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
Highly credible research organizations regularly conduct international rankings telling us that Canadians’ health isn’t what it should be given what we spend on health care. Yet, our “middle of the pack performance,” as the Conference Board of Canada has described it, looks only at measures of effectiveness in the acute care hospital system.
In our opinion these reports mislead by focusing solely on the acute care system, which fuels the belief that pouring more money into it will translate into better health. Yes, we want that system to be strong, accessible, safe and effective. But the evidence says that even spending every cent of our GDP on the acute care system isn’t going to improve population health much. The most sophisticated, advanced and effective hospital system on earth will not get us the “top five” health status we deserve as a nation.
What we need is a system and an approach that is about healthy living and population health. We must shift the conversation, and the international metrics by which we rank our performance, to the value of broad-based primary health care services, which means team-based care options, linked to care in homes and communities, centred on people and focused on programs and services that improve population health.
But a real return on our investment is about much more than health-care options. To achieve top-five health status befitting our top-five spending, we must deal head-on with thorny issues like security of food, water, employment, income and housing for all Canadians. We are not talking about pouring a lot more money into pricey services. We are talking about shifting our priorities so we spend money on the things that really make a difference to health — and in turn, to our shared costs and national productivity. We haven’t found many people or much evidence to disagree with this solution; yet we still haven’t made it happen.
The OECD notes that the weak correlation between health spending and life expectancy in countries like Canada, which is already spending a lot on health care, suggests “there is room to improve the efficiency of health systems to ensure that the additional money spent on health brings about measurable benefits in terms of health outcomes.”
Similar conclusions have been reached by a series of credible, evidence-informed reports over the last decade — the National Expert Commission just the latest among them. Evidence and expert opinions from many fields are now coalescing, consistently calling for a strongly-performing acute care system along with other primary health care services (e.g., wellness, primary care, home care, care of aging citizens) that help people get well, stay well and stay out of our overworked hospitals. According to the Conference Board of Canada, “Canada has no choice but to adopt a model that focuses on sound primary care practices and population health approaches — particularly preventing and managing chronic diseases — and recognizes and rewards high-quality health-care services.”
We can fix this. As economist Bob Evans has said, “policy is possible.” Earlier this year, for example, the Health Council of Canada recommended that “Targeted investments to advance self-management [of chronic disease] hold potential to yield big wins on many levels — for individuals and their families (e.g., better quality of life); for health care providers (e.g., better outcomes for their patients); for the efficient, effective, and sustainable use of health care resources; and for a healthier, more productive Canada.” And this past June, the National Expert Commission offered a nine-point plan for system transformation, driven by evidence and strongly based in broad social, economic, environmental and indigenous determinants of health.
We have a mountain of evidence about the need for change, and we have plenty of tested innovations that have led to affordable, effective transformations to health-care systems globally. We can fix this. More effective use of the intellectual capital of Canada’s existing 268,500 registered nurses — already licensed and working in the system — is but one mechanism we could rally quickly to help shift direction. What we haven’t yet found is a mountain of courage to radically scale up system-level change. And let’s be clear: major change is needed. We are long past the tinkering stage.
We know Canadians place a strong value on our publicly funded, not-for-profit health system. To preserve and strengthen it we need to make some fundamental changes to the way we are spending our money. So we have a choice: maintain a system that keeps our costs in the top five or make the decisions that could place our health in the top five.
We’ve talked with Canadians across the country, and we think they come down firmly on the side of better health, better care and better value. If so, then every Canadian should demand a blueprint showing how our politicians, health system leaders, corporate Canada and civil society will work together to reach top five status on key indicators by 2017, as we celebrate our nation’s 150th birthday. Together, we can recast Canada as a global health leader — home to a health system rated “A,” not just for high spending, but for remarkable health outcomes and performance.
Canada is among the world’s wealthiest nations, having the 14th largest economy. But despite our wealth, did you know…
On any given day, more than 1,400 Canadian communities are under a boil water advisory.
• The United Nations in 2006 called housing and homelessness in Canada a national emergency.