Health Care Systems and Policies

125 Pages·5.359 MB·English

by  Ewout van Ginneken, Reinhard Busse (eds.)

Health System in Canada
Gregory Marchildon
Abstract providing citizens with deep financial protec-
Withapopulationof35millionpeoplespread tion against hospital and physician costs, the
over a vast area, Canada is a highly narrow scope of coverage has also produced
decentralized federation. Provincial govern- some gaps in coverage and equitable
ments carrymuchoftheresponsibilityforthe access(Romanow2002).
governance, organization, and delivery of
health services although the federal govern-
ment plays an important role in maintaining Contents
broad standards for universal coverage, direct
Introduction............................................ 1
coverageforspecifiedpopulations,datacollec-
OrganizationandGovernance....................... 2
tion, health research, and pharmaceutical reg-
ulation.Roughly70%oftotalhealthspending Financing............................................... 5
is financed from the general tax revenues of
PhysicalandHumanResources...................... 5
federal, provincial, and territorial govern-
DeliveryofHealthServices........................... 6
ments. Most public revenues are used to pro-
videuniversalaccesstoacute,diagnostic,and Reforms................................................ 7
medicalcareservicesthatarefreeatthepoint Assessment............................................. 8
of service as well as more targeted (non-
References.............................................. 9
universal)coverageforprescriptiondrugsand
long-term care services. In the last decade,
therehavebeennomajorpan-Canadianhealth Introduction
reforms, but individual provincial and territo-
rialgovernmentshavefocusedonreorganizing Canadaisthesecondlargestcountryintheworld
and fine-tuning their regional health system asmeasuredbyarea,withamainlandthatspansa
structureandimprovingthequality,timeliness, distance of 5514 km from east to west and
and patient experience of primary, acute, and 4634 km from north to south. The climate is
chronic care services. While Canada’s system northern in nature with a long and cold winter
of universal coverage has been effective in seasons experienced in almost all parts of the
country.Thecountryhasapopulationof35mil-
lion with most of the population concentrated in
G.Marchildon(*)
urbancentersclosetotheborderwiththeUnited
InstituteofHealthPolicy,ManagementandEvaluation,
Statesandtheremainderscatteredovervastrural
UniversityofToronto,Toronto,Canada
e-mail:[email protected] andremoteareas(Fig.1).
#SpringerScience+BusinessMediaLLC2015 1
E.V.Ginneken,R.Busse(eds.),HealthCareSystemsandPolicies,HealthServicesResearch,
DOI10.1007/978-1-4614-6419-8_5-1
2 G.Marchildon
Fig.1 MapofCanada
Canada is a high-income country with an Nations and Inuit. The second order of govern-
advanced industrial economy and one of the ment consists of ten provincial governments
world’shighestHumanDevelopmentIndexrank- which bear the principal responsibility for a
ings.RelativetootherOECDcountries,Canada’s broad range of social policy programs and ser-
economicperformancehasbeensoliddespitethe vices(Marchildon2013).
recessiontriggeredbythefinancialcrisisof2008.
Theburdenofdiseaseisamongthelowestinthe
OECD even though Canada’s ranking, based on Organizationand Governance
health-adjusted life expectancy (HALE), slipped
from second in 1990 to fifth by 2010 (Murray et In Canada, the governance, organization, and
al.2013).ThetwomaincausesofdeathinCanada deliveryofhealthservicesarehighlydecentralized
arecancerandcardiovasculardisease. for at least three reasons: (1) the constitutional
Canadaisaconstitutionalmonarchy,basedon responsibilityofprovincesforthefunding,admin-
aBritish-styleparliamentarysystem,andafeder- istration,anddeliveryofmosthealthservices,(2)
ationwithtwoconstitutionallyrecognizedorders thestatusofphysiciansasindependentcontractors,
ofgovernment.Thefederalgovernmentisrespon- and (3) the existence of multiple organizations,
sibleforcertainaspectsofhealthandpharmaceu- from regional health authorities to privately
tical regulation and safety, data collection, owned and governed hospitals and clinics, all of
research funding, and some health services and which operate at arm’s length or independently
coverageforspecificpopulations,includingFirst fromprovincialgovernments.
HealthSysteminCanada 3
Provincial and territorial governments are responsible for system-wide national planning.
responsible for administering their own tax- Provincial ministries of health are responsible
funded universal, first-dollar coverage programs. forplanningandregulatingtheirrespectivehealth
Historically, the federal government used its systems, but they collaborate through mecha-
spending power to encourage theintroduction of nisms such as federal-provincial-territorial coun-
theseprogramsbasedonhigh-levelnationalprin- cilsandworkinggroupsofMinistersandDeputy
ciples, including the portability of coverage Ministers of Health. The provincial and federal
among provinces and territories. In most prov- governments have also established a number of
inces,healthservicesareorganizedanddelivered specializedintergovernmentalagenciestopursue
byregionalhealthauthorities(RHAs)whichhave morespecializedobjectivesincludinghealthdata
been legislatively delegated to provide hospital, collectionanddissemination(theCanadianInsti-
long-term, and community care as well as tuteforHealthInformationorCIHI),healthtech-
improve population health within defined geo- nology assessment (the Canadian Agency on
graphicalareas. Drugs and Technologies in Health or CADTH),
Provincial ministries of health retain the electronic health records (Canada Health
responsibility to provide targeted coverage for Infoway),andpatientsafety.
pharmaceuticalsandforremuneratingphysicians. Provincialandterritorialgovernmentsregulate
Mostphysiciansworkonfee-for-servicewithfee healthfacilitiesandorganizationssinceRHAsare
schedules determined through negotiations delegated authorities without a law-making or
between the medical associations and ministries regulatory capacity. These governments are also
ofhealthattheprovinciallevelofgovernment.As responsibleformanagingbloodproductsandser-
independent professionals as opposed to salaried vicesthroughCanadianBloodServicesinmostof
employees, physicians have considerable auton- thecountryandHéma-Québecintheprovinceof
omyintermsofthemanagerialcontrolofprovin- Quebec. Provincial or othergovernments are not
cialhealthministriesorRHAs. directly involved in facility accreditation, and
Despitethisapparentdecentralization,thefed- healthorganizationsareaccreditedonavoluntary
eral government retains significant steering basis through Accreditation Canada, a member-
responsibilities. Through its cash transfers to the ship-based nongovernmental body. Most health
provincial governments and the threat of their professions,including physicians andnurses,are
withdrawal, the federal government sets pan- self-regulatingwithineachprovinceandterritory
Canadianstandardsforhospitalandmedicalcare basedonframeworklawsestablishedbytherele-
servicesthroughtheCanadaHealthAct.Thefed- vantgovernments.
eral department of health – Health Canada – is Six provincial governments have established
responsible for ensuring that provincial govern- health quality councils to work with health pro-
ments areadheringtothefivecriteriaintheAct: viders and organizations to improve quality and
public administration, comprehensiveness, uni- safety, as well as report outcomes to the general
versality, portability, and accessibility. public.However,nogovernmenthasgivenapro-
Established in 2004 in response to the lack of vincialqualitycouncilthepowertoregulatequal-
nationaldirectionduringthesevereacuterespira- ityorsetenforceablestandards.
torysyndrome(SARS)epidemictheyearbefore, The federal government through Health Can-
the Public Health Agency of Canada performs a adaregulatesmedicaldevices;determinestheini-
broad array of public health functions including tialapprovalandlabelingofallprescriptiondrug
infectiousdiseasecontrol,surveillance,andemer- therapies, herbal medicines, and homeopathic
gency preparedness and, through community preparations; and prohibits direct-to-consumer
partners,facilitatesvarioushealthpromotionand advertising of pharmaceuticals. Pharmaceutical
illnesspreventioninitiatives(Fig.2). advertisingtargetingphysiciansissubjecttofed-
Duetotheconstitutionaldivisionofpowersin erallawaswellastocodesestablishedbyindustry
Canada, there is no single ministry or agency associations. The federal government has
4 G.Marchildon
CanadianConstitution
ProvincialandTerritorial Transferpayments FederalGovernment StatisticsCanada
Governments
Federal- CanadianInstitutesfor
Regional Ministers Provincial- HealthResearch
Health and Territorial MinisterofHealth
Authorities Ministriesof Conferences&
Health Committees
PublicHealth Patented
CanadaHealth
HealthCanada Agencyof MedicinePrices
mental home hospital Act,1984 Canada ReviewBoard
health careand and
and long-term medical
public care services
health providers providers
providers
ProvincialandTerritorial
prescriptiondrugprograms
CanadianAgencyfor
DrugsandTechnologies CanadianInstitutefor HealthCouncilofCanada CanadaHealthInfoway Canadian
inHealth HealthInformation (2003-2013) (2001) PatientSafetyInstitute
(1989) (1994) (2003)
Canadian
BloodServices
(1996)
Fig.2 OrganizationoftheCanadianhealthsystem
exclusive jurisdiction over the patenting of new does appear that hospitals in Canada are also
inventions,includingpharmaceuticals,andpatent behindintheiradoptionanduseofICT(Urowitz
protectionissetatthe20-yearOECDnorm.Pro- etal.2008).
vincial governments use a number of regulatory Three provincial organizations and one
tools, including reference pricing, licensing of national-level organization provide health tech-
generics, bulk purchasing, tendering, and nologyassessments(HTA)toprovincialandfed-
discounting,tocontainthecostoftheirrespective eral ministries of health and delegated health
prescriptiondrugplans(ParisandDocteur2006). authorities. As the sole pan-Canadian HTA
Due to a high degree of health system decen- agency, CADTH’smandate istoprovideevalua-
tralization,physicianautonomy,andonerouspri- tionsofnewprescriptionsdrugs,aswellasmed-
vacy laws, Canada has been slower than other ical devices,procedures, andsystems, tofederal,
countries in integrating information and commu- provincial,andterritorialgovernments.CADTH’s
nicationstechnology(ICT)intohealthdelivery.In recommendationsareadvisoryinnature,anditis
a2009surveyof11OECDcountriesbytheCom- up to the governments in question to decide
monwealthFund,Canadianfamilydoctorsscored whetherornottointroducethesetechnologies.
the lowest in terms of using electronic health The patient rights movement is relatively
records (EHRs) and had the lowest electronic underdeveloped in Canada compared to similar
functionality (Schoen et al. 2009). Although the movements in the United States and Western
evidence is limited and now somewhat dated, it Europe. While there are patient-based
HealthSysteminCanada 5
organizations focusing on particular diseases, health insurance (11.8%), and other sources
there are only a handful of more broadly based, (3.1%)(CIHI2013).
rights-oriented patient groups. In recent years, Since the Canada Health Transfer constitutes
patient rights have been exercised through the roughly 20% of total provincial government
courts,relyingontheconstitutional“righttolife, health expenditures, the provincial governments
libertyandsecurityoftheperson”intheCanadian areresponsibleforraisingthelion’sshareofrev-
Charter of Rights and Freedom, although most enuesforhealth(CIHI2013).Provincialtaxrev-
attempts to extend this to a right of access to enuescomefromanumberofsources,including
qualityhealthcarewithinareasonabletimehave (inroughorderofimportance)individualincome
failed(Jackman2010). taxes, consumption taxes (including “sin” taxes
Patients and their respective physicians have onalcoholandgambling),andcorporationtaxes.
beenmoresuccessfulinusingsuchCharterrights Inthoseprovincesbenefittingfromanabundance
tocreatearighttoprivatehealthcareandprivate of natural resources, resource royalties and taxes
health insurance. In 2005, the Supreme Court of are significant sources of revenue (Marchildon
Canadaprovidedalimited formofthisrightina 2013).
situation where the majority of the court Consistent with being a tax-based Beveridge-
interpreted public waiting lists for certain types style health system, there is limited pooling of
of elective surgery as unreasonable (Flood et al. funds in the Canadian system. However, there is
2005). atypeofpoolingthroughcashtransfers–fromthe
federal government (which collects tax at the
national level) to the provincial and territorial
Financing governments and from provincial governments
(which pool federal transfers with own-source
Every provincial and territorial government pro- revenues) to RHAs – which, as public non-
vides universal coverage to medically necessary governmental bodies, have no autonomous pow-
hospital, diagnostic, and medical care ser- ersoftaxation.
vices (Taylor 1987). These 13 governments act
as single payers in providing full coverage for
their respective provincial and territorial resi- Physical and Human Resources
dents. In return for receiving federal transfers,
provincialandterritorialbenefitsareprovidedon From the 1940s until the 1960s, Canada experi-
a first-dollar basis and on the same terms and encedaboominhospitalbuildingencouragedby
conditions to all residents as stipulated in the the introduction and expansion of universal hos-
Canada Health Act. Moreover, these benefits are pital coverage and federal hospital construction
portable among the provinces and territories. grants.Bythe1990s,muchofthishospitalinfra-
Beyondthisso-calledMedicarecoverage,federal, structure was outdated. Some provincial govern-
provincial,andterritorialgovernmentsoffertheir mentsalsofeltburdenedwithtoomanysmalland
owncategoricalprogramsin,andtargetedbenefits inefficienthospitalsinruralandremoteareas.Asa
for,long-termcareandprescriptiondrugs. result, hospitals were closed, consolidated or
Based on 2011 data, federal, provincial, and converted,and,insomeprovinces, putunderthe
territorial governments were responsible for governance and ownership of newly created
funding 70.4% of all health spending inCanada, RHAs(Ostry2006).
the majority of which is raised through general Despite recent reinvestments in hospital capi-
taxation. Three provinces supplement their reve- tal,lessinbricksandmortarandmoreinmedical
nues through annual health-care premiums, but equipment, imaging technologies, and ICT, the
these too flow into provincial general revenue number of acute care beds per capita has contin-
funds. The remaining health financing comes ued to decline. This is in part the result of
from out-of-pocket payments (14.7%), private improvements in clinical procedures and the
6 G.Marchildon
expansion of non-hospital-based surgical clinics College of Physicians and Surgeons of Canada.
that specialize in day surgeries. Although in the Although mandated through policy and practice
pastCanadahadfallenbehindotherOECDcoun- ratherthanlaw,GPsandfamilyphysiciansactas
tries in terms of the supply and use of advanced gatekeepers, deciding whether patients should
imaging equipment, the supply of computed obtain diagnostic tests and prescription drugs or
tomography (CT) scans, magnetic resonance bereferredtomedicalspecialists.
imaging (MRI), and positron emission (PT) Provincial ministries have renewed efforts to
scansisnowclosertotheOECDaverage. reform primary care in the last decade. Many of
After a lengthy period in the 1990s when the thesereformsfocusontransitioningfromthetra-
supply of physicians and nurses was reduced ditional physician-only practice to
because of the concerted efforts of governments interprofessional primary teams capable of pro-
to reduce spending and pay down accumulated viding a broad range of primary, health promo-
public debt, spending on the health workforce tion,andillnesspreventionservices.
hasclimbedsteadilysincetheturnofthecentury. Almost all acute care is provided in public or
Medical,nursing,andotherhealthprofessionfac- private nonprofit hospitals, although specialized
ulties haveexpandedtheirseatstoproducemore ambulatoryandadvanceddiagnosticservicesare
graduates, even while an increasing number of sometimes provided in private for-profit clinics,
foreign-educated doctors and nurses have immi- particularlyinlargerurbancenters.Mosthospitals
gratedtoCanada. have an emergency department that is fed by
With theexceptionofphysicians,mosthealth independentemergencymedicalserviceunitspro-
workers are employees of health-care organiza- viding first response care to patients while being
tions,RHAs,andhealthministriesandareremu- transported to the hospital. Due to the scattered
nerated through salary and wage income. The natureofremotecommunitieswithoutsecondary
majority of health workers in the public sector andtertiarycare,provincialandterritorialgovern-
are unionized, and their remuneration is set ments provide air-based medical evacuation, a
through collective bargaining agreements. The major expenditure item for the most northern
majority of physician remuneration is through jurisdictions(MarchildonandTorgerson2013).
fee-for-service. However, alternative payment Long-termcareservices,includingsupportive
contracts – particularly for general practitioners home and community care, are not classified as
(GPs)–arebecomingmorecommoninpartasa insuredservicesrequiringuniversalaccessunder
resultofprimarycarereforms. the five national criteria set out in the Canada
Health Act. As a consequence, public policies,
subsidies, programs, and regulatory regimes for
Deliveryof Health Services long-termcarevaryconsiderablyamongtheprov-
incesandterritories.Facility-basedlong-termcare
All provincial and territorial governments have (LTC) ranges from residential care with some
publichealthprograms.Theyalsoconducthealth assisted living services to chronic care facilities
surveillance and manage epidemic response. (originally known as nursing homes) with 24-
While the Public Health Agency of Canada hour-a-day nursing supervision. Most residential
developsandmanagesprogramssupportingpub- careisprivatelyfunded,whereashigh-acuityLTC
lichealthprogramsattheprovincial,regional,and (requiring 24-hour-a-day nursing supervision) is
localcommunitylevels,thestewardshipformost heavily subsidized by provincial and territorial
day-to-daypublichealthactivitiesandsupporting governments (Canadian Healthcare Association
infrastructureremainswiththeprovincialandter- 2009).
ritorialgovernments. Until the 1960s, the locus of most mental
Most primary care is provided by GPs and healthcarewasinlarge,provinciallyrunpsychi-
familyphysicians,withfamilymedicinerecently atrichospitalswhichinturnhadevolvedoutofthe
recognized as a specialization by the Royal nineteenth century asylum and the twentieth
HealthSysteminCanada 7
centurymentalhospital.Withtheintroductionof Aboriginal approach to health and health care
pharmaceutical therapies and a greater focus on (Marchildon2013).
reintegration into the community, mental health
conditions have since been mainly treated on an
outpatientbasisor,inthecaseofsevereepisodes, Reforms
inthepsychiatricwardsofhospitals.GPsprovide
themajorityofprimarymentalhealthcare,inpart There have been no major pan-Canadian health
because medical care is an insured service with reforms in the past decade. However, individual
first-dollar coverage, whereas psychological ser- provincialgovernmentshaveconcentratedontwo
vicesareprovidedlargelyonaprivatebasis. categories of reforms: (1) structural change
While drugs administered in hospitals are involving the governance and management of
fully covered as an insured service under the healthservicesasamoreintegratedhealthsystem,
CanadaHealthAct,everyprovincialandterrito- mainlythroughthereorganizationandfine-tuning
rialgovernmenthasaprescriptiondrugplanthat oftheirregionalhealthsystems,and(2)process-
covers a portion of the cost for outpatient pre- type reforms, aimed at addressing bottlenecks in
scriptiondrugs.Themajorityofthesedrugplans delivery, improving patient responsiveness and
target low-income or retired residents. The fed- elevatingbothqualityandsafety.
eralgovernmentprovidespharmaceuticalcover- The introduction of RHAs allowed provincial
age for eligible First Nations and Inuit. These governmentstodirectlymanagethehealthsystem
public insurers depend heavily on health tech- through arm’s-length delegated bodies. RHAs
nology assessment to determine which drugs manage services as purchaser-providers except
should be included in their respective in Ontario when the local health integration net-
formularies. works(LHINs)fund(purchase)butdonotdeliver
Almostalldentalcareisdeliveredbyindepen- servicesdirectly.Thepurposeofthereformwasto
dent practitioners, and 95% of these services are gainthebenefitsofverticalintegrationbymanag-
paid privately. Dental services are paid for ingfacilitiesandprovidersacrossabroadcontin-
through private health insurance – provided uum of health services and to improve the
mainly through employment-based benefit plans coordination of “downstream” curative services
– or out of pocket. As a consequence of access with more “upstream” public and population
being largely based on income, outcomes are health services and interventions. In the last
highlyinequitable. decade,therehasbeenatrendtoreducethenum-
Forhistoricalreasons,thefederalgovernment ber of RHAs, thereby increasing the geographic
finances a host of health service programs andpopulationsizeofRHAsineachprovince,in
targeting Aboriginal Canadians, in particular eli- order to capture greater economies of scale and
gible First Nation and Inuit citizens. These ser- scope.
vices include health promotion, disease Influencedchieflybyqualityimprovementini-
prevention, and public health programs as well tiativesintheUnitedStatesandtheUnitedKing-
ascoverageformedicaltransportation,dentalser- dom, provincial ministries of health have
vices, and prescription drug therapies. Despite established new institutions, mechanisms, and
these targeted efforts, the gap in health disparity tools to improve the quality, safety, timeliness,
betweentheseAboriginalcitizensandthemajor- and responsiveness of health services. Six prov-
ityofsocietyremainslarge.Sincethe1990s,there inces have established health quality councils to
have been a series of health-funding transfer accelerate quality improvement initiatives at the
agreements between the federal government and provincial, regional, and clinical levels. Some
First Nation governments – largely based on provinces have also launched patient-centered
reserves in rural and remote regions of Canada. careinitiativesaimedatimprovingtheexperience
At the same time, there has been an Aboriginal ofpatientsandinformalcaregivers.Patientdissat-
healthmovementadvocatingforamoreuniquely isfactionswithlongwaittimesforelectivesurgery
8 G.Marchildon
aswellasspecialistanddiagnosticserviceshave There is also an historic east-west economic
triggeredeffortsinallprovincestobettermanage gradient dividing the less wealthy provinces in
andreducewaittimes. eastern Canada and the wealthier provinces in
Incontrast,thefederalgovernmenthaslargely the more western parts of the country from
removeditselffromengagingtheprovincesinany Ontario to British Columbia. In the present, the
pan-Canadian reform efforts. This is in part the economic division is more between those prov-
consequence of the perceived failure of the “10- incesrichinnaturalresources–particularlypetro-
Year Plan to Strengthen Health Care,” signed by leum-producing provinces such as Alberta,
the Prime Minister and the Premiers of all prov- Saskatchewan and Newfoundland – and those
incesandterritoriesin2004. provinces without such resources. These differ-
The “10-Year Plan” ends in the fiscal year ences are addressed through equalization pay-
2013–2014. In December 2011, the federal gov- ments from federal revenue sources to “have-
ernmentannounceditsreconfigurationoftheCan- not”provincesthatensurethelatterhavetherev-
ada Health Transfer for the decade following the enues necessary to provide comparable levels of
10-YearPlan.After2014,increasesinthetransfer public services, including health care, without
totheprovinces,originally6%perannum,willbe resortingtoprohibitivelyhighertaxrates.
heldtotherateofeconomicgrowthwithamini- While Canadians are generally satisfied with
mumfloorof3%,andalltransferswillbemadeon thefinancialprotectionofferedbyMedicare,they
a pure per capita basis, without taking into con- are less satisfied with their access to particular
sideration the tax capacity of the provinces. The services.Beginningwiththebudgetcutstohealth
removal of any equalization component in the careinthe1990s,emergencyroomsbecameover-
transfer will make it more difficult for lower- crowded and waiting times for nonurgent care
incomeprovincestocontinuetoensurecoverage became lengthier (Tuohy 2002). Based on a sur-
is maintained at the standard enjoyed in higher- vey of patients in selected OECD countries
incomeprovinces. conducted in 2010, Canada ranked poorly in
terms of waiting times for physician care and
nonurgentsurgery(Schoenetal.2010).However,
Assessment basedonrelevantmortalityandmorbidityindica-
tors of health system performance, such as ame-
The model of universal Medicare has been effec- nablemortality,Canadafaresconsiderablybetter,
tiveinprotectingCanadiansagainsthigh-costhos- posting better outcomes than those in the United
pital and medical care. At the same time, the KingdomandtheUnitedStates(NolteandMcKee
narrow scope of the benefit package has resulted 2008).
inlargergapsincoverage,aspharmaceuticalther- Canadian performance in terms of the quality
apies and LTC have grown in importance over of health care has also improved in recent years.
time. Since 70% of financing for health care in This may be a result of the policy focus of pro-
Canada comes from general taxation, there is vincialgovernmentsonquality,assistedbyhealth
more equity in financing, but there is less equity quality councils and the comparative indicators
infinancingfortheremaining30%,whichcomes collectedanddisseminatedbytheCanadianInsti-
fromout-of-pocketsourcesandemployment-based tuteforHealthInformation.Thisimprovementis
insurancebenefitsassociatedwithbetter-paidjobs. now being extended to patient responsiveness in
There are disparities in terms of access to the hope that this will improve the quality of the
health care, but outside of a few areas such as patientexperience.
dental care and pharmaceuticals, they do not There have been few studies oftechnical effi-
appeartobelarge.Forexample,thereappearsto ciencyofhealthsystemsinCanada(CIHI2011).
beapro-poorbiasintermsofprimarycarebuta However, some provincial governments are
pro-rich bias in the use of specialist physician beginning to arrange for external evaluations of
services,butthegapineithercaseisnotlarge. recent reforms. In the particular, the recent
HealthSysteminCanada 9
applicationof“leanproduction”methodologiesin Fine BA, et al. Leading lean: a Canadian healthcare
someprovincialhealthsystemscanbeinterpreted leader’sguide.HealthcQ.2009;12(3):32–41.
as an effort to achieve greater efficiency. First Flood CM, Roach K, Sossin L, editors. Access to care,
access to justice: the legal debate over private health
developedbyToyotatoachievegreatertechnical insurance in Canada. Toronto: University of Toronto
efficiency and higher quality in automobile pro- Press;2005.
ductions, lean techniques have been applied to JackmanM.Charterreviewasahealthcareaccountability
mechanisminCanada.HealthLawJ.2010;18:1–29.
hospitalsandotherhealthsettingsinanumberof
MarchildonGP.Canada:healthsystemreview.HealthSyst
provinces.Theobjectivesoftheleanprojectshave Transit. 2013;15(1):1–179. Copenhagen: WHO
ranged from reducing surgical wait times to RegionalOfficeforEuropeonbehalfontheEuropean
improvingpatientsafety(Fineetal.2009). ObservatoryonHealthSystemsandPolicies.
Marchildon GP, Torgerson R. Nunavut: a health system
Due to the number of trends and institutional
profile. Montreal/Kingston: McGill-Queen’s Univer-
changes,healthsystemsinCanadaaremoretrans- sityPress;2013.
parent today than in the past. Whether in their MurrayCJL,RichardsMA,NewtonJN,etal.UKhealth
rolesascitizens,taxpayers,patients,orcaregivers, performance:findingsoftheGlobalBurdenofDisease
Study.Lancet.2013;381:997–1021.
Canadianshavebeendemandinggreatertranspar-
NolteE,McKeeM.Measuringthehealthofnations:updating
encyonthepartoftheirgovernmentsandpublicly anearlieranalysis.HealthAff.2008;27(1):58–71.
funded health-care organizations and providers. Ostry A. Change and continuity in Canada’s health care
They now receive a range of health information system.Ottawa:CHAPress;2006.
ParisV,DocteurE.Pharmaceuticalpricingandreimburse-
andanalysisfromanumberofnewprovincialand
ment policies in Canada. Paris: Organisation of Eco-
intergovernmental organizations, including the nomic Co-operation and Development, Health Work
HealthCouncilofCanadawhichprovidesacces- Group;2006.
siblereportsonthestateofCanadianhealthcare. RomanowRJ.Buildingonvalues:thefutureofhealthcare
in Canada. Saskatoon: Commission on the Future of
In addition, a number of advocacy organizations
HealthCareinCanada;2002.
and think tanks also provide regular reports on Schoen C, et al. A survey of primary care physicians in
health system issues of concern and interest to elevencountries.HealthAff.2009;28(6):w1171–83.
thegeneralpublic. Schoen C, Osborn R, Squires D. How health insurance
designaffectsaccesstocareandcosts,byincome,in
elevencountries.HealthAff.2010;29:w2323–34.
TaylorMG.HealthinsuranceandCanadianpublicpolicy:
References thesevendecisionthatcreatedtheCanadianhealthcare
system.2nded.Montreal:McGill-Queen’sUniversity
Press;1987.
CanadianHealthcareAssociation.Newdirectionsforfacil-
TuohyCH.Thecostofconstaintandprospectsforhealth
ity-basedlongtermcare.Ottawa:CanadianHealthcare
carereformsinCanada.HealthAff.2002;21(3):32–46.
Association;2009.
Urowitz S, et al. Is Canada ready for patient accessible
CIHI.Healthcare costdrivers: Thefacts. Ottawa: Cana-
electronichealthrecords?Anationalscan.BCMMed
dianInstituteforHealthInformation;2011.
CIHI. National health expenditure trends, 1975–2013. Inform Decis Making. 2008;8:33. http://www.
biomedcentral.com/1472-6947/8/33. Accessed 25
Ottawa: Canadian Institute for Health Information;
Sept2012.
2013.
Health System in China
David Hipgrave and Yan Mu
Abstract health reforms remain encouragingly specific
The health of China’s population improved but not prescriptive on strategy; set in the
dramatically during the first 30 years of the decentralized governance structure, they
People’s Republic, established in 1949. By avoidtheissueofrelianceonlocalgovernment
themid-1970s,Chinawasalreadyundergoing supportforthenationalequityobjective,leav-
the epidemiologic transition, years ahead of ingthedetaileddesignofhealthservicefinanc-
other nations of similar economic status, and ing, human resource distribution and
by 1980, life expectancy (67 years) exceeded accountability,essentialdruglistsandapplica-
that of most similarly low-income nations by tion of clinical care pathways, etc. to local
7 years. Almost 30 years later, China’s 2009 health authorities answerable to local govern-
health reforms were a response to deep ineq- ment, not the Ministry of Health. Community
uityinaccesstoaffordable,qualityhealthcare engagement in government processes, includ-
resultingfromthreedecadesofmarketization, inginprovisionofhealthcare,remainslimited.
including de facto privatization of the health Thischapterusesthedocumentationandliter-
sector,alongwithdecentralizedaccountability ature on health reform in China to provide a
and, to a large degree, financing of public comprehensive overview of the current situa-
health services. The reforms are built on ear- tion of the health sector and its reform in the
lier, equity-enhancing initiatives, particularly People’sRepublic.
the reintroduction of social health insurance
since 2003, and are planned to continue until Abbreviations
2020, with gradual achievement of overarch- CDC Communicablediseasecontrol
ing objectives on universal and equitable GDP Grossdomesticproduct
accesstohealthservices.Thesecondphaseof HMIS HealthMIS
reform commenced in early 2012. China’s HSR Healthsystemreform
LMIC Low-andmiddle-incomecountries
MCH Maternalandchildhealth
D.Hipgrave(*)
MDGs MillenniumDevelopmentGoals
UNICEF,NewYork,NY,USA
MIS Managementinformationsystem
NossalInstituteforGlobalHealth,Universityof
MoH MinistryofHealth
Melbourne,Melbourne,VIC,Australia
NCDs Noncommunicablediseases
e-mail:[email protected]
NDRC NationalDevelopmentandReform
Y.Mu
Commission
UNICEFChina,Beijing,China
e-mail:[email protected] NEDL NationalEssentialDrugsList
#SpringerScience+BusinessMediaLLC2015 1
E.V.Ginneken,R.Busse(eds.),HealthCareSystemsandPolicies,HealthServicesResearch,
DOI10.1007/978-1-4614-6419-8_6-1