Life expectancy in Canada exceeds the EU average by a year for women and a year and a half for men. Canada is the second largest country geographically in the world, with a dispersed population, and has a federal system of government with 10 provinces and two territories. Details of healthcare may differ from province to province, but the principles remain the same. Since 1972, every Canadian has been covered by national health insurance for medical and hospital care. Saskatchewan was the first province to introduce public insurance for hospital services in 1947. It was also the first province to extend cover to all medical care from 1962 despite a three-week physicians' strike.
Universal coverage, free at the point of delivery, is now provided to all Canadians for all "medically necessary services". Canadians who take out private health insurance do so to cover what are regarded as non-medical necessary services such as dental care, physiotherapy and prescription drugs. It is not legal to use private health insurance to gain faster access to medical services from publicly funded hospitals and physicians.
There is, however, a growing debate in Canada about extending the role for private health insurance. Prof Thomas Rathwell from Dalhousie University, Nova Scotia, visited Ireland last year to study our system and in a paper entitled Private Medical Insurance in Canada - Panacea or Pandora's Box argued that to extend the role for private insurance "would create a two-tier system whereby those with private insurance would get preferential treatment. This is clearly something to be avoided.
"There is acceptance in Ireland that the current public-private mix in healthcare does create a two-tier structure with those wholly dependent upon the public system getting a lesser level of service," he wrote.
While arguing against the extension of private insurance, Prof Rathwell recommended that if Canada were to do so "drawing on the Irish experience, the conditions to avoid are the designation of private beds in public hospitals and permitting specialists to have both a public and private practice".
Canadians pay for their healthcare through their federal government tax, which is channelled to the provinces. The administration and purchase of healthcare is then managed by a provincial health insurance plan, which is accountable to each provincial government. These health insurance plans are non-profit making and in each province act as the single purchaser of healthcare either from non-profit hospitals which are generally owned by charitable bodies, religious orders or municipalities, or from physicians, who are mostly self-employed. The plans operate either from within the Ministry of Health or through a separate agency closely linked to the ministry.
Provinces will not receive full federal funds unless they adhere to the Canada Health Act. The unanimous passage of this legislation by the Federal Parliament in 1984 in the teeth of much opposition from organised medicine was an indication of how seriously Canadians view equal access to healthcare. The Act strengthens the application of the five national principles which govern Canadian healthcare:
- universal coverage: 100 per cent of the insured population must receive the same services on the same terms and conditions;
- comprehensive coverage: the plan must cover all insured health services;
- reasonable access: no barriers such as user charges or extra billing;
- portability of coverage: when Canadians move within Canada and sometimes abroad;
- public administration of the insurance plans on a non-profit basis.
The Act provided for financial penalties for provinces that permitted hospital user charges or physician extra-billing.
Historically, Canada has spent much more on healthcare than the Republic. Canadian and Irish gross domestic product (GDP) per capita are now comparable, although, since Irish GDP overstates national income because it includes multinationals' profits, Canada is a wealthier country than Ireland.
Total health spending in Canada has exceeded 9 per cent of GDP since 1989, peaking at 10.1 per cent in 1992. At 9.2 per cent of GDP last year, it compares with an estimated Irish figure of 6.8 per cent of GDP and more than 8 per cent of gross national product (GNP). As the graph for per capita health spending makes clear, although Irish spending may be converging on Canadian levels there have been decades of comparative under-investment in Irish healthcare. In 1989, after a decade of cutbacks, Irish per capita public spending on health was 41 per cent of the Canadian level.
Doctors in Canada are paid primarily on a fee-for-service basis. Their payments are defined in detailed lists of fees based on negotiations between provincial governments and medical associations. The Canadian Institute for Health Information records that in 1997/98 insurance plans typically paid doctors an average of $29.50 (IR£16.70 at 1997 exchange rates) for services such as consultations and visits. Fees for surgical procedures varied from $94 (£53) for a vasectomy to $1,100 (£624) for cardiac bypass surgery.
Family doctors' gross incomes averaged $177,191 (£100,507) and specialists $239,322 (£135,750). These gross incomes must also cover practice expenses such as office and secretarial support, which the Canadian Medical Association estimates range between 26 and 42 per cent of income.
Some provinces have sought to limit doctors' earnings. In Ontario, earnings are capped at $400,000 (£250,000) for gross income, although cardiac surgeons and radiation oncologists may earn above this. However, most provinces have stopped capping and instead are looking at changing the model of payment from fee-for-service.
Canadians think they have a waiting-list problem. "Reports of lengthy queues and waits for care have been interpreted as evidence that the healthcare system is failing," one Canadian think-tank study commented.
While there is no such thing as a Canada-wide waiting list, a study by the conservative Fraser Institute reported last month that waiting times for patients between their GP referrals to eventual surgical treatments, averaged across all 12 specialities and 10 provinces surveyed, had risen from 13.1 weeks in 1999 to 16.2 weeks in 2000/2001.
"Canadians wait longer than Americans and Germans for cardiac care although not as long as New Zealanders or the British," the institute commented.
In reality, compared to Irish waiting times, Canada's are in another universe. It is instructive to compare the Fraser Institute's figures with Irish waiting lists. In Ireland, the length of time between a general practitioner's referral and seeing a specialist is not counted as waiting-list time. Even when Irish patients see a specialist and are recommended for surgery, they must wait a further three months before they are officially judged to be "waiting" and finally qualify for inclusion on the waiting list, according to the Harvard Association study published this summer.
When the Fraser Institute excluded the time between a GP's referral and seeing a specialist - as is the Irish practice - and only counted the time between seeing a specialist and undergoing surgery, Canadians waited on average eight weeks for treatment in 1999 and nine weeks in 2000. At that rate, the average Canadian (and this means all Canadians since there are no public and private patients) would never achieve the three-month wait which would warrant inclusion on an Irish "waiting" list.
Furthermore, the Fraser Institute's study has been criticised as overstating Canadian "waiting lists" because it is based on physicians' subjective impressions rather than observed patient experience. Other studies have recorded decreases in waiting times. The Canadian Institute for Health, in its annual reports, has recorded some waiting-time data. In British Columbia in 1999, the median wait ranged from 2.4 weeks for vascular surgery to 4.3 months for corneal transplants. Ontario's Cardiac Care Network recorded that patients in need of emergency bypass surgery had median waits of three days in 2000; which rose to eight days for semi-urgent cases and 44 days for elective cases.