Introduction

Politicians in both Canada and the United States are again discussing the merits of publicly financed medicine versus private healthcare. The debate should not be with a focus on “funding” while but rather a discussion about the fundamental concepts of quality and values.

A frequently discussed issue in the American model is the issue of access with over 40 million persons uninsured. Limited access is a symptom of poor resource allocation which can result in the provision of unnecessary or ineffective care, as well as shortages of primary care physicians. Another factor are the heightened expectations from expensive and experimental care which often comes to the marketplace before it has undergone appropriate analysis using both medical and economic criteria.

Canada is considered to be a model demonstrating the benefits of a publicly financed health system. In Canada near universal coverage exists, but access is also limited with many patients without primary care physicians, as with queues for investigation as well as treatment.

The Canadian experience in 2003 serves as an example when funding is focused on without first considering the core values of the healthcare model. The SARS experience in Ontario highlights the need to re-examine the values upon which we will build, assess and then fund future healthcare systems. SARS resulted in the near implosion of the healthcare system.

Shortly before the outbreak of SARS (January and February 2003) the Ministry of Health went through an accounting exercise where the financial health of hospitals which were over budget were publicly scrutinized by a forensic accountant. These hospitals were not examined through the managerial prism. Ignored were the human resource policies and practices of these hospitals. Issues such as ethics, employee trust and empowerment, continuing training and education, or the treatment of whistleblowers were never considered. Not scrutinized were patient safety, quality of care, or the effectiveness or efficiency of treatment in the debtor institutions.

Money was given to the debtor hospitals to treat the financial symptoms. The question of how resources were allocated in these hospitals was never probed. Financial deficits are the symptoms of decisions about resource allocation. Deficits are not the disease, just symptoms. The underlying managerial and administrative problems must be diagnosed prior to prescribing a tonic for the financial symptoms. Less than two months later several of the debtor hospitals were severely impacted by SARS and Ontario's healthcare system almost collapsed.

Ontario's publicly funded system has spent decades focusing on the cost of healthcare.. Quality parameters including safety, efficiency, and effectiveness have only recently been considered. If basic principles of risk management were a priority in 2003, and if the emphasis was on providing effective treatment in safe environments for patients and healthcare workers , then the experience in Ontario during the SARS pandemic may have been different

The healthcare systems in both America and Canada requires complete re-engineering. We need to agree on the core principles, values, and practices of the health-care system. There must be frank discussions about what type of healthcare we will deliver in the future. The qualitative as well as quantitative parameters of the system must be defined. The expectations of the patients must also be clarified .When such expectations by patients are based on solid medical evidence then these expectations must be met.

Only after there is agreement by all parties on the core-values and quality of healthcare can there be a meaningful discussion about how the society will fund such a system.