The fight at the frontlines of Covid-19 is being waged in clinics and hospitals around the world. But the success of that fight has, in large part, depended on the effectiveness of the healthcare systems in each country.

So far, there’s been a noticeable correlation between a country’s ability to contain the virus and previous rankings of its healthcare system to provide positive health outcomes.

For this report, we looked specifically at the 2019 The Legatum Prosperity Index, conducted by the eponymous London-based think tank, which measures economic and social prosperity policies and conditions based on 12 pillars in 167 nations.

The health pillar of the index specifically measures the extent to which people in each country are healthy and have access to the services necessary to maintain good health, including health outcomes, healthy systems, illnesses and risk factors, and mortality rates.

We talked to doctors and residents in some of the top-ranked countries within the health pillar to understand which aspects of the medical establishment have enabled them to manage the virus and its outcomes, what continued challenges lie ahead, and how locals are feeling about living there.

Japan

Ranked second in the index’s health pillar, Japan has been praised globally for its early successful management of Covid-19, though a recent infection spike has put the country back on alert, with the prime minister issuing a state of emergency across much of the country on 7 April. Despite that, the country has not yet enforced a lockdown, and this is in large part due to the ability of the country’s medical system to manage the virus in its early stages.

Even if residents can’t get a Covid-19 test (which are still restricted here to those with severe symptoms), they can visit a local clinic and be quickly diagnosed with a CT scan. “A patient with no symptoms can get diagnosed with pneumonia by CT scan even if the patient has a very early stage of pneumonia,” said Tokyo-based Dr Mika Washio, a doctor at AirDoctor, a service that connects travellers with doctors around the world.

“Then the patient can get treatment quickly. This is one of the reasons Japan doesn’t have many severe cases.” Japan is also still working on finding and managing the clusters of infections to minimise the spread.

The existing health-conscious culture of Japan has also minimised the impact of the Covid-19 crisis. “Many Japanese already wear a face mask, especially in winter and spring, and it is also one of the reasons that we don't have a big outbreak yet,” said Washio.

“Additionally, more than 60% of Japanese have an annual health check-up, and we try to keep [in] good health condition, so it is another cause of less severe cases.”

That doesn’t mean there might not be challenges ahead. Washio notes that many patients who are diagnosed should be at the hospital under normal circumstances, but the country is trying to save the beds for the most severe cases as the government prepares additional resources.

South Korea

Coming in at fourth place in Legatum’s health pillar, South Korea was particularly prepared to handle the Covid-19 outbreak after the experience of containing Middle-East respiratory syndrome (Mers) in 2015.

Healthcare providers and hospitals were already equipped and trained to act in such a crisis. The country has been able to test more than 450,000 people, just under 1% of its population of 51 million, and the daily new caseload has been hovering at just 47 to 53 infections in recent days.

The nature of Korea’s healthcare system also contributed to the early diagnosis and treatment of Covid-19 across its population, where every citizen is covered by the National Health Insurance Service (NHIS).

“Due to relatively low medical cost thanks to universal public insurance coverage coupled with government-driven price setting, in addition to a fee-for-service model, imaging and lab tests are widely performed in South Korea's healthcare system,” said Seoul-based Dr Brandon B Suh, also the CEO of Lunit, a company working to give AI tools to healthcare providers.

“With the Covid-19 outbreak, many [people] were diagnosed early and proper management was applied in a timely manner.”

The government and businesses have also moved quickly moved to implement effective health measures. “The government stabilised the supply of masks by implementing a new measure in the purchase of the mask, matching each day with the last digit of the birth year,” said Seoul office worker Yongbok Lee.

“Many [places] check body temperatures before entering buildings and large buildings even have thermal cameras installed. The Korea Centres for Disease Control and Prevention and other government agencies are working hard in the front line, and people are showing great appreciation towards the efforts they put in.”

Private insurance is also popular here as well, with 77% of citizens enrolled to cover costs that the NHIS does not cover, according to Insurance Business Asia magazine. This can be a bonus, by sometimes enabling access to a better quality of care and the use of cutting-edge technology, but Suh cautions that the system can sometimes encourage lucrative invasive procedures even when clinical evidence is lacking.

“There needs to be a transition to a more value-based healthcare model,” Suh said. Overall, the success of the early interventions here has brought more hope than despair.

“Objectively, the outbreak is definitely on the down-trend,” said Suh.

“People have started to resume outdoor activities, although everyone still puts on a mask at all times.”

As a resident of Daegu, one of the hardest hit areas, Won-Jeong Whang is starting to see things become stable.

“We go out for a quick walk around the neighbourhood, but we still try not to go to crowded or confined places. I believe that it is right, for the safety of the society and the individuals, to stay home with limited movement,” she said. Still, she looks forward to the day when she can go to the parks and amusement parks that her child loves.

“I'd love to go out with friends to chat and drink and enjoy our time together.”

Freshman student Woobaek Lee, based in in Chuncheon, Gangwon-do Province, also looks forward to the new normal. “I’m looking forward to offline classes,” he said. “The first thing I'd want to do when this is all over is to make friends in university.”

Israel

When it came to monitoring and reacting to the emergence of Covid-19 in Wuhan, few countries moved more swiftly than Israel, ranked 11th in the health index. By the end of January 2020, the Minister of Health had already signed the People's Health Ordinance Decree to expand the Ministry's powers to deal with the potential outbreak.

While the measures, which included avoidance of non-essential international travel and home isolation for 14 days for citizens who returned from “hot spots”, may have seemed strict early on, the action has paid off in an overall lower rate of infection and hospitalisations than other similarly sized countries.

Accurate testing was also established early on in Israel.

“A molecular diagnostic test (RT-PCR) to detect coronavirus in respiratory samples was developed very early by the Central Virology Laboratory, and was expanded to numerous laboratories across the country,” said Dr Khitam Muhsen, professor of epidemiology and preventive medicine at Tel Aviv University and one of the consultants to the Ministry of Health in Israel regarding the Covid-19 crisis.

“Israel is among the leading countries in the number of coronavirus tests per million population.”

“I'm actually very proud of the number of tests that we are doing here and we are among the top testers, which is why our numbers are so high,” said Talia Klein Perez, who lives in Kfar Saba (north-east of Tel Aviv) and blogs at Hul With Kids.

“On the other hand, our mortality rate is one of the lowest and I believe that the fairly quick quarantine is part of it.” 

The publicly based healthcare system also allows for a more integrated and centrally controlled response.

“People are not afraid to reach out for medical help because they know they will be covered and it will be free of charge,” said Professor Arnon Afek, deputy director-general of Israel's Sheba Medical Centre, the first hospital in the country to treat coronavirus patients.

“The cost of the healthcare system is very important because, in a situation like this, you want people to seek out care when they have symptoms so we can find them and they won’t continue to spread the disease.”

One downside, according to Afek, is that not enough of Israel’s GDP is directed toward healthcare, which means fewer resources. “However, this means that we are very efficient, extremely active and quick to adapt,” said Afek.

“At Sheba, we are always thinking two steps ahead and trying to solve problems before they arise. We projected forward and built a dedicated coronavirus ICU and trained additional physicians to work there before the caseload rose significantly. When the patients came, we were prepared.”

The country also has unique challenges in its diverse population. The ultra-orthodox community, for example, does not consume traditional media and experienced a larger outbreak than the rest of the country.

“We had to learn to approach them in a different way,” said Afek. “Now that we have reached them, they are fully committed to stopping the spread.”

In light of the lockdown, Klein Perez is staying positive by mentally preparing for things to be on hold for a long time.

“I find that it's easier to expect a longer lockdown and be surprised, than expect it to be short and be depressed,” she said.

“I mostly look forward to some quiet and time alone, [and] coffee with friends. Flights and restaurants are still quite a way off; they are saying possibly September.”

Germany

With an overall lower Covid-19 mortality rate than many of its European neighbours, Germany – ranked 12th in health in the index – has been hailed as an international success story, but experts there caution that the country isn’t yet out of the woods.

“Vastly higher levels of testing in Germany can create an illusion around how well the country’s healthcare is coping, and also how low the mortality rate actually is in comparison to other countries,” said Francis de Véricourt, chaired professor of management science at the European School of Management and Technology in Berlin and keynote speaker at the International Congress on Infectious Diseases.

However, the wide testing capabilities of the country have led to success at separating sick and asymptomatic patients from the healthy population, helping contain the spread.

This low rate of infection could potentially backfire if the country is not careful. “With less people having Covid-19, it means less people are immune,” said de Véricourt.

“Therefore, relaxing our behaviour and relaxing social-distancing measures should only occur when the country has virtually wiped out Covid-19 cases, otherwise there could be another big wave.”

Residents are resigned to the fact that things won’t be back to normal in the near future but are trying to stay hopeful.

“The hardest thing for me is to keep my mum from leaving the house,” said Ingrid Gruhs, resident of Murnau am Staffelsee on the edge of the Bavarian Alps, “so, this is why I made a mask for her and went shopping with her today for the first time after three weeks; it was so important for her to do the shopping herself.”

“As the number of new infections is decreasing, I believe that is the right move now to think about how to ease the measures. I trust that the authorities will do their best to find a good balance between getting back to normal circumstances and maintaining rules and regulations to protect people.”

The country’s healthcare system is well-positioned when it comes to mounting an effective country-wide response. As a federal system (with power given to states) as opposed to a national programme like the UK or France, Germany has distribution built in.

“There are a lot more beds available, a lot more ICUs and more doctors,” said de Véricourt. “The management of these resources are further decentralised, and hence falls to the responsibility of the local government. This means that all political parties, from the left to the right, have a responsibility. This facilitates cooperation, key to contain a pandemic and care for the patients.”

“I feel very privileged to live in Germany and I was very glad when the Bavarian government set the lockdown, a necessary and good reaction in a very difficult situation,” said Laura Gruhs, a student at the Technische Universität München.

“I had originally planned to go to Buenos Aires for a semester abroad beginning in July. This won't happen probably, which makes me really disappointed. I know that I'm still very lucky, so I try not to complain about the restrictions I have to make in my personal life. It's a good opportunity to relax and take time for things I normally don't do.”

The real test will be the medical system’s management of supply chain concerns, which spawn well beyond the medical considerations like hospital staff, ventilators and PPE. “It’s not only the number of beds, but everything down to the number of supplies available to staff and patients,” said de Véricourt.

“As one example, the increase in hand sanitiser purchasing made it virtually out of stock in many European countries. However, there was still hand gel available, just no plastic bottles to put them. This highlights the impact of items you wouldn’t even expect on the healthcare supply chain.”

Australia

Coming in at 18th in the health pillar in the index, Australia has currently managed to keep the growth rate of cases to less than 5% – “well beyond our expectations” and projected case models, according to the Prime Minister in an address to the country on 7 April.

Australia’s “blended” healthcare system, a mixture of universal coverage through Medicare and a much-used private system, has helped prepare the country for any worst-case scenarios.

“In the current pandemic, this two-tier system is particularly suitable to accommodate projected increase in demand for emergency services and ICU beds,” said Dr Alex Polyakov, clinical senior lecturer at the University of Melbourne.

“The federal and state governments directed all non-essential surgeries to be postponed. This allowed the private hospitals to be placed on standby for the anticipated influx of Covid-19 patients.”

That, in combination with the federal government agreeing to financially back private hospitals in exchange for using beds and staff, has essentially doubled the capacity of the public system.

Australia has also seen a low incidence of local transmission, and the government introduced rapid contact tracing and mandatory quarantine for those who travelled overseas or had contact with an infected individual.

“In the event that local transmission can be kept at bay, I would anticipate very low daily increase in numbers over a long period of time,” said Polyakov. “That is the very definition of a ‘flattened’ curve.”

“When the Covid-19 pandemic started to really kick off I was actually based in Sri Lanka. Things quickly escalated there, resulting on my having to bounce out of the country at 48 hours’ notice,” said Chris Stevens, who blogs at Stoked For Travel.

“I had two options, head back to Europe to my parents’ place or head to Australia at my brother’s house. After a quick chat with my Dad, a paramedic of 40 years, he advised me Australia was the better option.” Stevens had to self-isolate for 14 days upon entering the country as a precaution to stem the spread.

If current trends continue, it’s expected that the Australian healthcare system will be able to manage the expected increase in need for ventilators and ICU beds.

“The availability of extra capacity provided by the private system will allow for the majority of people who may require such interventions to receive them in a timely manner,” said Polyakov.

After the shutdowns are eased, residents are awaiting a return to the simple pleasures. “I look forward to a simple cup of coffee in the sunshine at my favourite cafe with my best friends having a laugh,” said Sydney-based Jennifer De Luca, who writes at Luxury Adventure Travel.

“Something that we used to do weekly and an activity that I completely took for granted.”