I can speak to countries where the population is quite heavy. France is an example. A lot of people wouldn't be happy with the French model even though, if you did a survey of the population, it's probably one of the most liked.
They have a significant copayments, but most of the population has private insurance through Mutuelle de France.
They cover many more drugs than most other markets, but they have a very significant process for negotiating agreements with the manufacturers. They negotiate price volume agreements. I think one thing they do quite well in France—and we're starting to see it in Germany and some other markets—is to assess the relative value in two ways for drugs.
First, they look at the basic benefit of the drug, which they call service médical rendu, and then they look at the improvement the drug offers, called amélioration du service médical rendu. They use these two elements to decide what price point they will accept, and whether or not the drug should be reimbursed. They've been doing this for a long time, and they do a very good job of it. Most drugs end up being reimbursed there, with the exception of some very expensive drugs which get funded through an alternate process. It's quite different.
The Germans, and some of the other markets, have a social insurance type of system. As a result, almost all of the insurers are private—most of them not-for-profits. It's the same, I believe, in the Netherlands and Japan. In many other places, they rely on that completely. In Germany, if a drug is approved by the European Medicines Agency, it has to be reimbursed. All they can do is negotiate the price, and they do that.
I'm not suggesting that there's one country we should emulate, but there are best practices in many of these markets we can look at, not only in terms of getting cost-effectiveness in Canada and limiting the budgetary impact, but also to ensure that there is good access to drugs. Every system has pros and cons, strengths and weaknesses.