Where are the world's best healthcare systems and why? How do they compare to Scotland and could we adopt one here?

It is an issue at the heart of every nation’s government – how to run the country’s healthcare system successfully.

The Covid crisis exposed cracks in the healthcare systems of almost every country, with staffing shortages, problems with national vaccine roll-outs and inequalities evident across the world.

Although many countries have some kind of universal health care system, few have a fully-funded NHS like Scotland and the rest of the UK.

The Scottish Government came under fire in recent weeks for a paper that considered the possibility of a “two tier” system, which would see people on higher incomes pay for some treatment. However, First Minister Nicola Sturgeon has since insisted the NHS will be protected at all costs.

Rob Williamson lives in Taiwan with his wife Xenia Wu and their son, Charlie.

Here, in part one of a special five-part series, we take a look at the world’s best healthcare systems, according to the The Legatum Institute’s Prosperity Index. We find out how they are funded – and if people living in countries with top-ranked healthcare believe they receive good treatment.

The top ranked systems are, in order: Japan; Singapore; South Korea; Norway and Taiwan. Components measured by the index include a country's basic mental and physical health, health infrastructure, and the availability of preventative care.

Mark Hellowell, director of the Global Health Policy Unit at the University of Edinburgh, says what most of the top ranked systems have in common is they require people to pay into a ring-fenced state health insurance system.

He says: “In countries where there is social insurance like South Korea, like Japan and like most Western European countries, people think of that as a separate thing to the tax that they pay. It is ring fenced and it goes into health care, which is something that they value. When surveys are carried out in these countries, practically everybody thinks that healthcare expenditure should increase.

Steven Brown lives in Singapore with his wife, Hilwah and their three children Aaliyah, 12, and Yasmin, 9 and Harris, 8.

"Here in the UK, it all comes from our taxes into one pot, Meanwhile, when there's something like social insurance, people feel like they know where that's going. It's going into providing coverage for health expenses and benefiting you and your family and your friends in your community in some meaningful sense.”

Hellowell says successful systems involve people visiting primary healthcare settings early due to easy access and affordability, rather than waiting until things have become urgent and needing to go to hospital.

He says: "What you really want to do is try and make sure that people present initially in primary care settings. The most inefficient health systems around the world are those where people routinely bypass primary care and go straight to hospital or some other expensive setting in which care is provided.” He adds: "When you think about health care, it's really about people. It's really about people and their skills and their minds and so you've got to make sure that you get the supply side decisions right.”

Hellowell says in some countries with successful healthcare systems, staff recruitment is easier – and more affordable for healthcare authorities – than in the UK.

“For whatever reason, it seems to be relatively inexpensive to hire well trained physicians,” he says. “In Japan and Taiwan, it doesn't seem to be as expensive to recruit and retain an adequate number of staff.”

Ben Zaranko, senior research economist at the Institute of Fiscal Studies, who has written papers on global healthcare systems, agrees. "They've got just an enormous number of hospital beds,” he says, adding that many Asian countries have staffed their health system to cope with older people living longer.

“Asia was the first region to have to worry about the ageing of its population. So, some countries there are ahead of lots of other countries in that they’ve come up with systems for how to live with that and manage that because they're just further along the path than the rest of us.”

Zaranko says, however, most healthcare systems have sprung up organically, rather than being closely thought out.

"Different countries have extremely different models of how they provide health care,” he says. “I don't think there is a best model. It can be from historical accident, political reasons or cultural reasons. There's no grand design often in how these things are created. It's very difficult to just drop your model and pick up somebody else's when it's based on decades and decades of built up systems and processes.”

"I think that if we were looking at the NHS, rather than saying ‘should we abandon it and create some sort of insurance model, like the German system? Or drop it entirely and create something like the Singaporean system’, it should be much more about how we use the resources we have within our existing setup.”

JAPAN

Spends 10.74 per cent of GDP on health.

Life expectancy: 84.3 years – 86.5 for women and 81.5 for men.

Japan has a statutory health insurance system, which provides universal coverage, funded by both taxes and individual contributions.

Everyone has to enrol in either an employment-based insurance plan, which is taken out by around 60 per cent of the population, or a residence-based plan. A separate Public Social Assistance Program, for people living in poverty, is used by around 1.7 per cent of the population.

In employment-based plans, employers and employees share mandatory contributions. The contribution rates are about 10 per cent of both monthly salaries and bonuses and are determined by an employee's income. In addition to the basic insurance premiums, people also have to pay 30 per cent of the cost of most services – or a fixed rate fee. These extra costs are cheaper for children and adults who are on low incomes. Hospitals in Japan, by law, must be run as non-profit and be managed by medical staff.

SINGAPORE

Spends 4.08 per cent of GDP on health.

Life expectancy: 83.2 years – 85.5 for women and 81 for men.

Financing of healthcare costs in Singapore is done through a mixture of direct government subsidies, compulsory comprehensive savings, a national healthcare insurance and cost sharing. A compulsory medical saving scheme, Medisave, allows families to save for medical expenses and then share the money across family groups for whoever needs it, usually for routine care. This is paid for through contributions taken directly out of a worker’s pay packet, usually totalling between 8 and 10 per cent of their earnings.

Taxes cover about a quarter of Singapore’s total health costs. Individuals and their employers pay for the rest in the form of mandatory life insurance schemes and deductions from the compulsory savings plan.

For bigger medical expenses, citizens use Medishield, the basic health insurance scheme used to pay for large bills, as well as costly outpatient treatments like kidney dialysis.

Patients can choose to pay more for more luxurious hospital facilities – ranging from a “Ward A”, which is a private room with en-suite, TV and telephone – as well as a choice of specialist doctor – to “Ward C”, which has up to 12 people in one room and a basic flat bed, as opposed to an electric hospital bed. The costs vary accordingly, from more than £300 a day for the top level ward, to less than £30 a day.

Steven Brown, 44 from Skye, has lived in Singapore for 18 years, where he is married to Hilwah and works as a subsea engineer. He is now a Singaporean citizen. The couple has three children – Aaliyah, 12, Yasmin, nine, and Harris, eight.

He says: “I have lived in Singapore for 18 years and have limited experience with the healthcare system, but when I have used it, it has been seamless. I have needed to see specialists for cardiology, stomach issues and sleep issues and have been able to get an appointment in a few days to see top specialists.

“The cost is covered by insurance, so it depends on your policy. I have company medical insurance and a secondary policy that I pay for which is actually quite cheap.

“I have had two children in the government hospital and the service was exceptional. In the state hospitals, it's better care, but slightly less comfort – ie not like a five-star hotel. The medical service is even better in the government hospitals, but with less frills.

"My children are Singaporean, so they get lots of subsidies and incentives – because Singapore tries to encourage growth of the population – so the birth costs are essentially free and covered by the 'baby bonus' and then on top of that there is a large tax rebate that grows the more children you have, so having babies is net profit.

“Singaporeans get some extra benefits from local polyclinics, which cover simple medical issues and these are very cheap.

“There are additional subsidies for medical expenses for people on low salaries.”

SOUTH KOREA

Spends 8.16 per cent of GDP on health

Life expectancy: 83.3 years – 86.1 for women and 80.3 for men.

South Korea's healthcare system is based on the country’s National Health Insurance Service, a public health insurance program run by the Ministry of Health. South Koreans earning a sufficient income pay contributions to insure themselves and their dependants, while those on low incomes have their healthcare funded by the nationalised Medical Aid Program.

However, the national health plan covers a maximum of 60 per cent of each medical bill, with a co-pay system for each procedure or appointment. Around three quarters of South Koreans take out extra private medical insurance to help cover this.

Chris Tharp, 51, a copywriter and teacher at a university in Busan, South Korea, is originally from the US. He has lived in Korea for 18 years with his wife, Minhee.

"Waiting lists are unheard of in South Korea,” he said. “I’ve only had one major incident, I was in a bike crash and was in hospital for 17 days – but I’ve used it for a lot of small stuff and it was great.

"The national insurance is nominal, it’s not very much and that gives you access to the health system. You’ll get treated and be seen right away. Say I have bronchitis and I go to see a doctor, I might have to wait ten minutes, he might have a look, do a chest X-ray and prescribe me some medicine and maybe I’ll pay equivalent to $7. Really specialised medicine gets more expensive, but for things like that it’s very cheap. It’s around 80 per cent covered by the government. The standard of living here is pretty good, people make pretty good money, so it’s very affordable for most people.

"If you have cancer, or need a major operation, however, there can be some significant out-of-pocket expenses. Some elderly people here are on very fixed incomes and that’s a problem. The safety net here in South Korea isn’t great, there’s not a lot of great welfare and social security and the government pension is only about $300 a month.

"Generally, you don’t hear a lot of complaints about the healthcare system. The only thing that ex-pats complain about is sometimes the manner of healthcare isn’t the same. In the hospitals, nurses don’t do personal care like bathing and changing your clothes – you have to bring your own caretaker. Family members usually do it, but if you don’t have that, you have to pay an agency.

"The one thing about South Korea is the saturation of healthcare: there are hospitals and clinics everywhere, it’s crazy.”

NORWAY

Spends 10.52 per cent of GDP on health

Life expectancy: 82.6 years – 84.1 for women and 81.1 for men.

While healthcare is run by the Norwegian state, users have to pay fees for the first 2460 Norwegian Krona (£205) they spend on public healthcare in a year. Once they reach that limit, they receive an exemption card (called a frikort for helsetjenester in Norwegian) and they no longer have to pay user fees for the remainder of the calendar year.

Children under 16, women with young babies and older people do not have to pay the excess, while there is also help on offer for people on low incomes. Dental treatment is not included and is paid for separately.

Airport security worker Christian Halle, a graduate of St Andrews University, now lives in his native Norway with wife Cathrine and three-year-old daughter Henriette. He says: “There’s a system where you're bound to one GP, so I always see the same doctor and I am very happy with that. He knows me, I know him. It is quite cheap, the system is semi privatised. You pay around £30 to see a GP, which is reasonable with Norwegian salaries. But you have to pay a maximum of about £200 a year for healthcare and if you go over that, the state pays the rest of your bills.

"My wife is a teacher and when she first started working in a primary school, she got ill a lot and went to her doctor multiple times that year. But once she had reached the £200 limit, she had a card saying that and she wasn’t charged any more. The same goes if you need care in a hospital emergency room, or an operation.

"Waiting lists are usually short if it is something urgent, like an operation you need immediately, or cancer treatment. They can be longer for ordinary, boring things, like if you messed up your knee playing too much football.”

Halle adds: "The care in the state system is very good, but some employers offer private medical insurance as well, which is usually used for things like this – the non-urgent operations that you might wait for. They pay it so their employee can get back to work quicker.”

TAIWAN

Spends 14.5 per cent of GDP on healthcare.

Life expectancy: 81 years – 84.4 for women and 77.8 for men.

*Not included in WHO ranking, this figure taken from 2022 United Nations World Population Prospects.

Enrolment in the national healthcare system is mandatory in Taiwan. While the healthcare system is national, doctors and hospitals still operate privately. Residents of Taiwan may choose which medical centres or hospitals they visit, but have to present their national healthcare cards when they receive treatment.

After treating patients, hospitals and doctors claim payment from the state. Depending on their income, patients can also be charged a co-payment towards the cost of treatment. However, the co-payments are capped, even for those on higher incomes.

Rob Williamson, a teacher, lives in Taiwan with his wife, Xenia Wu and son Charlie, three. "What you pay depends on how much you earn,” he said.

"I pay around £35 a month, then each doctor's appointment will be about a fiver. You see a doctor pretty much anytime you want. I live in a city and within walking distance, there are probably at least 20, if not more, doctors and specialists as well. You have doctors for children; eyes or ear; nose and throat or skin – all within my local area. You can pretty much walk in and get an appointment. They open six days a week and are usually open early morning and then have a break in the afternoon and reopen in the evening. So they match the times when people aren't working.

"My son has allergies and if he doesn't have medicine, he sneezes continuously and coughs. Going to a chemist is actually quite expensive, and if you see a doctor, it makes everything much cheaper. So we go to a children's doctor every week and get the same prescription – he's basically like family now.”