The purpose of this chapter is to reflect on the main trajectories of change that have characterized the health systems of OECD countries in the last three decades, from the fall of the Berlin Wall to the present day. For this purpose, it is possible to identify five major "reform themes" which traveled transversally through countries generating processes of emulation and policy transfer. The five major reform themes are as follows: (1) stimulation of greater competition; (2) promotion of integration (both in terms of financing and provision); (3) decentralization; (4) strengthening the rights of the patient; (5) extension of insurance coverage. For most of these five themes it is possible to identify a reform that has acted as a forerunner, which other countries have subsequently been inspired by and followed.