Series Canada’s global leadership on health 1 Canada’s universal health-care system: achieving its potential Danielle Martin, Ashley P Miller, Amélie Quesnel-Vallée, Nadine R Caron, Bilkis Vissandjée, Gregory P Marchildon Lancet 2018; 391: 1718–35 Access to health care based on need rather than ability to pay was the founding principle of the Canadian health-care Published Online system. Medicare was born in one province in 1947. It spread across the country through federal cost sharing, and February 23, 2018 eventually was harmonised through standards in a federal law, the Canada Health Act of 1984. The health-care system http://dx.doi.org/10.1016/ is less a true national system than a decentralised collection of provincial and territorial insurance plans covering a S0140-6736(18)30181-8 narrow basket of services, which are free at the point of care. Administration and service delivery are highly decentralised, See Comment pages 1643, 1645, 1648, 1650 and 1651 although coverage is portable across the country. In the setting of geographical and population diversity, long waits for See Perspectives pages 1658, elective care demand the capacity and commitment to scale up effective and sustainable models of care delivery across 1659, and 1660 the country. Profound health inequities experienced by Indigenous populations and some vulnerable groups also See Series page 1736 require coordinated action on the social determinants of health if these inequities are to be effectively addressed. This is the first in a Series of Achievement of the high aspirations of Medicare’s founders requires a renewal of the tripartite social contract between two papers about Canada’s governments, health-care providers, and the public. Expansion of the publicly funded basket of services and coordinated health system and global health effort to reduce variation in outcomes will hinge on more engaged roles for the federal government and the physician leadership community than have existed in previous decades. Public engagement in system stewardship will also be crucial to Women’s College Hospital and achieve a high-quality system grounded in both evidence and the Canadian values of equity and solidarity. Department of Family and Community Medicine, University of Toronto Introduction held by its ten provinces and three territories. The (D Martin MD) and Dalla Lana Founded on Indigenous lands and the product of province of Quebec, with its unique French-speaking School of Public Health Confederation that united former British colonies in linguistic and cultural context, often charts a policy path (D Martin, G P Marchildon PhD), 1 University of Toronto, Toronto, 1867, Canada is a complex project. 36 million people from that is independent from the rest of the country. The ON, Canada; Division of General a rich diversity of ethnocultural backgrounds live on a decentralisation of the Canadian polity is expressed in its Internal Medicine, Department vast geography bounded by the Arctic, Pacific, and health-care system—known as Medicare—which is not a of Medicine, Dalhousie Atlantic Oceans, across six time zones and eight distinct national system per se, but rather a collection of provincial University, Halifax, NS, Canada (A P Miller MD); McGill climate regions. and territorial health insurance plans subject to national Observatory on Health and Canada is among the world’s most devolved federations, standards.2,3 These taxation-based, publicly funded, Social Services Reforms, with substantial political power and policy responsibility universal programmes cover core medical and hospital services for all eligible Canadians, and are free at the point of care (figure 1). Key messages To Canadians, the notion that access to health care • Canada’s universal, publicly funded health-care system—known as Medicare—is a should be based on need, not ability to pay, is a defining source of national pride, and a model of universal health coverage. It provides national value. This value survives despite a shared border relatively equitable access to physician and hospital services through 13 provincial and with the USA, which has the most expensive and territorial tax-funded public insurance plans. inequitable health-care system in the developed world.4 • Like most countries that are members of the Organisation for Economic Co-operation Canadian Medicare is more than a set of public insurance and Development (OECD), Canada faces an ageing population and fiscal constraints in plans: more than 90% of Canadians view it as an important its publicly funded programmes. Services must be provided across vast geography and source of collective pride.5 This pride points to an in the context of high rates of migration and ethnocultural diversity in Canadian cities. implicit social contract between governments, health-care • In 2017, the 150th anniversary of Canadian Confederation, the three key health policy providers, and the public—one that demands a shared and challenges are long waits for some elective health-care services, inequitable access to ongoing commitment to equity and solidarity.6 Such a services outside the core public basket, and sustained poor health outcomes for commitment is inevitably challenged in each generation Indigenous populations. by an array of external shocks and internal problems. • To address these challenges, a renewal of the tripartite social contract underpinning Currently, wait times for elective care, inequitable access Medicare is needed. Governments, health-care providers (especially physicians), and the to health services in both the public and private systems, public must recommit to equity, solidarity, and co-stewardship of the system. and the urgent need to address health disparities for • To fully achieve the potential of Medicare, action on the social determinants of health and Indigenous Canadians threaten this equity and solidarity. reconciliation with Indigenous peoples must occur in parallel with health system reform. In this first paper of a two-part Series on Canada’s health • Without bold political vision and courage to strengthen and expand the country’s health system and global health leadership,7 we analyse the system, the Canadian version of universal health coverage is at risk of becoming outdated. unique history and features of the Canadian health-care system and consider the key factors challenging domestic 1718 www.thelancet.com Vol 391 April 28, 2018 Series Department of Epidemiology, A Governance Biostatistics and Occupational Canadian Constitution Health, and Department of Sociology, McGill University, Canada Health Act Provincial and territorial Montréal, QC, Canada Federal government Canada Health Transfer and governments A Quesnel-Vallée PhD); other transfer payments Provincial and Department of Surgery, territorial medical Northern Medical Program and Federal Minister associations Federal Minister of Health Federal–provincial– Provincial and territorial Centre for Excellence in of Indigenous Services Negotiations territorial conferences, Ministers of Health Indigenous Health, University committees Health professional of British Columbia, Prince Health Canada unions George, BC, Canada Collaborative contributors Eligible Canadians (N R Caron MD); School of Public Health to multiple pan-national First Nations Nursing and Public Health Agency of Canada organisations, such as Inuit Regional health Research Institute, Université • Canadian Agency for Drugs Canadian Forces Canadian Institutes authorities de Montréal, SHERPA Research and Technologies in Health Eligible veterans of Health Research Centre, Montréal, QC, Canada • Canadian Institute for Health Federal inmates (B Vissandjée PhD); and Patented Medicine Information Some refugees Johnson-Shoyama Graduate Prices Review Board • Canada Health Infoway School of Public Policy, Canadian Food University of Regina, Regina, Inspection agency SK, Canada (G P Marchildon) Correspondence to: Dr Danielle Martin, Women’s College Hospital, Toronto, Direct reporting relationship ON M5S 1B2, Canada Health-care coverage and delivery: layer one and some layer two Arm’s length relationship [email protected] B Coverage Services Funding Administration Delivery Layer one Hospitals Public taxation Universal single-payer systems Private professional for-profit and Public services (Medicare): Physicians Private self-regulating not-for-profit facilities, and public all public funding Diagnostics professions arm’s length facilities Layer two Prescription drugs Public taxation Public coverage is targeted Private professional for-profit and Mixed services: Home care Private insurance Public regulation of not-for-profit facilities, and public combination of public and Long-term care Out-of-pocket payments private services arm’s length facilities private funding Mental health care Layer three Dental care Primarily private insurance, Private ownership Private professional for-profit facilities Private services: Vision care out-of-pocket payments, Private professions almost all private funding Complementary medicine with some public taxation Limited public regulation Outpatient physiotherapy Figure 1: Overview of the Canadian health system Adapted from references 2 and 3. policy makers and the system’s potential to be a model for Social Democratic Premier of Saskatchewan, he imple- the world. We then propose a renewal of the tripartite mented universal public health insurance for the province, social contract in service of accessible, affordable, high- making it the first jurisdiction with