Intended for healthcare professionals

Education And Debate

Decentralised health care in Canada

BMJ 1999; 318 doi: (Published 01 May 1999) Cite this as: BMJ 1999;318:1201
  1. Pat Armstrong, director (,
  2. Hugh Armstrong, associate professorb
  1. aSchool of Canadian Studies, Carleton University, Ottawa, ON, Canada K1S 5B6
  2. bSchool of Social Work, Carleton University
  1. Correspondence to: Dr Hugh Armstrong

    Editorials by Leys and Diderichsen

    An indicator of the size of Canada is that St John's, Newfoundland, is equidistant from Moscow and Dawson City, Yukon. Yet Canada has a population of just over 30 million. Its 10 provinces vary in population from tiny Prince Edward Island with under 140 000 inhabitants to Ontario with well over 11 million. Its three territories together have barely 100 000 residents spread over 3.9 million square kilometres of land.

    Since Canada became a nation in 1867, health care has been primarily the responsibility of the provinces

    It is no surprise, then, that since its inception the Canadian public healthcare system has been decentralised. Since Canada became a nation in 1867, health care has been primarily a responsibility of the provinces. They have strongly defended their rights, and have often been supported by private insurers and providers in their resistance to a national health system. Yet the 1937 Royal Commission on Dominion-Provincial Relations emphasised the chaotic financial results on business if some provinces, acting independently on health insurance, levied taxes on employers that placed them in a less competitive position with respect to business in provinces that did not.1 Thus, when a public healthcare system became a top priority after the second world war, planners sought to balance local control with the need for some degree of uniformity throughout Canada, and therefore in the collection of tax contributions by the federal government.

    The federal government, unable to achieve federal-provincial consensus, used its spending power to bring provinces into a national plan. The strategy was simple. Making an offer no province could resist, the federal government promised to pay half the costs of hospitals and, later, of doctors' services, as long as the provinces conformed to some basic principles. These two initiatives were later brought …

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