Health Care Systems Around the World: A Comparative Guide

The country rankings provide a list of the top 10 and bottom 10 countries in rank order on different measures related to health and health care systems. The purpose is to give the reader opportunities to compare how different countries, which are similar in some factors, provide health care to their citizens, with the proviso that many factors may influence both a country's health care system and the health of its population. Unless otherwise noted, all information is from the CIA World Factbook (2012 edition).

2635–2155 b.c.e.: During the Old Kingdom in Egypt, texts contain the names of at least 50 physicians.

ca. 1700 b.c.e.: The Code of Hammurabi includes sections on the liability of physicians for failed surgical procedures and also on physicians' compensation; in both cases, the amount of the penalty or payment is based on the status of the patient, not the difficulty of the medical procedure

ca. 1600 b.c.e.: Tablets believed to be a collection of Mesopotamian medical knowledge over several centuries include guides for diagnosing diseases and conditions including fevers, worms, venereal disease, neurological conditions, and skin lesions

ca. 1500 b.c.e.: An ancient Egyptian text, the Ebers Papyrus, describes illnesses resembling schizophrenia, dementia, and depression

ca. 1400 b.c.e.: An ancient Indian text, the Atharva Veda, describes mental illness as being caused by an imbalance of humors

ca. 1000 b.c.e.: In China, the Yellow Emperor's Classic of Internal Medicine describes epilepsy and dementia.

5th century b.c.e.: The Greek philosopher Empedocles, writing in his treatise On Nature, says that the human body is created out of the elements of earth, ether, fire, and water and that health was created by the appropriate mixture of wet and dry and hot and cold

460–377 b.c.e.: The Greek physician Hippocrates, sometimes termed the father of medicine, attributes human illness to natural factors, including environmental conditions, rather than divine intervention; the Hippocratic Oath is still used today

ca. 312 b.c.e.: The Romans construct an aqueduct to supply potable water from distant streams and springs to the city of Rome

ca. 1st century c.e.: Several Roman writers mention valetudinaria, rooms in imperial households reserved for the care of ill or exhausted slaves; archeological excavations later confirm these reports and also the existence of valetudinaria within military facilities

ca. 1st century: The Greek physician Dioscorides writes an encyclopedia of medicinal substances, De Material Medica.

ca. 200: The Roman physician Galen writes works that form the foundation of Western medicine for the next millennium

314: The Church of the Synod of Ankyra creates a religious ritual to sanctify the separation of lepers from the rest of society

[Page xxii]499: Eusebius, bishop of Edessa (a city in Anatolia), orders that the city's poor be provided with food, shelter, and nursing care.

6th century: A leper house is established in Franconia in southern Gaul to house and care for lepers.

ca. 530: The Rule of St. Benedict includes the specification that monks should care for the ill and disabled among them; this principle is later extended to providing medical care for laypersons.

603: Pope Gregory I founds a hospice in Jerusalem to care for ill pilgrims.

ca. 707: An Islamic hospital is founded in Damascus, Syria.

830: Plans for a monastery for the monks of St. Gall include an infirmary with separate rooms for monks requiring different levels of care and a guesthouse for lay visitors.

874: A bimaristan (hospital) is founded in Cairo, Egypt.

918: A bimaristan (hospital) is founded in western Baghdad; a second bimaristan is founded in eastern Baghdad in 981.

ca. 980–1027: During his lifetime, the Iranian physician Abu Ali Sina (Avicenna) writes numerous books, including the Canon of Medicine and The Book of Healing.

ca. 1080: Founding of a hospice, staffed by Benedictine monks, in Jerusalem; it is dedicated to St. John the Baptist.

ca. 1100: The Knights of St. Lazarus establish a hospice to care for lepers in Jerusalem; similar houses subsequently established throughout Europe are referred to as “lazarrettos” or Houses of St. Lazarus.

ca. 1136: Founding of the Pantocrator monastery in Constantinople, including five separate wards or dormitories for persons with different levels of disease.

1179: The Third Lateran Council reinforces the segregation of lepers, banning them from attending parish churches and from burial in parish cemeteries 1247: The Order of the Star of Bethlehem builds a priory in London; it begins to admit mentally ill patients in the 1350s, making it the oldest psychiatric hospital in Europe; it is colloquially known as “Bedlam.”

1257: Founding of the “Bürgerspital,” the oldest hospital in Vienna, Austria.

1300s: In some European countries, craft guilds create mutual assistance associations, an early form of social insurance.

1311: At the Council of Ravenna, one topic of discussion is the increasing corruption of monastic hospitals; Pope Clement V later prohibits clerics from profiting personally from the operation of these hospitals.

1348: In response to the plague pandemic sweeping Europe, Jehan Jacme publishes a tractate exhorting European city leaders to assume responsibility for safeguarding the population against disease outbreaks.

1348–1350: The Black Death (bubonic plague) sweeps Europe, killing an estimated quarter of the population.

1496: Pox houses are established in several German cities to care for people suffering from morbus gallicus, probably a form of syphilis.

1505: The city of Paris, France, assumes control of the Hotel Dieu, a hospital with more than 1,000 beds.

1518: In Great Britain, King Henry VIII orders the founding of the Royal College of Physicians.

1530: Emperor Charles V cedes Malta to the order of the Knights Hospitallers, an order founded to provide care for pilgrims to Jerusalem.

1592: In response to a plague outbreak, public officials in London begin publishing the Bills of Mortality, listing the cause of death for deaths within the city.

1637: Construction begins on the first hospital in Canada, the Hotel-Dieu de Quebec; it begins operation in 1639, staffed by members of the Augustines de la Misericorde de Jesus from France and, in 1644, is moved to its current site on the Rue du Palais.

[Page xxiii]1644: The Hotel-Dieu de Montreal in Canada is founded by Jeanne Mance; the building is completed in 1645 and is run by Mance until it is taken over in 1659 by the Hospitallers of St. Joseph.

1647: The Massachusetts Bay Colony establishes a quarantine for ships arriving in Boston harbor.

1656: In an effort to control the plague, Roman officials quarantine Trastavere, a community on the Tiber floodplain in Rome, Italy.

1659: The first known typhus outbreak in Canada.

1720: Westminster Infirmary, the first voluntary hospital in England, opens.

1736: Creation of the New York City Almshouse including a six-bed hospital ward; this facility will later become Bellevue Hospital.

1747: James Lind demonstrates that consumption of citrus fruits is the best remedy for scurvy in small-sample clinical trials with British seamen comparing oranges and lemons with other substances, including seawater, garlic, and horseradish.

1776: In order to encourage enlistment in the army, the U.S. Continental Congress provides pensions for disabled soldiers.

1780s: Institutional mortality of more than 21 percent is reported for the Hospice de Charité and almost 25 percent for the Hotel Dieu, both in Paris, France.

1784: Opening of the Allgemeines Krankenhaus (General Hospital) in Vienna, Austria.

1792: In France, Philippe Pinel leads a reform effort for more humane treatment of people in mental hospitals.

1796: Edward Jenner successfully vaccinates a child against smallpox using the cowpox virus.

1811: The United States creates the first federal medical facility for disabled veterans.

1821: Massachusetts General Hospital opens in Boston; from the start, founders emphasize the hospital's multiple roles of educating physicians, conducting research, and caring for the sick.

1831: Canada creates a sanitation committee and strengthens quarantine laws in response to the threat of cholera being spread by immigrants from Europe.

1832: La Grosse Ile, an island in the St. Lawrence River near Quebec City in Canada, becomes a quarantine station during a cholera epidemic; immigrants are examined at the island before being permitted to enter the mainland, but despite these efforts, the disease spreads to Montreal and Quebec City.

1839: A group of physicians in Toronto, Canada, many of whom had been educated in Great Britain, are incorporated as the College of Physicians and Surgeons of Upper Canada.

1840s: Working at the General Hospital of Vienna, Austria, Ignaz Semmelweis successfully reduces deaths from puerperal fever by requiring physicians to disinfect their hands between performing autopsies and delivering babies.

1842: In England, Edwin Chadwick publishes the Report… on Inquiry Into the Sanitary Condition of the Laboring Population of Great Britain, calling for city engineers to create more healthful conditions in order to control disease.

1846: Physicians successfully use ether to render patients unconscious during surgery.

1847: A typhus epidemic in Ireland spreads to Canada as many Irish emigrate due to the so-called potato famine; despite efforts to examine immigrants at La Grosse Ile quarantine station, the disease spreads to Montreal and Quebec City.

1851: The first International Sanitary Conference meets in Paris, France, to harmonize quarantine requirements among European countries.

1854: During a cholera epidemic in London, England, John Snow traces the source of infection to a specific water pump in the city.

1860: Florence Nightingale founds a training school for nurses at St. Thomas' Hospital in London, England.

[Page xxiv]1861–1865: During the Civil War, American hospitals develop several innovative methods for treating patients, including the ward system (grouping beds for patients with similar ailments together in order to treat them more easily) and the development of specialty orthopedic care and the use of prosthetic limbs.

1863: Founding of the International Committee of the Red Cross in Geneva, Switzerland, prompted by Henry Dunant's desire to aid those wounded in war without reference to which side they fought on.

1863: During the American Civil War, the U. S. federal government creates the Invalid Corps to employ disabled veterans in war-related tasks; the name is change in 1864 to the Veteran Reserve Corps.

1865: London, England, completes its sewage system.

1866: In the United States, New York City creates the Metropolitan Board of Health, which later becomes the New York City Health Department.

1867: Founding of the Canadian Medical Association.

1867: Joseph Lister publishes a series of articles arguing for the use of carbolic acid to prevent infection during surgery.

1867: In Great Britain, passage of the Metropolitan Poor Act requires workhouses (institutions housing the poor) to maintain hospitals separately from the main workhouse site.

1867: In Canada, jurisdiction over public health is divided by the Constitution Act into federal and provincial responsibilities, the former being responsible for border quarantine and the latter for creating and running hospitals.

1869: Massachusetts creates the first state public health department in the United States.

1872: Dr Stephen Smith, commissioner of the Metropolitan Health Board of New York City, founds the American Public Health Association.

1873: In the United States, the federal government creates the Marine Health Service, the forerunner of the U.S. Public Health Service.

1874: The first nursing school in Canada is established at the General and Marine Hospital in St. Catharines, Ontario.

1881: A nursing school based on the principles established by Florence Nightingale is founded at the Toronto General Hospital in Canada.

1881: Founding of the U. S. American Red Cross by Clara Barton; the same year, the first local chapter is founded in Dansville, New York, and the American Red Cross delivers its first disaster relief services to victims of forest fires in Michigan.

1882: Ontario, Canada, establishes a provincial board of health.

1883: Germany enacts a mandatory national health insurance program.

1883: Sir Francis Galton coins the term eugenics.

1885: A major smallpox epidemic in Montreal leads to riots, as some believe the disease was spread by vaccination, a practice not yet universal in Canada.

1887: The U.S. Marine Hospital creates one of the world's first bacteriological laboratories.

1890: A nursing school based on the principles established by Florence Nightingale is founded at the Montreal General Hospital in Canada.

1893: Lillian Wald creates the profession of public health nursing by founding the Henry Street Settlement in New York City in the United States.

1896: In Germany, Emil Kraepelin begins the modern process of classifying mental illness by distinguishing between mania and paranoia.

1906: The U.S. Congress passes the Pure Food and Drug Act, authorizing the government to monitor purity and safety of food and drugs.

1908: The United States creates a workmen's compensation system for federal employees.

1909: The U.S. insurance company Metropolitan Life hires Lee Frankel, an industrial social worker, to write [Page xxv]pamphlets promoting health education; the first, centering on tuberculosis prevention, is distributed to more than 10,000 individuals.

1910: About half of all U.S. physicians are members of the American Medical Association (AMA); the approximately 70,000 members of the AMA at this time comprise a substantial increase from the approximately 8,000 members in 1901.

1910: Abraham Flexner issues a report highly critical of the state of American medical education, which leads to the creation of higher standards and the closing of numerous medical schools.

1912: In the United States, the Progressive Party and its candidate Teddy Roosevelt endorse social and health insurance as part of its platform.

1913: Founding of the American College of Surgeons.

1916: In the United States, the Council on Medical Education recommends that medical schools require students to have completed one year of college; in 1918, this is increased to two years of college.

1917: As the United States enters World War I, the federal government establishes a new system of benefits for veterans, including insurance, vocational rehabilitation, and disability compensation.

1918: In the United States, the federal government makes its first state grants for public health services.

1918: A report by the American College of Surgeons states that only 13 percent of U. S. hospitals meet its standards; by 1932, more than 90 percent meet them.

1919: Canada creates a federal department of health to set standards for food and medicines, enforce quarantines, and cooperate with voluntary organizations and the provinces; the department was created in part in response to the influenza pandemic of 1918.

1919: The International Federation of Red Cross and Red Crescent Societies is founded in Paris, France (as the League of Red Cross Societies).

1919: In the United States, a commission from the state of Illinois reports that, for most people, the primary cost of illness is not medical treatment but lost wages.

1919: The University of British Columbia creates Canada's first university degree program for nurses.

1926: Joseph Goldberger demonstrates that pellagra, a disease endemic in the American South, is caused by a deficiency of niacin, after previously establishing that consumption of a diet based primarily on corn (typical of the poor in the South) was associated with pellagra.

1928: In London, Sir Andrew Fleming discovers penicillin and observes that it destroys colonies of bacteria; however, regular use of the drug does not begin until the 1940s.

1929: Baylor University develops a health insurance plan for hospital care for a group of Dallas, Texas, teachers; this plan is a precursor of the Blue Cross system.

1929: Atlantic City, New Jersey, hosts the first International Hospital Congress; observers note that American hospitals provide more clinical education and are used by a broader range of social classes than those in Europe.

1930: In the United States, Congress creates the Veterans Administration to consolidate services provided to military veterans.

1930: In the United States, 70 percent of graduates from medical schools also hold bachelor's degrees; by 1945, this is increased to 80 percent.

1932: The U.S. Public Health Service begins the Tuskegee Study, observing the course of syphilis in African Americans while not informing them of their disease nor providing medical treatment; the study ends in 1972, long after penicillin had become available, and prompts creation of the National Research Act in 1974.

1933: The American Hospital Association approves private hospital insurance.

1933: In the United States, the hospital bed occupancy rate falls to 55 percent as fewer people can pay for care due to the Great Depression.

1935: In the United States, passage of the Social Security Act creates a system of old-age and survivors' pensions funded by contributions from employees and employers, but it does not include health insurance.

1938: The U. S. Technical Committee on Medical Care publishes its report, A National Health Program.

1938: In Italy, the physician Ugo Cerletti begins using electroshock therapy to treat depression.

1941: The American Red Cross begins collecting blood for the military under the National Blood Donor Services, directed by Dr Charles Drew.

1941: The Netherlands adopts a mandatory national social health insurance system.

1941–1945: Wage and price controls on American employers during World War II prompt many to offer health benefits as additional compensation.

1943: In the United States, clinical trials begin for penicillin; once proven effective, production is scaled up in the next few years to supply the military, and the price drops substantially ($0.55 in 1946 for one dose versus $20.00 for one dose in 1943).

1944: U.S. President Franklin Roosevelt mentions the right to medical care in his State of the Union address.

1945: U.S. President Harry Truman proposes creation of a national universal health insurance program; it is opposed by the American Medical Association and denounced by a subcommittee of the House of Representatives as a communist plot.

1945: The United Nations (UN) creates the United Nations Children's Fund (UNICEF) to provide food, clothing, and health care to impoverished children.

1945: During meetings to establish the UN, representatives from Brazil and China propose creation of an international health organization, first called the Interim Commission; in 1948, it becomes the World Health Organization (WHO).

1946: In the United States, creation of the Communicable Disease Center (CDC), later the Centers for Disease Control and Prevention 1947: Writing in the British Medical Journal, Austin Bradford Hill argues that medical practices should be evaluated using statistical methods.

1948: The first modern clinical trial is conducted in the United Kingdom; it demonstrates that streptomycin is an effective therapy for tuberculosis.

1948: The American Red Cross opens a blood collection center in Rochester, New York. It is the first such center created in the United States under the civilian National Blood Program.

1948: Great Britain founds the National Health Service (NHS).

1949: In the United States, the National Labor Relations Board rules that unions are permitted to negotiate benefit packages for their members, including health insurance and pension plans.

1950: Dr Jonas Salk introduces the Salk vaccine for polio.

1952: In the United Kingdom, the NHS begins charging one shilling for prescriptions.

1954: In Boston, Massachusetts, physicians Joseph Murray and John Merrill carry out the first successful living donor transplant with a kidney obtained from the patient's identical twin.

1957: Canada passes the Hospital Insurance and Diagnostic Act of 1957, giving the Canadian government authority to create a universal coverage plan for hospital, laboratory, and radiology services; this is the first part of the current Canadian national health insurance plan.

1958: In the United States, almost three-quarters of citizens have private health insurance.

1958: In the United Kingdom, the NHS launches a program to immunize everyone aged 14 and younger against polio and diphtheria.

1960s: Development of antipsychotic drugs allows many psychiatric patients to be released from asylums and treated in community mental health facilities instead.

1961: In Canada, the Royal Commission on Health Services is created to study the Canadian health care system; its 1964 report becomes the cornerstone of the contemporary health system in Canada.

1962: In the United States, the Migrant Health Act funds medical clinics for migrant workers.

1964: The U. S. Surgeon General's report on smoking and health lends weight to efforts to control the advertising and sale of tobacco products.

1965: In the United States, the Medicare and Medicaid programs are created as part of the Social Security Act of 1965; Medicare provides federal funding for health insurance for persons age 65 and older, the disabled, and those with end-stage renal disease, while Medicaid is a joint federal-state program providing funding for insurance for the poor.

1965: In the United Kingdom, the NHS drops charges for prescriptions; the charges are reinstated in 1968.

1965: In the United States, only 37 percent of U. S. physicians are general practitioners versus 84 percent in 1940.

1966: Henry Beecher publishes a research article in the New England Journal of Medicine identifying 22 biomedical studies he believed were unethical due to issues such as lack of consent and harm caused to the subject of the research.

1966: In the United States, the first collection of the Household Component of the Medical Expenditure Panel Study (MEPS) occurs; data collected includes health status, conditions, and utilization; health care expenditures; and health insurance coverage.

1966: Canada passes the Medical Care Act of 1966, extending health insurance to cover physician services; this is the second part of the current Canadian national health insurance plan.

1971: Founding of Doctors Without Borders (Médi-cins sans Frontières) in France to respond to flooding in Bangladesh and war and famine in Biafra (Nigeria).

1971: In the United States, tobacco advertising is banned on television 1973: In the United States, the federal Health Maintenance Organization Act spurs the development of health maintenance organizations (HMOs) across the country.

1974: In response to the Tuskegee Study, which became public knowledge in 1974, the U.S. Congress passes the National Research Act, requiring creation of Institutional Review Boards (IRBs) to ensure ethical conduct of research.

1974: In the United States, the federal government establishes the Women, Infants, and Children (WIC) program to provide nutritious food to low-income women, infants, and children.

1975: Doctors Without Borders establishes its first large-scale program to aid Cambodians fleeing the Pol Pot regime.

1979: The National Commission for the Protection of Research Subjects of Biomedical and Behavioral Research (United States) publishes the Belmont Report, identifying three basic principles necessary for the ethical conduct of research: respect for persons, beneficence, and justice.

1979: Announcement of the successful eradication of smallpox, a fact confirmed by WHO in 1980.

1980: In the United Kingdom, the Black Report finds that social class remains related to health outcomes, such as life expectancy and infant mortality, despite the efforts of the National Health Services (NHS).

1981: The Morbidity and Mortality Weekly Report, published by the U.S. Centers for Disease Control and Prevention, reports five cases of a rare type of pneumonia; these patients are among the first identified cases of acquired immune deficiency syndrome (AIDS).

1983: San Francisco General Hospital establishes a ward for AIDS patients dedicated to research on the disease as well as patient care

1984: In the United States, the Centers for Disease Control and Prevention begins collecting data in 15 states with the Behavioral Risk Factor Surveillance System, a survey designed to collect information on health behaviors such as smoking, exercise, and eating habits; [Page xxviii]by 1995, all 50 states plus Puerto Rico, Guam, and the U. S. Virgin Islands take part in the annual survey.

1984: In Canada, physicians are prohibited from charging fees greater than those specified in provincial benefit schedules.

1986: In the United States, the Emergency Medical Treatment and Active Labor Act (EMTALA) requires hospitals to treat patients with medical emergencies without regard to their insurance status or ability to pay

1986: Ian Chalmers and colleagues at Oxford University in the United Kingdom publish the first medical systematic review of perinatal interventions

1987: Fluoxetine (Prozac) offers better, safer treatment for depression and other mental illnesses, including panic disorder and anxiety disorders; it is the first of many selective serotonin reuptake inhibitor (SSRI) drugs introduced to the pharmaceutical marketplace

1988: Doctors Without Borders establishes its first mental health program to serve survivors of an earthquake in Armenia

1988: The NHS in the United Kingdom introduces a national program of screening for breast cancer

1990: In the United States, tobacco smoking is banned on all domestic airplane flights.

1993: Founding of the Cochrane Review, a leading source of information about clinical effectiveness and controlled trials of medical interventions

1993: In the United States, the Family and Medical Leave Act mandates large employers to allow 12 weeks of unpaid leave for employees for reasons such as the birth of a child, a serious health condition, or the need to care for an ill family member; the law covers approximately 40 to 50 percent of the population

1996: In the United States, the first collection of the Insurance Component of the Medical Expenditure Panel Survey (MEPS) occurs It gathers information from households and employers about employer-based health insurance

1999: Doctors Without Borders launches a campaign to increase access to essential medicines by the world's poor

2000: Doctors Without Borders begins providing antiretroviral therapy to persons with human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS) in Thailand; the following year, the program is extended to Cambodia, Guatemala, Cameroon, Kenya, Malawi, and South Africa

2001: WHO launches the Measles Initiative in partnership with UNICEF, the Centers for Disease Control and Prevention, the United Nations Foundation, and the American Red Cross

2001: In the United Kingdom, tobacco advertising on billboards is banned, and tobacco companies are banned from sponsoring most sporting activities by 2003.

2004: WHO adopts a Global Strategy on Diet, Physical Activity, and Health

2005: The European Commission creates the Executive Agency for Public Health Programs to improve community health programs in the European Union through means such as supporting scientific research and collaboration, implementing public health programs, and awarding grants and contracts

2006: Doctors Without Borders creates a surgical program in Jordan to care for victims of the Iraq War as physicians are unable to operate safely in Iraq.

2008: In the United Kingdom, patients are allowed to seek treatment in any clinic or hospital that meets NHS standards.

2010: In the United States, the Affordable Care Act becomes law; 2010 changes include tax credits for small businesses and nonprofit organizations, creation of a program to provide insurance to individuals with preexisting conditions, allowing young adults to remain covered by a parent's health plan until they turn 26, prohibition of the practice of rescission (retroactively cancelling insurance coverage) in the absence of fraud, and broadening of Medicaid eligibility; various other phases become active from 2011 to 2014.

2011: In the United States, a Center for Medicare & Medicaid Innovation is created to develop methods to provide quality care at lower cost.

2012: The U. S. Supreme Court hears arguments on the constitutionality of the Affordable Care Act.

2012: In the United Kingdom, the British Social Attitudes Survey estimates that public satisfaction with the NHS fell from 70 percent in 2010 to 58 percent in 2011, the largest fall since the survey began in 1983.

2012: In the United States, the medical loss ratio (MLR) requires insurance companies to spend at least 80 percent (85 percent for large plans) of collected premiums on providing care or making quality improvements.

2013: In the United States, states are required to pay physicians for services delivered to Medicaid patients at rates at least as high as the rate for Medicare patients.

2014: In the United States, the final provisions of the Affordable Care Act are scheduled to take effect, including the creation of insurance exchanges to offer health insurance policies to people who do not receive coverage from their employers and requiring most people to purchase a basic health insurance policy or pay a penalty.