In 1990 the national health services in the United Kingdom and Sweden started to split up in internal markets with purchasers and providers. It was also the year when Brazil started to implement a national health service (SUS) inspired by the British national health service that aimed at principles of universality, equity, and integrality. While the reform in Brazil aimed at improving equity and effectiveness, reforms in Europe aimed at improving efficiency in order to contain costs. The European reforms increased supply and utilization but never provided the large increase in efficiency that was hoped for, and inequities have increased. The health sector reform in Brazil, on the other hand, contributed to great improvements in population health but never succeeded in changing the fact that more than half of health care spending was private. Demographic and epidemiological changes, with more elderly people having chronic disorders and very unequal comorbidities, bring the issue of integrality in the forefront in all 3 countries, and neither the public purchaser provider markets nor the 2-tier system in Brazil delivers on that front. It will demand political leadership and strategic planning with population responsibility to deal with such challenges.