(Version française disponible ici)

The COVID-19 pandemic identified cracks in the health-care system and put the issue at the top of people’s minds. Last year, the perception that the system is in crisis has continued to rise to levels not seen before according to an analysis of the annual Confederation of Tomorrow Survey. It’s even worse this year.

Long wait times for essential treatments and overcrowded emergency rooms have made lack of access to care the single most important factor explaining bad performance evaluation of the whole health-care system.

Those who use the system are often the most critical of it. This includes the most vulnerable Canadians – women, the elderly and low-income households. They are almost twice as likely as other Canadians to say the health system is in crisis.

These crisis-level evaluations are vitally important because they stand to threaten the long-term viability of the system. If governments don’t take steps to increase access, a vicious circle could develop: Doubts that care will be available when needed could cause even lower satisfaction with the system, and a lack of willingness by taxpayers to fund it.

Steadily rising dissatisfaction 

Dissatisfaction with the health-care system has been steadily rising. According to the 2024 Confederation of Tomorrow survey, which looks at trust in provincial and federal decision-making on key issues, the proportion of those who responded positively about the health-care system has continuously deteriorated since 2019.

To put this into perspective, in 2023, 28 per cent of Canadians considered the health-care system to be in crisis. One year later, it’s 32 per cent. In 1988, that proportion was only 5 per cent.

Figure 1 shows the evolution of Canadians’ views of the health-care system. The possible answers were:

1) the system is working well and only small changes are needed;

2) there are good things about the health-care system but fundamental changes are needed;

3) our health-care system is so bad that we should rethink it entirely.

The last option suggests that respondents think the system is in crisis.

The survey asked: “If you or a member of your family were to get sick and need to see a doctor, how confident are you that you would be able to get treatment from the health-care system within a reasonable period of time?”

The proportion of respondents who are very or somewhat confident that they can access timely care decreased from 58 per cent to 53 per cent in a year (figure 2).

This perception of crisis is not felt equally. Those who are in frequent contact with the health system can have generally positive experiences, but their assessment tends to be worse than those with less contact with the system, especially regarding its ability to meet future demands.

Only nine per cent of those over the age of 55 and 10 per cent of women responded that the health system “works well,” the 2024 Confederation of Tomorrow survey shows. By comparison, nearly twice as many men (19 per cent) and Canadians under 55 (17 per cent) have a positive view of the health system.

This is likely because women, the elderly and low-income households use the public health-care system more often than other Canadians, and they experience its problems firsthand. They are also generally less able to afford the private system.

In short, these assessments reflect social-health inequalities.

Provinces with older and poorer populations, such as those of the Atlantic region, maintain the lowest evaluation. Although heath care spending tends to be higher than elsewhere in the country, it costs more to provide high-quality health care for an older population, and the region has traditionally been constrained by weak economic growth.

The only silver lining for the Atlantic provinces is that perceptions have improved slightly since 2023 while they deteriorated in all other provinces with the exception of Saskatchewan where the perception of the system is more evenly distributed (figure 3).

The influence of political ideology

In many ways, performance evaluation is also ideological. The left-right divide partly determines crisis-level assessments. When controlling for partisanship, those on the left are more likely than those who are right-leaning to believe the health system is in crisis.

There are two potential explanations: On the one hand, political ideology can serve as a marker for health-related values and beliefs, such as, for example, religiosity, which is associated with self-rated better health and with those who lean to the right.

On the other hand, those who place themselves on the left of the spectrum often expect more from the health system, and when it does not improve, they are more likely to give the system a lower rating. Those who are right-leaning are likely more content with the status quo.

Root causes

We can point to several explanations for poor performance evaluation.

First, insufficient federal transfers for health care spending put financial pressures on provincial health systems. The federal share of health-care funding had been declining until a 2023 federal-provincial agreement on health-care transfers (which occurred after the 2023 survey).

That agreement increased investment to keep the federal share of funding constant over time. However, the bulk of the new spending came out of bilateral agreements between Ottawa and each individual province, which took time to negotiate, and the impact of the new federal funding cannot be felt immediately. This means that the effects of the bilateral agreements are not yet captured in the survey data.

Secondly, the 2023 survey was conducted during a period of economic gloom following a period of high inflation. Citizens feeling economically vulnerable tend to have lower satisfaction with public services and lower trust in government.

Indeed, the 2024 survey shows that the share of Canadians trusting neither the federal nor their provincial government to make the right decisions in important issues such as health care, the environment and the economy, has been steadily growing. Public institutions play a pivotal role in the well-being of Canadians. When public trust in institutions is low, there are potential consequences for the health-care system.

A racial justice agenda for medicare

Federal budget an opportunity to seed transformational change to fix failing primary care system

Honour Tommy Douglas and stand up for public denticare

Community health hubs could provide sorely missing primary care

A third potential explanation could be the lack of popularity of Prime Minister Justin Trudeau.

Interestingly, the survey shows a clear incumbent effect at play. Those who voted for the Liberal Party of Canada are more likely to think the system “works well,” and less likely to think that is has it “needs complete rethink”, as shown in figure 4.

However, this relationship works both ways. Discontent with the Liberals’ handling of the health-care system has the potential to contribute to a decline in its popularity. The effect of this has been mirrored in the level of satisfaction with other public services, too.

This assessment of crisis levels in health care matters for the legitimacy and the sustainability of the Canadian welfare state. It also opens a space for calls for further privatization of the health-care system.

And another vicious circle is possible: private health-care services could drain resources from the public system without reducing total health-care costs while expansion of a parallel private system could reduce citizens’ support for the public system.

Increasing access to health care to improve the performance evaluation of the system should be a top priority for governments in Canada.

Do you have something to say about the article you just read? Be part of the Policy Options discussion, and send in your own submission, or a letter to the editor. 
Ally Hays-Alberstat
Ally Hays-Alberstat is a PhD student in political science at McGill University. She is a research assistant in the department of political science and the department of equity, ethics and policy.
Olivier Jacques
Olivier Jacques is an assistant professor in the department of management, evaluation and health policy at the school of public Health at the Université de Montréal and a researcher at CIRANO. His research focuses on public finance, the welfare state and health policy. He can be reached on LinkedIn and Twitter @Olijacques89.

You are welcome to republish this Policy Options article online or in print periodicals, under a Creative Commons/No Derivatives licence.

Creative Commons License