Troubling Diagnosis: Comparing Canada’s Healthcare with International Peers

Summary:
Page Title:Troubling Diagnosis: Comparing Canada’s Healthcare with International Peers – C.D. Howe Institute
Article Title:Troubling Diagnosis: Comparing Canada’s Healthcare with International Peers
URL:https://cdhowe.org/publication/troubling-diagnosis-comparing-canadas-healthcare-with-international-peers/
Published Date:January 14, 2025
Accessed Date:February 15, 2025

Study in Brief

  • In international comparisons with its peers, Canada ranks ninth out of 10 countries, performing below the international average in access to care, administrative efficiency and equity – and ranking last in timeliness. For those who can access care, the quality of care is relatively high. Canada performs above the average in the care-process category, reflecting strengths in preventative care and safe care across most provinces.
  • All Canadian provinces and territories fall below the international average for overall healthcare performance, with Newfoundland and Labrador and Nunavut showing the weakest outcomes. Access to timely care, obtaining after-hours care and long wait times are nearly universal challenges.
  • Improving access to care should be a nationwide priority. Enhancing timely access, expanding drug and dental access and improving the affordability of mental health and homecare could help provinces like PEI, Quebec, Ontario and BC surpass the international average. Adopting best practices from countries such as the Netherlands, Germany, and the UK could further elevate healthcare outcomes across Canada.

 

Press release

 

The author thanks Rosalie Wyonch, William Robson, Parisa Mahboubi, Mawakina Bafale, Janet Davidson, Don Drummond, Jennifer Zelmer and anonymous reviewers for comments on an earlier draft. The author retains responsibility for any errors and the views expressed.

Introduction

After the COVID-19 pandemic, healthcare systems worldwide faced challenges ensuring access to care amid healthcare worker shortages, clinician burnout and growing administrative burdens. Canada was no exception. Today, many Canadians lack primary care providers, face long wait times for surgical and specialty care and struggle with access to needed mental health services, highlighting the system’s vulnerabilities and the urgent need for change. Benchmarking Canada’s healthcare systems against those in comparable wealthy nations can provide insights into Canada’s relative performance and inform priorities for improvement. Provincial and territorial comparisons also enable us to explore which provinces excel compared to other advanced economies and which fall behind. This Commentary compares the health systems of 10 high-income countries, including Canada, and also examines how Canada’s provinces and territories measure up on an international scale.

Box 1: Commonwealth Fund International Health Policy Surveys

The annual Commonwealth Fund (CMWF) International Health Policy Surveys (see Box 1) conduct ongoing surveys of seniors, primary care physicians and the general public, shedding light on persistent gaps between Canada’s healthcare system and those of nine other advanced economies. In addition to core topics, recent surveys included new questions on mental health, virtual care, care coordination and equity, which helped construct a more comprehensive analysis of Canada’s healthcare system in comparison to international peers.

This Commentary examines 118 measures across five main categories – access to care, care process, administrative efficiency, equity and healthcare outcomes. The majority of these measures are derived from the 2021, 2022 and 2023 CMWF surveys,1See online Appendix B1 for more information about the data and sampling methodology of these surveys. with some statistics supplemented by the World Health Organization (WHO), the Organisation for Economic Co-operation and Development (OECD) and the Canadian Institute for Health Information (CIHI).

The scope of the CMWF survey questions at the provincial level has expanded in recent years. This Commentary updates and improves a similar previous study by incorporating new indicators available since 2017, adding nuanced details to both international and provincial comparisons (Busby, Muthukumaran and Jacobs 2018). (See online Appendix A1 for changes in measures between the 2018 report and the current analysis).

The latest CMWF surveys published between 2022 and 2024 rank Canada ninth out of the 10 countries.2See online Appendix A2 for detailed methodology for the calculations of performance scores and rankings. The analysis shows that Canada performed fairly well in the care-process category, but that the population faces persistent challenges accessing healthcare services due to long wait times and limited availability of care. In addition, Canada fared poorly in affordability, administrative efficiency and equity.

When it comes to overall healthcare performance, all Canadian provinces and territories fell below the international average. Even the top-performing provinces – Prince Edward Island, Quebec and Ontario – trail most international comparators, excluding the United States. At the other end of the spectrum, Newfoundland and Labrador, along with Nunavut, are the poorest performers, with Nunavut ranking below all comparator jurisdictions, including the United States.

Using a restricted set of measures from the most recent surveys to compare the findings to Busby, Muthukumaran, and Jacobs (2018) shows Quebec moved up the ranking, from seventh among provinces to first. It is also the only province to meet the international average in overall healthcare system performance with these measures. In contrast, Alberta saw the largest decline, falling from first to fifth, and dropped from above to below the international average.

Common challenges among Canadian jurisdictions include access to timely care, attaining after-hours care, and long wait times – issues that seem nearly universal in Canada. The performance gap between the top-performing Canadian jurisdictions and those lagging behind highlights the potential for interprovincial learning and knowledge sharing to improve healthcare delivery. However, domestic best practices alone may not suffice, as even Canada’s top provinces still lag most international comparators. Countries like the Netherlands and the United Kingdom provide valuable insights and best practices that could help Canadian jurisdictions surpass the international average and enhance healthcare outcomes.

To improve Canada’s international standing in healthcare, some fundamental policy and organizational issues need to be addressed. Overall, improving access to care should be a priority across the country. While addressing access issues could bring some provincial health systems to the international average, others will need to do more to meet average performance. Specifically, enhancing timely access to care, expanding drug and dental access, improving the affordability of mental health and homecare could elevate Prince Edward Island, Quebec, Ontario and British Columbia above the international average. To further improve their international rankings, other provinces will also need to focus on reducing wait times, increasing patient engagement and promoting equity.

Overall Health System Performance

The top-performing countries in the most recent survey were the Netherlands and the United Kingdom (Figure 1). The Netherlands ranked first in access to care and second in equity and healthcare outcomes. It demonstrates exceptional healthcare performance, particularly in affordability and care accessibility. Its universal healthcare coverage ensures minimal financial barriers, with only 0.5 percent of the population reporting unmet medical needs, according to the OECD (2023). An impressive 99 percent of survey respondents have a regular healthcare provider or place of care, and the country has the lowest rates of difficulty accessing after-hours care due to its robust primary care infrastructure. These achievements stem from a healthcare system designed to provide more patient and provider choice, more competition and cost-effective medical services with high patient satisfaction (Blomqvist 2022, Wittevrongel, Eder and Faubert 2024).

Figure 1: Overall Health System Performance Score.

Canada ranked ninth overall3Busby, Muthukumaran and Jacobs (2018), using previous surveys, also ranked Canada ninth out of 11 countries, ahead of France and the United States. Norway was excluded from this analysis due to lack of data availability, reducing the number of comparator countries to 10. despite its higher spending on healthcare as a percentage of GDP than the Netherlands (OECD 2023). Canada ranked second last on access to care, fourth on the care process category, sixth on administrative efficiency, seventh on equity and sixth on healthcare outcomes. It remains below the international average on many measures and ranked at the bottom for timeliness. Some readers may notice that my scores for international countries differ slightly from those published by the Commonwealth Fund. This is largely due to adding new measures and subcategories, adjustments in rounding and reweighting4Survey responses were reweighed if more than 5 percent of respondents selected “unsure or uncertain.” This re-weighting helps address discrepancies in international comparison, ensuring a more accurate and unbiased representation of the overall results. and the inclusion of the United States in calculating international averages.

All Canadian provinces and territories fell below the international average on overall healthcare performance (Figure 1), with Nunavut ranking last among all comparator jurisdictions. Notably, even Canada’s best-performing province ranked below all comparator countries, excluding the United States. Considering the US’s poor performance in several categories such as affordability, equity and healthcare outcomes, excluding it from the international average would further worsen the rankings of Canadian jurisdictions.

Table 1: Provincial Ranking of Healthcare Performance

Among provinces and territories, PEI ranked first, driven mainly by its above-international-average performance in care process, equity and healthcare outcomes (Table 1). While most jurisdictions performed well in care-process areas like preventative care and safe care, their overall health results fell short of the international average. Access to timely care, obtaining after-hours care and long wait times are nearly universal challenges. No province reported scores near the international average in these categories.

Similarly, most provinces underperformed when it came to equity. Meanwhile, Newfoundland and Labrador ranked below the international average across all categories and Nunavut ranked last on care process and healthcare outcomes. Saskatchewan also faced serious challenges, with scores significantly below the international average in three out of four categories.

Figure 2: Access to Care, Comparison to International Average.

Access to Care

Access to care includes two subcategories: affordability and timeliness. Canada ranked ninth among its international peers in this overall category. And when compared against international countries, all provinces and territories ranked below comparator countries except the United States (Figure 2). Nova Scotia and Newfoundland and Labrador ranked last.

Still, Canada’s affordability of healthcare has improved slightly compared to past survey results (Busby, Muthukumaran and Jacobs 2018),5In the following sections, past survey results refer to Busby, Muthukumaran and Jacobs’s study in 2018. Using their work shows how Canada and its jurisdictions have improved over time. moving from seventh to sixth place.

Clearly, a lack of financial protection can reduce patients’ access to healthcare, undermine their health status and exacerbate health inequalities.

Healthcare in Canada operates under a mixed system of public and private spending, with the proportion of private spending comparable to many other countries except the United States. In 2021, Canadian households spent 3.3 percent of final household consumption on healthcare goods and services, the same as the OECD average (OECD 2023). Most of Canadians’ total out-of-pocket spending on healthcare was driven by pharmaceuticals (41 percent), long-term care (29 percent) and dental care (16 percent). In most comparator countries, public coverage for pharmaceuticals is more extensive, with more than half of these costs funded by government or compulsory insurance schemes (OECD 2023). For example, Germany offers the most generous coverage, with 82 percent of pharmaceutical costs covered through these mechanisms. In contrast, Canada covers less than 40 percent of pharmaceutical costs, and dental treatment is only provided for specific population groups as of 2023.

In 2023, nearly one-third (31 percent) of Canadians skipped dental care or dental checkups for cost reasons.6There are significant disparities in dental care affordability across jurisdictions: 22.7 percent in Quebec responded that they skipped dental care or dental checkups due to cost, compared to 39 percent in Newfoundland and Labrador. In addition, a higher proportion of respondents in 2023 (24 percent) spent more than $1,000 for out-of-pocket medical treatments compared to respondents in 2016 (15 percent).7Several factors, such as inflation and an aging population, might contribute to this increase. However, the nine-percentage point increase highlights the growing issue of healthcare affordability that Canadians are facing. These costs disproportionately affect households with low incomes, people of colour and rural residents (Gunja et al. 2023). Nearly one-quarter of people with lower or average incomes in Canada reported at least one cost-related barrier to accessing healthcare in 2023, more than twice as many of those with higher incomes (12 percent) (Gunja et al. 2023). This suggests strongly that people with lower or average incomes may have forgone medical care or failed to follow care instructions as prescribed, potentially exacerbating their health issues.

Affordability continues to be a significant barrier in the Atlantic provinces (excluding PEI), Alberta, BC and Yukon, where a higher proportion of adults reported forgoing medications, needed mental health services or homecare due to cost concerns. PEI was the only province with an affordability score significantly higher than the international average.8The 2023 CMWF survey, conducted between March and August 2023, likely reflects the impact of federal and PEI collaboration to improve drug coverage. This initiative included improving the provincial drug formulary, reducing copays and deductibles, and expanding eligibility for public programs. For more information, see https://www.princeedwardisland.ca/en/news/governments-of-canada-and-prince-edward-island-continue-work-to-improve-access-to-medications. Compared to past survey results, PEI and Quebec showed the most improvement in this measurement.

Timeliness encompasses 10 measures, including access to a regular doctor or place of care, same or next-day care, urgent after-hours care and short wait times for specialist appointments or elective surgeries. It also includes measures related to mental health access and after-hours availability in physician practices.

Canada ranked worst (10th out of 10 countries) in timeliness. It placed at the bottom on four measures of timeliness: having a regular doctor or place (86 percent), saw a doctor or nurse on the same or next day (25 percent), waited two months or longer for specialist appointment (47 percent) and waited two months or longer for elective surgery (59 percent). All provinces ranked far below the international timeliness average, the same as in previous survey results. This confirms the ongoing challenge of timely access to care that Canadians have encountered for years.9The difference from the international average is statistically significant for all provinces and territories except the Northwest Territories.

Having a regular doctor or place of care is essential for preventative care, early-disease detection and treatment, and chronic disease management. Canada ranked the lowest on this measure. Canadians with lower household-income levels, younger adults and males are less likely to have a regular doctor or designated place of care (CIHI 2024b, Gumas et al. 2024). Among Canadians without a regular primary care provider, 39 percent reported having at least one chronic condition and 29 percent were taking one or more prescription medications. This lack of access to primary care can exacerbate their chronic conditions.

Accessing after-hours care is also a significant issue in Canada. While more than three-quarters (77 percent) of Canadians reported difficulty in obtaining after-hours care, only 44 percent of adults in the Netherlands face similar challenges. The problem is even more severe in the Atlantic region, where 83-to-91 percent struggled with after-hours access. In the Netherlands, 88 percent of practices have after-hours care arrangements, while fewer than half of Canadian practices do the same. Expanding such access is crucial, especially for individuals whose work schedules limit their ability to seek care during regular business hours. Better access to after-hours care can also reduce reliance on emergency departments for non-urgent issues.

Enhancing Canadians’ access to healthcare hinges on improving patients’ attachment to care and after-hours care availability and reducing wait times. While recent years have seen some progress, affordability challenges persist in several provinces, particularly for prescriptions, dental care, mental health and homecare. Timeliness of care remains a consistent and pressing issue that requires focused attention.

Care Process

Care process is a composite measure covering preventative care, safe care, engagement and patient preferences, coordinated care and virtual care (Table 2). The US ranked first in this category, driven by its higher performance across each subcategory, followed by the Netherlands. Canada ranked ninth among all comparator jurisdictions, with most provinces ranking above the international average, except Newfoundland and Labrador and Nunavut.

The five sub-categories show some common successes for Canadian jurisdictions: most ranked above the international average on preventative care and safe care. However, Canada and more than half of the provinces and territories performed poorly on patient engagement and virtual care.

Preventative Care includes discussions with healthcare providers about smoking, alcohol, stress, diet or exercise. It also includes mammography screening, vaccination rates and avoidable hospital admissions for conditions such as diabetes, asthma and congestive heart failure.10These are common long-term conditions that can be effectively managed through primary care, meaning hospital admissions for these conditions are largely preventable (OECD 2023).

In this subcategory, Canada ranked fourth among its international peers, with more than half of its provinces and territories scoring significantly above the international average. The Northwest Territories performed particularly well, ranking higher than the United States. In contrast, Newfoundland and Labrador and Nunavut scored significantly below the international average. This suggests an opportunity for these regions to learn from other jurisdictions on improving the proportion of adults who discuss smoking, alcohol use and stressors with their healthcare providers.

Safe Care includes four survey items: routine review of medications, incidents of medical or lab mistakes, postoperative sepsis after abdominal surgery and pulmonary embolism in hip and knee replacements. Canada ranked second in this subcategory, with all provinces and territories scoring significantly above the international average. Since 2018, Canada’s ranking has improved from fifth to second. Notably, all provinces have shown progress, with Manitoba and Nova Scotia improving significantly, moving from negative to positive scores.

Table 2: Care Process, Comparison to International Average

Engagement and Patient Preferences includes 27 questions on whether patients feel confident managing their health and whether they feel informed, respected and involved in care decisions. The subcategory also includes measures on whether primary care physicians develop treatment plans, contact chronically ill patients between visits and monitor their conditions. The Netherlands achieved the highest performance in this subcategory, with adults reporting the highest continuity rates with the same doctor. Its robust primary care system also contributes to its strong performance in patient interactions and physicians’ familiarity with personal situations (Blumenthal et al. 2024). Nearly all Dutch citizens (95 percent) choose and register with a general practitioner (GPs) and have the flexibility to switch GPs as needed.

Canada ranked sixth, placing close to the international average. Among Canadian jurisdictions, Saskatchewan and Alberta fared well, with scores significantly above the international average. However, Newfoundland and Labrador, New Brunswick, Manitoba, Yukon and Nunavut scored significantly below the international average. In Nunavut, just over one-half of respondents reported nurses always treated them with courtesy and respect during their hospital stay, and only 30 percent felt involved in their treatment plans – well below the Canadian average of more than 85 percent. Compared to previous survey results, Newfoundland and Labrador and New Brunswick experienced significant declines, shifting from positive to negative scores, while Prince Edward Island experienced the opposite, showing marked improvement (Busby, Muthukumaran and Jacobs 2018). These shifts warrant further investigation into the underlying factors driving these changes. In addition, they highlight the potential for interprovincial learning and knowledge sharing.

Coordinated Care includes communication between specialists and regular doctors and coordination between doctor visits and follow-up care after hospital stays. Canada ranked fifth, with one-half of its jurisdictions scoring above the international average. However, Nunavut performed significantly worse than the national average. It particularly stands out for reports of poor communication between specialists and primary care physicians.

From the perspective of primary care physicians, Canada’s performance in healthcare coordination fell below the international average (Figure 3). Canadian family doctors highlighted several challenges, including poor communication with hospitals upon patient discharge, inadequate communication with homecare providers and infrequent notifications when patients receive after-hours care. The gap is particularly significant in after-hours care notification with only 43 percent of Canadian physicians receiving these updates, compared to 99 percent in the Netherlands. This poor communication between care providers can lead to fragmented care, causing missed follow-ups and inconsistent treatment plans. It can also negatively impact patient outcomes, and increase risks of medical errors and delayed interventions.

Figure 3: Physicians’ Perspectives on Professional and Institutional Coordination, Comparison to
International Average

Despite more than one-half of Canadian physicians’ practices coordinating care with social services or community providers, several obstacles remain. Fifty-six percent of physicians reported inadequate staffing to manage referrals and care coordination, and 50 percent cited a lack of follow-up from social service organizations. These challenges also lead to delays, fragmented services and gaps in care, which can increase inefficiencies and healthcare costs and worsen patient outcomes.

Virtual Care includes 13 survey items assessing the use of web-based portals for health information, virtual consultations with primary care providers and satisfaction with these visits.11This subcategory within the Care Process measure is newly introduced, stemming from the inclusion of new questions in the 2022 and 2023 Commonwealth Fund surveys. Virtual care has significant potential to reshape patient care, improve workforce productivity, enable equitable access to health services and improve health outcomes. Including this subcategory provides valuable insights into Canada’s performance in advancing the quality of care through virtual care. It also includes primary care physicians’ perspectives on video consultations and the use of web-based portals for managing medical concerns, test results and patient summaries.

The US performed the best in this subcategory while Canada ranked seventh (Figure 4). Most provinces and territories scored below the international average, with Prince Edward Island and Nunavut the furthest behind.

Despite the expansion of virtual care during the pandemic, online access to health information in Canada remains limited. Only one-third of Canadians have used an online portal to view or download their health information, compared to 71 percent in the United States. Access varies widely across provinces and territories, with 47 percent of BC residents having online access to their health information such as visit summaries and laboratory results, but only one percent in Nunavut.

Figure 4: Virtual Care, Comparison to International Average

Other survey results show that Canadians desire access to virtual care and those who have access to electronic health information feel more informed and better able to manage their health.12For more information, see https://insights.infoway-inforoute.ca/data_table_2022. Despite the benefits, a smaller proportion of Canadian physicians use telehealth or virtual appointments to serve patients than in comparator countries. Just 3 percent of Canadian physicians reported high telehealth use in 2022,13High telehealth use denotes primary care physicians saying they used telehealth in more than 75 percent of their patient encounters. compared to one in 10 in New Zealand and more than one-quarter in the UK (Gumas et al. 2024).

In 2022, nearly one-half of Canadian primary care physicians provided video consultations and allowed patients to communicate through email or secure websites regarding medical concerns, double the proportion in the 2019 CMWF physician survey. However, it remains below the international average. Primary care clinicians in the UK and the US were the most likely to report using video consultations, at 85 percent and 84 percent. Meanwhile, only close to one-quarter of Canadian primary care physicians allowed e-prescriptions, compared to 97 percent in Sweden. These areas require further improvements to bring Canada in line with its international peers.

In general, Canadian primary care physicians were more satisfied with practising telehealth than were their international peers (84 percent vs. 68 percent). They also found telehealth to be helpful and impactful. For example, 83 percent of Canadian physicians said it, at least to some extent, improved the timeliness of care.

Administrative Efficiency

Administrative efficiency measures how effectively health systems minimize the paperwork and bureaucratic tasks for patients and primary care physicians. It includes six metrics on primary care physicians’ time spent on administrative issues, referrals, and documentation required by insurance plans and government agencies. Two patient-reported measures assess emergency department visits due to the unavailability of regular doctors and time spent on medical bill paperwork or disputes.

In this category, Australia and the United Kingdom were the top performers (Figure 5), and they both minimize payment and billing burdens for patients and physicians. In Australia, electronic claims processing enables instantaneous payments from both public and private payers (Blumenthal et al. 2024). Similarly, UK physicians are compensated directly by the National Health Service based on patients’ electronic health records, eliminating the need to bill patients or the government for each service.

Figure 5: Administrative Efficiency, Comparison to International Average

Canada ranked sixth in this category. Notably, its performance remained unchanged compared to 2018. Canadian primary care physicians were more likely to report significant time spent updating electronic health records and coordinating referrals with specialists. Close to one-half of Canadian physicians indicated that coordinating referrals with specialists is a major problem, significantly higher than the international average of 33 percent.

Both American and Canadian adults are more likely than those in other peer countries to visit the emergency department for non-emergency care, leading to inefficient use of hospital resources and higher costs. Notably, 40 percent of Canadian respondents indicated that they visited an emergency department for a condition that could have been treated by regular doctors, had they been available.

Equity

Equity measures patients’ experiences of unfair treatment because of their racial or ethnic backgrounds, as reported by physicians and seen in income-related disparities in access to care.14The survey findings were analyzed by self-reported income level relative to the average annual household income to identify differences in each country between those with lower or average incomes and those with higher incomes (Gunja et al. 2023). It reflects how people with below-average and above-average incomes differ in their access to care and care experience. France and the Netherlands ranked the highest in this category, meaning adults in these countries experienced among the lowest rates of affordability problems and the fewest income-related disparities (Figure 6). The US ranked last, demonstrating the largest disparities between income groups.

Canada ranked seventh, showing a slight improvement over recent years (Schneider et al. 2021). Compared to other countries, Canada shows notable income-related inequities in healthcare affordability. Approximately one-quarter of Canadians with lower or average incomes reported experiencing at least one cost-related barrier to accessing healthcare in the past year, such as not receiving medical care or following prescribed care instructions. This rate is double that of higher-income counterparts, who reported fewer cost-related barriers to healthcare access.

The difference in adults reporting skipped dental care due to cost was also statistically significant between income groups: 36 percent of those with lower or average incomes compared to 24 percent of those with higher incomes.

In general, 15 percent of Canadians have reported experiencing unfair treatment when receiving healthcare. Among those individuals, the most commonly cited reasons were age (31 percent), disability or chronic disease (25 percent) and gender (20 percent). Due to these factors, between 69-to-78 percent felt they did not receive the care or treatment they needed.

Except for PEI, all Canadian jurisdictions have among the lowest equity scores across most comparator countries. Fewer seniors in PEI thought the healthcare system treated them unfairly, and fewer adults reported experiencing unfair treatment when receiving care. In contrast, a higher percentage of adults in New Brunswick, Manitoba and Yukon felt they have been treated unfairly, with these regions scoring significantly below the international average.

Figure 6: Equity, Comparison to International Average

Healthcare Outcomes

Healthcare outcomes refers to health results such as infant mortality, maternal mortality and suicide rates. Sweden and the Netherlands performed the best in this category (Figure 7). Sweden had the lowest infant mortality rate (1.8 deaths per 1,000 live births), while the Netherlands reported the lowest 30-day-in-hospital mortality rate following acute myocardial infarction for those aged 45 and older (2.9 deaths per 100 admissions).

Canada ranked sixth, slightly below the international average. Among the nine measures, Canada had the second-highest infant mortality rate and second-highest 30-day-in-hospital mortality rate following stroke. Within Canada, only British Columbia had a notable positive score in healthcare outcomes. In contrast, Nova Scotia, Saskatchewan, Newfoundland and Labrador, the Northwest Territories and Nunavut were performance drags, scoring significantly below the international average, largely due to their higher rates of avoidable mortality and suicide deaths. Nunavut ranked last on healthcare outcomes, driven by its alarmingly high suicide rate, which was eight times the Canadian average. This highlights the critical need for enhanced mental health support and life promotion initiatives in the territory.15For more information, see https://www.cbc.ca/news/canada/north/nunavut-mla-brewster-suicide-emergency-1.7029358.

Figure 7: Healthcare Outcomes, Comparison to International Average.

Improvement Potential

According to the latest CMWF surveys, Canada has fallen behind its international peers in several key areas, including access to care, administrative efficiency, and equity. To understand how Canadian provinces and territories could improve, I simulate scenarios where these jurisdictions meet the highest international standards for specific survey metrics.16Similar to Busby, Muthukumaran and Jacobs (2018), I select top performers in the category for Canada to match. Given Canada’s critical primary care access challenges, I have identified the access-to-care category as the top priority for improvement.

Scenario 1: Improving Timely Access to Care

Access to care requires both insurance coverage and convenient and timely primary care. The first simulation focuses on improving timely access measures to match top performers like Germany and the Netherlands. Specifically, all provinces and territories would have 98 percent of adults with a regular doctor or place of care, 51 percent of respondents reporting they can get same or next-day appointments with a doctor or nurse, and only 54 percent experiencing difficulty to obtain after-hours care. By achieving these improvements, all jurisdictions would see a boost in access-to-care scores, with Prince Edward Island and Quebec surpassing the international average. PEI’s overall healthcare performance would shift from negative to positive (Figure 8).17Nunavut was excluded from the simulations because it is such an outlier that requires significant improvements in both care process and healthcare outcomes.

Figure 8: Simulation of Improved Policy for Provinces and Territories (Nunavut excluded), by Scenario

To increase the percentage of Canadians attached to a regular doctor or place of care, it is essential to expand the number of primary care providers to meet the needs of a growing and aging population. Optimizing the efficiency and utilization of the existing workforce is equally important. Substantial reforms in the organization and funding of care delivery, along with an expanded scope of practice for other primary care providers, will be necessary to address both current and future demands (Zhang 2024). The use of telehealth and remote monitoring can also improve access to care while potentially reducing costs.

Both the Netherlands and Germany provide universal coverage and remove cost barriers, ensuring people can access care when needed. This coverage includes essential preventative services, primary care and effective treatments for chronic conditions. In the Netherlands, for example, primary care physicians are obligated to provide at least 50 hours of after-hours care (between 5:00 p.m. and 8:00 a.m.) annually in order to maintain their professional licensure. The country also has local and regional GP posts that provide after-hours care and help reduce the need for emergency room visits (Blumenthal et al. 2024). Most GPs are also part of networks that offer care during evenings or weekends. In Germany, physicians are also required to offer after-hours care, with regulations varying from region to region (Blumenthal et al. 2024).

Strengthening enforcement of contractual obligations, such as after-hours care, in Canadian jurisdictions could yield significant benefits. While some Canadian provinces use financial incentives to encourage after-hours care, many do not require it. In Ontario, after-hours care is required for all models except comprehensive care and nurse practitioner-led clinics. However, there are no regulations enforcing this requirement, nor have evaluations been conducted on its effectiveness in improving patient access (Zhang 2024).18For instance, a report by the Office of the Auditor General of Ontario (2016) revealed that in 2014/15, 60 percent of family health organizations and 36 percent of family health groups did not work the number of weeknight or weekend hours required by the ministry.

Scenario 2: Improving Drug and Dental Care Access

Reducing cost barriers to drug and dental care would also improve the overall health performance ranking of provinces and territories. If all Canadian jurisdictions improved drug and dental access to levels with the top two performers (where only 6 percent of adults skip medications and 9.7 percent forgo dental care), alongside improvements in timely access to care, all regions would see improvements in their total scores. However, only Prince Edward Island would top the international average, with Quebec aligning with the average.

Prince Edward Island and Quebec already make prescriptions more affordable due to their special strategies aimed at addressing the care gaps. The fill-in-the gap collaboration between the federal and PEI governments has improved the provincial drug formulary, reduced copays and deductibles and expanded eligibility for public programs.

Quebec’s pharmacare model requires mandatory patient enrolment in either a public or private plan. The public version includes deductibles and copayments, similar to private plans, but with monthly caps on out-of-pocket costs. Risk pooling helps keep premium costs relatively lower than in non-mandatory, universal eligibility, public insurance schemes such as Alberta’s. Adopting a prescription drug insurance model that includes a funding mechanism, where enrollees pay an annual premium, would help reduce the potential for short-term strain on government budgets (Wyonch and Robson 2019).

In Germany, public coverage for pharmaceuticals is more comprehensive, with 82 percent of pharmaceutical costs covered through government or compulsory insurance schemes. Overall, medical costs are capped at 2 percent of gross income for all patients and 1 percent for people with chronic illness (Blumenthal et al. 2024).

Canadian jurisdictions can draw valuable lessons from both domestic and international best practices. Efforts should prioritize achieving universal coverage, expanding formularies and reducing out-of-pocket payments. Provinces and territories must commit to maintaining their current level of coverage while addressing gaps in access to health insurance, ultimately working toward universal coverage for all. These affordability objectives are achievable as ongoing federal initiatives continue to address gaps in pharmacare and dental care access.

However, while the Canadian Dental Care Plan’s focus on dental services for seniors is a step forward, those who are uninsured or unable to pay should also be included. In Ontario, the consideration of portable benefits to extend health benefits coverage to workers without employer-sponsored insurance is another important strategy (Bonnett 2023). These steps are crucial in bridging gaps in access to health insurance and working towards broader universal coverage.

Scenario 3: Improving Mental Health and Homecare

If provinces and territories were to achieve the top-tier performance in mental health and homecare affordability (meaning only 2.7 percent and 4 percent of people, respectively, forgo these services due to cost), alongside improvements in timely access to care and drug and dental access, PEI and Quebec would advance to middle-tier performers, similar to Germany and Switzerland. Ontario and BC would also reach the international average, though many other regions would still lag behind. This implies that these other jurisdictions need to reduce wait times, improve patient engagement, increase use of virtual care and improve equity to further improve their international standing. Addressing affordability barriers could also help enhance equity across Canada.

Top-performing countries such as the Netherlands and Germany have limits on cost-sharing to ensure that the ability to pay is not a significant barrier to accessing necessary health services. In Germany, out-of-pocket expenses are capped at a fixed percentage of income while in the Netherlands, healthcare services, except for primary care visits, maternity care and child health services, are covered once patients meet their annual deductible. As a result, fewer than 5 percent of adults in these two countries reported cost-related barriers to accessing needed mental health services, regardless of income level.

The Netherlands and Germany also invest in homecare and encourage seniors to live independently for as long as possible (Wyonch and Zhang 2023). The German long-term care system prioritizes cost containment through emphasizing the role of informal care alongside formal healthcare and homecare with institutional inpatient care considered a last resort (Wyonch 2021). Community nurses play a key role by encouraging and training seniors’ relatives and family to participate in their care, providing both preventative and curative care. This municipal-level approach to care empowers seniors and gives them freedom, autonomy and wellness.

Alberta, British Columbia and Yukon, where a higher than average proportion of adults reported forgoing needed mental health services or homecare due to cost concerns, should look to these international examples for guidance. Investing in mental health services and homecare, alongside adopting similar funding mechanisms, is important. By implementing comprehensive coverage models, these regions can reduce financial barriers, improve access to essential care and alleviate the financial burden on the public system.

The lack of provincial and territorial data for the 2022 CWMF survey makes it difficult to identify which provinces excel in areas such as administrative efficiency and which are lagging behind. However, the country-wide results still point to this as an area that needs improving.

Administrative inefficiency imposes significant costs in both time and money for patients and physicians. Top-performing countries often reduce administrative burdens that detract from time, resources and expenditures that could otherwise be directed toward improving healthcare outcomes. They simplify their health insurance and payment systems, usually through legislation, regulation and standardization (Schneider et al. 2021). Reducing the variation and complexity of insurance plans is particularly crucial (Blumenthal et al. 2024). By minimizing administrative burdens, Canadian primary care physicians could dedicate more time to direct patient care, ultimately enhancing healthcare delivery and outcomes.

Some provinces, such as Nova Scotia, have taken positive steps to reduce healthcare red tape. Other jurisdictions also need to evaluate areas where forms can be streamlined and duplication of information eliminated (Zhang 2024). Additional strategies to ease administrative workloads and improve care delivery include redesigning healthcare processing technology – such as electronic health records and other electronic administrative tools – with direct input from physicians to ensure efficiency and usability (Gumas et al. 2024). The integration of artificial intelligence, including tools for automatically summarizing or transcribing patient conversations into electronic medical notes, offers further potential to simplify complex billing and documentation systems, reducing the administrative burden on healthcare providers (Zhang 2024).

Conclusion

Countries worldwide are developing new models of care, aiming to enhance population health, improve patient experiences, reduce healthcare costs, support the well-being of healthcare professionals and promote health equity. Benchmarking the performance of Canada’s healthcare system against international peers shows our relative performance and priority areas for improvement and provides international examples that can inform domestic policy and healthcare delivery changes.19See online Appendix B2 for data limitations.

This Commentary indicates that Canada’s healthcare system still faces challenges, particularly in access to care, administrative efficiency, and equity. In international comparisons, Canada ranks ninth out of 10 countries, falling below the international average on many measures and ranking last for timeliness of care. However, Canada performed relatively well in the care-process category, suggesting many Canadian provinces excelled in preventative care and safe care, despite broader systemic challenges.

Compared to previous survey findings, Canada’s performance has improved slightly in some subcategories such as affordability, coordinated care, equity and healthcare outcomes. However, Canada’s performance has worsened in other critical subcategories, including timeliness of care. This decline once again highlights the pressing need to address access-to-care issues in Canada.

Among Canadian provinces and territories, Newfoundland and Labrador and Nunavut are the main performance laggards, with Nunavut ranking below all comparator jurisdictions, including the United States. Across all 10 provinces and three territories, common challenges include access to timely care, obtaining after-hours care and long wait times. Only one jurisdiction reported scores above the international average in these measures. The Atlantic provinces appear to face the most serious issues, with significant difficulties in these categories.

Recent expansions in drug and dental care coverage, while not yet reflected in the most recent surveys, have the potential to enhance Canada’s performance in the affordability subcategory. However, simply addressing coverage gaps on drug and dental care and improving timely access to care would enable only two provinces to surpass the international average in overall health rankings. This highlights the need for broader improvements across all jurisdictions, particularly in mental health and homecare affordability, reducing wait times, enhancing patient engagement and addressing equity challenges.

To achieve these improvements, Canadian jurisdictions can draw on best practices from countries like the Netherlands and Germany, which have successfully implemented funding mechanisms and ensuring affordability for all. While closing the affordability gaps may require increased public spending, evidence from these countries demonstrates that it is possible to spend wisely by focusing on value-based care. Investing in targeted improvements that enhance both access and quality of care can yield better outcomes without unnecessarily escalating overall costs.

Canada has a positive reputation for its pilot projects and innovative strategies, yet provincial and territorial health silos often prevent horizontal collaboration and sharing of lessons learned across jurisdictions (Bégin, Eggertson and Macdonald 2009). To avoid duplicating efforts, provinces and territories should share best practices to improve care access and healthcare performance.

However, domestic solutions alone may not be enough. Even Canada’s highest-performing provinces fall behind most international comparators. Drawing insights from countries like the Netherlands, Germany and the UK could provide Canadian jurisdictions with actional strategies to exceed the international average and achieve better healthcare outcomes. Cross-jurisdictional collaboration, combined with the adoption of proven international practices, represents a critical pathway to closing performance gaps and improving healthcare systems across the country.

The road to a high-performing healthcare system is long and requires addressing fundamental policy and organizational challenges. It is a complex challenge that requires the implementation of targeted and comprehensive strategies.

References

Bégin, Hon. Monique, Laura Eggertson, and Noni Macdonald. 2009. “A Country of Perpetual Pilot Projects.” Canadian Medical Association Journal. 180(12): 1185. June.

Blomqvist, Åke. 2022. Going Dutch: Choice, Competition and Equity in Healthcare. Commentary 621. Toronto: C.D. Howe Institute. April.

Blumenthal, David, et al. 2024. “Mirror, Mirror 2024: A Portrait of the Failing U.S. Health System.” Commonwealth Fund. September. Available at https://www.commonwealthfund.org/publications/fund-reports/2024/sep/mirror-mirror-2024.

Bonnett, Chris. Better for Workers, Better for All? Assessing a Portable Health Benefits Plan in Ontario. Commentary 639. Toronto: C.D. Howe Institute. February.

Busby, C., R. Muthukumaran, and A. Jacobs. 2018. “Reality Bites: How Canada’s Healthcare System Compares to its International Peers.” E-Brief. Toronto: C.D. Howe Institute. January. Available at https://cdhowe.org/sites/default/files/attachments/research_papers/mixed/Final%20for%20release%20e-brief_271_Online.pdf.

Canadian Institute for Health Information (CIHI). 2022. “How Canada Compares: Results From the Commonwealth Fund’s 2021 International Health Policy Survey of Older Adults in 11 Countries – Data Tables.” Ottawa.

________. 2023. “How Canada Compares: Results From the Commonwealth Fund’s 2022 International Health Policy Survey of Primary Care Physicians in 10 Countries — Data Tables.” Ottawa.

________. 2024. “How Canada Compares: Results From the Commonwealth Fund’s 2023 International Health Policy Survey of the General Population Age 18+ in 10 Countries – Data Tables.” Ottawa: CIHI. Available at https://www.cihi.ca/en/commonwealth-fund-survey-2023.

________. 2024b. “Primary health care.” Available at https://www.cihi.ca/en/primary-health-care.

Gumas, Evan D., et al.2024. “Finger on the Pulse: The State of Primary Care in the U.S. and Nine Other Countries.” Commonwealth Fund. March. Available at https://www.commonwealthfund.org/publications/issue-briefs/2024/mar/finger-on-pulse-primary-care-us-nine-countries.

Gunja, Munira Z., et al. 2023. “The Cost of Not Getting Care: Income Disparities in the Affordability of Health Services Across High-Income Countries – Findings from the Commonwealth Fund’s 2023 International Health Policy Survey.” Commonwealth Fund. November. Available at https://www.commonwealthfund.org/publications/surveys/2023/nov/cost-not-getting-care-income-disparities-affordability-health.

Hewitt, Marisa, and Michael C. Wolfson. 2013. Making Sense of Health Rankings. Healthcare Quarterly 16(1): 13-15. January.

Organisation for Economic Cooperation and Development (OECD). 2023. “Health at a Glance 2023: OECD Indicators.” Paris: OECD Publishing. November. Available at: https://doi.org/10.1787/7a7afb35-en.

Office of the Auditor General of Ontario. 2016. “Value-for-Money Audit: Physician Billing.” Available at https://www.auditor.on.ca/en/content/news/16_summaries/2016AR percent20summary percent203.11.pdf

Schneider, Eric C., et al. 2021. “Mirror, Mirror 2021 Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries.” The Commonwealth Fund. Available at: https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly.

Wittevrongel, Krystle, Conrad Eder and Emmanuelle B. Faubert. 2024. “International Health Perspectives: Comparing Primary Care in Canada, Germany, and the Netherlands.” Montreal Economic Institute. Available at https://www.iedm.org/international-health-perspectives-comparing-primary-care-in-canada-germany-and-the-netherlands/.

Wyonch, Rosalie. 2021. Ounce of Prevention is Worth a Pound of Cure: Seniors’ Care After COVID-19. Commentary 614. Toronto: C.D. Howe Institute. December.

Wyonch, Rosalie, and William B.P. Robson. 2019. Filling the Gaps: A Prescription for Universal Pharmacare. Commentary 544. Toronto: C.D. Howe Institute. June.

Wyonch, Rosalie, and Tingting Zhang. 2023. “Shortcomings in Seniors’ Care: How Canada Compares to its Peers and the Paths to Improvement.” E-Brief. Toronto. C.D. Howe Institute. September. Available at https://cdhowe.org/sites/default/files/2023-09/E-Brief_346%20new%20%281%29.pdf.

Zhang, Tingting. 2024. The Doctor Dilemma: Improving Primary Care Access in Canada. Commentary 660. Toronto: C.D. Howe Institute. May.

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