Perchance to dream: Mr. Romanow's final report ============================================== It is not an idealist's dream but a practical programme within Canada's ability, financially and practically … — Emmett Hall, *Royal Commission on Health Services,* 1964 Without accountability, democracy does not work. — Janice Gross Stein, *The Cult of Efficiency*, 2001 Mr. Romanow has determined that Canadians would rather live with the imperfections of a publicly funded health care system than with the imperfections of private health care. We think he's right. Despite the erosion of confidence in our health care system, Romanow affirms that medicare, “Canada's post-war public miracle”1 is still our most “cherished” social program. More than that, he believes we can strengthen medicare by increasing its scope in home care, pharmacare, diagnostic services and Aboriginal health. We must persevere in this national dream, he urges. We must find the will, and the money, to sustain it. This is a welcome but not surprising conclusion. The survival of public health care was fervently wished for in the mandate of Romanow's commission to “ensure over the long term the sustainability of a universally accessible, publicly funded health system.”2 This has proven to be largely a notional exercise, a marshalling of evidence (and rhetoric) to disprove the socially corrosive idea that a public health care system cannot be sustained in the modern marketplace. Sustainability, the mantra of public policy discourse ranging from environmentalism to international development, requires that we desist from attempting, or even wanting, what we cannot afford. Romanow's discussion of sustainability turns this logic on its head with explicit emphasis on values and implicit reference to priorities: medicare, he argues, is as sustainable as we *want* it to be. But Romanow also insists that the sustainability of our public system is a question of evidence, not merely desire. There is evidence, he affirms, that private services are more expensive to administer than single-payer services; there is no evidence that their outcomes are better. But what will dispel the doubts that provoked this commission or satisfy the litany of grievances ranging from intolerable waiting lists to a contaminated blood supply to the misallocation of diagnostic equipment funds? Accountability is Romanow's answer. Gone are the days when accountability was simply implied in the notion of public adminstration.3 The public, no longer mere citizens but savvy consumers, crave information, responsiveness and transparency. Accountability must be explicit, and Romanow means to make it so through new, national creations — a health covenant, a health council and a drug agency — and by entrenching the very notion of accountability in the Canada Health Act. In our public system (with some exceptions), government does not *provide* the health services it pays for, but must ensure their quality just the same. Romanow hangs his hopes for accountability on the pegs of evidence-based standards, monitoring and assessment, proposing the development of a “pan-Canadian electronic health record framework” and new agencies for drug and technology assessment and for policy research. These infrastructures of information will account for quality, speed, cost-effectiveness and outcomes — and, clearly, any accounting made in the public trust must answer to all of these. But the accountability of our health care system must *also* be to values affirmed through the political process: values that include the notion of health care as a right of citizenship; a willingness to share the burden of misfortune; social cohesion; equity and procedural fairness. It is this broad understanding of accountability, in our perception, that has spurred Romanow to urge a bigger role for federally conceived initiatives in health care. Predictably, some provinces have balked at the prospect of more federal funding with “strings attached,” as if they were the only legitimate guardians of the public interest. But it's difficult to see how the ungainly marionette of Canadian health care can be managed *without* strings. A worse idea would be to let antifederalist wrangling trammel any hope of meaningful change. To naysay a national vision for standards of care, more compassionate service and responsible oversight strikes us as not only unimaginative, but also perverse. — *CMAJ* ## References 1. 1. Marmor T. The rage for reform. In: Drache D, Sullivan T, editors*. Market limits in health reform: public success, private failure*. London and New York: Routledge; 1999. p. 263. 2. 2. Romanow RJ. *Building on values: the future of health care in Canada*. Saskatoon: Commission on the Future of Health Care in Canada; 2002. p. xi. 3. 3. Armstrong P. Evidence-based health-care reform: women's issues. In: Armstrong P, Armstrong H, Coburn D, editors. *Unhealthy times: political economy perspectives on health and care in Canada.* Toronto: Oxford University Press; 2001. p. 128.