Canadians will spend about $200 billion on health care this year — 50 per cent more than just 20 years ago. Not counting the United States, with its focus on profit-making health care, our health system is the world’s fifth most expensive. Although usually compared with the other 33 countries in the Organisation for Economic Co-operation and Development (OECD), our per capita costs exceed those of nearly 200 other nations. So it is reasonable for Canadians to expect that our collective health and our health system performance should also rank near the top of the list. But they do not. And here the story takes a decidedly sharp turn, because our outcomes, based on comparative international rankings, are a murky story at best.
What is our $200 billion buying?
Life expectancy is one important measure thought to roughly reflect population health. Here Canada has improved markedly over the past century. We live longer than ever, even though our life expectancy still ranks only 12th among the 34 OECD nations. Yet interestingly, Statistics Canada sees steady increases in life expectancy as resulting from things like improved nutrition and hygiene, and access to safe drinking water — in other words, factors well beyond medical intervention. Right away we see that investing in health beyond formal health care helps to explain why Austrians, Italians, Japanese and Swedes live longer, healthier lives than Canadians while spending less on health care.
Certainly, investments in treatments such as antibiotics, vaccines and surgery have helped beat down historic killers like infections, communicable diseases and traumatic injuries. Today, however, Canadians’ long lives are often accompanied by chronic, non-communicable diseases. Half live with one chronic disease, and more than a quarter live with two or more. Chronic conditions are now responsible for 9 in 10 deaths in Canada (half from cancer and heart disease). In part, the increasing burden of chronic disease reflects the fact that some diseases once considered fatal are now managed more like long-term chronic illnesses (obviously positive for survivors, though posing long-term challenges for the health system).
But other chronic diseases with more ominous roots — diabetes, lung diseases and Alzheimer’s, for example — are also more prevalent. Similar to life expectancy, successfully dealing with these will require that we look beyond treatment-oriented solutions alone. As the OECD’s 2011 Health at a Glance report notes, “much of the burden of diseases in OECD countries nowadays is linked to lifestyle factors, with tobacco smoking, alcohol consumption, obesity, unhealthy diet and lack of physical activity being largely responsible.” On the other hand, “People who live a physically active life, do not smoke, drink alcohol in moderate quantities, and eat plenty of fruit and vegetables have a risk of death in a given period that is less than one-fourth of those who have invariably unhealthy habits.” More proof here of what we already know: 75 per cent or more of our good health stems from factors completely outside the health-care system. In fact, OECD data confirm that the ratio of social service expenditures to health service expenditures — not the amount spent on health services — is what most directly improves population health on key indicators like infant mortality and life expectancy.
Left unchecked, we face a real problem: with the number of Canadians aged 65 and over expected to reach 25 per cent of the population by 2036, and chronic diseases more likely to impact older people, our social and economic chronic disease burden is set to grow steadily and dramatically.
This growing burden confronts us with a major conundrum. We have built a disease- and treatment-focused system with many strengths. But we simply can’t buy large-scale improvements in population health with this system alone. The truth is, if we really want better health and a sustainable, effective health-care system, we must direct more health resources where health issues arise.
Better value for our shared investment