Comparing Performance in 10 Nations
AUTHORS
David Blumenthal, Evan D. Gumas,Arnav Shah, Munira Z. Gunja,Reginald D. Williams IIDOWNLOADS
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Abstract
- Goal: Compare health system performance in 10 countries, including the United States, to glean insights for U.S. improvement.
- Methods: Analysis of 70 health system performance measures in five areas: access to care, care process, administrative efficiency, equity, and health outcomes.
- Key Findings: The top three countries are Australia, the Netherlands, and the United Kingdom, although differences in overall performance between most countries are relatively small. The only clear outlier is the U.S., where health system performance is dramatically lower.
- Conclusion: The U.S. continues to be in a class by itself in the underperformance of its health care sector. While the other nine countries differ in the details of their systems and in their performance on domains, unlike the U.S., they all have found a way to meet their residents’ most basic health care needs, including universal coverage.
SECTIONS
- 01Performance Overview
- 02Access to Care
- 03Care Process
- 04Administrative Efficiency
- 05Equity
- 06Health Outcomes
- 07What the U.S. Can Do to Improve
- 08How We Conducted This Study
- 09How We Measured Performance
Introduction
Mirror, Mirror 2024 is the Commonwealth Fund’s eighth report comparing the performance of health systems in selected countries. Since the first edition in 2004, our goal has remained the same: to highlight lessons from the experiences of these nations, with special attention to how they might inform health system improvement in the United States.
While each country’s health system is unique — evolving over decades, sometimes centuries, in tandem with shifts in political culture, history, and resources — comparisons can offer rich insights to inform policy thinking. Perhaps above all, they can demonstrate the profound impact of national policy choices on a country’s health and well-being.
In this edition of Mirror, Mirror, we compare the health systems of 10 countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland, the United Kingdom, and the United States. We examine five key domains of health system performance: access to care, care process, administrative efficiency, equity, and health outcomes (each is defined below).
Despite their overall rankings, all the countries have strengths and weaknesses, ranking high on some dimensions and lower on others. No country is at the top or bottom on all areas of performance. Even the top-ranked country — Australia — does less well, for example, on measures of access to care and care process. And even the U.S., with the lowest-ranked health system, ranks second in the care process domain.
Nevertheless, in the aggregate, the nine nations we examined are more alike than different with respect to their higher and lower performance in various domains. But there is one glaring exception — the U.S. (see “How We Conducted This Study”). Especially concerning is the U.S. record on health outcomes, particularly in relation to how much the U.S. spends on health care. The ability to keep people healthy is a critical indicator of a nation’s capacity to achieve equitable growth. In fulfilling this fundamental obligation, the U.S. continues to fail.
PREVIOUS EDITIONS OF MIRROR, MIRROR
Mirror, Mirror 2021: Reflecting Poorly
Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care
Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally
How We Measured Performance
Our approach to assessing nations’ health systems mostly resembles recent editions of Mirror, Mirror, involving 70 unique measures in five performance domains. The data sources for our assessments are rich and varied. First, we rely on the unique data collected from international surveys that the Commonwealth Fund conducts in close collaboration with participating countries.1 On a three-year rotating basis, the Fund and its partners survey older adults (age 65 and older), primary care physicians, and the general population (age 18 and older) in each nation. The 2024 edition relies on surveys from 2021, 2022, and 2023.
We also rely on published and unpublished data from cross-national organizations including the World Health Organization (WHO), the Organisation for Economic Co-operation and Development (OECD), and Our World in Data, as well as national data registries and the research literature.
Mirror, Mirror 2024 differs from past reports in certain respects:
- It covers 10 countries instead of the previous 11, after Norway exited the Commonwealth Fund’s international surveys. Norway was the top-ranked country in the 2021 edition of Mirror, Mirror.
- It accounts for the impact of COVID-19 on health system performance, as we are able to use data collected since the onset of the pandemic and do not use data pre-2020.
- It investigates several dimensions of equity. In addition to comparisons between residents with above-average and below-average income, this edition examines health system performance differences based on gender (limited to male and female because of insufficient sample size to include additional gender identities) and location (rural and nonrural) as well as patients’ experiences of discrimination, as reported by physicians. Comparisons of performance with respect to race and ethnicity were not possible because of data limitations: many countries do not collect information on these variables and the constructs of identity vary from country to country. To allow for continuity and comparison with previous editions, we present separate analyses for those based only on income and those based on income, gender, and geography combined. Only the analysis based on income was included in our overall rankings. For further detail, see “How We Conducted This Study.”
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