Canada’s health care system: the promises and challenges of a federated system

Canada’s universal health 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 system, with some of these arising from historical legacies of this federated health care system. For instance, while the federated nature of the system allowed different regions to adapt and showcase resilience, limited federal leadership in coordinating actions and communication between these subnational jurisdictions prevented the rapid diffusion of these innovative solutions. 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. Finally, the post-pandemic recovery is looking uncertain, as systemic issues that were present prior to its onset (e.g. health human resources shortages) are even further exacerbated.