Health Care in a Highly Decentralized
Federation: The Case of Canada
Gregory P. Marchildon, Ph.D.
Johnson-Shoyama Graduate School of Public Policy, University of Regina, Canada
Symposium on Decentralization of Health Care: Reform of Belgian Health Care
Sponsored by Flemish Physicians Association: Vlaams Gennesheren Verbond
Brussels, Belgium, 18 October 2008
Overview of Presentation
• Nature and origins of political and health
system decentralization
• Some health service differences among
provinces
• Decentralization and language of health
care delivery
• SWOT analysis of decentralization
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Political Decentralization
Decentralization and Role of
Private Sector in Canada
Public & Universal
(Canada Health Act)
hospital, diagnostic and
physician services
Mixed goods and
services, including
most prescription
drugs, home care, and
long-term care
Private goods and
services including
dental and vision care
as well as over-thecounter drugs and
alternative medicines
and therapies
Funding
Administration
Delivery
Public taxation (general
revenue funds of
governments)
Universal, single-payer
provincial systems.
Private self-regulating
professions under
provincial legislative
framework
Private professional
and for-profit, not-forprofit and public arm’s
length facilities and
organizations
Public taxation, private
(often employmentbased) insurance and
out-of-pocket payments
Public services that are
generally welfarebased and targeted,
and private services
regulated in the public
interest by government
Private professional,
private not-for-profit,
for-profit, and public
arm’s length facilities
and organizations
Private insurance and
out-of-pocket payments
including full payments,
co-payments and
deductibles
Private ownership and
control; private
professions, some self
regulation with state
regulation of foods,
drugs and natural
health products
Private providers and
private for-profit
facilities and
organizations
Public Universal System
• Medicare: universal hospital + medical care
services
– Narrow (40% of THE) but Deep (no user fees or co-payments)
• Defined as medically necessary or medically
required services
• Funded by both orders of government
– 75% by provincial taxation – general revenue funds
– 25% by federal government – cash transfers to provinces
• Provincial single-payer administrations
• National framework of Canada Health Act
– Five funding conditions/principles: universal, portable, public
administered, comprehensive, and accessible
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Decentralization of Health Services
• Do differences in health services increase
over time within a decentralized system?
• Are differences encouraged by particular
forms of decentralized governance,
administration or delivery?
• Snapshot of differences in physician and
hospital services in 6 more western
provinces
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Number of Physicians and Nurses
(per 100,000 people), 2006
BC
AB
SK
MB
ON
QC
Physicians
199
191
159
180
174
215
Nurses
773
909
1063
1089
807
924
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Family Medicine-Specialist and
Nurse-Physician Ratios, 2006
BC
AB
SK
MB
ON
QC
Family Physician
to Specialist ratio
1.21
1.18
1.30
1.07
0.93
1.03
Nurse to
Physician ratio
3.88
4.76
6.69
6.05
4.64
4.30
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Inpatient Hospitalization Rates
(per 100,000 people, age-standardized)
BC
AB
SK
MB
ON
QC
19951996
10,579
11,229
14,526
11,504
10,216
10,386
20042005
7,870
9,467
11,828
9,664
7,665
8,202
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Average Length of Hospital Stay
BC
AB
SK
MB
ON
QC
19951996
6.4
5.8
6.8
9.3
6.6
9.0
20042005
7.1
6.9
6.0
9.9
6.4
8.6
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Language of Health Care Delivery
• Important factor in access to, and quality of,
health care
• Mainly determined by provincial governments
– English-speaking (8) – majority with 4.2% or less with French as mother
tongue (and 2.5% using French as primary language at home)
– French-speaking (1) – Quebec with 80% having French as mother
tongue and 82% using French as primary language at home
– Officially bilingual (1) – New Brunswick – 65% with English and 33%
with French as mother tongue
• But federal government underwrites cost of
providing services to linguistic minorities due to
policy (and law) of official bilinguilism
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Status of Two Official Languages, 2006
Province
Population
(thousands)
Percentage EnglishSpeaking (%)
Percentage FrenchSpeaking
Mother
tongue
Primary in
home
Mother
tongue
Primary in
home
Ontario
12,160
69.1
81.7
4.2
2.5
Quebec
7,546
8.2
10.6
79.6
81.8
New
Brunswick
730
64.7
69.0
32.7
29.7
CANADA
31,613
57.8
66.7
22.1
21.4
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Quebec
• Motivation behind attaining greater autonomy
• Control over culture and language
• Control over public health care: CLSCs and
regionalization
• Montreal and “bilingual” hospitals and institutions
– McGill University: Montreal General; Royal Victoria; Montreal Children’s
Hospital; Montreal Neurological Institute; and Montreal Chest Institute
– Jewish General Hospital
– Saint Mary’s Hospital
– Lakeshore General Hospital
• Alliance Quebec and subsequent action by federal
Minister of Health: $30 m investment
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Ontario
• Health Services Restructuring
Commission
• Order to close Montford Hospital, Ottawa
• Pressure on Ontario government from civil
society as well as other governments
• Court action
• Reversal of decision and re-investment
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Conclusion
SWOT Analysis of Decentralization
• Strengths
– Freedom and capacity of provinces to innovate and experiment
– Intergovernmental collaboration, federal spending power and balance
• Weaknesses
– Non-cooperative strategies of blaming and cost-shifting
– Difficulty of setting “national” direction
• Opportunities
– Replace old system of cost-sharing with more effective federalprovincial approach
• Threats
– Increased non-cooperation and, possibly, secession
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