Commonwealth Report 2021

Illustrations by Michele Marconi

Eric C. Schneider,  Arnav ShahMichelle M. Doty,  Roosa TikkanenKatharine Fields,  Reginald D. Williams II



  • Issue: No two countries are alike when it comes to organizing and delivering health care for their people, creating an opportunity to learn about alternative approaches.
  • Goal: To compare the performance of health care systems of 11 high-income countries.
  • Methods: Analysis of 71 performance measures across five domains — access to care, care process, administrative efficiency, equity, and health care outcomes — drawn from Commonwealth Fund international surveys conducted in each country and administrative data from the Organisation for Economic Co-operation and Development and the World Health Organization.
  • Key Findings: The top-performing countries overall are Norway, the Netherlands, and Australia. The United States ranks last overall, despite spending far more of its gross domestic product on health care. The U.S. ranks last on access to care, administrative efficiency, equity, and health care outcomes, but second on measures of care process.
  • Conclusion: Four features distinguish top performing countries from the United States: 1) they provide for universal coverage and remove cost barriers; 2) they invest in primary care systems to ensure that high-value services are equitably available in all communities to all people; 3) they reduce administrative burdens that divert time, efforts, and spending from health improvement efforts; and 4) they invest in social services, especially for children and working-age adults.

     The U.S. ranks #11 — last.
    [Canada ranks #10]

Access to Care: Universal, Affordable Coverage Is Paramount

Access to care includes measures of health care’s affordability and timeliness. The Netherlands performs best on this performance domain among the 11 countries, ranking at or near the top in both subdomains. Norway and Germany also performed well on access to care (Exhibit 1), but all three are outranked on affordability by the U.K. 

People in the countries performing the best on the timeliness subdomain are more likely to be able to get same-day care and after-hours care.

Equity: Income-Related Disparities Are Largest in the U.S., Canada, New Zealand, and Norway

Achieving better health outcomes will require policy changes within and beyond health care.

How have top-performing countries reduced avoidable mortality? A comparison of the featuresof top-performing countries and poorer-performing countries suggests that top-performing countries rely on four features to attain better and more equitable health outcomes:

  1. They provide for universal coverage and remove cost barriers so people can get care when they need it and in a manner that works for them.
  2. They invest in primary care systems to ensure that high-value services are equitably available locally in all communities to all people, reducing the risk of discrimination and unequal treatment.
  3. They reduce the administrative burdens on patients and clinicians that cost them time and effort and can discourage access to care, especially for marginalized groups.
  4. They invest in social services that increase equitable access to nutrition, education, child care, community safety, housing, transportation, and worker benefits that lead to a healthier population and fewer avoidable demands on health care.

Top-performing countries achieve near-universal coverage and much higher levels of protection against medical costs in the form of annual out-of-pocket caps on covered benefits and full coverage for highly beneficial preventive services, primary care, and effective treatments for chronic conditions. Germany abolished copayments for physician visits in 2013, while several countries have fixed annual out-of-pocket maximums for health expenditures (ranging from about USD 300 per year in Norway to USD 2,645 in Switzerland).

Access to care, however, requires more than insurance coverage. Convenient and timely primary care is also vital. Top-ranking countries like the Netherlands and Norway ensure timely availability to care by phone on nights and weekends (with in-person follow-up at home as needed). In the Netherlands, cooperative “GP posts” are staffed by general practitioners (primary care physicians), who are obligated to provide at least 50 hours of after-hours care (between 5:00 pm and 8:00 am) annually in order to maintain their professional licensure. In Norway, the Patients’ Rights Act specifies a right to receive care within specific timeframes and with maximum wait times applying to covered services, including general practitioner visits, hospital care, mental health care, and substance use treatment.

The Commonwealth Report 2021