The share of a population covered for a core set of health services offers an initial measure of access to care and financial protection. Most OECD countries have achieved universal or near-universal coverage for a core set of health services, which usually include consultations with doctors, tests and examinations, and hospital care (Figure 5.1). National health systems or social health insurance have typically been the financing schemes for achieving universal health coverage. A few countries (such as the Netherlands and Switzerland) have achieved universality through compulsory private health insurance – supported by public subsidies and strong regulation on the scope and depth of coverage.

A fundamental principle underpinning all health systems across OECD countries is to provide access to high-quality care for the whole population, irrespective of their socio‑economic circumstances. Yet access can be limited for several reasons, including limited availability or affordability of services. Policies therefore need to ensure an adequate supply and distribution of health workers and healthcare services throughout the country, and address any financial barriers to care (OECD, 2019[1]; 2023[2]).

In addition to the share of the population entitled to core health services, the extent of healthcare coverage is defined by the range of services included in a publicly defined benefit package and the proportion of costs covered. Differences across countries in the extent of coverage can be the result of specific goods and services being included or excluded in the publicly defined benefit package (such as a particular drug or medical treatment), different cost-sharing arrangements or some services only being covered for specific population groups in a country (such as dental treatment).

Health systems provide adequate financial protection when payments for healthcare do not expose people to financial hardship. A lack of financial protection can reduce access to healthcare, undermine health status, deepen poverty, and exacerbate health and socio‑economic inequalities. Exposure to financial hardship for people using health services can also lead to catastrophic health spending, with poorer households and those who must pay for long-term treatment – such as medicines for chronic illness – particularly vulnerable. Financial protection is weakened by a health system’s reliance on out-of-pocket (OOP) payments for healthcare. On average across OECD countries, just under one‑fifth of all spending on healthcare comes directly from patients through OOP payments (see section on “Health expenditure by type of financing” in Chapter 7).

Consultations with primary care doctors are for many people the most frequent contact with health services, and often provide an entry point for subsequent medical treatment. Consultations take place in doctors’ clinics, community health centres, hospital outpatient departments or, in some cases, patients’ own homes. Increasingly, teleconsultations are offered to patients, whereby consultations take place online, often through video calls (OECD, 2023[1]).

A digital health transformation is reshaping how health services are delivered, public health is protected, and chronic disease is managed and prevented. Through the expanded use of digital tools such as telemedicine and artificial intelligence, as well as utilising health information to monitor population health and manage system performance, countries are investing more in digital health systems. The COVID‑19 pandemic demonstrated that the most resilient countries had strong digital systems for collecting and sharing health information. Health systems with robust digital infrastructure and the ability to utilise quality health information were able to inform evidence‑based policy making and respond more flexibly and quickly to system shocks (OECD, 2023[1]). As a result, the use of digital tools such as telemedicine and artificial intelligence is expanding. These digital interventions have the potential to reshape patient care, improve workforce productivity, enable equitable access to health services, and achieve better health outcomes.

The COVID‑19 pandemic highlighted the need to have sufficient hospital beds and flexibility in their use, to address any unexpected surge in demand for intensive care. Still, adequate staffing was more of a pressing constraint than bed numbers (OECD, 2023[1]). Further, a surplus of hospital beds may lead to overuse and therefore costs, as many patients can be treated effectively on a same‑day basis in hospitals or primary healthcare facilities. Therefore, a balance needs to be found between ensuring sufficient bed capacity and value‑for-money considerations.

Hospital discharge rates – the number of patients who leave a hospital after staying at least one night – are a core indicator of hospital activity. Improving timely discharge of patients can help the flow of patients through a hospital, freeing up hospital beds and health worker time. Both premature and delayed discharges worsen health outcomes and increase costs: premature discharges can lead to costly readmissions; delayed discharges use up limited hospital resources.

Technologies play an important role in medical diagnoses: from physical examination and results processing and sharing, to accessing patients’ health records, to the review of clinical histories. However, new technologies are acknowledged as a major cost driver in health systems (Lorenzoni et al., 2019[1]). This section presents data on the availability and use of three diagnostic imaging technologies: computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET). CT and MRI examinations (exams) both show images of internal organs and tissues, while PET scans show other information and problems at the cellular level.

Hip and knee replacements are some of the most frequently performed and effective surgeries worldwide. The main indication for hip and knee replacement (joint replacement surgery) is osteoarthritis, which leads to reduced function and quality of life.

Over the past few decades, the number of surgical procedures carried out on a same‑day basis has increased markedly in OECD countries. Advances in medical technologies – in particular, the diffusion of less invasive surgical interventions – and better anaesthetics have made this development possible. These innovations have improved patient safety and health outcomes. Further, by shortening the treatment episode, ambulatory surgery can save important resources without any adverse effects on quality of care. It also frees up capacity within hospitals to focus on more complex cases or to reduce waiting lists. However, the impact of the rise in same‑day surgery on overall health spending may not be straightforward, since the reduction in unit costs (compared to inpatient surgery) may be offset by overall growth in the volume of procedures performed. Any additional costs related to post-acute care and community health services following the interventions also need to be considered.

Long waiting times for elective (non-emergency) surgery have been a longstanding issue in a number of OECD countries – one that has been massively exacerbated by the COVID‑19 pandemic. By postponing the expected benefits of treatment, it means patients continue living with pain and disability for longer than they need to, and may worsen health outcomes for patients after the intervention.