NUFFIELD TRUST/CHSRF MASTERCLASSCANADIAN HEALTH SPENDING: MANAGING IN A DOWNTURN (1990-1999)May 17, 2011 – London, England

Terrence Sullivan

Professor, Dept of Health Policy Management and Evaluation

Dalla Lana School of Public Health, University of Toronto

CURRENT PICTURE SASKATCHEWAN ONTARIO U.K.

Combined Life expectancy at birth (‘97)

79.5 81 79.7

Population (2011) 1M 13.2M 60.5M

Current Debt (2011) • 20 millionsurplus

• Net Debt: 7% of provincial GDP

• $16.7B deficit• Net Debt: 37.6%

of Provincial GDP

• £ 163B deficit• Net Debt: 59% of

GDP

Per Capita GDP (2009) C$45,718 C$43,847 US$32,798

2

SourcesFigure 1: Canadian Institute for Health Information; United

Kingdom Office for National StatisticsFigure 2/3: OECD Health Data 2010. 3

• Recession hits North America hard (Black Friday/Gulf War/Oil Shocks)

• Significant growth in debt burden by federal/provincial governments

• Multiple Premier’s Commissions on Health Reform

• Experimentation with regionalization emerges in English Canada

• Significant contraction caused decline in public confidence but no evidence of any adverse health outcomes

• Significant National Reform Commission Efforts followed in early 2000

Important Context for Canada (1990-2000)

4

Source: Public Accounts and 2000 budgets.

Total health expenditure per capita, US$ PPP

5

Federal and provincial-territorial surplus/deficit(-)Public Accounts basis

Source: Public Accounts and 2000 budgets.

6

Source: Public Accounts and 2000 budgets.

Federal and provincial-territorial net debtPublic Accounts basis

7

$25,000

$30,000

$35,000

$40,000

$45,000

$50,000

REAL PER CAPITA GDP, CANADA:before, during and after the recession (1985 to 2000)

8

$1,500

$2,000

$2,500

$3,000

$3,500

$4,000

$4,500

REAL PER CAPITAPUBLIC SECTOR HEALTH EXPENDITURE:Canada, 1980 to 2010(f)

Trend (1980 to 1991)

Trend (1992 to 1996)

Trend (1997 to 2010)

Actual

Source: Canadian Institute for Health Information

9

Provincial/Territorial Government RevenuesConstant Dollar Indices (1993 = 100), Canada, 1993 to 2009

federal revenue as a proportion in the current document

Change in Federal Transfers

Source: NHEX Database, CIHI.

10

ONTARIO & SASKATCHEWANCASES

11

-10%

-5%

0%

5%

10%

REAL PER CAPITA SPENDING GROWTH ON HOSPITALS AND OTHER INSTITUTIONS:Ontario, 1990 to 2000

Hospitals

Other Institutions

Source: OECD Health Data 2010

12

-10%

-5%

0%

5%

10%

REAL PER CAPITA SPENDING GROWTH ON HOSPITALS AND OTHER INSTITUTIONS:Saskatchewan, 1990 to 2000

Hospitals

Other Institutions

Source: OECD Health Data 2010

13

Per Capita Physician Spending 1981-2010

14

0

1

2

3

4

5

6

7

819

80

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

Hospital beds per 1,000 population

Source: OECD Health Data 2010.

15

Evolution of Assessments of the Quality of the Health Care System“Thinking broadly about Canada's health-care system and the quality of medical services it provides, how would you describe it overall? Would you say it is excellent, very good, good, only fair, poor or very poor?”

Source: Department of Finance.

16

QUESTIONS?

17

18

Source: Department of Finance.

Net Debt-to-GDP Ratio

19

Source: 2000 Federal Budget

20

21

The provinces and territories recorded an aggregate surplus in 1999-2000

Federal and provincial-territorial budgetary balancePublic Accounts basis

Source: Public Accounts and 2000 budgets.

22

Federal and provincial-territorial surplus/deficit(-)Public Accounts basis

Source: Public Accounts and 2000 budgets.

23

Provincial-territorial revenues and program spendingNational Accounts basis

Source: National Income and Expenditure Accounts.

24

Interprovincial comparison of taxpayer-supported debt as a percentage of GDP

Source: Moody’s Investors Service Inc.

25