Does the system need surgery?
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* Donalee Moulton

Major surgery is needed to put Canada's ailing health care system back on its feet, a new report from the Atlantic Institute for Market Studies (AIMS) claims. The controversial report, which calls for greater private-sector involvement, has already been tabled in the Alberta legislature by Premier Ralph Klein.

Dr. David Zitner, the director of medical informatics at Dalhousie University and one of the study's authors, applauds Klein's action. "I was glad the paper ... had an influence. We currently have a multitier system with unequal access, and no jurisdiction in Canada routinely informs its constituents about either access to care or the effectiveness of the care that is provided."

The report, *Operating in the Dark: The Gathering Crisis in Canada's Public Health Care System,* calls for fundamental reform in 4 areas: information gathering, competition, openness to more private-sector participation and changes in the payment system for physicians. The authors conclude that a lack of information gathering has made it difficult to evaluate the system's performance, while a lack of competition translates into a lack of accountability.

"We have a circumstance where governments are responsible for delivering care and also for evaluating the care that is provided," Zitner says. "This conflict of interest could be resolved if governments either contracted out services and did the evaluation, or if governments organized care and the evaluation was done by independent groups."

The options for private-sector involvement include using privately paid practitioners, contracting out services and giving individuals vouchers (often called medical savings accounts) that would allow them to choose among services offered by both the public and private sectors. "We ... need to implement proper studies to learn how best to provide care - when the public sector is best able to deliver services, and when the private sector is," Zitner says. "Contracting out is not unusual. Indeed, primary care in Canada is largely provided by independent practitioners who provide care to all Canadians who are covered by Canada's universal health insurance system." FIGURE

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/162/4/547.2/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/162/4/547.2/F1)

Figure. Dr. David Zitner: identifying fundamental problems

AIMS is a private, nonprofit think tank based in Halifax. The report is available at [www.aims.ca](http://www.aims.ca).