The literature review the authors have used in their research The authors propose an empirical investigation of the technical effectiveness of healthcare systems in 21 middle-income countries based on the works of scholars such as Lovell, who analyzes the relationship between technical and productive efficiency. The concept of technical efficiency in the health sector and related issues such as cost-effectiveness and value for money are among the most widely discussed aspects of the health system (Nassar et al., 2020). These concepts show how effectively the resources invested in the healthcare system in the form of financial investments are used in terms of fulfilling the goals of the healthcare system. The authors also analyze technical efficiency on the macro and micro levels. This research is based on the works of Wagstaff, Zuckerman, Chirikos, Magnussen, Colombia, and others. The used studies help the authors to conclude that the technical performance of the selected countries serves as an indicator of the extent to which the system can minimize the use of resources to achieve specified outputs (Nassar et al., 2020). The system seeks to provide maximum intermediate results for a given level of resources. In either case, any deviation of performance indicators from the maximum possible level is evidence of technical inefficiency or waste. The stylized facts used in the research One of the stylized facts used in the research is the fact that health indicators have improved significantly in most middle-income countries over the past 30 years. Life expectancy has increased from 64.1 to 71.7 years (Nassar et al., 2020). A similar improvement is also observed in the rates of infant, neonatal and under-five mortality. Besides, the maternal mortality rate fell from 295 to 177 per 100,000 births during the period between 2000 and 2017 (Nassar et al., 2020). Despite health gains in middle-income countries, where the number of doctors and nurses has increased slightly, it remains correspondingly lower than in high-income countries. However, the number of hospital beds fell from 3.1 in 1990 to 2.4 in 2011 in middle-income countries and remained lower than in high-income countries with four beds per 1000 people (Nassar et al., 2020). Some middle-income countries continue to suffer from high per capita personal spending on health care, with disastrous consequences for the poorest segments of the population. The results of the study The results of the study show that the top-performing countries are Vietnam, Mexico, and China, which have adopted a social health insurance system. It covers almost the entire population intending to increase access to health services. Besides, decentralization in the health sector has helped to adopt health policies based on specific health conditions and needs of the regions. The least efficient countries are South Africa, Russia, and India (Nassar et al., 2020). This suggests that 21 middle-income countries are performing at a relatively high level on average. Less efficient countries can achieve efficiency gains by adopting long-term policies aimed at reforming the structure of the health care system, for example, a compulsory insurance system. The implications of the study