The Virchow-Villermé’s ranking of health in 30 European Countries

Understanding health determinants remains crucial in public health research. Rankings of health determinants may help to give an overview for stakeholders in order to improve health. Different health rankings exist, but most of them do not include a comprehensive set of health determinants as they are mainly focused on comparing health systems (Bloomberg Rankings, 2013; Davis et al., 2014; World Health Organization, 2000) or are rather focused on comparison within the US (United Health Foundation, 2013; University of Wisconsin Population Health Institute, 2014). Indeed, attempting to quantify the health of a population is complex and can be approached from many angles.


The Virchow-Villermé Ranking

As rankings of health determinants in the European region are still scarce, the Centre Virchow-Villermé for Public Health Paris-Berlin established a ranking of health determinants in 30 European countries. Based on America’s Health Rankings the primary aim is to encourage discussions about public health issues.

In our ranking, data were mainly used from WHO, Eurostat and World Bank databases. We used premature mortality as a stand-alone health outcome as it has been shown to be an important and crucial measure of a population’s health as it emphasises the deaths that could have been prevented had the health system been stronger. In addition, four different subcategories of health determinants were set up based on the conceptual framework model of population health improvement developed at the University of Wisconsin (Peppard et al., 2008).


Health outcome and health determinants measures used for Virchow-Villermé Ranking
Health outcome: Premature mortality below 65 years

Health behaviour: Alcohol consumption, Percentage of smokers and Body-mass-index (BMI)

Socio-economic factors: Education, Income inequality, Unemployment, Housing, Crime rates

Health care: Number of dentists and general practitioners per 100,000 inhabitants

Physical environment: Greenhouse gas emissions, Food production index


Since the measures are expressed in a number of different units, all measures were standardized and transformed into the same metric by using a z-score (Raghavan et al., 2013). Summary scores were calculated and weights were applied for each subcategory: 25% premature mortality, 30% health behaviour, 22.5% socio-economic factors, 15% health care and 7.5% physical environment. More details can be provided upon request.


The results show that Norway ranked overall first followed by Sweden and Italy. They showed a good performance especially in the subcategory health behaviour. However, Eastern European countries occupied the last places: Latvia, Hungary and Lithuania. A reason for these positions is for instance a relatively high premature mortality in these countries.

France and Germany are both placed in the centre of the overall ranking. In general, both countries are presenting average scoring in the different subcategories, except for “health care” where France and Germany performed quite well.


The objective of the Virchow-Villermé ranking of health determinants was to call attention to and encourage discussion about the variation in public health among European countries.

Although limitations regarding the methods used exist, this first attempt to rank European countries provides some insights to identify sectors where more support and alternative policy decisions are necessary in order to finally improve health.


We understand that rankings of countries can be seen as controversial. Our ranking is presented in the spirit of encouraging improvement and discussion on public health issues in Europe. Feedback regarding the methods or measures used is welcome.



Bloomberg Rankings, 2013. Most efficient health care.

Davis, K., Stremikis, K., Squires, D., Schoen, C., 2014. Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally. The Commonwealth Fund.

Peppard, P.E., Kindig, D.A., Dranger, E., Jovaag, A., Remington, P.L., 2008. Ranking Community Health Status to Stimulate Discussion of Local Public Health Issues: The Wisconsin County Health Rankings. Am. J. Public Health 98, 209–212. doi:10.2105/AJPH.2006.092981

Raghavan, M., Martin, B.D., Aoki, F., Mackalski, B., Christensen, H., 2013. Use of Z-scores to rank applicants to professional degree programs. J. Vet. Med. Educ. 40, 63–68. doi:10.3138/jvme.0612-063R

United Health Foundation, 2013. America’s Health Rankings: a call to action for individuals and their communities. United Health Foundation, Minnetonka.

University of Wisconsin Population Health Institute, 2014. County Health Rankings Key Findings 2014.

World Health Organization, 2000. The world health report 2000: health systems: improving performance. World Health Organization.



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