Thank you very much.
Good afternoon and thank you for the invitation to contribute to the committee's study on Canada's health workforce. It is an honour to be here, and I hope what I have to say is of some value to the esteemed members.
I should state up front that, although I am the director of health policy studies at the Fraser Institute, a non-partisan Canadian think tank, the organization does not hold any positions. Therefore, my testimony is based on my own views and published research.
My understanding is that my job today is to try to set the stage by providing information that may be pertinent to the committee's subsequent discussion on the matter. As such, I would like to focus on three areas: first, highlighting Canada's relative scarcity of key medical resources; second, decoupling the impact of COVID from structural issues; and third, looking through the lens of supply and demand to identify potential solutions.
First, let's take stock. Canada has a relative scarcity of key medical resources, including human and capital resources. Our most recent report on health care performance found that in 2019, out of 28 high-income countries with universal health care coverage, Canada ranked 26th for physicians, 18th for nurses and 25th out of 26 for curative care or hospital beds. Canada also ranked 22nd out of 24 for MRI units and 24th out of 26 for CT scanners per million population.
This relative scarcity existed despite the fact that Canada ranked sixth highest for health care expenditure as a percentage of GDP and the 10th highest for health care expenditure per capita in the same year.
Second, it's important to acknowledge the pressures of COVID in the current context, but to not conflate them with larger structural issues. I provide three quick examples.
The data I mentioned are from 2019. That's a year before the pandemic. Canada's relative scarcity of physicians spans decades. Physician density began to diverge in the mid-1970s and deepened following the Barer-Stoddart report of 1991. While there has been an uptick since the turn of the millennium, projections from a 2018 report I co-authored suggest Canada will still have fewer physicians per 1,000 population in 2030 than the OECD average way back in 2018. It is worth noting here that Canada's relative scarcity is more prominent for specialists than it is for family doctors.
Wait times have certainly gone up during COVID, but have been increasing for decades. The Fraser Institute's survey reports an estimated 25.6 week wait between referral from a family doctor to getting medically necessary elective treatment in 2021. However, in 2019, a year before the pandemic, the wait time was still 20.9 weeks. Similar observations can be made with other international surveys, such as those by the Commonwealth Fund in 2020 and 2016.
The takeaway is that context is important. COVID has exacerbated but is not the cause of the current challenges with the health care workforce. Moreover, the combination of backlogs due to surgical ramp-downs, potential long-term effects of COVID and an aging population will ensure these challenges persist long after the pandemic has passed. The obvious question is, what can be done?
We need to start by understanding that the imbalance between demand and supply of medical services manifests in a number of ways that includes things like: overflowing hospitals, which we also had before the pandemic; overburdened staff, which we're currently grappling with; and rationed care for patients, which Canada has struggled with for decades. Any solution, therefore, lies in reconciling this imbalance between supply and demand through increasing supply, tempering demand and better aligning incentives.
Many successful universal health care countries, including Switzerland, the Netherlands, Germany and Australia, do this in three ways. They embrace the private sector as a partner or pressure valve on the supply side. They employ patient cost-sharing on the demand side to temper demand, with supports for vulnerable populations and exemptions. They encourage competition and incentivize treatment through activity-based hospital funding, which contrasts with Canada's global budgeting approach.
In the absence of these types of reforms [Technical difficulty—Editor] improving efficiencies at the margin. However, these will cost the government money and be limited in scope.
Supply can be expanded in a number of ways, including: increasing domestic enrolment and residencies, which are also very important for physicians, as an example; promoting immigration of foreign trained physicians or other important health care staff, such as nurses; and increasing the adoption of new technologies, such as telemedicine, otherwise known as virtual care.
Each of these face unique challenges, but they're not insurmountable. For example, it takes a while to train doctors domestically, and virtual care may eventually face challenges from the Canada Health Act. There's no point having more doctors if their services are not funded, or if they can't find employment, both of which are documented problems under Canada's global budgeting approach for hospital remuneration.
In summary, there is a documented relative scarcity of key medical resources. This scarcity is structural and will persist in the postpandemic world. Solutions do exist within the current framework, but in the absence of potentially significant reform, they will likely be expensive, limited in scope and only temporarily successful in nature.
I hope these comments have been of some value to the members of the committee.