Canada’s Health Care System: The Promises and Challenges of a Federated System

Canada’s universal health care system is often portrayed as a single entity internationally. The reality on the ground is more complex, however, given the constitutional division of powers between the federal government and the 13 provinces and territories. The federal government’s leadership is indeed limited to setting priorities through financing and agreements, which has historically left a substantial amount of autonomy for the provinces and territories in determining the breadth of services covered and in implementing delivery models. As in many other jurisdictions, the COVID-19 pandemic exposed weaknesses in Canada’s health care system, with some of these arising from historical legacies of this federated health care system. Nevertheless, Canadians have generally fared well compared to similar countries, though this likely owes more to their trust in institutions rather than the system’s efficiency. The objective of this case study is to descriptively and analytically present the promises and challenges of a federated health care system, drawing on Canada’s health care system. First, we describe the major features of Canada’s health care system relating to its historical development, organization, regulation, and financing, with particular emphasis on the federal government’s role. Within this backdrop, we then shed light on previous and ongoing policy reforms in Canada. We draw on cases where the federal government initiated policy reforms or where federal leadership was championed, and others where a federated system implied challenges with sub-national entities. In particular, we draw on reforms related to medical assistance in dying, public coverage for pharmaceuticals, long-term care, intergovernmental collaboration, and the response to the COVID-19 pandemic. This analysis will encourage reflection on the sustainability of a federated system to address future challenges and opportunities on matters related to health care, in Canada and abroad