The Canadian health-care system has been the source of concern and rigorous debate over the last decade. Some recent international surveys suggest that Canada might need to fundamentally rethink its health-care system. But as John Lydgate in his Debate between the horse, goose, and sheep, circa 1440, first noted, "Odyous of olde been comparisonis." Caution is required, as comparing performance across health-care systems is notoriously difficult to do. For example, a 2000 study published by the World Health Organization (WHO) ranked the French health-care system first in the world; Canada ranked a lowly thirtieth. This result is often used by privatization advocates to prove how poor the Canadian system is relative to countries that have two-tier (i.e., that allow people to use private funds to queue jump or buy better care) health-care systems. But a quick review of health outcomes in both countries raises questions about this apparently abysmal performance on Canada's part. For instance, France and Canada record similar health-care outcomes and, indeed, Canada performs better on many important indicators such as male life expectancy and infant and maternal mortality.

So why did Canada perform so badly in the WHO study? As one analyst explains, Canada's poor ranking is largely due to the fact that the WHO study discounted Canada's performance with respect to health outcomes because Canada spends more money on education and money spent on education is assumed to be a determinant of health. In other words, because the French spend less on education, their positive health outcomes, the WHO study argues, are more directly attributable to their health-care system.

This kind of methodology is highly suspect and open to criticism, but most reporters or policy pundits are unlikely to have the time or resources to more than dip their toes into the complex methodological debates over comparative health system performance.

A number of Commonwealth Fund studies have also tried to compare health system performance. A 2007 survey of adults' health-care experiences ranks Canada seventh out of seven countries in terms of wait times for elective surgery. A more recent study, however, ranks Canada sixth out of 19 countries in terms of the amenable mortality rate (i.e., avoidable deaths from treatable conditions), a valuable performance indicator that can point to potential weaknesses in a nation's health-care system. In this study, Canada does better than the UK (18^th), the US (15^th), New Zealand (14^th), Germany (11^th), and the Netherlands (8^th); indeed, it performs better than all countries apart from Australia that were part of the earlier wait times survey. The bottom line is that many factors affect health-care system performance and when making decisions intended to improve the health-care system, Canadian decision makers would do well to carefully examine the full array of research evidence.

While an improved understanding of comparative research evidence puts Canada's system in a better light, the path forward cannot be the status quo. According to the 2007 Commonwealth Fund survey, 60% of Canadians reported that the health-care system requires fundamental change. But if there is one consolation to Canadian governments as they wrestle with the future of Medicare, it is that sustainability and access concerns are not unique to Canada. A clear lesson that arises from cross-national comparisons is that, counter-intuitively, moving to greater degrees of private financing does not solve the broader sustainability and accessibility concerns. All countries, regardless of the level of private financing in a system, wrestle with these issues and face similar pressures on public spending (remember that the US spends more public dollars per head than in Canada despite the fact that at least 47 million citizens have no health insurance).

Research funded by CIHR and partners is pointing the way to positive, constructive change and success stories are accumulating quickly. One particular example is the contribution CIHR-funded research made to the establishment of Canada's first ever national benchmarks for wait times in 2005. CIHR-funded research also suggests that in the Canadian context, physician-lead innovation in wait time management is a critical component of success. We need more research on how to successfully reduce and manage wait times, as well as ways to identify, translate and apply success stories across all provincial systems.

Finally, we must keep in mind wait time problems reflect larger systematic issues in the health-care system, including health human resources, lack of a pan-Canadian health information system, the rise of chronic diseases, and the need for primary care reform. CIHR and its partners are investing in all these critical areas of research; research that is essential if policy-makers are to make informed decisions that will lead to improved health for Canadians and a strengthened and sustainable health-care system.

Dr. Colleen Flood
Scientific Director
CIHR Institute of Health Services and Policy Research