It is fair to say that the timelines are getting longer, on average. I will quickly go through why.
The first step, prior to getting, or even seeking, public reimbursement—or, for that matter, private reimbursement—is that you have to go through the Health Canada process to get your market authorization to sell. Canada does a pretty good job on that process. Our HTA processes at CADTH, and INESSS in Quebec, are also quite well-established processes. There are a couple of factors, though. Health Canada, on average, tends to be slower to approve a drug than, say, the European Union and the FDA. There are some reasons for that we can talk about later. We also find that our members, on average, tend to file a little later, because we see them moving a little more slowly. You could find, for example, that an American or a European patient may have access to a drug that is available in the world much sooner than one in Canada, just because of the filing times, when they choose to file.
Once it comes through and gets a market authorization, it goes into CADTH or INESSS, depending on whether it is going for reimbursement in Quebec or the rest of Canada. That process runs fairly well. There was a bottleneck at some point in time. That determines, from an HTA or a health technology assessment point of view, the clinical goodness compared to other drug therapies, and establishes cost-effectiveness. A recommendation then goes out to the payers. What is now in place, through the pan-Canadian Pharmaceutical Alliance, is a negotiating table. The challenge of this table is that, when you go to negotiate, they have only so much capacity, and there has to be a minimum number of jurisdictions that agree to participate to make it worthwhile for both parties to do that.
Some of those go quite quickly. Some of those take very long. I will pass it on to Brett here, but I believe that, on average, that process—from time of filing at Health Canada to reimbursement—is now in the order of four years.