Canadians are, at best, only "marginally confident" in the future of Canada's healthcare system (Nanos and Jenkins 2014). They are skeptical that simply spending more money can address the issues underlying Canadian healthcare, yet they also doubt the country's capacity to harness innovative strategies to improve healthcare (ibid). These issues are central to Canadians' concerns about healthcare reform: increased funding is no guarantee of better quality or access to healthcare and may reinforce inefficient patterns of health spending (Canadian Institute for Health Information 2012). For example, Contandriopoulos showed that since 2007 in Québec, total physician compensation, average physician compensation and average unit cost per service all rose quickly but the total number of services, number of services per capita and average number of services per physician were either level or declined (Contandriopoulos and Perroux 2013). However, simply pressuring provinces and territories to do more with less may also be counterproductive, because it creates immediate delivery pressures that reduce opportunities for careful deliberation of strategies for enduring and meaningful improvement.

In this article, we present an approach to making the Canadian healthcare system more effective, efficient and sustainable. The program maintains the autonomy of the provinces and territories while renewing federal leadership. The core idea is to use federal healthcare transfer payments to incentivize greater efficiency, better access, better outcomes and increased health equity. Our goal is to set out this model for discussion. We acknowledge that measuring health outcomes, healthcare quality and health equity is challenging. Developing and implementing such measures will require conceptual development and detailed technical plans that are beyond the scope of this article. Moreover, we can only touch briefly on the political processes required to implement a model that balances federal leadership with provincial autonomy. Our goal here is to stimulate discussion by presenting a new model for funding and delivering healthcare.