A common observation is that both single- and multi-payer health care systems will achieve lower overall costs if they use primary care gatekeeping. Questioning this common wisdom, we focus on the health care access system, that is, the way in which patients gain access to health care. Gatekeeping, the use of primary care providers to control access to more specialized physician and hospital services, has come under intense scrutiny in the United States and in Europe. The few international comparative studies that have focused on the issues of quality of care, cost containment, and patient satisfaction find weak or no support for common assumptions about gatekeeping. Hence, we examine the institutional environments in seven countries in order to: (a) define and categorize health care access systems; (b) identify the components of a health care access system; (c) explore the notion of a strategic fit between health care financing systems and access system configurations; and (d) propose that the health care access system is a key determinant of process-level cost efficiency. Drawing upon institutional and governance theories, we posit that the structure and organization of an access system is determined by how it addresses six essential questions: Who is covered? Which services are included? What are the points of access? How much time elapses before access? What are the ways of selecting among points of access? and Are services and their quality the same for everyone? This analytical framework reveals that national health care access systems vary the most in their points of access, access times, and selection mechanisms. These findings and our explanations imply that access systems are one of the only tools for demand management, that any lasting change to an access system typically is implemented over an extended time period, and that managers of health care organizations often have limited freedom to define governance structures and shape health care service production systems. © 2005 Elsevier Ltd. All rights reserved.