From crisis to reform: Health system reform trends in 32 high-income countries from 2018-2026

Background

Health system have to respond to financial constraints, demographic and epidemiological shifts, deepening social inequality, as well as external shocks such as climate change, conflict, and pandemics. Policymakers struggle to develop reforms that are sustainable, equitable, and resilient. Cross-country comparative reform analyses can support cross-border learning, helping policymakers identify what works, under which conditions, and why.

Methods

To compare countries’ health system responses between 2018-2026, we analysed over 700 reforms reported by experts across 32 high-income countries. These were classified into 14 thematic clusters, guided by the European Observatory’s Health System in Transition framework, and mapped to the WHO’s health system objectives. Reforms were compared across four periods: pre-(2018-19), peak-(2020-21), late-(2022-23), and post-pandemic (2024-26).

Results

Pre-pandemic reforms concentrated on strengthening care coordination and primary and ambulatory services. During the peak-pandemic period, priorities shifted toward financial sustainability, coverage expansion, digitalization, pharmaceuticals, and mental and public health. In the late-pandemic, attention turned to workforce capacity, healthcare purchasing, and investment in primary care – developments that continued beyond the pandemic, together with a renewed focus on care coordination. Despite similarities across countries in terms of challenges and objectives, countries pursued different reform areas to achieve similar objectives.

Conclusions

Across countries, reforms shared policy goals—improving efficiency, access, coverage, quality, and safety—yet used different policy instruments to achieve them. Crises have shifted priorities from service optimiation to system resilience, opening opportunities for enhanced European coordination on cross-border challenges. This underscores the continued importance of context-specific and comparative research for informing policy.

Key messages

• While shocks such as COVID-19 reshape health reform priorities, high-income countries consistently converge on core goals: improving access, efficiency, quality and system resilience.

• Countries pursue similar goals through different policy approaches, highlighting the need for context-sensitive reform and cross-country learning.