Education And Debate

The future of health care in Canada

BMJ 2001; 323 doi: (Published 20 October 2001) Cite this as: BMJ 2001;323:926
  1. Steven Lewis, adjunct professor,
  2. Cam Donaldson, Canadian Institutes of Health Research senior investigator (,
  3. Craig Mitton, PhD candidate,
  4. Gillian Currie, assistant professor
  1. Centre for Health and Policy Studies (CHAPS), Department of Community Health Sciences, University of Calgary, 3330 Hospital Dr NW, Calgary, AB T2N 4N1, Canada
  1. Correspondence to: C Donaldson
  • Accepted 25 June 2001

Canada's healthcare system, commonly known as Medicare, took shape in the 1950s and '60s. Founded on the principles of universality, accessibility, comprehensiveness, portability, and public administration, the system was considered the crown jewel of Canadian social programming and enjoyed both massive public support and international admiration. Its achievements seemed particularly impressive compared with those of its US neighbour, which realised none of these five principles despite much higher costs. The issue seemed settled, and health care ranked very low on policymakers' list of concerns, particularly at the national level.

Times have changed, and a decade of turbulence has transformed Medicare from icon of Canadian values and organisational know how to an apparent state of crisis.1 A further blow to an already-shaken collective psyche was the publication of the World Health Organization report that rated Canada's healthcare system 30th in the world in terms of achievement relative to potential.2 (The media chose to downplay its seventh place ranking in terms of goal attainment, further promoting the air of crisis.) Has Medicare gone wrong, and, if so, what went wrong?

Summary points

Canadians continue to favour a publicly funded, comprehensive healthcare system but seem pessimistic about whether it is sustainable

Increasing privatisation, in numerous forms, has crept into the system

Numerous reports have called for substantial reforms, but achieving a consensus based solution remains elusive

To date, the government has simply given more resources to the system, while largely ignoring calls to enhance its comprehensiveness and accessibility

Culture, context, and recent history

To understand the evolution of Canadian health care, one must understand its constitutional arrangements and political culture. Canada is a federal system whose powers are formally and sometimes contentiously divided between the national and provincial governments. Section 92 of the Constitution Act of 1982 confirms the British North America Act of 1867 assignment of responsibility …

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