Health Systems in Transition Canada - 3rd Edition
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Canada v
9 Appendices 169
9.1 References 169
9.2 Useful websites 189
9.3 HiT methodology and production process 190
9.4 The review process 192
9.5 About the authors 193
Index 195
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PREFACE
The Health Systems in Transition (HiT) series consists of country-based
reviews that provide a detailed description of a health system and of reform
and policy initiatives in progress or under development in a specific country.
Each review is produced by country experts in collaboration with staff at
the North American Observatory on Health Systems and Policies and the
European Observatory on Health Systems and Policies. In order to facilitate
comparisons between countries, reviews are based on a template prepared
by the European Observatory, which is revised periodically. The template
provides detailed guidelines and specific questions, definitions and examples
needed to compile a report.
HiTs seek to provide relevant information to support policy-makers and
analysts in the development of health systems in Europe and other countries.
They are building blocks that can be used to:
learn in detail about different approaches to the organization,
financing and delivery of health services, and the role of the main
actors in health systems;
describe the institutional framework, process, content and imple-
mentation of health care reform programmes;
highlight challenges and areas that require more in-depth analysis;
provide a tool for the dissemination of information on health
systems and the exchange of experiences of reform strategies
between policy-makers and analysts in different countries; and
assist other researchers in more in-depth comparative health
policy analysis.
Compiling the reviews poses a number of methodological problems. In
many countries, there is relatively little information available on the health
system and the impact of reforms. Due to the lack of a uniform data source,
quantitative data on health services are based on a number of different
viii Health Systems in Transition
sources, including data from national statistical offices, the Organisation
for Economic Co-operation and Development (OECD), the International
Monetary Fund (IMF), the World Bank’s World Development Indicators
and any other relevant sources considered useful by the authors. Data col-
lection methods and definitions sometimes vary, but typically are consistent
within each separate review.
A standardized review has certain disadvantages because the financing
and delivery of health care differ across countries. However, it also offers
advantages because it raises similar issues and questions. HiTs can be used
to inform policy-makers about experiences in other countries that may be
relevant to their own national situations. They can also be used to inform
comparative analysis of health systems. This series is an ongoing initiative
and material is updated at regular intervals.
Comments and suggestions for the further development and improve-
ment of the HiT series are most welcome and can be sent to
[email protected].
who.int.
HiTs and HiT summaries are available on the Observatory’s website
(http://www.healthobservatory.eu).
ACKNOWLEDGEMENTS
The Health Systems in Transition (HiT) profile on Canada was co-produced
by the European Observatory on Health Systems and Policies and the North
American Observatory on Health Systems and Policies (NAO) in Canada,
which is a member of the Health Systems and Policy Monitor (HSPM)
network. The NAO is a collaborative partnership of interested researchers,
governments and health organizations promoting evidence-informed health
system decision-making with academic directors in Canada, the United
States of America and Mexico. The NAO partnership secretariat is hosted by
the Institute of Health Policy, Management & Evaluation at the University
of Toronto. The HSPM is an international network that works with the
Observatory on Country Monitoring. It is made up of national counterparts
that are highly regarded at national and international level and have particular
strengths in the areas of health systems, health services, public health and
health management research. They draw on their own extensive networks in
the health field and their track record of successful collaboration with the
Observatory to develop and update the HiT.
This 2020 edition was written by Gregory P Marchildon and Sara Allin
(NAO, University of Toronto). It was edited by Sherry Merkur (European
Observatory on Health Systems and Policies). The basis for this edition
was the previous HiT on Canada, which was published in 2013, writ-
ten by Gregory P Marchildon and edited by Anna Sagan. The European
Observatory on Health Systems and Policies and NAO are grateful to
Robert S Bell (former Deputy Minister of Health and Long-Term Care
in Ontario), Colleen M Flood (Director, University of Ottawa Centre for
Health Law, Policy and Ethics), Kathleen Morris (Vice President, Research
and Analysis, Canadian Institute for Health Information) and her col-
leagues at the Canadian Institute for Health Information, and Anna Maresso
(European Observatory on Health Systems and Policies) for reviewing the
report. The authors are also grateful to Michael Sherar, University of Toronto,
for research assistance, and to Stephen Lucas (Deputy Minister) and his
x Health Systems in Transition
colleagues at Health Canada as well as those at the Public Health Agency
of Canada, the Canadian Institutes of Health Research, Employment and
Social Development Canada, Global Affairs Canada and Indigenous Services
Canada who reviewed specific sections of the HiT. Thanks are also extended
to the OECD for their Health Statistics Database and to the World Bank
for their World Development Indicators.
The HiT uses data available in November 2019, unless otherwise indicated.
The HiT reflects the organization of the health system, unless otherwise
indicated, as it was in June 2020. The European Observatory on Health
Systems and Policies is a partnership, hosted by WHO/Europe that includes
the Governments of Austria, Belgium, Finland, Ireland, Norway, Slovenia,
Spain, Sweden, Switzerland, the United Kingdom and the Veneto Region
of Italy; the French National Union of Health Insurance Funds (UNCAM);
the Health Foundation; the European Commission; the World Bank; the
London School of Economics and Political Science (LSE); and the London
School of Hygiene & Tropical Medicine (LSHTM). The Observatory is
composed of a Steering Committee, core management team, research policy
group and staff. Its Secretariat is based in Brussels and has offices in London
at LSE, LSHTM and the Berlin University of Technology. The Observatory
team working on HiTs is led by Josep Figueras, Director; Elias Mossialos,
Martin McKee, Reinhard Busse (Co-directors); Ewout van Ginneken and
Suszy Lessof. The Country Monitoring Programme of the Observatory
and the HiT series are coordinated by Anna Maresso. The production and
copy-editing process was coordinated by Jonathan North.
LIST OF ABBREVIATIONS
AND ACRONYMS
ALC alternate level of care
ALOS average length of stay
BC British Columbia
BMI body mass index
CADTH Canadian Agency for Drugs and Technologies in Health
CHA Canada Health Act
CHST Canada Health and Social Transfer
CHW Committee on Health Workforce
CIHI Canadian Institute for Health Information
CIHR Canadian Institutes of Health Research
CMA Canadian Medical Association
COPD chronic obstructive pulmonary disease
CPAC Canadian Partnership Against Cancer
CPHA Canadian Public Health Association
ED emergency departments
EHR electronic health records
EMR electronic medical records
EPF Established Programs Financing
FFS fee-for-service
FPT federal, provincial and territorial
GDP gross domestic product
GP general practitioner
GRF general revenue funds
HALE health-adjusted life expectancy
HHR health human resource
ICT information and communications technology
IHD ischaemic heart disease
xii Health Systems in Transition
IMG international medical graduates
LHIN Local Health Integration Networks
LTC long-term care
NGO nongovernmental organizations
NIHB non-insured health benefits
OECD Organisation for Economic Co-operation and Development
OOP out of pocket
PAHO Pan American Health Organization
PCHO pan-Canadian health organizations
PHA provincial health authorities
PHAC Public Health Agency of Canada
PMPRB Patent Medicine Prices Review Board
PT provincial and territorial
RCPSC Royal College of Physicians and Surgeons of Canada
RHA regional health authorities
RN registered nurse
UHC universal health coverage
UK United Kingdom
USA United States of America
WHO World Health Organization
LIST OF TABLES,
FIGURES AND BOXES
Tables
TABLE 1.1 Population and percentage of the Canadian provinces and
territories (capital cities in parentheses), 2019 4
TABLE 1.2 Trends in population/demographic indicators in Canada,
selected years 4
TABLE 1.3 Macroeconomic indicators, selected years 7
TABLE 1.4 Mortality and health indicators, selected years 11
TABLE 1.5 Health status, Canada and selected countries, latest available year 11
TABLE 1.6 Main causes of death in Canada and selected countries by
sex, latest available year 12
TABLE 1.7 Percentage of the population with measured body weight
as overweight and obese, aged 15 and older, Canada and
selected countries, latest available years 14
TABLE 1.8 Obesity, based on self-reported height and weight (% of population) 15
TABLE 2.1 Chronology of the evolution of universal health coverage in
Canada, 1946–1984 19
TABLE 2.2 Five funding criteria of the Canada Health Act (1984) 22
TABLE 2.3 Arm’s-length health administration and service agencies in Canada 25
TABLE 2.4 Pan-Canadian health organizations (PCHOs), in order of
budgetary size in 2018 30
TABLE 2.5 Health Canada’s medical device classification under the Food
and Drugs Act 45
TABLE 2.6 Patient information 47
TABLE 2.7 Patient choice for universal health coverage services 48
TABLE 2.8 Patient rights 51
xiv Health Systems in Transition
TABLE 3.1 Trends in health expenditure in Canada, 2000–2018 (selected years) 54
TABLE 3.2 Expenditure on health (as % of total current health expenditure)
according to function and type of financing, 2018 (provisional) 61
TABLE 3.3 Summary of OOPs and protection mechanisms for outpatient
prescription drugs 66
TABLE 4.1 Inpatient hospitalization rates in acute care hospitals (per
100 000 population) in Canadian provinces and territories,
age- and sex-standardized, 2010–2011 and 2017–2018 83
TABLE 4.2 Operating indicators for hospital-based acute care in Canada
and selected countries, latest available year 83
TABLE 4.3 Number of selected diagnostic imaging exams, per 1 000
population, in Canada and selected countries, latest available year 86
TABLE 4.4 Number of selected imaging technologies per million
population by province, 2017 86
TABLE 4.5 ICT Development Index (IDI) levels based on 11 indicators,
level and rank, in Canada and selected countries, 2010 and 2017 88
TABLE 4.6 Use of health IT by primary care physicians (% of physicians), 2019 88
TABLE 4.7 Supply of selected health professions, per 100 000 population,
for available provinces and territories, 2008, 2013 and 2017 93
TABLE 4.8 Health workforce density by province and territory, rate per
100 000 population, 2017 94
TABLE 7.1 Patient views on waiting times, access and health systems,
2016 (% of respondents in the 2016 Commonwealth Fund
International Health Policy Survey of Adults) 143
TABLE 7.2 Percentage of patients receiving care within pan-Canadian
benchmarks, by province, 2018 144
TABLE 7.3 Unmet needs for a medical examination (due to cost, waiting
time) by income (% of respondents), 2016 147
TABLE 7.4 OOP spending relative to private health insurance coverage
for non-medicare services, amount ($ billions) and % of total
health care spending in Canada, 2017 149
Figures
FIG. 1.1 Map of Canada 2
FIG. 2.1 Overview of the health system: Canada 24
Canada xv
FIG. 3.1 Current health expenditure as a share (%) of GDP in OECD
countries, 2018 56
FIG. 3.2 Trends in current health expenditure as a share (%) of GDP in
Canada and selected countries, 2000–2018 57
FIG. 3.3 Current health expenditure in US$ PPP per capita in OECD
countries, 2018 58
FIG. 3.4 Public expenditure on health as a share (%) of current health
expenditure in OECD countries, 2018 59
FIG. 3.5 Public expenditure on health as a share (%) of general
government expenditure in OECD countries, 2015 or latest
available 60
FIG. 3.6 Financial flows in Canada 62
FIG. 4.1 Hospital beds per 1 000 population in Canada and selected
countries, 2000–2018 82
FIG. 4.2 Practising nurses and physicians per 1 000 population, 2018 or
latest available year 91
FIG. 4.3 Number of physicians per 1 000 population in Canada and
selected countries, 2000–2018 91
FIG. 4.4 Number of nurses per 1 000 population in Canada and
selected countries, 2000–2018 92
FIG. 5.1 Patient pathway 108
FIG. 7.1 Share of households that experienced catastrophic health
expenditure, 2010 or latest available year (10% threshold) 152
FIG. 7.2 Avoidable hospital admission rates for asthma, COPD,
congestive heart failure, hypertension, and diabetes-related
complications, 2017 or latest available 154
FIG. 7.3 In-hospital mortality rates (deaths within 30 days of
admission) for admissions following acute myocardial
infarction, haemorrhagic stroke and ischaemic stroke, Canada
and selected countries 155
FIG. 7.4 Cancer survival rates for breast cancer (among women), colon
cancer, and leukaemia (among children) 156
FIG. 7.5 Amenable and preventable mortality in Canada and selected
countries, 2000–2016 158
FIG. 7.6 Causes of amenable deaths in Canada, 2000 and 2016 159
xvi Health Systems in Transition
Boxes
BOX 3.1 What are the key gaps in coverage? 67
BOX 3.2 Is health financing fair? 69
BOX 3.3 Are resources put where they are most needed? 72
BOX 4.1 Are hospitals properly distributed in Canada? 84
BOX 4.2 Are health care workers (doctors and nurses) appropriately
distributed in Canada? 95
BOX 5.1 Are public health interventions making a difference? 106
BOX 5.2 What are the key strengths and weaknesses of primary care? 110
BOX 5.3 Are efforts to improve integrated care working? 112
BOX 5.4 What do patients think of the hospital care they receive? 113
BOX 5.5 Is there waste in pharmaceutical spending? 118
ABSTRACT
This analysis of the Canadian health system reviews recent developments in
organization and governance, health financing, health care provision, health
reforms and health system performance. Life expectancy is high, but it plateaued
between 2016 and 2017 due to the opioid crisis. Socioeconomic inequalities
in health are significant, and the large and persistent gaps in health outcomes
between Indigenous peoples and the rest of Canadians represent a major
challenge facing the health system, and society more generally. Canada is a
federation: the provinces and territories administer health coverage systems for
their residents (referred to as “medicare”), while the federal government sets
national standards, such as through the Canada Health Act, and is responsible
for health coverage for specific subpopulations. Health care is predominantly
publicly financed, with approximately 70% of health expenditures financed
through the general tax revenues. Yet there are major gaps in medicare, such
as prescription drugs outside hospital, long-term care, mental health care,
dental and vision care, which explains the significant role of employer-based
private health insurance and out-of-pocket payments. The supply of physi-
cians and nurses is uneven across the country with chronic shortages in rural
and remote areas. Recent reforms include a move towards consolidating
health regions into more centralized governance structures at the provincial/
territorial level, and gradually moving towards Indigenous self-governance
in health care. There has also been some momentum towards introducing a
national programme of prescription drug coverage (Pharmacare), though
the COVID-19 pandemic of 2020 may shift priorities towards addressing
other major health system challenges such as the poor quality and regula-
tory oversight of the long-term care sector. Health system performance has
improved in recent years as measured by in-hospital mortality rates, cancer
survival and avoidable hospitalizations. Yet major challenges such as access
to non-medicare services, wait times for specialist and elective surgical care,
and fragmented and poorly coordinated care will continue to preoccupy
governments in pursuit of improved health system performance.
