World Health Day is on April 7, and people around the globe are turning their attention to health issues. The global infant mortality rate of 33.6 deaths per 1,000 live births in 2013 has followed a long-term downward trend. Similarly, life expectancy has improved dramatically in recent decades. The improvements were uneven, however, and health conditions continue to vary widely between nations.
In order to assess the overall state of a country’s health, 24/7 Wall St. reviewed a host of factors broadly categorized as health indicators, access measures, or the economy. The healthiest country, Qatar, led the countries reviewed with the highest overall score, while the least healthy country, Sudan, received the lowest score. These are the most and least healthy countries worldwide. (Click here for our complete methodology)
Negative health outcomes were far less common in the healthiest countries than in the least healthy ones. Chief among them, life expectancy, tended to be far higher in the nations with the strongest overall health measures. Life expectancy at birth in all of the healthiest countries exceeded the global expectancy of approximately 70 years. A child born in Iceland is expected to live longer than 80 years, the highest life expectancy in the world.
According to Gaetan Lafortune, senior economist at the OECD Health Division, life expectancy is perhaps the best way to measure the health of a nation. However, a range of indicators is necessary to capture the complex picture of a national population’s health. Similarly, no single measure can explain a health outcome like life expectancy. Rather, only a wide range of behaviors, infrastructure characteristics, and economic factors can explain the strong or weak health outcomes in a nation.
For example, seven of the healthiest nations reported less than 10 incidents of tuberculosis per 100,000 people in 2013, a fraction of the global rate of 126 incidents of tuberculosis per 100,000 people. While lung diseases and other poor health outcomes were far less common in these nations, risk factors such as smoking were not necessarily less prevalent. The residents of the healthiest nations were actually more likely than most nations reviewed to report a smoking habit.
The quality of a nation’s infrastructure and health system are closely related to a low prevalence of disease. Doctors were far more available in the healthiest countries than in the least healthy ones, for example. The prevalence of physicians in seven of the healthiest countries was at least double the global ratio of 1.52 physicians per 1,000 people. In all of the least healthy countries, on the other hand, there was less than one doctor per 1,000 people.
The quality of infrastructure is also very important for the health of a country’s residents. “Access to clean water in particular is absolutely crucial to avoid all sorts of diseases that lead to death for children and adults,” Lafortune said. In all of the healthiest countries, drinking water is treated before it reaches residents’ homes In half of the least healthy countries, less than half of the drinking water consumed in rural areas was treated.
Health care spending and the availability of resources are also major determining factors of nationwide health. As Lafortune noted, “It is not too good for your health to be poor.” Poor people — in any country — will be in worse health and live shorter lives than rich people.
All of the healthiest nations spent more than $2,000 per capita on health annually, versus the global expenditure of just over $1,000 per capita. With only one exception — Equatorial Guinea — the least healthy nations spent far less than the global figure. In fact, health care expenditures in seven of the least healthy countries was less than $100 per capita.
Of course, high spending does not guarantee strong health outcomes. Annual health spending in the United States totalled $8,895 per capita, more than the spending of all but two other countries reviewed. Yet, the health of U.S. residents was rated worse than 33 other nations.
As Lafortune explained, the return from health spending is far higher in countries already spending very little. For example, immunization rates — which were as low as 25% in the Central African Republic for measles — can be increased dramatically with little resources. “As spending goes up, what becomes more important is the efficiency of the spending,” Lafortune said.
In many of the least healthy countries, living conditions are so poor that “unhealthy” may actually be an understatement. Recent regional violent conflicts may account for a country’s exceptionally low life expectancy much more than other unhealthy behaviors, for example. Four of the least healthy countries — Mozambique, Guinea-Bissau, Yemen, and Sudan — have all been through at least one civil war since 1990. Haiti, while not exactly war torn, is still recovering from a devastating earthquake in 2010 as well as a cholera epidemic that emerged in the aftermath of the natural disaster.
These are the most (and least) healthy countries in the world.
The Healthiest Countries
> Life expectancy: 79.9 (5th highest)
> Infant mortality rate (per 1,000 live births): 3.4 (21st lowest)
> Health expenditure per capita: $6,140 (6th highest)
> Unemployment rate: 5.7% (58th lowest)
Based on an assessment of healthy behaviors and outcomes, access to health services, and various economic factors, Australia is the 10th healthiest country in the world. The country’s strong national health care system compared to most countries largely explains its ranking. There were about 3.3 physicians per 1,000 Australians in 2011, the 26th highest such ratio out of the 174 nations reviewed, and well more than twice the global prevalence of just over 1.5 physicians per 1,000 people. In addition, annual health spending totalled $6,140 per capita, sixth highest of all countries reviewed and nearly six times the global expenditure of $1,030 per capita. Partly as a result, country residents had among the world’s longest life expectancies at nearly 80 years in 2012. However, Australia also had a relatively high obesity rate, at 28.6%, and a relatively high alcohol consumption rate.
> Life expectancy: 79.9 (5th highest)
> Infant mortality rate (per 1,000 live births): 2.4 (8th lowest)
> Health expenditure per capita: $5,319 (10th highest)
> Unemployment rate: 8.1% (62nd highest)
Like in most of the healthiest countries, Sweden has universal health coverage, with patient fees covering only a very small percentage of health costs. The country’s annual health expenditures totalled $5,319 per capita, the 10th highest spending worldwide. The high health care spending and strong coverage have resulted in good health outcomes compared to most countries. There were just two infant mortalities per 1,000 live births and four maternal deaths per 100,000 live births in Sweden, both nearly the lowest such rates worldwide. Swedes also live longer than most people, with a life expectancy at birth of roughly 80 years. Compared to other healthy countries, however, Sweden’s 2013 unemployment rate of 8.1% was relatively high.
> Life expectancy: 79.9 (5th highest)
> Infant mortality rate (per 1,000 live births): 2.2 (5th lowest)
> Health expenditure per capita: $2,426 (22nd highest)
> Unemployment rate: 2.8% (13th lowest)
The small island nation of Singapore has a remarkably strong economy. Less than 3% of Singapore’s workforce was unemployed in 2013, one of the lowest unemployment rates worldwide. Also, Singapore’s GDP per capita of $55,182 in 2013 was one of the higher economic outputs worldwide. In addition to a strong economy, Singapore fares especially well in health measures. The nation’s obesity rate of 6.2% was among the lower rates worldwide, and especially low compared to the healthiest countries. A child born in 2013 was also expected to live roughly 80 years, tied for the fifth highest life expectancy worldwide. While the city-state’s health care system is universal, like many other especially healthy countries, it is a unique system. Residents are subject to a forced savings rate, and funds for medical expenses are saved in a Medisave Account. Catastrophic health insurance enrollment is automatic for all residents as well, although people can opt out.
> Life expectancy: 78.4 (20th highest)
> Infant mortality rate (per 1,000 live births): 3.2 (15th lowest)
> Health expenditure per capita: $5,407 (9th highest)
> Unemployment rate: 4.9% (45th lowest)
Health care spending in Austria totalled about $5,400 per capita annually, ninth highest out of all countries reviewed. Like many other healthy countries, the relatively high level of health care expenditure helps increase the number of physicians and quality of health care. There were nearly five doctors per 1,000 Austrians in 2011, the fourth highest ratio globally. As in most of the healthiest nations, the Austrian government controls most functions of the country’s health care system. While Austria is one of the healthiest countries, nearly half of adult Austrians reported a smoking habit in 2011, one of the higher smoking rates worldwide.
> Life expectancy: 81.6 (the highest)
> Infant mortality rate (per 1,000 live births): 1.6 (tied-the lowest)
> Health expenditure per capita: $3,872 (16th highest)
> Unemployment rate: 5.6% (56th lowest)
Iceland, by population, is the smallest of the 10 healthiest countries. Iceland is the sixth healthiest country worldwide partly because it had the highest life expectancy, which at 81.6 years was also a full year longer than Switzerland, the country with the second highest life expectancy. About 18% of adult Iceland women smoked, the 88th highest rate of all countries, while 19% of all adult males smoked, 17th highest of all countries. Iceland also had the lowest infant mortality rate, at just 1.6 deaths per 1,000 live births. Iceland’s low infant mortality rate came even though a relatively low 91% of children aged 12 to 23 months received DPT — diphtheria, pertussis (whooping cough), and tetanus — and measles vaccines.
> Life expectancy: 79.9 (4th highest)
> Infant mortality rate (per 1,000 live births): 2.1 (3rd lowest)
> Health expenditure per capita: $4,752 (11th highest)
> Unemployment rate: 4.0% (32nd lowest)
With 127 million people, Japan is the most populous of the 10 healthiest countries in the world. Ironically, it had the highest death rate of the top 10 countries, at 10 per 1,000 people. About one quarter of the nation’s population was over 65 last year, a testament to the longevity and health of Japanese people. One factor contributing to the strong overall health rating is Japan’s adult obesity rate of 3.3%, which was seventh best in the world and the best out of the 10 healthiest countries. Despite its high ranking, Japan has relatively high smoking rates for both males and females and one of the higher rates of CO2 emissions, at 9.2 metric tons per capita, almost twice the global average of 4.9 metric tons per capita. Japan’s tuberculosis rate of 18 per 100,000 people was far below the global rate of 126 per 100,000 people.
> Life expectancy: 79.1 (16th highest)
> Infant mortality rate (per 1,000 live births): 1.6 (tied-the lowest)
> Health expenditure per capita: $7,452 (4th highest)
> Unemployment rate: 5.9% (63rd lowest)
With the fourth highest per capita health care spending, Luxembourg, the only grand duchy in the world also has the fourth best health results, suggesting a link between health spending and outcomes. Luxembourg had the lowest mortality rates for both infants and children under five years old. But like most of the 10 healthiest countries, Luxembourg has a relatively high death rate. Though it is reasonably strong, the country’s overall health ranking is likely held back by its residents’ relatively high alcohol consumption of 11.9 liters per capita, and relatively high obesity rate of 23.1%.
> Life expectancy: 80.6 (2nd highest)
> Infant mortality rate (per 1,000 live births): 3.6 (24th lowest)
> Health expenditure per capita: $8,980 (2nd highest)
> Unemployment rate: 4.4% (40th lowest)
With the second highest life expectancy of all nations, Switzerland is the third healthiest country in the world. Switzerland had 3.9 physicians per 1,000 people, the ninth highest ratio of the 172 nations reviewed. The country ranked high overall despite a relatively high death rate of nine deaths per 1,000 people as well as prevalent risk factors. The per capita alcohol consumption in Switzerland of 10.7 liters was almost 73% higher than the global average. Also, an estimated 22% of adult females and 31% of adult males smoked. The incidence of tuberculosis in Switzerland of 6.5 cases per 100,000 people was 16th highest in the world. Despite these habits, Switzerland’s population remains very healthy, perhaps due to its health care expenditure. An annual $8,980 per capita was spent on health in the country, the second highest globally.
> Life expectancy: 79.5 (9th highest)
> Infant mortality rate (per 1,000 live births): 2.3 (6th lowest)
> Health expenditure per capita: $9,055 (the highest)
> Unemployment rate: 3.5% (22nd lowest)
Norway spends more on health care per capita than any other country. The country’s annual health care spending totalled $9,055, ahead of Switzerland’s $8,980 and the United States’ $8,895. Norway had a relatively high death rate of 8.4 deaths per 1,000 people, six times that of Qatar. Norway’s infant mortality rate, its mortality rate for those under five, and life expectancy rate at birth all ranked within the top 10 of all nations, however. While the country fared relatively poorly on health measures, its economy is very strong, and residents have some of the best access to health professionals and facilities in the world. Norway had the second best access to services, reflecting clean water and that its entire population had access to electricity. There were also nearly four physicians per 1,000 people in the country, one of the highest shares.
> Life expectancy: 77.6 (28th highest)
> Infant mortality rate (per 1,000 live births): 7.0 (44th lowest)
> Health expenditure per capita: $2,029 (25th highest)
> Unemployment rate: 0.5% (2nd lowest)
While Qatar topped 24/7 Wall St.’s health rankings, it was the only country of the 10 healthiest not to have a national health care system. As the emirate is transitioning to a universal system, however, the health of its population may become even better. Qatar plans to have its entire population covered by the end of this year. With 7.7 physicians per 1,000 people, more than any other country, the country’s health system is already very good. Qatar fared very well in health, access, and economic measures, largely on the strength of its relatively low overall death rate of 1.4 deaths per 1,000 people and relatively low maternal mortality rate. The small Middle Eastern country, which is about the size of Connecticut, took steps to protect its citizens from diseases with 99% of children receiving the DPT and measles vaccines. As in several other prosperous and healthy nations, Qatar had the second-highest obesity rate in the world.
The Least Healthy Countries
> Life expectancy: 47.7 (3rd lowest)
> Infant mortality rate (per 1,000 live births): 36.3 (52nd highest)
> Health expenditure per capita: $384 (80th highest)
> Unemployment rate: 18.4% (13th highest)
Botswana spent roughly $384 per person on health care in 2013, a fraction of the global spending figure, but also one of the higher expenditures compared to other unhealthy countries. Despite the relatively high health care spending, Botswana had among the world’s worst health outcomes. Life expectancy in Botswana was just 47.7 years, tied for the second-lowest in the world. This is despite having some of the elements that make for a healthy population. More than 90% of the population had access to clean water, and the country had above average immunization rates for its children. The country also had above average literacy rates and reasonably low smoking rates. In part, the poor health outcomes are due to cultural and economic factors that its health care system seems unable to cope with effectively. The HIV/AIDS epidemic in the country is severe, with roughly 25% of the population living with HIV. The country also suffers from very high levels of infant mortality and high rates of infectious diseases such as tuberculosis.
9. Equatorial Guinea
> Life expectancy: 51.2 (11th lowest)
> Infant mortality rate (per 1,000 live births): 69.3 (13th highest)
> Health expenditure per capita: $1,138 (37th highest)
> Unemployment rate: 8.0% (64th highest)
Equatorial Guinea is one of the more interesting countries among the world’s 10 unhealthiest countries. Its health care expenditure per capita of $1,138 in 2013 was above average, yet it had exceptionally poor health outcomes. The nation had one of the world’s highest infant mortality rates, which at 69.3 deaths per 1,000 live births was 13th highest in the world. It also had very low rates of child immunization. For example, it had the lowest rates of immunization for DPT of any of the 172 countries reviewed. These kinds of results raise the question: how is the money spent on health care being used? Transparency International ranks Equatorial Guinea among the most corrupt countries on the planet.
> Life expectancy: 48.9 (6th lowest)
> Infant mortality rate (per 1,000 live births): 61.5 (18th highest)
> Health expenditure per capita: $37 (17th lowest)
> Unemployment rate: 8.3% (58th highest)
Mozambique ranked poorly across essentially all of the factors that 24/7 Wall St. considered in assessing the state of health in a country. The quality of infrastructure in the country is poor, with only 35% of the rural population having access to clean water. The country also suffers from high levels of malaria, which account for roughly 26% of hospital deaths. The health care infrastructure is poorly equipped to deal with these conditions. Per capita expenditures on health care were roughly $37 dollars in 2013, 17th lowest in the world. The country has too few doctors at 0.04 per 1,000 people. The result of such low health spending and so few doctors is very poor health outcomes. The nation’s life expectancy is sixth lowest in the world at 48.9 years, and the infant mortality rate is 18th worst in the world.
> Life expectancy: 60.9 (41st lowest)
> Infant mortality rate (per 1,000 live births): 54.7 (29th highest)
> Health expenditure per capita: $53 (32nd lowest)
> Unemployment rate: 7.0% (81st lowest)
Even among the least healthy nations, Haiti ranked lower than most in several factors. When it comes to life’s basics, Haiti ranked among the lowest in access to clean water and electricity. For example, less than 75% of the country’s urban population had access to adequately clean water in 2012, the 6th lowest access level in the world. Against this backdrop, health care spending was just $53 per capita as of 2013. The poorest country in the Western Hemisphere also had some of the lowest child immunization rates in the world. The combination of poor infrastructure and economic conditions as well as poor health care spending resulted in poor health outcomes. Among these is an infant mortality rate of 54.7 deaths per 1,000 live births, the 29th highest rate in the world. Haiti is still recovering from a devastating earthquake in 2010 as well as a cholera epidemic which emerged in the aftermath of the natural disaster.
> Life expectancy: 55.4 (23rd lowest)
> Infant mortality rate (per 1,000 live births): 55.8 (25th highest)
> Health expenditure per capita: $96 (46th lowest)
> Unemployment rate: 13.3% (29th highest)
Violent conflicts can have a detrimental effect on the health of people in a country. While several of the least healthy countries have suffered from violent histories and ongoing conflicts, Zambia has been relatively peaceful. Still, the lack of resources and the weak economy likely make it difficult for Zambians to achieve better health outcomes. Zambia’s unemployment rate of 13.3% was more than double the global rate in 2013. Additionally, nearly three-quarters of the population lived in poverty in 2010, one of the higher rates compared to countries where data was available. Health spending was less than $100 per capita annually. Also, as in other countries with poor health measures, access to basic services and the infrastructure quality were severely lacking in Zambia. For example, just 18.5% of the population had access to electricity, one of the lowest percentages and considerably lower than the global figure of 83.1%.
> Life expectancy: 52.5 (14th lowest)
> Infant mortality rate (per 1,000 live births): 77.9 (7th highest)
> Health expenditure per capita: $30 (13th lowest)
> Unemployment rate: 7.1% (83rd highest)
Like several other least healthy countries, especially those in Africa, Guinea-Bissau was crippled by a relatively recent civil war, and continues to suffer from violence in the region. While a high birth rate can be positive for a nation, Guinea-Bissau’s high birth rate of nearly 38 births per 1,000 people may be related to other, less healthy behaviors. Like in other West African nations, for example, it may mean people are failing to use contraceptives even when having a child is not desired. This can also lead to higher vulnerability to infectious diseases. The annual health expenditure of $30 per capita was especially low, even among several of the least healthy countries. By contrast, global annual health spending was more than $1,000 per capita. Lack of resources may account for the lack of doctors and facilities. For every 20,000 people in Guinea-Bissau there was only about one doctor in 2010, a fraction of the global ratio of physicians to people.
> Life expectancy: 59.9 (36th lowest)
> Infant mortality rate (per 1,000 live births): 67.1 (15th highest)
> Health expenditure per capita: $52 (31st lowest)
> Unemployment rate: 31.0% (the highest)
Consumption of alcohol in Mauritania was just 0.1 liters per capita in 2010, the lowest level of all countries reviewed. This could be due in part to the country’s large Muslim population, but also to the fact that Mauritanians are likely unable to afford such habits. In 2013, 31% of the country’s labor force was unemployed, the highest unemployment rate worldwide and more than five times the global rate of 6%. The life expectancy at birth of less than 60 years was also among the lower figures compared to other countries. The term “unhealthy” may be an understatement for Mauritania, as large portions of the country are either at risk of death or currently living in slavery. The country abolished slavery in 1981, long after every other country in the world had already done so. And according to the Global Slavery Index, Mauritania has the highest incidence of slavery in the world.
3. Yemen, Rep.
> Life expectancy: 61.6 (45th lowest)
> Infant mortality rate (per 1,000 live births): 40.4 (45th highest)
> Health expenditure per capita: $71 (38th lowest)
> Unemployment rate: 17.4% (15th highest)
Like several other countries with the worst health indicators, Yemen has been the center of several violent conflicts. Just four years after the Republic of Yemen was formed in 1990, a civil war devastated the country. The ensuing displacement of country residents, strained political climates, and war-torn public infrastructure largely account for Yemen’s near-bottom position on this list. Less than half of the country’s population had access to electricity in 2010, one of the lowest proportions worldwide. And with only about one doctor per 5,000 residents, physicians were likely nearly impossible to access in times of need. The data available likely does not even capture the current state of poor health in the country. In February, rebels deposed the president, prompting multiple countries led by Saudi Arabia to bomb Yemen, resulting in further devastation.
2. Central African Republic
> Life expectancy: 47.7 (2nd lowest)
> Infant mortality rate (per 1,000 live births): 96.1 (3rd highest)
> Health expenditure per capita: $18 (4th lowest)
> Unemployment rate: 7.6% (71st highest)
The Central African Republic faces some of the same issues that its northeast neighbor Sudan faces. Central African Republic spent an annual $18 per capita on health, less than all but three other countries. The country has high infant mortality rates at birth, and among children under five, as well as the fourth highest death rate in the world. Less than one-quarter of children in the area were vaccinated against measles and DPT — diphtheria, pertussis (whooping cough), and tetanus — both the worst and second-worst shares, respectively, in the world. About 28% of Central African Republic residents are considered obese, one of the higher rates in the world. As in other unhealthy nations, the literacy rate of less than 37% was among the lowest percentages worldwide.
> Life expectancy: 60.1 (39th lowest)
> Infant mortality rate (per 1,000 live births): 51.2 (33rd highest)
> Health expenditure per capita: $115 (53 lowest)
> Unemployment rate: 15.2% (22nd highest)
Sudan’s ranking as the country with the worst health outcomes in the world comes on the heels of more than a decade of turmoil and violent crisis. The country has been embroiled in conflict in western Darfur since 2003. The conflict has resulted in more than 200,000 deaths. Sudan continues to struggle with the inflow of refugees from nearby Ethiopia, Eritrea, Chad, Central African Republic, and South Sudan. The inflow is taxing Sudan’s resources and infrastructure, particularly after South Sudan’s secession in 2011 split the country and its oil reserves. Perhaps as a result, the country spends the equivalent of just $115 per capita on health, just slightly more than 10% of the global average expenditure. Sudan is near the bottom in almost every health measure. With a population of almost 38 million, Sudan is the most populous of the 10 countries with the worst health outcomes.
To determine the most and least healthy countries, 24/7 Wall St. collected data on 21 measures on more than 170 countries. These measures were grouped into three categories: health, access, and economy.
While our index aspires to be comprehensive, many measures are also interrelated. To account for interdependence, our index was created using a geometric mean rather than the traditional arithmetic mean. We then used the geometric mean of each index to calculate a country’s overall score. Potential scores ranged from one to 172, with lower values indicating better scores.
One challenge was data availability for all 172 countries. We addressed this challenge in two ways. The data is for the most recent year available but also needed to be no older than 2010. Secondly, data had to be available for at least 75% of countries. In addition, we only considered countries with at least 150,000 people.
The health category captured both outcomes and residents’ behaviors in each country. Infant mortality, fertility, maternal mortality, and the incidence of various diseases came from the World Bank. We used the World Bank’s life expectancy figure for males as a proxy for life expectancies for all people because it is much more widely available in the countries reviewed. Smoking rates and the percentage of children with certain immunizations also came come the World Bank. Lastly, we considered per capita alcohol consumption and adult obesity rates from the World Health Organization (WHO).
The access category was designed to measure the availability of specific resources that are critical to the health of a nation’s people. We looked at the share of a country’s population with access to clean water, clean air, and electricity — all data from the World Bank. Additionally, we looked at the concentration of physicians in each country as a proxy for how easily residents can access health care.
Economic conditions also have an impact on health and health outcomes. The economy category included per capita health expenditure by public and private sources, as well as poverty and unemployment rates. All economic data came from the World Bank.
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