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One of the glaring gaps in Canada's universal healthcare system is the low level of public financing of prescription drugs - 42.7% of total spending in 2018. At the federal level there is renewed interest in moving towards universal coverage, supported by a recently commissioned report on how to achieve it. It will take superb political navigation to extract Canadian pharmaceutical policy and practice from the grasp of interests that profit handsomely from the status quo. This perspective suggests the conditions under which a genuinely fair, effective, and efficient pharmacare plan can emerge. [ABSTRACT FROM AUTHOR]

The author reflects on the health care system in Canadian provinces as of February 2015. Topics discussed include the adoption of universal hospital insurance, the setting of rates based on income and the major gaps in publicly funded services that contradict the principle of comprehensiveness embodied in the Canada Health Act. Also mentioned are the problems in drug coverage and the interprovincial collaboration to reduce generic-drug prices. INSETS: Myocardial Infarction;Pregnancy and Childbirth.

Background: Some populations targeted in survey research can be hard to reach, either because of lack of contact information, or non-existent databases to inform sampling. Here, we present a methodological "case-report" of the yield of a multi-step survey study assessing views on health care among American emigres to Canada, a hard-to-reach population. Methods: To sample this hard-to-reach population, we held a live media conference, supplemented by a nation-wide media release announcing the study. We prepared an 'op-ed' piece describing the study and how to participate. We paid for advertisements in 6 newspapers. We sent the survey information to targeted organizations. And lastly, we asked those who completed the web survey to send the information to others. We use descriptive statistics to document the method's yield. Results: The combined media strategies led to 4 television news interviews, 10 newspaper stories, 1 editorial and 2 radio interviews. 458 unique individuals accessed the on-line survey, among whom 310 eligible subjects provided responses to the key study questions. Fifty-six percent reported that they became aware of the survey via media outlets, 26% by word of mouth, and 9% through both the media and word of mouth. Conclusion: Our multi-step communication method yielded a sufficient sample of Americans living in Canada. This combination of paid and unpaid media exposure can be considered by others as a unique methodological approach to identifying and sampling hard-to-reach populations. [ABSTRACT FROM AUTHOR]

Comments on evidence-based decision making in "Auton v. British Columbia", a court case about Medicare. Facts and issues of the case.

Reports on health care in Canada as of October, 2001. History of Medicare which was founded on principles of universality, accessibility, comprehensiveness, portability, and public administration; View that the system has deteriorated from an icon of Canadian values and organisational know how to an apparent state of crisis; Proposed reasons for the deterioration, including less federal funding for the system; Impact of privatization.

Interpretation: Members of Saskatchewan district health boards supported the general goals of health care reform and believed that changes already undertaken had been positive. There were few major differences in views between appointed and elected members and between provider and nonprovider members. However, tensions related to authority and representation will require resolution. [ABSTRACT FROM AUTHOR]

Offers a study that discusses differences in measurement approaches and a lack of awareness of the effectiveness of different approaches to managing waiting lists and waiting times and how they hamper progress in the Canadian health care system. Causes in the variability in perceptions of waiting lists; Public opinion.

Argues that the Canadian medical profession has failed to provide adequate support for public medical care in relation to the Supreme Court decision of June 9, 2005. Comment on the support of the provision for single-tier health care; Areas in the Canadian health care system that need reform; Factors which contribute to the poor performance of organized medicine in the country.

Discusses the case of Nancy Olivieri, a specialist in hereditary blood diseases at the Hospital for Sick Children (HSC) in Toronto, Ontario. Contracts of Olivieri with Apotex Inc. to test deferiprone on patients; Medical risks discovered by Olivieri; Studies of the legal and ethical aspects of Olivieri's relationships between Apotex and the HSC; Outlook for further studies.

Editorial. Criticizes another editorial by Gordon et al in this issue regarding the raising of revenue for the Canadian health care system. Assertion that the editorial's principles and logic are self-contradictory; Estimates of wrong potential gross and net revenues; Five untrue assertions in the editorial; Peculiar incentives; Need for better alternatives.

Focuses on the exaggerated health care spending in Canada during the Christmas season. Medical ventures that provided no guarantees for health care improvement; Business model utilized by medical care; Consequences of careless health care spending for Canadians.

Looks at the status of the health care system in Canada. Allegation that the country's health care system as of 2004 is unsustainable; Identify the areas of the country's health care system that are performing excellent; Suggestion on how to tackle the problems or flaws of the country's health care system.

Argues that federalism in Canadian health care can improve the system. Belief of many politicians that federalism has failed; Suggestion of ways to improve federalism, including increased spending by Ottawa on health care; Perceived failure of provincial initiatives to unify health care.

Offers observations on studies of Canadian clinical practice guidelines (CPGs). Reference to an article by Graham et al in this issue; Use of the Appraisal Instrument for Clinical Guidelines to assess CPGs; Suggestion that all CPGs should be judged more on the basis of the quality of their recommendations than on the explicit processes of their creation; Conclusion that there should be one nationally-produced and federally-funded guideline for each area.

Examines the impact of rural hospital closures on the health care system in Saskatchewan. Alternative health services provided by the government; Perception of rural residents on hospital closure; Observation on hospital use patterns and health status.

Nursing is everywhere in healthcare and at all levels, and is among other things numerically dominant. Yet it arguably plays a less prominent role in charting the future course of the system than it should. As in any complex system, power matters in health, and the history of healthcare and gender relations explains a good deal of why nursing's influence has not rivaled that of medicine. But society has progressed immensely in the last century and nursing has both contributed to and benefited from these broader social trajectories. If the profession is to expand its leadership role in healthcare, it will have to reflect on its internal politics, its culture of representation and decision-making, and how to translate its diversity into a coherent change agenda. Perhaps above all it must champion and focus on the public interest to avoid being defined as just another interest group.

Context: An evidence base that addresses issues of complexity and context is urgently needed for large-system transformation (LST) and health care reform. Fundamental conceptual and methodological challenges also must be addressed. The Saskatchewan Ministry of Health in Canada requested a six-month synthesis project to guide four major policy development and strategy initiatives focused on patient- and family-centered care, primary health care renewal, quality improvement, and surgical wait lists. The aims of the review were to analyze examples of successful and less successful transformation initiatives, to synthesize knowledge of the underlying mechanisms, to clarify the role of government, and to outline options for evaluation., Methods: We used realist review, whose working assumption is that a particular intervention triggers particular mechanisms of change. Mechanisms may be more or less effective in producing their intended outcomes, depending on their interaction with various contextual factors. We explain the variations in outcome as the interplay between context and mechanisms. We nested this analytic approach in a macro framing of complex adaptive systems (CAS)., Findings: Our rapid realist review identified five "simple rules" of LST that were likely to enhance the success of the target initiatives: (1) blend designated leadership with distributed leadership; (2) establish feedback loops; (3) attend to history; (4) engage physicians; and (5) include patients and families. These principles play out differently in different contexts affecting human behavior (and thereby contributing to change) through a wide range of different mechanisms., Conclusions: Realist review methodology can be applied in combination with a complex system lens on published literature to produce a knowledge synthesis that informs a prospective change effort in large-system transformation. A collaborative process engaging both research producers and research users contributes to local applications of universal principles and mid-range theories, as well as to a more robust knowledge base for applied research. We conclude with suggestions for the future development of synthesis and evaluation methods., (© 2012 Milbank Memorial Fund.)

Hurley et al. document the rise of care provided by workers' compensation boards (WCBs) in Canada and suggest that they potentially represent the "proverbial canaries in the coal mine) for the publicly funded healthcare system. Given WCBs' potential draw on similar resources and their ability to purchase services through incentive-based funding, some may argue that these systems do indeed challenge our current understanding of equitable access under the public system. Here we suggest, however, that while in some circumstances WCB behaviours and policies can create problems for the universal system, they can also serve as role models in their emphasis on prevention, evidence-based practice and timely service.

Objective: To design a training intervention and then test its effect on nurse leaders' perceptions of patient safety culture., Study Setting: Three hundred and fifty-six nurses in clinical leadership roles (nurse managers and educators/CNSs) in two Canadian multi-site teaching hospitals (study and control)., Study Design: A prospective evaluation of a patient safety training intervention using a quasi-experimental untreated control group design with pretest and posttest. Nurses in clinical leadership roles in the study group were invited to participate in two patient safety workshops over a 6-month period. Individuals in the study and control groups completed surveys measuring patient safety culture and leadership for improvement prior to training and 4 months following the second workshop., Extraction Methods: Individual nurse clinical leaders were the unit of analysis. Exploratory factor analysis of the safety culture items was conducted; repeated-measures analysis of variance and paired t-tests were used to evaluate the effect of the training intervention on perceived safety culture (three factors). Hierarchical regression analyses looked at the influence of demographics, leadership for improvement, and the training intervention on nurse leaders' perceptions of safety culture., Principal Findings: A statistically significant improvement in one of three safety culture measures was shown for the study group (p<.001) and a significant decline was seen on one of the safety culture measures for the control group (p<.05). Leadership support for improvement was found to explain significant amounts of variance in all three patient safety culture measures; workshop attendance explained significant amounts of variance in one of the three safety culture measures. The total R(2) for the three full hierarchical regression models ranged from 0.338 and 0.554., Conclusions: Sensitively delivered training initiatives for nurse leaders can help to foster a safety culture. Organizational leadership support for improvement is, however, also critical for fostering a culture of safety. Together, training interventions and leadership support may have the most significant impact on patient safety culture.

Remodelling the kitchen won't help the house with a weak foundation. The same holds truth in healthcare. We cannot solve quality and access problems or deal effectively with wait times unless primary healthcare the foundation of the system--is solid.

This paper revisits the purposes and achievements of regionalization, a decade after its widespread implementation across Canada, and considers to what extent changes in healthcare concepts, emphasis and delivery can reasonably be attributed to it. The authors address four main questions. What, conceptually, is regionalization in healthcare, and what distinguishes it as a structure? How was regionalization intended to contribute to the achievement of the goals for the health system articulated in the 1980s and 1990s? How has regionalization been implemented in Canada, and how have these factors affected its potential to achieve its intended impact? And finally, with the experience gained over the last decade, how might we now (re)design regionalization to better contribute to health system goals? In Canada, regionalization of healthcare has entailed more than devolution and decentralization of services from provincial governments to regional authorities. It included consolidation of authority from local boards and agencies, and some centralization of services. Regionalization was the remedy proposed for the diagnosis of fragmentation and incoherence made by commissions across the country in the 1980s. Regionalization addressed the organizational dimensions of the perceived problems, but provincial governments added goals unrelated to structural change to its mandate. The authors assess the potential impact of regionalization on health system goals and take stock of current Canadian circumstances. Even where regionalization's impact is theoretically high, there are many practical limits to its effect. Although it can facilitate or impede change, in the end the will and actions of provincial governments, providers and other actors in the health system are fundamental to attaining more substantive goals. Many health reform goals require nothing less than a transformation of how society views health, and in the culture of healthcare delivery. Further, the authors argue that the implementation of regionalization in Canada has been limited. Devolution has typically been halting and provisional; there has been little stability; and there have been constraints on the ability to act. These limitations have reduced its potential effect. The authors conclude with proposals for increasing regionalization's contribution to health reform goals. These include a more stable and transparent provincial-RHA relationship, information and measures to better align resources to needs, increased regional-level system integration and changes to organizational culture and practice in the health system.

This year's Health Care in Canada report prepared by the Canadian Institute for Health Information profiles what is changing, and what is not, in Canada's healthcare system, including a selection of findings related to this year's focus topic: primary healthcare.

One function of drug formularies is to allow health care providers to exert some control over spending. Decisions about whether to include a given medication in a formulary are based on estimates of its costs and effectiveness, relative to other treatment strategies. These decisions are made from a societal perspective, as opposed to that of individual patients, which sometimes results in conflicts. The clinical response to a medication often varies widely among subjects, which means that a small subgroup of patients might benefit dramatically, while others with the same disease do not. The result would be that a drug might appear not to be cost effective in an economic analysis, even though it is of proven value for some patients. New and innovative medications are assessed according to high standards of cost effectiveness, even though established treatments are wasteful of valuable health care resources. Moreover, quality-adjusted life-years (QALYs) discriminate against certain patient groups, including those with diseases that are associated with a high morbidity but a low mortality. Such patients often incur high indirect costs, including loss of employment income and costs incurred by family caregivers that QALYs do not reflect. Therefore, even though QALYs are transparent and widely applicable, they are not necessarily appropriate in the evaluation of a particular therapeutic intervention. A new paradigm should be developed for evaluating emerging therapies. An example would be a risk-sharing approach, whereby the pharmaceutical industry and public insurers share in the costs and rewards of introducing new treatments. This would have implications for the prices charged for new medications.