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Health System Sustainability

Partner Institute: 
Canadian Policy Research Networks (CPRN), Ottawa
Survey no: 
(14) 2009
Margaret MacAdam, Ph.D., Senior Fellow, Health
Health Policy Issues: 
Funding / Pooling, Benefit Basket, Responsiveness
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no yes no no no no


The Canadian health care system is under stress in every province because of its continuing expenditure growth. Health expenditures as a percentage of GDP are not the highest among developed countries (France, Germany and the US spend more, but there is growing concern that we may not be spending our money wisely. In 2009, the Health Council of Canada published the first in a series of papers designed to engage Canadians in a discussion of value for money in health care.

Recent developments

Surveys of Canadians over the past four years indicate that while Canadians remain firmly committed to universal health care, they are concerned about a number of issues. One of them is that accountability for health expenditures should be improved. Others are accessiblity to needed care and quality of care. Perhaps in response to concerns about access and quality, more Canadians are indicating a willingness for private sector provision of health care as an addition to, not a replacement of, the public health care system (Soroka, 2007) (for information on the increasing role of private delivery see report 12/2008). 

In response to these issues, the Health Council of Canada is initiating a series of papers that explore aspects of the sustainability of the Canadian health care system. The first paper, entitled "Value for Money: Making Canadian Health Care Stronger" is summarized in this report.  To date, the Council has not publicized the topics to be covered in future papers.  One feature of this initiative is the use of an interactive web site for Canadians to post their thoughts on our health care system.

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Characteristics of this policy

Degree of Innovation traditional rather traditional innovative
Degree of Controversy consensual neutral highly controversial
Structural or Systemic Impact marginal neutral fundamental
Public Visibility very low low very high
Transferability strongly system-dependent strongly system-dependent system-neutral
current current   previous previous

At the moment, the dialogue in response to the Council's report has been very muted.  Eventually it may turn out that this initiative formed the beginning of a movement for change but it is more likely that  public opinion will be shaped by widely publicized issues and positions taken by powerful stakeholders.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no yes no no no no

Initiators of idea/main actors

  • Government

Stakeholder positions

There are a variety of stakeholders involved in public debate about health care in Canada. The Health Council of Canada is a publicly funded agency established in 2003 to report on the progress of health renewal in Canada. In particular, its mission is to report progress on achieving the goals of the First Ministers' Accord on Health Care Renewal. These areas have been reported in earlier HealthPolicyMonitor reports (for example, see Wait Times; A Canadian Update, 11 (2008)).

The Health Policy Council has taken the position that an explicit discussion about value for money in the health care system will assist Canadians to become clearer in their expectations about the health care system and more informed about options for the future.

There have been no responses from health provider organizations, to date, about the report.  However, the public has, to a limited extent, begun to post their thoughts on the website. Most postings see opportunities for service delivery improvement.

Actors and positions

Description of actors and their positions
Health Council of Canadavery supportivevery supportive strongly opposed
current current   previous previous

Influences in policy making and legislation


Legislative outcome


Actors and influence

Description of actors and their influence

Health Council of Canadavery strongstrong none
current current   previous previous
Health Council of Canada

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

The main vehicle for collecting responses from Canadians on the Value for Money  report is the blog that the Health Council has established (  To date responses have been received on such topics as, team-based care, unnecessary use of the health care system, funding in the system, access, shortages of health professionals, prescription drugs, preventing illness and promoting health, seniors care, and technologies.  The topics receiving the most attention are preventing illness and promoting health, team-based care, unnecessary use of the health care system, and funding in the system.   the vast majority of posts were received in the months just after the announcement of the project in February, there have been very few posts since June, 2009. 

Monitoring and evaluation

The Council's report identified various facets of a national value for money discussion. The concept of ' value' has been formulated in several ways. For example, health itself has a social value: there are trade-offs between health and other social goods such as education. Equity is another component of value. Another is that Canadians spend about 10% of GDP on health, or about $172 billion annually, and achieve results that are better than or the same as some countries that spend more. But some countries spend less on health care and achieve results that are at least as good and, in some cases, better than our results. Therefore, a component of value is the worth of the results compared to the price.

The argument is made that spending more on health care will not necessarily solve our health care problems. For example, health care spending doubled from 1997 to 2007, with the largest share (48%) of the increase due to the provision of more services. The value for money issue is whether the intensification of utilization is good value for money. One of the challenges in assessing value for money is accurately measuring value received and money spent. Outside of drug formularies and health technology assessment, there are few good tools or criteria for assessing the value gained from the money spent in the health care sector (Health Council of Canada, 2009).

Expected outcome

The Value for Money initiative of the Health Council should add a new level of discussion to the sustainability debate in Canada. Today health care spending is consuming about 40% of total provincial budgets and there is concern that if that proportion creeps up to 45% there will be great pressure on governments to reform the system, perhaps by allowing a private pay option, or by reducing access to services. Some groups such as the Canadian Medical Association, which represents the country's 80,000 physicians, have already issued calls for reform. This year the CMA made reform the theme of its annual meeting: "Health Care Transformation: We Can All Do Better". Unlike the US health care reform dialogue, the Canadian discussion is quieter, less fractious, and likely to lead to incremental changes rather than a major transformation of the system.

An interesting aspect of the Value for Money initiative is its effort to engage Canadians in the debate about the future direction of national health policy.  To date, there has been very little use of the website ( it has received a total of 260 posts).  Additionally there has been no publicity about this project since its inauguration in the winter of 2009.   Unless the Council develops new methods to reach out to Canadians it appears that this effort could fail.


Impact of this policy

Quality of Health Care Services marginal rather marginal fundamental
Level of Equity system less equitable neutral system more equitable
Cost Efficiency very low high very high
current current   previous previous

It is too early to tell whether the debate about value for money in the health care system will result in changes in quality, equity or cost efficiency, but there is potential for increased cost-efficiency.


Sources of Information

  • Health Council of Canada.(2009).  Value for Money: Making Canadian Health care Stronger.
  • Soroka, Stuart.  2007. Canadian Perceptions of the Health Care System: A Report to the Health Council of Canada.  Health Council of Canada. Toronto. ON

Author/s and/or contributors to this survey

Margaret MacAdam, Ph.D., Senior Fellow, Health

Suggested citation for this online article

Margaret MacAdam, Ph.D., Senior Fellow, Health. "Health System Sustainability". Health Policy Monitor, October 2009. Available at