Healthcare Quarterly

Healthcare Quarterly 4(2) December 2000 : 6-9.doi:10.12927/hcq.2000.20568

Quarterly Letter: Is Canada's Medicare System Sustainable? A Review of Recent Policy Recommendations

Our national medicare system was a topic of great debate in 2000. Readers may be interested in the following synthesis of the recommendations or policy options from a number of Canadian health policy scholars.


The following represents a rudimentary analysis of the recommendations put forward in four documents/reports that came forward in 2000. For the most part these were targeted at health ministers and first ministers. The four reports are as follows:

Each report was reviewed, and discrete recommendations were identified, and then grouped into categories. Some 82 recommendations or options (not unique) were identified in the four reports. A listing of the recommendations by source with page references may be obtained from

The results reported below should be reviewed with a degree of caution. There is some overlap between the reports in terms of contributors. There is also a degree of subjectivity in determining what constituted a discrete recommendation or policy option. One could also think of different ways of classifying them. To do this properly, one would need to carry out a more structured qualitative or content analysis. Moreover, there were also a number of other meetings in Canada during 2000 that touched on issues of health policy. In addition, many organizations and groups offered recommendations on sustaining medicare. There are also several public and proprietary population-based surveys that would be worthy of further examination. One could also look internationally for instance at the comprehensive report put forward in the U.K. in 2000 for the National Health Service (


The recommendations were classified into 10 categories. The category of comprehensiveness emerged as the clear favourite, with 16 recommendations directed at it. The categories appear as follows:

Comprehensiveness - 16
Funding - 9
Integration - 8
Incentives - 8
Intergovernmental relations - 7
Health human resources - 7
Health information - 6
Values - 5
Accountability - 4
Miscellaneous - 12


The detailed results are shown below. Several of the larger categories have sub-categories within them.

Comprehensiveness - 16

Home care - 5

  • Increase CHST payments to expand home care services
  • More comprehensive services (e.g., home care)
  • National standards for home care
  • Expand in-home medical service provision
  • Extend federal funding mechanisms to cover changing sites of care
Pharmacare - 4
  • National pharmacare program - 3
  • Manage the prescription drug budget
Canada Health Act (CHA) - 3
  • New rules for medicare - add principles of quality and accountability
  • Apply the CHA in letter and spirit
  • Reform CHA without abandoning solidarity and equity - add flexibility
Medical necessity - 3
  • Review and update definitions of medical necessity
  • Confront rationing - articulate principles
  • Define necessary services
National Dental Hygiene Program - 1

Funding - 9

Public (primarily federal) - 6

  • Bring CHST funding up to $19 billion annually
  • Focus on restoring public confidence in financing
  • Clarify federal funding commitment
  • New money from federal government to make changes (i.e. health reform)
  • Capital investment in technology
  • Joint Federal/Provincial Health Technology Resources Fund
Private - 3
  • Bring private capital to the table without compromising accessible medical care
  • Parallel private system
  • More funding would most likely have to come from the private sector
Integration - 8
  • Implement integrated delivery systems - 2
  • Adopt integrated financing - 2
  • Establish local health organizations of about 100,000 people to coordinate and purchase services
  • Reduce duplicate administrative costs resulting from regionalization
  • Increase pluralism in the organization and delivery of care
  • Focus on reform of delivery and allocation - not financing
Incentives - 8

Provider (supply) side - 4

  • Change physician remuneration away from fee for service
  • Adopt incentive mechanisms to promote reforms
  • Introduce incentives to the management of hospitals
  • Hold hospital administrators accountable for deficits
Patient (demand) side - 4
  • Medical savings accounts (healthcare accounts) with public funding - 2
  • Make patients fiscally responsible
  • Make people aware of their stake in healthcare
Intergovernmental Relations - 7
  • P/T governments articulate a vision of what healthcare systems are to achieve
  • Strengthen stewardship
  • Establish council of health ministers
  • Create independent and non-partisan federal and provincial health commissioners
  • Establish a new partnership between f/p/t governments - national health council - to reinterpret principles
  • Identify an apolitical group to assess the system
  • Establish mechanisms for ongoing review of changing delivery realities
Health Human Resources - 7
  • Commission on the future structure and needs for the healthcare workforce
  • Divide labour between nurses and physicians
  • Allow RNs to complement the work of doctors
  • Open up and restructure the roles and responsibilities of health practitioners
  • Charge an exit fee to migrating physicians
  • Promote physician retention - recruit from small communities/ promote group practice
  • More physicians and nurses in rural communities with better funding to promote retention
Health Information - 6
  • Invest in information systems
  • Improve management of waiting lists
  • System-wide governance through report cards
  • Regulation and validation of health information by government
  • Turn information into action
  • Present systematic evidence (information) e.g., Canadian Institute for Health Information
Values - 5
  • Federal government to develop consensus and interpret values
  • Forum to clarify national values
  • Reassess traditional values in the CHA
  • Clarify CHA values and principles
  • Revisit/reaffirm values
Accountability - 4
  • Add 6th CHA principle of accountability
  • Devolve decision-making to local authorities with accountability mechanisms
  • Improve accountability at the provincial and local level (performance agreements, choice)
  • Direct accountability mechanisms between providers and patients
Miscellaneous - 12
  • No-fault compensation for people who contract disease from tainted blood
  • Establish a healthcare management and industries sector
  • Patient Charter with ombudsperson
  • Primary care reform - 24/7
  • Include alternative and non-traditional health practices in hospitals
  • Rethink our conception of public health
  • Aligned and honest public discourse
  • Reframe discourse from market to sustainable community
  • Reduce professional control and increase self-management of illness
  • More involvement of patients in investigation of health and illness
  • Expand the number of health-related expenses that are allowable income tax deductions
  • National strategy for excellence


It is evident from the breadth of the solutions put forward that there is no single solution directed at any single party that is likely to achieve a sustainable medicare program in Canada. It is encouraging to see the level of interest in developing policy options as evidenced by these reports.

In 2001 we can anticipate several other reports on the Canadian healthcare system, including:

About the Author(s)

Owen Adams,
Director, CMA Research Directorate,


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