Canada’s health-care debate has long been trapped between two options: the system we have, and the American system we fear.
Experts say that binary thinking is costing us. Dozens of countries offer universal care, and many do it more efficiently and with better health outcomes than Canada.
“There’s a false dichotomy often in Canadians’ heads, this idea that there’s only two ways to do health care in the world, the Canadian universal way … or the American non-universal way,” said Nadeem Esmail, director of health policy at the Fraser Institute, a think tank.
“There are far better ways to deliver universal access to health care.”
The Commonwealth Fund report, which compares 10 high-income countries’ health system performance, highlights the possibilities.
In the fund’s most recent report, Canada ranked seventh. “The three top-performing countries in 2024 are Australia, the Netherlands, and the United Kingdom,” the report says.
Over a series of articles, Canadian Affairs will dig into the report’s findings, with a specific focus on Australia’s system and why it consistently ranks at or near the top.
Australia is a good country for Canada to benchmark against, and not only because Australia is a world leader in health care.
“We love Canada … we have so many similarities,” said Mark Cormack, a professor and health‑system policy expert at the Australian National University.
“In my current area of research interest, which is the health workforce, we would share and collaborate more with Canada than any other country in the world,” said Cormack, who has represented Australia at the OECD and World Health Organization.
Canada’s ranking
The Commonwealth Fund is a private, U.S.-based foundation that focuses on improving access to health care.
The fund has published its Mirror, Mirror reports since 2004, typically releasing a new report every two to three years.
The foundation uses patient and physician surveys and standardized international health data to assess health systems across five categories: health outcomes, access to care, care process, administrative efficiency and equity.
The report cites health‑care spending for context, but does not include it as a factor in the rankings. Australia spends the least as a percentage of GDP, at 9.8 per cent; Canada is in the middle of the pack, spending 11.2 per cent.
The report identifies some specific deficiencies with Canada’s system.
“Canadians face longer wait times and more difficulty getting timely access to primary care than top-performing countries,” reads the report.
These findings match other recent Canadian data. Roughly half of Canadians do not have a family doctor or struggle to see the doctor they have, according to a February poll. Canadians also wait longer than Americans and Europeans to access life-saving medicines.
The Commonwealth Fund report shows Canada also performs poorly on income equity, which refers to “how people with below-average and above-average incomes differ in their access to health care and their care experience.”
Lower equity scores are linked to higher out-of-pocket costs, gaps in private coverage, and experiences of unfair treatment or not being taken seriously by health professionals.
High-ranking health care
Australia delivers health care at lower cost and achieves better health outcomes than Canada, while maintaining comparable levels of health equity.
Esmail, of the Fraser Institute, identifies four policy features that help explain Australia’s strong performance.
One factor is modest co-payments. Like Canada, Australia provides universal primary care coverage through its Medicare system, but certain services require small co-pays, which encourage patients to use care thoughtfully.
“The basic principle is we all spend our own money more wisely and more carefully than we spend someone else’s,” said Esmail.
Another factor is private competition in hospital delivery. In Australia, private hospitals perform roughly two-thirds of elective surgeries. In Canada, by contrast, hospitals are overwhelmingly managed by provincial health authorities.
Hospitals are also funded differently. In Australia, the funding model is activity-based funding, where hospitals are paid for each patient treated. In Canada, hospitals typically receive a fixed annual budget.
Australia also delivers much of its publicly funded services through private providers, giving patients more choice and easing pressure on public services.
“We have a very strong private system, and in primary care, most of the health care that is funded through the Medicare arrangement is delivered by private businesses,” said Cormack.
Esmail made similar observations. “It’s a system that really perceives the private sector as a partner and as part of the system, as opposed to something to be regulated out of existence, like we do here in Canada,” he said.
Lastly, Australia’s Pharmaceutical Benefits Scheme, a system of publicly funded drug coverage, ensures affordable access to a wide range of medicines, with low co-payments and income-sensitive safety nets.
Why Australia?
In the coming weeks, Canadian Affairs will dig into these features of Australia’s system in more detail.
Australia is a country Canada is well-positioned to learn from, in part because there are numerous structural similarities between the countries.
Both have comparably sized populations and federal systems of government, where national and state or provincial governments share responsibility for health care.
Both countries have high levels of immigration and large rural and remote populations, which can affect access to care and health outcomes.
“Australia has this peculiar population distribution: 80 per cent of the population live in a small number of major cities, and then 20 per cent of the population is dispersed across unimaginably vast areas, exactly as you have in Canada,” said Don Nutbeam, executive director of Sydney Health Partners, a research collaborative.
Both countries also provide universal public health coverage supplemented by private sector care for non-urgent services.
And in both countries, poorer and less educated populations tend to have greater health needs.
“Generally speaking, just like Canada, the people that tend to need more health care and have more things wrong with them tend to be those that are poorer and less educated,” said Cormack.
Esmail says Australia’s system offers many lessons for Canada.
“We can see clearly that it has given them a more efficient, more accessible health-care system for lower cost than the Canadian system.”
