, which could improve access to health services.
• Regulatory Oversight: The structure shows clear paths of regulatory oversight with agencies like the National Health Surveillance Agency and the Chamber of Drug Price Regulation. This indicates a commitment to controlling health service prices and ensuring the safety and quality of medical products.
• Emphasis on Health Information Coordination: Highlighting the role of health information coordination at the Ministry of Health level suggests a focus on data-driven decision-making and the importance of health informatics.
• Challenges of Coordination and Quality Control: While the decentralised approach allows for tailored regional health policies, it may also pose challenges in maintaining quality standards and efficient resource allocation across a vast and diverse country.

This system reflects the complexity of administering healthcare in a large country with significant regional diversity. Effective functioning within this framework requires robust coordination mechanisms, transparent governance, and active community engagement. Brazil’s health system’s success relies heavily on the balance between local autonomy and national unity, the synergy of public and private sectors, and the commitment to uphold principles of universality and comprehensiveness as enshrined in its constitution.

Alright, I know what you’re thinking.?

Where’s that comparison table, right?

I don’t blame you.

The many layers of governance, financing, and regulation show how multifaceted these systems are, demanding continuous adaptation and innovation.?

It becomes evident that there is no Magic Mirror.?

But if let’s say, there were a Magic Mirror, how would it be??

It would be multi-dimensional.?

If such a mirror existed, it would not merely show us a reflection but reveal the depth of each system's structure, from the demographics they serve to the economic engines that fuel them, the health statuses they aim to improve, and the access they provide. This Magic Mirror wouldn't simplify but instead illuminate the complexities, allowing us to grasp the nuances of healthcare planning, the balance of expenditure against GDP, and the critical policies that shape each nation's health destiny.

How, you ask?

By shining light on these dimensions.?

Geography, Demography, Economy

• Total Population: Essential for understanding the scale of health systems.
• Demography: Focus on the ageing population percentage or youth percentage, as these are critical for healthcare planning.
• Current GDP: Reflects economic capacity for health spending.
• Health expenditure as a % of GDP: Indicates the priority given to health in the economy.
• Literacy rate: Correlates with health awareness and outcomes.

Health Status

• Life Expectancy at birth: A primary indicator of overall health.
• Major chronic conditions: Highlights prevalent health challenges.
• Infant mortality rate: A key indicator of healthcare effectiveness.

Risk Factors

• Smoking and Alcohol consumption rates: Major preventable health risk factors.
• Obesity prevalence: Reflects lifestyle disease risk.
• Total Disease Burden: Focus on prevalent diseases impacting health systems.

Access

• Health Insurance coverage: Indicates accessibility of healthcare.
• Hospital Beds and Physicians per 1000 people: Reflects healthcare capacity.
• Out-of-pocket spending: Reveals affordability of healthcare.

Health Expenditure / Affordability

• Health Expenditure by the government as a % of GDP: Reflects government commitment.
• Public vs. Private health expenditure: Shows health financing structure.

Policy

• Key Health Policies: Highlights the approach to healthcare challenges.
• Membership in International Health Groups: Indicates global health integration.

Digital Health Strategy

• National digital health roadmap: Shows commitment to modernising health systems.
• Focus areas in digital health: Indicates specific priorities.

As we look into this Magic Mirror, we uncover layers beyond the immediate reflection.?

This mirror does something unusual; it invites us to dive deeper, to move beyond the obvious.?

But where is the data, you ask?

I hear you.

In Data, we trust

Remember how I said earlier that I never thought I’d finish? It was because of this table. This is the one I dreaded, and it took me months to compile the information now condensed in this table.?

There was no single place to collect data, but I landed on some high-quality sources, which I have referenced below.?

So mirror, mirror on the wall, which is the best health system of them all?

Before we answer that Q, there’s one last thing.?

It’s a trump card of sorts.?

Enter Artificial Intelligence

A superpower in today’s world that almost all nations have access to and that can truly change a country’s healthcare trajectory. AI promises to redefine efficiency, accuracy, and accessibility in health systems, making optimal use of resources a reality.?

Remember the Iron Triangle of Healthcare??

Yeah, the one that says there is always a trade-off between access, cost, and quality, suggesting improvement in one area must compromise another. AI challenges that notion by enabling simultaneous advancements across all three vertices. Integrating artificial intelligence (AI) into the Iron Triangle of Healthcare changes traditional constraints into opportunities for simultaneous improvement across access, cost, and quality.?

AI breaks the Iron Triangle constraint by

• Enhancing Access: AI democratises healthcare access through telemedicine, mobile health apps, and online consultations, reaching underserved populations and remote areas.?
• Reducing Costs: AI-driven technologies streamline operational efficiencies, automate administrative tasks, and optimise resource allocation, significantly reducing costs.?
• Improving Quality: AI enhances diagnostic accuracy, personalises treatment plans, and monitors patient outcomes in real-time, elevating the quality of care.

However, the transition from potential to real hinges on proactive policy-making that embraces innovation while safeguarding ethical standards and patient privacy. Countries like the United States, China, and Estonia have emerged as frontrunners, actively integrating AI into healthcare delivery and policy.

• United States: The US has been a leader in AI in healthcare, with policies supporting research and development, including the American AI Initiative. The private sector, including tech giants and startups, significantly drives AI innovation.
• China: China aims to become a global leader in AI by 2030, with healthcare being a key sector for AI development. The government has launched multiple initiatives to integrate AI into healthcare services, emphasising cancer diagnosis, medical imaging, and disease prediction.
• Japan: Japan is focusing on utilising AI to address the challenges of the ageing population. Its policies support the development of AI in healthcare diagnostics, patient care, and robotics. The government actively promotes research and collaboration between the medical and tech industries.
• Brazil: Brazil is in the nascent stages of integrating AI into healthcare, with some initiatives aimed at using AI for disease tracking, diagnostics, and improving healthcare delivery in remote areas. However, comprehensive national AI healthcare policies are still developing.
• India: India's National Digital Health Mission aims to revolutionise healthcare through technology, including AI. Compared to the US and China, it’s in the early stages. The government encourages startups and research in AI for health diagnostics and telemedicine.

AI introduces a paradigm shift in healthcare, suggesting that the Iron Triangle might not be as rigid as we once thought. By leveraging AI, healthcare systems can aspire to achieve a balance of access, cost, and quality previously considered unattainable, paving the way for a future where comprehensive, high-quality healthcare is a reality for all.

And here, I would like to quote specific examples from my homeland.?

I follow the Indian health tech landscape very closely, and two companies using artificial intelligence to disrupt the healthcare universe are - Dozee and Vizzhy.?

Dozee is a technology company that has developed a contactless health monitoring system. Dozee's product is designed to monitor vital signs and sleep patterns using advanced AI algorithms and signal-processing techniques. The system consists of a sensor placed under the bed mattress, which then collects data on heart rate, respiration rate, sleep stages, and other health parameters while the user is asleep. This data is analysed and can be accessed via a smartphone app, providing users and healthcare professionals with insights into the user's health and sleep quality. Try to understand their technology; you’ll think it’s indistinguishable from magic.?

I especially love Vizzhy because it is venturing into developing foundational models.?

Foundational models are designed to provide a broad base of capabilities that can be fine-tuned or adapted for specific tasks or applications across a wide range of domains, including but not limited to natural language processing, computer vision, and decision-making systems. These models leverage massive amounts of data and compute resources to learn patterns, relationships, and structures in the data they're trained on, enabling them to generate responses, predictions, or insights that can be remarkably accurate and contextually relevant.

Vizzhy has attacked metabolic diseases, offering a solution that is the first of its kind globally. Their full-stack metabolic signature program is designed to tackle the root causes of metabolic disorders head-on. At the heart of their solution lies an AI-powered multi-omics platform, an advanced integration of genomics, metabolomics, microbiome analysis, and biomarker identification. Vizzhy is redefining the landscape of metabolic disease management, paving the way for personalised, data-driven healthcare solutions.

In the context of Indian healthcare, companies like Vizzhy and Dozee matter significantly due to the country's unique healthcare challenges. India's healthcare landscape is marked by a vast and diverse population, a wide range of health disparities, and an increasing burden of both infectious diseases and non-communicable diseases such as diabetes and heart conditions.?

India needs many more Dozees & Vizzhys!

Alright, dear reader. Thank you for reading this far. As we conclude our exploration, it's time to return to the question that sparked this discourse.

To think of the "best health system" purely in terms of numbers would be to miss the essence of what healthcare truly entails. Healthcare transcends mere metrics and statistics; it is about the real impact on real lives.

The "best health system" is not a destination but a horizon towards which we continuously move. It represents not a crown to be won but a commitment to be honoured—a promise that every person, no matter where they are in the world, has access to the healthcare they rightfully deserve.

With Artificial Intelligence rapidly reshaping the landscape, we stand on the brink of a new dawn. AI promises to revolutionise how care is delivered, making it more personalised, efficient, and equitable than ever before.?

The mirror has spoken.?

It's our turn now.

References

1. Challenges for Lower-Middle-Income Countries in Achieving Universal Healthcare: An Indian Perspective
2. https://data.worldbank.org/indicator/NY.GDP.MKTP.CD?end=2022&locations=NO-US-IN-AU-CN-IL&start=2022&view=bar
3. https://www.healthsystemtracker.org
4. https://www.commonwealthfund.org
5. https://pib.gov.in/PressReleaseIframePage.aspx?PRID=1796436
6. Brazilian National Digital Health Strategy?
7. Japanese Action Plan for Growth Strategy?
8. Federal HIT Strategic Plan USA