In 2000, the World Health Organization embarked on an exhaustive mission to rank the health care systems of 191 countries, with the African nation Sierra Leone ranking dead last and the United States ranking 37th at the time. Since then, however, the WHO has declined to update its rankings. In its stead, The Commonwealth Fund has conducted its own evaluation of various major countries’ health care systems, ranking them broadly by five criteria: quality care, access, efficiency, equity, and the number of people living healthy lives. Its latest report was released in 2014 and included 11 countries in total.

Let’s take a look at the bottom 5 countries counting down and see where they stack up.

New Zealand

Despite neighboring Australia, the fourth best ranked country, New Zealand proved to be near dead last in equity, which measured how often poorer citizens avoided seeing the doctor when sick or didn’t get recommended tests and screenings compared to their well-off counterparts. When it came to the number of citizens living healthy lives, measured by the infant mortality rate as well as healthy life expectancy at age 60, it was also ranked 9th.

On the other hand, it was 2nd with regards to providing effective and coordinated health care.

According to the World Bank, the country spent 11 percent of its GDP on health care expenditures in 2014.

Norway

Tied with New Zealand for 7th, Norway was especially poor at taking care of its sick citizens. It ranked last in providing safe, effective, and patient-centered care.

As for its positives, Norway was 3rd in ensuring that patients had few problems with not getting primary or specialized care because of cost, though 8th in making sure that care was provided in a timely fashion. That made it overall 6th in health care access.

It spent 9.7 percent of its GDP on health care expenditures in 2014.

France

Though it ranked 1st in the WHO’s evaluation in 2000, France was ranked 9th overall this time around.

That’s likely because it was ranked dead last in ensuring health care access, and only 8th in providing quality care or being efficient. It was however 2nd in providing safe care, and its citizens were the most likely above all to lead healthy lives.

It spent 11.5 percent of its GDP on health care expenditures in 2014.

Canada

Despite the country’s reputation as a socialized paradise with free health care, Canada was only one rung below the worst performer.

Across the board, it was ranked close to last in nearly every category, though it was especially abhorrent in making their health care safe, timely, or efficient. Its highest ranking, 5th, was ensuring patients could pay for their care.

It spent 10.4 percent of its GDP on health care expenditures in 2014.

United States

Though likely coming as no surprise, the United States has continued to rank especially low among the wealthier nations of the world in health care. Indeed, it ranked last in previous versions of The Commonwealth Fund’s report published in 2004, 2006, 2007, and 2010.

In the latest report, it was last in efficiency, equity, and healthy lives, while 9th overall in providing accessible health care. This despite being the biggest spender by a wide margin. The country spent a whopping 17.1 percent of its GDP on health care expenditures in 2014.

At the time, the authors speculated that its flailing performance could be largely explained by the country’s enduring reluctance to provide universal health insurance coverage — unique among similar industrialized countries. The implementation of the Affordable Care Act in 2014 has certainly improved the insurance gap, and there are signs that it has visibly improved the health care of once-neglected Americans as well.

Because the 2014 report only looked at data taken prior to the ACA, though, the scale of that improvement is still debatable for the time being.

Read More:

The Best Countries For Older People To Live In: US Takes 9th Place, But Falls Short When It Comes To Health And Income. Read here.

90% Of Americans Now Have Health Insurance: Does Having Coverage Make You Healthier? Read here.