The Canadian healthcare system was created in 1984 by the Canada Health Act to create a system that is portable, accessible, universal, comprehensive, and publicly administered. Over the years these goals have been challenged by the changing Canadian demography and the cost of medical care.
PORTABLITY OF THE CANADIAN HEALTHCARE SYSTEM
During the past decades the cost of medical care of Canadian citizens vacationing or working outside Canada, mainly in the United States, has become a heavy load on the Canadian health system. Most provinces have limited the re-imbursement of medical consultations abroad to the cost of the same consultations in the province of origin. At the same time, the coverage of the cost of a day in hospital has been caped to 100 or 200 CAN$, when the cost of day in intensive care in the United States may cost $10,000 US or more.
Solution: payment of a private travel medical insurance was made mandatory for Canadian citizens traveling outside Canada, in order to cover 100% of any medical expenditures outside the country.
ACCESSIBILITY TO THE CANADIAN HEALTHCARE SYSTEM
Accessibility has been challenged by demography as Canadian life expectancy is increasing by three months every year. Meanwhile, the number of Canadian citizens over 65 years is increasing dramatically, which results in a corresponding increase in the cost of care given to these aging citizens. Compounding this problem is that although the number of physicians per thousand has been rising steadily, it is not rising quickly enough to match the demands of the aging population. The Fraser Institute reported in 2015, “Canada ranks 29th out of 33 high-income countries for number of practicing physicians per thousand population. ……it would seem that Canada suffers from a relative scarcity of physician services ». (The Fraser Institute also reports that delays in seeing a doctor or a specialist in a different province have not improved much over the years.)
Furthermore, according to an Oct 2017 report by the Canadian Institute for Health Information, the majority of Canadian medical school graduates are women. This is an issue because female doctors on average work 4 to 5 hours less per week than male doctors. Although this is understandable since childcare and motherhood make it more difficult for females graduates to work 60+ hours a week, this reduced number of doctors’ hours nevertheless impacts Canadian accessibility to medical care.
Solution 1: one way to combat this shortage of physicians is to increase the number of medical graduates to satisfy the demand of an aging population.
Solution 2: not only the number of graduates/medical schools shall increase, but more international medical graduates (IMGs) should be accepted as well. The low number of CARMS Family Physicians’ Residency Positions offered to IMGs is difficult to justify since these IMGs have fulfilled all the examinations administered by Canada-trained doctors, and yet are still barred from residency programs. In the province of Quebec 20% of the population has no family physician, and each year 200 foreigners are denied to enter a family program residency, although they passed successfully all the licensing exams. At one Quebec university, dozens of family medicine residency programs positions were left empty last year, although 200 IMGs were qualified for these positions. By contrast, according to The Journal of the American Osteopathic Association, 24% of trainees and 26% of practising physicians in the U.S. are IMGs—even though the U.S. does not have a doctor’s shortage
PUBLIC ADMINISTRATION OF THE CANADIAN HEALTHCARE SYSTEM
Public administration places responsibility for healthcare budgets on provincial governments, a task which becomes more challenging each year because of the aging population. In a 2013 report (“Health and Health Care for an Aging Population ») the Canadian Medical Association predicted that by 2030 the number of Canadians 65 or older will approach 25% of the total population. This increase will have a major impact on the country’s economy, society, and health care system over the next two decades.
Perhaps a paradigm shift in financial allocation is the only solution for delivering this aging population the medical care they deserve. It may be time for provisional governments to stop allocating their entire the health budgets to treating diseases, and instead allocate a high proportion of the budget to preventing chronic illnesses.
Solution: prevention of chronic illnesses.
The World Health Organization (WHO) reports that in 2018 Canada was spending 11% of its GDP on health. Cutting healthcare spending to under 10% of the GDP can only happen if prevention becomes the focus. Prevention of chronic diseases is cost effective because every dollar invested in prevention will reduce the cost of future medical care by estimates of $5 or more within 10 years (Robert Wood Johnson Foundation). Also, according to the WHO: “the major causes of chronic diseases are known, and if these risk factors were eliminated, at least 80% of all heart disease, stroke and type 2 diabetes would be prevented; over 40% of cancer would be prevented”. The problem is that 10 years does not fit into a political calendar, which is based on four-year terms.
Finland is a good example of how prevention can succeed. It went from a country which 45 years ago was ranked first in Europe for cardiac mortality to becoming one of the world’s fittest, with public and private efforts to increase physical activity, smoking limitations, and controlling the diet of Finnish citizens. This national effort has been associated with an incredible 80% reduction in their all-cause mortality within 10 years, an 8% reduction in mortality every year, according to The International Journal of Epidemiology.
The Canadian Institute for Health Information (CIHI) reported that in 2017 the cost of medication increased by 4.2% per person. A lack of budget has delayed some new medication in Canada over the past three years, which has not happened in the U.S. Plus, the new medications once approved are not readily available. Provinces restrict the large usage of new expensive drugs by requesting the physician to fill first a long authorization request, in order to have these drugs actually paid by the province; the time to fill such formularies of these Exceptional Access Programs discourage many physicians to prescribe these drugs.
The solution: price control of new medications. The efforts of the Canadian Department of Health to protect Canadians from excessive drug prices has been a necessary step to negotiate the prices of new medications with the pharmaceutical industry.
The Role of Nurses.
Provinces can also offer better medical care by favoring the role of practicing nurses. Many provinces have a nursing shortage, and the annual income for nurses varies greatly from one province to the next.
The solution: increasing the salary of nurses and develop more programs for advanced practice nursing.
The Lack of Long-Term Care Facilities
Patients with loss of function are not being transferred rapidly enough from tertiary hospitals to long-term care facilities. These facilities are not responding to the trend of Canadians living longer, say long-term care advocates. On the contrary, many provinces have been reducing public long-term care facilities, trying to favor at-home maintenance of aging citizens. Although at-home maintenance can work, there comes a point when staying at home is impossible. Long-term care facilities are the only choice.
Solution: drastic increase in public long-term care facilities.
Many adjustments will be needed to be made at the provincial and federal levels to adjust to Canada’s changing demography in order to make medical care delivery satisfactory. The sooner we get started with those changes, the smoother will be the transition.