A first-of-its-kind ranking of 31 national health care systems on quality, choice, science & technology, and fiscal sustainability.

In the United States, the debate over health care reform revolves primarily around universality: how to ensure that every American has access to affordable health insurance and health care.

In nearly every other wealthy nation, however, universality has already been achieved. In these other countries, policymakers struggle to keep health care costs from overwhelming their budgets: a struggle made harder in countries with low economic growth.


Five countries with universal private health insurance—Switzerland, the Netherlands, Germany, Ireland, & Israel—top the 2021 rankings.

Photo by Ronnie Schmutz on Unsplash

By Gregg Girvan and Avik Roy

It turns out that legendary Swiss efficiency isn’t just for watches and train schedules—it’s also for health care. In 2021, as in 2020, Switzerland stood atop the FREOPP World Index of Healthcare Innovation, ranking highly in all four dimensions of Quality, Choice, Science & Technology, and Fiscal Sustainability.


The UAE’s two largest emirates have achieved universal coverage. Will the others follow?

Photo: Fredrik Ohlander / Unsplash

The United Arab Emirates ranks 20th in the World Index of Healthcare Innovation, with an overall score of 45.23. UAE scored highest on Fiscal Sustainability (#8, 65.79), owing to its low debt-to-GDP ratio of 19.7%, and its low public spending growth.

UAE’s heterogeneous system performed poorly in Choice (#28, 45.86) and only moderately well in Quality (#24, 46.72) and Science & Technology (#22, 22.53), despite considerable efforts by the Emiratis to attract foreign medical investment.

Overall, the UAE is a study in contrasts. In the wealthy, cosmopolitan emirates of Dubai and Abu Dhabi, UAE health care performs very well, but…


Switzerland’s universal system of individually-purchased health insurance is a model for U.S. reform.

Photo by Aaron Andrew Ang on Unsplash

By Gregg Girvan and Avik Roy

For the second straight year, the Swiss health care system ranks first overall out of 31 countries ranked in the World Index of Healthcare Innovation, with a score of 65.15, ahead of second-ranked Netherlands and third-ranked Germany.

Switzerland was at or near the top in every WIHI dimension, but especially in Quality (#1, 65.39), thanks to a high degree of patient-centered care and high-quality infrastructure. Switzerland ranked third for Choice (68.25), because it allows for freedom of choice both of providers and payers, under a universal private system. Switzerland ranked a distant but respectable…


Slovakia suffers from limited health insurance choices and poor health outcomes.

Photo: Martin Katler / Unsplash

By Gregg Girvan and Avik Roy

Slovakia ranks 29th in the World Index of Healthcare Innovation, with an overall score of 37.70. Slovakia performed strongest in Fiscal Sustainability (#14, 59.06), owing to its relatively low cost of care.

On the other hand, Slovakia performed poorly in Science & Technology (#30, 14.32) and Quality (#30, 28.75) due to its poor standing in medical infrastructure, lack of patient-centered care, and poor health outcomes.

Prior to World War I, Slovakia was part of the Austro-Hungarian Empire, which in 1887 instituted a health care system similar to the one installed by Otto von…


Portugal’s partly private system boasts excellent quality, but struggles to find a sustainable fiscal footing.

Photo: Tania Mousinho / Unsplash

By Gregg Girvan, Mark Dornauer, and Avik Roy

Portugal ranks 17th in the 2021 World Index of Healthcare Innovation, up from 21st in 2020, with an overall score of 46.92. The Iberian nation is a top-tier performer in Quality (#3, 63.15), garnering high marks for patient-centered care and health outcomes.

Portugal’s ranking was hampered by poor scores for Science & Technology (#28, 15.80) and Fiscal Sustainability (#20, 49.93). Portugal is not a major engine of scientific discovery, and its debt-to-GDP ratio of 128% is the third-highest among WIHI countries, only behind Japan and Greece.

The modern Portugal health care…


America’s runaway leadership in science & technology is marred by a fiscally unsustainable system of costly health care.

Photo: Moderna Inc.

By Gregg Girvan and Avik Roy

The United States ranks 6th in the 2021 World Index of Healthcare Innovation, with an overall score of 54.83, down from 4th in 2020. Thanks to its renowned research universities and robust biotechnology industry, the U.S. dominated the Science & Technology category (74.12). This innovation engine was on full display during the COVID-19 pandemic, as the U.S. government partnered with private companies to deliver coronavirus vaccines far faster than anyone had ever done before.

On the other hand, the U.S. ranked third-to-last in Fiscal Sustainability (#29, 34.35), because it is the country with the…


The law authorizes “the circulation of a digital currency whose value answers exclusively to free-market criteria.”

On June 8, the legislative assembly of El Salvador enacted its “Bitcoin Law,” making the country the first to adopt bitcoin as a legal currency usable for all payments within the country. (For background on the policy, please read my June 7 article in Forbes.) The full text of the law, in English, appears below, with slightly different formatting for clarity. The Spanish version can be found here.

  1. That in accordance with Article 102 of the Constitution of the Republic, the State is under the obligation to promote and protect private enterprise, generating the necessary conditions to increase national…


Unprecedented tax increases in the New York Health Act would impose job losses, wage reductions, and higher costs on low-income workers.

Photo: Rob Martinez / Unsplash

In New York state, efforts to abolish private health insurance and enact a single payer, government-run health care system have steadily advanced. In November 2020, Democrats gained a two-thirds, veto-proof majority in both chambers of the New York state legislature, raising hopes that a single payer bill called the New York Health Act is close to passage.

In 2017, we analyzed an earlier version of the New York Health Act, concluding that it “would require approximately $226 billion in new tax revenue per year, nearly quadrupling the state’s tax burden and leading, at minimum, to the loss of 175,000 jobs…


In an analysis of 31 high-income nations, Asian countries have performed the best.

Photo: Rumman Amin / Unsplash

The COVID-19 pandemic has been a challenge for the entire world. But, clearly, some countries are performing better than others. What can we learn from those that have done well — and also from those who have done poorly?

These questions animated the pandemic response measure in the FREOPP World Index of Healthcare Innovation, a comprehensive look at health care systems in 31 high-income countries.

Avik Roy

President, The Foundation for Research on Equal Opportunity (@FREOPP). Policy Editor @Forbes. Sr. Advisor @BPC_Bipartisan. Pronounced “OH-vick” (thanks mom).

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