Canada's healthcare system isn't in quite the shambles
everyone thinks, according to a major new report commissioned
by the World Health Organization (WHO). In fact, even
in areas where we think we're doing poorly — such
as public expenditure and stroke care — we're not
doing too badly, especially compared to other wealthy
nations.
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In the beginning...
Public healthcare origins
around the world
Germany: Considered the
true pioneer of public healthcare, Germany passed
its national health insurance law back in 1883
as part of a broad social welfare scheme. Barring
the dark interlude of the Nazi regime, which revoked
coverage for Jews and Socialists, the modern system
has been in continual evolution since.
Sweden: Another very
old system, Sweden's County Councils began offering
hospital services in 1928 and through a series
of reforms culminating in the 1946 National Health
Insurance Act the modern system took shape.
UK: The government of
David Lloyd George introduced the very modest
National Health Insurance Act of 1911, which provided
healthcare coverage to workers in certain occupations.
The National Health Service Act of 1946
brought universal healthcare to the UK.
Canada: Saskatchewan's
1947 universal hospital insurance would serve
as the model for the federal Medical Care Act
of 1966. The system was further solidified by
the 1984 Canada Health Act.
France: This elaborate
system has roots in the 19th century. Key developments
along the way include a 1930 law which provided
insurance to over half the population and a 1974
law which expanded coverage to all citizens.
USA: In 1965, Lyndon
B Johnson's administration created Medicaid, the
welfare health program for the very poor and Medicare,
an entitlement healthcare program mainly for seniors.
The US does not provide universal coverage.
Australia: In 1948, legislation
was passed to create a public health system akin
to Britain's. The Supreme Court found it unconstitutional,
and only a small part of the bill, a public prescription
drug plan, survived. The 1973 Health Insurance
Act brought in Medicare. In 1976 a government-run
voluntary supplementary program called MediBank
Private was added.
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This wasn't exactly what the report's
author, Gregory Marchildon, PhD, Research Chair in Public
Policy and Economic History at the University of Saskatchewan,
was expecting. "One of the biggest surprises was how
well Canada compared on the population health indicators
— better than I expected," says Dr Marchildon.
The 156-page report entitled Health
Systems in Transition: Canada, was released in April
and is part of a series of studies by the WHO's European
Observatory on Health Systems and Policies. Dr Marchildon
hopes physicians will find the 'eagle eye' sketch of
our system in his work useful. To put the whole thing
in context he compared our system to those of the US,
UK, France, Sweden and Australia.
So did he discover a healthcare
system out there that's eerily similar to our own? "No,"
he says bluntly. "In reality there are such significant
differences that I'd be hesitant to say that any country
really looks like Canada or that there are even two
countries out there that look alike. I came to realize
that because of very different histories and institutions
countries are going to produce different healthcare
outcomes."
LOOK
DOWN UNDER
Still, we can learn a lot by comparing our system to
those in similarly developed countries and perhaps the
most apt is Australia. "You can certainly see many of
the same sort of tensions we have in Canada in Australia,
which is also a federal system," says Dr Marchildon.
"Australia's commonwealth-state government meetings
have the same sort of calls for more money from the
states as our federal-provincial summits and the same
tensions over who does what."
In fact, this kind of funding tug-of-war
seems to be part and parcel of any federal system. In
Germany you'll find the Lènder frequently squabbling
with the feds in Berlin. And there's a lot more wrangling
over public health dollars between Washington and the
50 states than the casual observer would think.
Australia also shares two of Canada's
biggest problems, namely regional income disparities
and dreadful outcomes for aboriginal people. "I think
this a very important comparison," opines Dr Marchildon.
Australia's Health Systems in Transition report concluded
that: "Despite a generally positive assessment, there
is dissatisfaction with particular aspects (such as
long hospital waiting lists), and among particular population
groups (such as people in rural areas).... [T]he health
status of Aboriginal Australians remains abysmal."
SICKENINGLY
SWEDE
Sweden is regularly lauded as the best public system
in the world. On the surface, the Scandinavian nation
seems to be doing much better than Canada. It boasts
a higher life expectancy, lower infant mortality rate,
a better doctor-to-patient ratio and lower public expenditures.
But there's more than meets the eye. "Are they getting
a bigger bang for their public dollar?" muses Dr Marchildon.
"Maybe. But a bigger bang for their dollar overall,
I'm not so sure — there was a very significant
constraint on public expenditures during the 1990s and
a huge spike in private expenditure during this same
period." (See the chart "Who spends what" below for
more details.)
THE
BAD NEWS
The fact remains there are areas where Canada lags far
behind other similar countries. "I was surprised at
the mixed results of healthcare outcome rankings, some
were moderate-to-poor — like cancer," says Dr Marchildon
(see "How we die" below for rankings). "I wasn't quite
expecting that. More work needs to be done figuring
out why our infant mortality rates are what they are,
especially given how wealthy this country is and how
much we invest in healthcare. Clearly we should be seeing
better results."
Health Systems in Transition: Canada
is published by the University of Toronto Press ($25).
You can read a truncated version for free at www.euro.who.int/observatory/hits/TopPage
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