One Country, Many Health Systems: Q & A with Greg Marchildon, editor of provincial and territorial health system profiles book series

August 13, 2018

Profile of Greg Marchildon with North American Observatory on Health Systems and Policies banner in the background

You may be surprised to learn that in spite of the praise we receive for our nation’s health care, Canada does not in fact have a singular, unified health system. Each province or territory governs their own set of health care plans, making it difficult to determine where Canadians might be falling through the gaps.

Greg Marchildon, a professor at the Institute of Health Policy, Management and Evaluation, and founder and director of the North American Observatory on Health Systems and Policies has launched a new book series profiling provincial and territorial health systems in partnership with U of T Press. The main goal of these books is to provide the public and researchers with a deeper understanding of our country’s varied approaches to health care.
Following the recent publication of the third book in the series, Nova Scotia: A Health System Profile, IHPME Communications Coordinator Rebecca Biason spoke with Marchildon about the significance of the series, discoveries made throughout the process, and the importance of making residents across the country aware of how their health systems function.

What are some of the challenges or consequences that Canada’s fragmented health system poses for health system researchers and the public?

According to some standards, Canada is ranked as one of the most decentralized federations with respect to its health care system. With the provincial ministries of health determining the structure of how health is funded or provided, it makes it difficult to compare Canada as a whole to other countries. You are far better off comparing Ontario to Denmark or Germany if you want to make a comparative analysis.
As a country we do operate under some national rules, including the five criteria outlined by the Canada Health Act, but in terms of delivery and implementation of health services, that is entirely the province’s responsibility. So, if you want to understand how the system is working, you need to get at it from the provincial level, yet there are so few studies that provide either an overview of how a single province works, or how provinces compare to one another. The books in this series will try to do both, provide a description and analysis of the provincial or territorial health system, and where possible, make comparisons with others.

You have already published two profiles, one on Saskatchewan and one on Nunavut, was there anything about these health systems that stood out or surprised you in any way?

I didn’t anticipate it, but there were actually two things that stood out to me from each jurisdiction. I had not realized the extent to which Saskatchewan was a first mover in terms of regionalizing reforms in addition to its long recognition as one of the first provinces to implement Medicare in Canada in the 1950’s. While it has also led the way in terms of organizational reforms in the 1990’s it has since fallen very far behind, particularly with respect to primary care.

In Nunavut, it is difficult to recruit physicians to practice that far north and as a result, they operate on a nurse-based primary care system, something usually considered to be a second choice. Yet, this practice has created a very consistent and available primary care system for them, in some respects better than what is available in most provinces. However, they do have their own fair share of problems. Prior to conducting this study, I had been unaware of the deep effects of their employee turnover. People are changing jobs or leaving positions after six months, and often positions are left open for a year or more because they have difficulty finding replacements.

With respect to the most recent publication on Nova Scotia, were there any key highlights that stood out from this profile?

Perhaps one of the most interesting aspects is that the administrator of the universal medical insurance in Nova Scotia is not the provincial government, it is a not-for-profit non-governmental organization. Usually when we talk about single-payer financing of health systems we are referring to the government, but that is clearly not always the case.

Another key highlight is the extent to which Nova Scotia’s aging population is imposing significant extra costs on the delivery of health care services. When you think about it, the cost of dying is actually very high. In the last eight months of our life, we become high-cost users of the health system receiving numerous interventions, or dying in hospital. Even as we age, we absorb more health services such as with hip and knee replacements, and of course, long-term care can be very expensive. In this case, Nova Scotia is running a more expensive health system than most provinces as demographically speaking they have the oldest population with low rates of immigration and low birth rates. There is a real opportunity for the rest of the country to learn from Nova Scotia’s response to the complex needs of their population.

What are you hoping this series will offer to both students, the public, and policy makers at the government level?
Number one, for the public, a readable introduction and explanation of the health system in which they live, work, and obtain services. Number two, for administrators and decision makers to see how they fit into the system as a whole, and number three, for students, the option to use these books as a learning tool on a regular basis, so that they can focus on the provincial or territorial levels of health in order to further understand the workings of the system.

We also want to make these books accessible. We have an agreement with University of Toronto Press, after each book has been in circulation for a year, we will make them available for free online via the North American Observatory on Health Systems and Policies website. We are hoping that ultimately this is going to benefit decision makers, providers and the public, so that there will be more demand for improvements to our health systems, and we will be more capable of drawing upon lessons from across the provinces to lead improvements and change.