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  • Ieshan Misri



The emergence of the Covid-19 pandemic has put enormous strain on all the nations globally. It has not just exposed the long-standing gaps in the public health systems and services but also the inequalities and lags in underlying governance structures around the world even in high-income and developed economies. This study attempts to draw a comparative analysis of the health systems of the three countries i.e., India, Italy, and the United States of America which have very different health systems on the levels of capacities, functioning, and financing. The study is being done with the intent to investigate the robustness of the health systems of these countries and to check the levels of responsiveness of these health systems based on the parameters as indicated in the Global Health security index and overall experience of these countries in tackling the outbreak of the pandemic. This is being done with the aim of drawing some lessons and insights into what strategies and actions help the best in tackling the global pandemic crisis like the ongoing Covid19 pandemic.


A health care system is fundamentally an integrated sum-total of all the institutions, organizations, and resources that could be used to promote, maintain, and restore the health of a population. It is at its core a formal structure intended for a defined population. A health care system’s scope, management, content, and finance are defined by laws and regulations in general. A health system, therefore, is not just the pyramid of public or private health facilities but also includes behavioural change programmes, vector control campaigns, health insurance organizations, health, and safety legislation and also intersectoral actions, etc.

The health system of a nation ought to be directed and managed through a set of plans which are developed through evidence-based policymaking in partnership with all the stakeholders. On the other side, the working and efficiency of any health system is often influenced and shaped by determinants such as availability of financial and human resources, supplies of essential medicine and technologies, and a governance structure that is responsive and accountable to the general population. Thus, a responsive health system should be able to address the existing, perceived, and also projected health needs of their population.A health system’s responsiveness is the mark of its strength and preparedness to prevent, respond, protect and recover from large-scale health emergencies. The performance of a health system therefore could be gauged by looking into how well it copes with the sudden and disproportionate increase in the demand for health facilities.

A brief history of COVID-19 Progression

On 30th December 2019, the World Health Organization’s country office in the People’s Republic of China picked up an urgent notice by the Wuhan Municipal Commission about cases of a “viral pneumonia of unknown cause”. The very next day on 31st December 2019 an alert was issued of the unusual event caused by a novel virus that was later identified as SARS-CoV-2.Soon, thereafter a sharp rise of cases started getting reported from countries outside China, including Iran, South Korea, and Italy, while in China the outbreak remained largely confined to the Hubei province. The World Health Organization realizing the rapid spread of the disease declared it as a public health emergency of international concern on 30th January 2020.

With the declaration of Covid19 as a pandemic on 11th March 2020, there was seen a global shift wherein the cases were declining in China while there was a sustained rise in transmission in various other countries all around in the world from Europe, North and South Americas, South and Southeast Asia to Australia. Since then the situation has remained fluid with most of the countries witnessing two waves with a looming threat of the third wave of infections with the emergence of a new variant on the horizon.

The ongoing Covid19 pandemic is an unparalleled health emergency that brought with it an equally unprecedented social and economic crisis. It has affected all the spheres of life, pushed a great many towards marginalization, increased inequalities, and accentuated the divides. According to an estimate by World Bank Almost 40-60 million people have been pushed into extreme poverty globally due to the pandemic. It has now become evident that fighting an emergency as big as this would require a comprehensive recalibration and improvement of health care systems not just in the developing and lower-income countries but also in the developed world.

Health System and Covid Response

In the wake of a pandemic like Covid19, it has been observed that the resilience of the health care system, which comes by the virtue of its building blocks like service delivery, workforce, information system, and financing, etc. plays a very important role. A health system should be able to effectively perform heath surveillance for early detection of the infected individual and to respond rapidly. It should be efficient enough to implement key public health measures and communicate information about the risk and prevention to the community. It should be prepared enough to not get overwhelmed by the prolonged surge in the health care demand and finally it should be able to protect the most vulnerable in the society.

Methodology and Parameters of Analysis

This study attempts to draw a comparative analysis of the health systems of three countries vis a vis Italy, the United States of America, and India. These three countries have been chosen for the diversity of their geographic location, socio-economic and political situation, and also a chronological difference in the incidence of covid 19 waves. The health system framework provided by WHO forms the basis for assessing the responsiveness of the public health care systems in these countries. The standardized health system building block indicators as proposed by World Health Organization are taken as the input indicators to comparatively analyze the health system of the above-mentioned countries. These indicators are:

- Health Service Delivery

  • Number of inpatient beds per 10000 population

- Health Workforce

  • Number of Health Workers per 10000 population

  • Doctor-population ratio per 10000 population

  • Nurses per 10000 population

- Health Financing

  • Current Health Expenditure (as % of GDP) (2017)

  • Domestic general health expenditure as % of GDP (2017)

  • General government expenditure on health as a proportion to general expenditure

  • Out of Pocket payments for health (% of current expenditure on health)

The comparison of responsiveness of the health system is then assessed on the basis of the Global Health Security Index framework. Global Health Security framework assesses the health system response on the following parameters:

- Prevention of emergence or release of pathogens.

- Early detection and reporting for epidemics of potential international concern

- Rapid response to and mitigation of the spread of an epidemic

- Sufficient and robust health system to treat the sick and protect the health workers

- Commitment to improving national capacity, financing, and adherence to norms

- Overall risk environment and country vulnerability to biological threats

Comparative Analysis of the Health Systems and Responsiveness

Health Service Delivery and Workforce

Health service delivery which has been measured in terms of the number of inpatient beds available per ten thousand population Italy fares the best with around 34 inpatient beds followed by the United States of America on the second with 29 beds per 10000 people. Comparatively, India lags far behind with only 7 inpatient beds per 10000 people.

Table 1


The number of health force workers per ten thousand population India stands at almost half to that of Italy and USA wherein certain local regions the ratio even goes above the country average. Evidently, the doctor population ratio for every ten thousand people in Italy again fares at the top at around 41, with the USA at the second with 26 and India only having around 8. The ratio of the nurse population per ten thousand people is the best in the USA with Italy following it and India again at the last.

Figure 1: Comparison of Health Service delivery and workforce

Figure 1. gives a consolidated graphical comparative analysis of the workforce and health service delivery in India, Italy, and the United States of America.

Health System Financing

Italy has a tax-funded national health service which is mostly financed through corporate tax and value-added taxes and covers the entire population. Whereas the United States of America and India have mix system of financing the health system which involves private and social health insurance, government financing, etc. In terms of financing, these countries have been compared in terms of ‘Current health expenditure’ as a percentage of respective gross domestic product wherein the USA spends around 17.1%, Italy and India spend at around 8.8% and 3.5% respectively. Secondly, in terms of government health expenditure (as a percent of GDP) the USA again tops with around 8.6% followed closely by Italy at 6.5%. India only spends around 1% in governmental expenditure on health.

Table 2


The ratio of government expenditure on health to the general government expenditure stands at around 22.5 for the USA, 13.4 for Italy, and around 3.4 for India. Whereas in terms of ‘Out of Pocket expenditure (as a percentage of current health expenditure) on health India stands at the top with around 62.4% followed by Italy at 23.5% and then the USA at 11%.

Figure 2 gives a consolidated graphical comparative analysis of the health system financing in these countries.

Figure 2: Comparison of Health Financing Indicators

Health system Responsiveness

The Global Health Security (GHS) framework has several indicators that measure and rate the health systems' preparedness to face the pandemic and other health emergencies of a similar kind. As per the 2019 GHS index, no country in the world was fully prepared for a global health emergency like that of the Covid19 pandemic. According to the same report, the developed nations had an average score of 51.9 out of 100. The report also indicates that globally, apart from the political, socio-economic, environmental vulnerabilities many gaps existed in the health systems to effectively deal with a pandemic of this scale and nature.

Figure 3: GHSI, India, Italy, and the USA

It could be noticed in figure 3 above, apart from the USA the GHS score for both Italy and Inda are very competitive even when their health system indicators fare far apart. In both absolute and relative sense, comparatively strong parameters per se didn’t seem to be sufficient a factor to be able to translate into effective or even adequate responsiveness in the context of a global pandemic.

Table 3

Source: Global Health Security Index

The analysis shows that having a stronger public health system as is in the case of Italy and the USA doesn’t necessarily mean that it would automatically translate into an effective health system response. This is also quite aligned with the experience of different countries in the wake of the current pandemic.The responsiveness of the health systems of all three countries towards the Covid19 pandemic was not completely consistent with results emerging from the comparative analysis of their health systems. Italy having fairly good national health service coverage fared poorly in the containment and responsiveness to the covid 19 pandemic. USA which even fared very well in the GHSI also didn’t demonstrate effective responsiveness to covid19. On the other hand, India even with comparatively lower quality of health system and a low score on GHSI was able to respond and manage the pandemic relatively a bit well. Thus while rich economies with the best of health systems could not contain the epidemic while several low- and middle-income countries could demonstrate that strict and timely implementation of the activities was enough to reduce the impact.

Lessons Learnt

The trends have shown that the outbreak of cases rather begins slowly and then there is a sudden surge to the peak. The trajectory largely depends on how the particular country and its health system governance react to the unfolding crisis. There are several lessons that have come to forth in managing the pandemic.

Political leadership and Early Decisive Actions

The Political leadership characterized by early and decisive actions had a great bearing on response to the country’s response to the pandemic. Political leadership not just has to choose the correct path but also plays an important role in reassuring and convincing the population to follow the intended path and policies. The leadership that was successful in crafting a good narrative and communicating effectively has been successful in this regard.

Multi-pronged and comprehensive Strategy

Every country responded to the pandemic with a different mix of strategies and actions. These strategies either relied on forced social distancing to flatten the curve and use that time to build up the health system capacities like in India or depended on communities sharing the responsibilities of voluntary social distancing and government taking care of the sick as was seen in the USA.Plus a strong and secure public health surveillance and information system operationalized through a well-trained workforce are needed at all levels to trace, test, isolate and quarantine individuals who are exposed.

Protecting Vulnerable Population

Health-wise it was seen that adults over 65 years of age and those with underlying health conditions were most vulnerable to infections and deaths. In addition, pandemics also brought forth the vulnerabilities of those affected by poverty, migrants, slum dwellers, and daily wagers. These groups were not just socio-economically more vulnerable but also face the lack of basic resources like water, soap, and maintenance of social distancing in overcrowded living conditions.

Meaningful Community Engagement and Communication

It has been observed that as the pandemic started spreading the misinformation related to the disease went rampant and became an equally big hurdle to tackle in the management of pandemic. The misinformation not only crowded out science-based factual information but also the urgent public health messages and communication. Such misinformation misled and misguided a large proportion of the population and communities causing anxiety, stigma, and maintenance of public trust in authorities.

To tackle the misinformation public health communication ought to flow from channels that are perceived to be transparent, credible, and trustworthy. Since doctors and scientists are often trusted more than bureaucrats and politicians, they can serve as a vehicle to convey information to the public through various channels regularly. Besides this interpersonal communication through non-governmental organizations and community-based organizations play an important role in overcoming this menace of misinformation. This has also been a lesson from the Ebola outbreaks in Congo (DRC) and West Africa.


The current Covid 19 pandemic has exposed the weakness of the health systems in their preparedness and responsiveness globally. It has not just brought to fore the gaps in international cooperation in the time of global threats but also the inability of most of the nations to respond timely through effective policy responses. The preparedness and responsiveness of the health systems in the wake of such crises remain largely dependent on the ability to show resilience during the crises and not get overwhelmed. As per an estimate even in the developed health systems, large-scale epidemics like Covid would entail more than 170% utilization of intensive care level resources.

Regardless of the outcome of the current situation, it has become almost certain that pandemics in the future are inevitable. Efforts not just towards a collective betterment of health services and development of a synergetic coordination mechanism at all levels in addition to crisis planning supported by strong ethical, legal, and policy frameworks are the key to efficient handling of the crisis.

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About the author: Public Policy Professional, with a knack for complex comparative policy analysis. At present working on EV-mobility and Circular Economy in the South-Asian context.

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