For many, one allure of Canada is healthcare. A big part of any family’s expenditure is on healthcare, and no government support means more out-of-pocket expenses. Specialists, modern drugs, procedures—nothing is cheap. Many families go bankrupt simply because they can no longer afford to pay the healthcare bills. 

That is why the Canadian system appeals to many people. Unlike its more powerful neighbor, it is designed based on need, not financial ability.

Canadians are very proud of their universal healthcare system, which allows all citizens and permanent residents to access many healthcare services free of charge. 

Yes, it is still the tax money that pays for it. But think about low-income families or individuals who are outside the tax bracket. They could not otherwise afford these services. The Canadian system allows equitable access to everyone, so in that sense, it is a good utilization of tax dollars. 

How it works

Canada is a federation. Healthcare is a shared expenditure among the federal, provincial, and territorial governments. Provinces and territories cover most of the care, while the federal government offers specific services for selected groups. 

The Canadian healthcare system is commonly known as ‘Medicare.’ This is an interconnected system of all provinces and territories. A broad set of services are offered under this system, which was founded on the following five principles: 

– The healthcare plans are all non-profit and must be operated by a public body. This body will be accountable to the provincial or territorial government. 

– Necessary medical services offered by healthcare professionals (HCPs), hospitals, etc. must be insured.

– The government insurance plans should offer the same coverage, terms, and conditions to everyone insured.

– All plans should ensure that all insured have uniform access to facilities for necessary care without barriers (financial or otherwise). 

– Any provincial or territorial plan must be comprehensive enough to cover the insured’s travel expenses in another province/territory/country. 

For most Canadians, the healthcare journey starts at the primary level, with family physicians. In Bangladesh, they are usually known as general practitioners or GPs. Primary care includes many essential preventive and curative services, emergency support, referral to specialists or special facilities, mental health, end-of-life support, childhood care, rehabilitation, and maternal healthcare. Several diagnostic tests, home nurses, and allied health professional support all come under its purview.

Rising concerns

Universal healthcare has its limitations; not everything is included. Commonly covered items include family physician visits, essential surgery, and emergency treatment. However, medications, both prescription and over-the-counter, are excluded. 

Vision care, ambulance service, massage therapy, physiotherapy, psychotherapy, and chiropractors are all outside the scope of healthcare. One has to pay for these services. However, most of the time, these are covered by workplace or personal health insurance. Statistics show that about two of every three Canadians carry private health insurance. 

As medication is critical for any ailing patient, provincial and territorial governments have come up with a formula to cater to vulnerable groups so that they can afford lifesaving drugs that are not covered at all by public insurance. This includes low-income people, children, and older people. 

These plans are called supplementary health benefits and cover drugs, dental and ophthalmologist appointments, wheelchairs and prostheses, physiotherapy, etc. Each province and territory has its own supplementary plan, and the scope and coverage of those plans vary.

Three-layer financing

How is such an expansive service financed? The main source is the revenue generated through taxation, which accounts for at least 70% of the cost. The provinces share the burden with the federal government. The former provides 78% of the expense, and the federal government makes up the deficit. 

Total financing occurs at three levels. The first level is Medicare, which is free at the access point and includes physicians, hospitals, and limited diagnostic services. This part of Canadian healthcare is universal and allows equitable access to citizens without prejudice to their financial ability. 

From the second level onwards, the share of public insurance dwindles. These are managed mostly through private insurance and out-of-pocket expenses. Level two covers prescription drugs, long-term institutional support, and home healthcare services. There is still a public insurance portion, e.g., supplementary health benefits. 

The third level is exclusively private and out-of-pocket. Private dental care, specialist eye care, and other specialized therapies fall under this category. The good thing is that more than two-thirds of Canadians have private health or workplace insurance to cover these costs. 

Another aspect of Canada’s healthcare system is payment to family physicians. Certainly, they are not providing services for free. Their payment is structured based on the type of services negotiated between the government and medical professionals within a specific jurisdiction. 

Clinics, community health centers, etc., are managed through an alternative scheme. Hospitals have an annual budget as agreed with the government or regional health authority. 

Benchmarking

Based on the 2024 data by the Canadian Institute for Health Information (CIHI), more than 83%. Further stratification revealed that 92% of seniors and 74% of young adults use the public service. However, 17% are still struggling outside the system—a whopping five million people. 

So, how does the Canadian system fare compared to the world? Let us take a look at their closest neighbor, the USA. An analysis performed by the Ross University School of Medicine put the Canadian system on top. The main factors cited were the cost of healthcare and its accessibility. In the USA, healthcare expenditures are among the highest in the world, but many health outcomes are poor compared to other high-income countries.

Countries are ranked according to the quality of their healthcare services. The World Health Organization and Healthcare Access and Quality Index from the Global Burden of Disease Study regularly publish their own assessments based on these rankings. Canada consistently placed in the top 10% of these countries. 

Challenges crippling the system

The Canadian system is not without challenges. An aging population, an uncontrolled influx of immigrants, and a vast geography put too much stress on healthcare. 

Much of the infrastructure is not updated to accommodate Canada’s growing population, leading to longer wait times for healthcare. Economic stagnation is also causing financial constraints, which reduce funds for many programs. 

For urgent issues, e.g., stroke, heart attack, etc., the services are still prompt. However, many other problems are categorized as low priority, meaning patients must wait for hours before a physician comes to them. Elderly patients often keep languishing in hospital for months before being sent to long-term care. Specialists’ referrals take months, if not years. And many physicians are getting burned out by the sheer number of patients they need to manage daily. 

Inefficiency, lack of infrastructure, and financial difficulties negatively impact healthcare. A new study published in the Canadian Medical Association Journal (CMAJ) found that 20% of Canadians live without a family physician. Most have been on the waitlist for years. Sometimes, people make a call to distant towns or clinics, hoping to get a doctor. 

Due to these limitations, even those who have a family doctor are suffering from irregular access. One of the study authors, Dr. Tara Kiran, opined that the situation is worsening quickly and needs to be addressed immediately. 

The scope of provincial insurance is also not satisfactory. These plans are not comprehensive enough and exclude many important services, such as dental appointments, long-term care, and home care services. There is plenty of room for improvement. 

Bangladesh context

Can this model be applied to Bangladesh? Talk of government-funded healthcare for all citizens has been in the air for a long time now. In Bangladesh, healthcare expenditure is mostly out-of-pocket. Even when people go to public hospitals, they have to pay for many things. 

Workplace health insurance usually lacks comprehensive features, and private insurance is very costly and not affordable for everyone. So, a publicly funded insurance plan is essential.

However, there are certain challenges in Bangladesh. Canada has an efficient revenue generation system, which our country lacks. Taxation is the main source of income for any government, and without a proper collection method, there would never be enough money to invest in healthcare improvement. 

Also, our governance system is not decentralized enough, which may cause some bottlenecks in implementing universal coverage. Any such plans must have an agreement with the healthcare providers, which will require complex negotiations and compromise. 

A top-down approach is required. The government needs to earmark a large amount of investment in healthcare, which should remain consistent over a long period.

Dr. Imtiaz Ahmed graduated from Dhaka Medical College and currently resides in Canada. He has over seven years of experience in healthcare compliance. At present, he is working with patient support programs, as well as supporting auditors and external regulators to ensure alignment with applicable laws and procedures. He was part of the internal team that investigated opioid crisis-related issues at the company and coordinated with external stakeholders.