Promoting International Learning and Exchange at the Commonwealth Fund

Global Health Care Leaders Program, Harvard Medical School

August 2026

​

The Commonwealth Fund: A Brief Introduction

Established in 1918 by Anna Harkness, the Fund's mission is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, and people of color.

• 2

Health Care is Failing People in U.S.

• 3

A Shared Reality Around the World

​

• 4

Leadership Network: Harkness Fellowships in Health Care Policy and Practice

Harkness Fellowships: 100 Years of Impact

THE SOLUTION

• For 100 years, the Harkness Fellowships have provided a unique platform for policy leaders to explore, reflect, and innovate alongside global peers. Since 1998, the Fellowship has focused on international health policy research and leadership development.
• Fellows—midcareer policymakers, researchers, clinicians, health executives, journalists—come from Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Singapore, and the UK.

• 6

Harkness Fellowships: 100 Years of Impact

THE SOLUTION

During a year in the U.S., Fellows:

• Conduct internationally comparative research on priority issues
• Are based at leading universities, think tanks, and NGOs, with mentorship from leading researchers and policymakers
• Engage in leadership development and cross-national exchange
• Build a global network for long-term collaboration

​

​

• 7

Research: Comparisons and Case Studies�

Objectives of the Commonwealth Fund’s International Comparison work

• Benchmark U.S. health care system performance against other countries’ health care systems
• Identify policies, practices, and care models that could be adapted from other countries into the U.S. context
• Motivate policymakers and providers to take action on performance improvement
• Key audiences: legislators, regulators, payers, and delivery system leaders

​

• 9

International Health Policy Surveys Offer Insights on �System Performance

Over 20 Years of Global Insights: The Commonwealth Fund’s International Health Policy (IHP) Survey spans 10+ countries, capturing perspectives from primary care physicians, older adults, and individuals aged 18 and older

• 10

Mirror, Mirror

• To learn how high-income health systems achieve high performance
• To understand how and why U.S. performance lags
• In 2024, published the 8^th report since 2004 and first report since the end of the pandemic to learn how health systems achieve high performance by comparing the health systems of the 10 countries participating in the IHP surveys.

• 11

The United States lags behind its international peers considerably on health system performance.

Note: To normalize performance scores across countries, each score is the calculated standard deviation from a nine-country average that excludes US. See “How We Conducted This Study” for more detail.

​

Data: David Blumenthal et al., Mirror, Mirror 2024: A Tale of Continued U.S. Underperformance – Comparing Health Systems Across 10 Nations (Commonwealth Fund, Sept. 2024). https://doi.org/10.26099/ta0q-zp66

​

Lower �performing

Higher�performing

TOP-THREE AVERAGE

NINE-COUNTRY AVERAGE

• 12

U.S. Health Care from a Global Perspective

The 2026 edition evaluates the U.S. health system relative to 19 other OECD countries across four key areas: insurance coverage and access to care, affordability of care, delivery of care, and equity of health outcomes. Compares U.S. performance to the OECD average, for the 38 countries for which data are available.   

Mexico�Netherlands�New Zealand�Norway�Spain�Sweden�Switzerland�Türkiye�United Kingdom�United States

• 13

International Insights

Brief international looks at potential solutions to our domestic health policy problems

80 editions thus far and over 20,000 followers!

https://www.linkedin.com/newsletters/international-insights-6980949824397316096/

Topics include

• Rural health care �Long-term care
• Universal coverage
• Health outcomes and population health
• Older adults
• Payment reform
• Climate change
• Affordability and cost containment
• Crisis management
• Oral health

• Incarcerated population
• Community health
• Maternal health
• Substance use
• Indigenous populations
• Drug pricing
• Public health
• Undocumented migrants
• Homelessness
• Primary care
• Mental health
• Trans health

• 14

International Health Care System Profiles

• 31 profiles of international health systems describing the role of government, how systems are organized and financed, who and what is covered, and what is being done to ensure quality of care, reduce disparities, and promote care coordination
• https://www.commonwealthfund.org/international-health-policy-center/system-profiles

​

• 15

U.S. Maternal Health Care: An International Context�

Black women in the U.S. have the highest maternal death rate in the OECD.

Notes: 2024 data: CHL; 2023 data: CAN, GER, JPN, KOR, MEX, NETH, NOR, ESP, SWE, SWIZ, TUR, US; 2022 data: AUS, DNK, ISR, ITA; 2020 data: NZ. Data for CHL are provisional; definitions for AUS and DNK differ from other countries; data for NETH and NZ are estimated. OECD average reflects the average of the most recent data available within the past six years of 36 OECD member countries, including ones not shown here.

Data: OECD Health Statistics 2026. US race and ethnicity data come from: Donna L. Hoyert, “Health E-Stat 100: Maternal Mortality Rates in the United States, 2023,” National Center for Health Statistics, Centers for Disease Control and Prevention, Feb. 2025.

Maternal mortality, deaths per 100,000 live births

OECD average: 9.5

Munira Z. Gunja, Evan D. Gumas, and Reginald D. Williams II, U.S. Health Care from a Global Perspective, 2026: Expanded Edition (Commonwealth Fund, May 2026). https://doi.org/10.26099/2egm-8b76

Two-thirds of U.S. pregnancy-related deaths occur during the postpartum period.

Notes: Data from Maternal Mortality Review Committees in 36 US states; specific timing information is missing (n=2) or unknown (n=14) for 16 (1.6%) pregnancy-related deaths.

Data: Susanna Trost et al., Pregnancy-Related Deaths: Data from Maternal Mortality Review Committees in 36 US States, 2017–2019 (Centers for Disease Control and Prevention, 2022).

Distribution of pregnancy-related deaths by timing of death in relation to pregnancy, 2017–2019

Pregnancy

Delivery/Birth

After birth (postpartum)

9 months (“prenatal”)

Day of delivery

“Late” maternal deaths �(days 43–365 postpartum)

Postpartum �deaths �(days 1–42)

65% postpartum (after birth)

The U.S. stands alone as the only high-income country where there is no federally mandated paid leave policy.

Notes: All country numbers reflect 2022 data. Information refers to paid maternity, paternity, parental and home-care leave entitlements to care for young children in place as of April 2022. Data reflect entitlements at the national or federal level only. It is assumed that: the relevant birth is of a healthy single child who is the first child in the household. For more details on assumptions, methodology, and definitions, see Organisation for Economic Co-operation and Development, “PF2.1. Parental Leave Systems,” last updated Dec. 2022. SWE does not have a separate maternity leave scheme. For AUS, it is assumed that mothers take the first 12-week block of Parental Leave Pay right after birth are recorded as maternity leave. For NZ, the weeks of primary care leave are recorded as maternity leave. For JPN, the periods of parental leave that are earmarked for fathers and mothers must be used simultaneously if both parents are to use the entirety of their entitlement.

Data: OECD Health Statistics, 2023.

Total weeks of federally mandated paid maternity, parental, and home care leave available

The U.S. stands alone as the only high-income country where there is no federally mandated paid leave policy.

What Does the Best Parental Leave Policy in the World Look Like?

All countries, apart from the U.S., guarantee at least one such home visit within one week postpartum

The U.S. and Canada continue to have the lowest supplies of midwives and ob-gyns.

Note: * The sum figures shown to the right of the horizontal bars do not reflect the total maternity care workforce, since primary care physicians/family practitioners also deliver some care in many countries (not shown here). Each sum may not reflect the arithmetic sum of figures shown for ob-gyn and midwife providers because calculations were performed on exact figures, while the graph presents rounded figures.

Data: OECD Health Statistics 2023 data extracted on February 29, 2024, representing “practicing midwives” for all countries except CAN, CHL, and US, where data reflect midwives “licensed to practice.” Data for professionals “licensed to practice” tend to be higher than data for “professionally active,” while numbers of “practicing” professionals tend to be the lowest. 2021 data for FRA, GER, NETH, NZ, NOR, SWIZ, and US (ob-gyns); 2020 data for AUS, CAN, CHL, JPN, KOR (ob-gyns), SWE, and UK; 2016 for US (midwives); 2015 for KOR (midwives).

Number of providers (head counts) per 1,000 live births*

The U.S. and Canada continue to have the lowest supplies of midwives and ob-gyns.

Chile Has Far More Midwives and Far Fewer Maternal Deaths Than the U.S.

Maternal Care in Germany and the Netherlands

​

• 4.2 maternal deaths per 100,000 live births
• Midwives outnumber ob-gyns:
• Midwifery care is considered a legal right
• Midwifery care fully covered by health insurance from prenatal to postnatal care
• Comprehensive postpartum support, including up to 36 home visits three months after giving birth
• 58 weeks of paid leave

​

​

• 4.3 maternal deaths per 100,000 live births
• The rate of midwives is more than double the rate of ob-gyns
• Midwives are integrated into the community
• Midwives are fully covered by health insurance in most instances
• Maternal care is fully covered from prenatal to postnatal care; home visits by midwives up to 10 days postpartum
• 16 weeks of paid leave

​

Germany:

The Netherlands:

Resources – Lemonada, Uncared For Season 1

Germany: Where Parents Feel Supported: https://lemonadamedia.com/podcast/germany-where-parents-feel-supported/

​

The Netherlands: Fairy Godmothers of Postpartum Care: https://lemonadamedia.com/podcast/the-netherlands-fairy-godmothers-of-postpartum-care/

​

• 25

What Can the U.S. do to Eliminate Maternal Deaths?

Access: Provide universal coverage for all women, invest in primary care, and remove cost barriers so people can get care when they need it and in a manner that works for them.

Workforce Capacity: Strengthen the maternal care workforce with an emphasis on midwifery and community-based providers

Timing is everything: Provide comprehensive postpartum support, including extending Medicaid coverage for a full year after birth.

Inequities: Address racial inequities and implicit biases in care delivery and center equity as a core principle in any future maternal health policy changes

• Source: Eric C. Schneider et al., Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries (Commonwealth Fund, Aug. 2021). https://doi.org/10.26099/01dv-h208

• 26

Access: Provide universal coverage for all women, invest in primary care, and remove cost barriers so people can get care when they need it and in a manner that works for them.

• Source: National Center for Health Statistics, Mortality data, 2018-2022. National Center for Health Statistics, Natality data, 2023.

• 27

• 28

Workforce Capacity: Strengthen the maternal care workforce with an emphasis on midwifery and community-based providers

• 29

Workforce Capacity: Strengthen the maternal care workforce with an emphasis on midwifery and community-based providers

• Sources: ¹ Bushman JS, The Role of Certified Nurse-Midwives and Certified Midwives in Ensuring Women’s Access to Skilled Maternity Care. Presentation, Nov 2015. ² http://www.unfpa.org/sowmy. ³ Shaw D, et al. Lancet. 2016;388(10057):2282-95.

• 30

Workforce Capacity: Strengthen the maternal care workforce with an emphasis on midwifery and community-based providers

• Sources: ¹ Bushman JS, The Role of Certified Nurse-Midwives and Certified Midwives in Ensuring Women’s Access to Skilled Maternity Care. Presentation, Nov 2015. ² http://www.unfpa.org/sowmy. ³ Shaw D, et al. Lancet. 2016;388(10057):2282-95.

• 31

Workforce Capacity: Strengthen the maternal care workforce with an emphasis on midwifery and community-based providers

• Sources: ¹ Bushman JS, The Role of Certified Nurse-Midwives and Certified Midwives in Ensuring Women’s Access to Skilled Maternity Care. Presentation, Nov 2015. ² http://www.unfpa.org/sowmy. ³ Shaw D, et al. Lancet. 2016;388(10057):2282-95.
• National Center for Health Statistics, “Supplemental Tables,” National Vital Statistics Report 70, no. 17 (Feb. 7, 2022).

​

• Only 11 percent of births in the U.S. are attended by a midwife and only 2 percent of births occur outside of hospital settings. Most of the U.S. midwifery workforce (95%) reports working exclusively in hospital settings.

• 32

Provide comprehensive postpartum support, including extending Medicaid coverage for a full year after birth.

• Source: https://www.aging.senate.gov/imo/media/doc/Maine%20Medicaid%20Fact%20Sheet.pdf

• 33

Provide comprehensive postpartum support, including extending Medicaid coverage for a full year after birth.

• Source: https://www.aging.senate.gov/imo/media/doc/Maine%20Medicaid%20Fact%20Sheet.pdf

• 34

Inequities: Address racial inequities and implicit biases in care delivery and center equity as a core principle in any future maternal health policy changes

• https://www.commonwealthfund.org/publications/issue-briefs/2024/feb/revealing-disparities-health-care-workers-observations

• 35

• 36

• 37

• 38

Black women in the U.S. have the highest maternal death rate in the OECD.

How the Maldives Reduce Maternal Mortality by More Than 90 Percent – While the U.S. Rate Has Since Tripled

Observations from Poland’s Abortion Ban

How Pakistan Is Boosting Health Outcomes for Mothers and Babies

Belgium Has Made IVF Affordable and Access. The U.S. Is Another Story.