HEALTH CARE FINANCING:
Prepared by Odette Madore
PROS AND CONS OF USER CHARGES
OF USER CHARGES IN CANADA AND
AND PRIVATE FUNDING OF HEALTH
HEALTH CARE FINANCING:
Canadian health care costs
are continuing to rise and to represent an increasing percentage of the
Gross Domestic Product (GDP). Health sector expenditures, which totalled
$2.1 billion in 1960, rose to $66.8 billion in 1991, while the proportion
of GDP devoted to health care almost doubled, going from 5.4% to 9.9%
over the same period.(1) This
rapid growth in costs is likely to continue, especially with the pressures
of an aging population and the adoption of new medical technologies. Because
health care services are largely government funded, expenditure control
in the health sector is a major public finance challenge, particularly
in the present climate of budgetary constraint.
Due to the relative scarcity
of public resources, governments are more and more wondering whether to
increase user participation in financing health care by imposing user
charges. Opinions differ, however, as to the potential impact of such
increased user participation. While some maintain that user fees will
make it possible to limit public health sector expenditures, others fear
that such charges would raise barriers to universal access to health care.
This paper provides a summary
of the current situation with respect to health care user fees. In the
first section, we briefly define different types of user fees, while in
the second section we outline the theoretical arguments for and against
their use. The third section describes the experience of Canada and other
OECD countries and summarizes studies that have attempted to assess the
results of imposing user fees. Finally, in the fourth and final section,
the sharing of health costs between the public and private sectors is
examined, as is the opportunity for increasing private sector participation
by means of user fees.
are the share of costs a patient pays for medical and hospital services
covered by public health insurance plans. As specified below, there are
several different types of such charges.
is the simplest form of user charge. Under this system, the patient is
required to pay a fixed percentage (say 5%) of the cost of services received.
Thus, the higher the cost of the service, the larger the fee. Major users
are at a disadvantage, as they must contribute a higher amount than other
is an alternative to co-insurance. Under this system, instead of having
to pay a share of costs, the patient is required to pay a flat fee per
service (for example, $5) which does not necessarily bear any relation
to the cost of the service. The same amount is charged, no matter what
the cost of the health care provided. More intensive use (more services)
naturally leads to a higher total payment.
A system of deductible
amounts requires the patient to pay the total cost of services received
over a given period up to a certain ceiling, which is the deductible amount.
Above this ceiling, costs of services to the patient are covered by the
public health insurance plan. All users must pay a standard minimum deductible
amount, which is independent of the quantity of services received. This
type of plan places heavy users of the health care system at less of a
disadvantage than the other plans.
These three types of user
charges are usually described as "sickness taxes," because only
health care recipients are required to pay them. Since low income groups
generally use health care services more than others, user charges are
frequently viewed as a regressive tax which hurts those least able to
may also be considered a type of user charge. In this instance, however,
the patient's private contribution does not cover part of the costs of
insured services, but rather pays costs not covered by the public plan.
In such a system, the doctor providing the service can bill the patient
for an extra fee over and above the established government rate. All patients
requiring medical services are affected, no matter what their income.
In the case of an income
tax on services, the patient does not pay directly for a share of
the cost of insured services received; rather, the contribution is paid
through the income tax system. An income tax on services takes both income
and use of services into account. The tax rate applies to the sum of taxable
income and the cost of services used. This type of charge is one of the
options being considered by the Government of Quebec.(2)
It is a progressive tax in that, for equal use of services, a patient
with a higher income pays relatively more than one with a lower income.
Furthermore, an income tax on services does not apply to those who do
not pay income tax.
is an extreme form of user charge whereby the government decides to reduce
the range or the extent of services insured. De-insurance may apply to
a particular service, such as cosmetic surgery, or may affect only certain
groups of individuals, for example those in a high income bracket. Patients
using the services no longer covered by the public health insurance system
are obliged to pay the entire cost.
PROS AND CONS OF USER CHARGES
The imposition of user charges
is put forward as a theoretical means of reducing the use of services
and limiting public expenditures in the health sector; however, the issue
is very controversial. Opinion is divided as to the true impact of such
charges on the rate of use and on costs.(3)
Those who maintain that
user charges would reduce public expenditures on health services base
their argument on traditional demand theory, according to which the consumer
who faces a price increase will reduce the quantity of the good or service
demanded. The size of the reduction is a function of the price elasticity
of demand: the more sensitive the consumer is to price, the more the quantity
demanded declines. According to the proponents of this view, user charges
limit the use of health services and lead to a decline in public expenditures.
The opponents of user charges
maintain, on the other hand, that the demand for health services is relatively
inelastic; that it is not dependent on price as much as on necessity.
According to this view, if patients are not very sensitive to pricing,
user fees will not necessarily reduce the use of health services; even
if public expenditures on health services decline because they are partially
replaced by user charge revenues, total combined public and private expenditures
are liable to increase. The impact of user charges on total health expenditures
is difficult to measure, however, as it is dependent on the amount of
the fees charged.
Other opponents of user
charges observe that, while the demand for health services is generally
inelastic, price sensitivity varies according to patient income. Thus,
user fees act as a regressive tax in that they discourage low income individuals
from using the health system to obtain needed services. It is recognized,
however, that any delay in seeking necessary medical care substantially
increases the ultimate cost of services. A patient who does not consult
a doctor when symptoms first appear is liable to increase the severity
of his or her illness, to have to undergo longer and more costly treatment,
and to have a reduced probability of a complete cure.
Proponents of charges believe
that a free health care system leads patients to overuse or even abuse
it. According to this view, user charges automatically lead to more efficient
use of health services, with a resulting decrease in health costs. Opponents
of charges, on the other hand, question whether there can be abuse or
inappropriate use of health care services when patients have little decision-making
power in this respect. This is particularly so in the case of hospital
services, which the doctor, rather than the patient, decides whether or
not to use. For this reason, their opponents believe that user charges
will have little impact on use of the system or on health care costs.
Other arguments are also
advanced to show that user charges do not limit health care expenditures.
First, some suggest that doctors might begin to expand their activities
in response to declining numbers of patients; proponents of this view
argue that the fee-for-service method of payment to doctors tends to encourage
such behaviour. Second, there are those who note that imposing user charges
has a negligible impact because of a "rebound effect," whereby
one service is substituted for another. For example, if user charges are
imposed for doctors' services, patients may have an incentive to go to
hospitals (particularly emergency services) rather than going to a doctor
and paying an additional direct fee. Third, some maintain that user charges
incur high administration costs, which could easily exceed any savings
to governments. Fourth, some believe that if a high percentage of the
population has to pay a substantial amount in user fees, consumers will
seek to protect themselves against the financial risk of illness and resort
increasingly to private insurance. A system in which private insurance
predominates, as is the case in the United States, does not guarantee
effective control of health care costs.
Finally, some opponents
of health care user charges find the very idea of imposing them incompatible
with basic health insurance principles; they believe they are liable to
lead to the dismantling of Canada's free and universal nationwide health
care system. These critics often refer to equity. They maintain that direct
charges prevent those who are most disadvantaged from consulting a doctor,
and discourage them from following medical advice. Yet, according to various
sources, it is these very disadvantaged groups who are in the greatest
need of health care. The critics also maintain that if user charges were
imposed, the poor, the elderly and the very ill -- those least likely
to be covered by supplementary insurance -- would be forced to spend a
higher proportion of their income on health care than the rest of the
population. The proponents of charges argue, however, that the regressivity
of user charges could be balanced by exemptions for disadvantaged groups.
OF USER CHARGES IN CANADA AND
In the early 1980s, most
provincial governments in Canada authorized extra-billing and imposed
user fees of one sort or another. In most provinces, doctors extra-billed
their patients directly, though the extent of this practice varied a good
deal by province. Table 1 shows that in 1981 over half of all doctors
in Nova Scotia charged additional fees, whereas only one doctor in British
Columbia did so. While the revenues from extra-billing were relatively
minor in Newfoundland and New Brunswick, they represented almost 5% of
the total value of medical services in Alberta.
Council of Welfare, Medicare: The Public Good and Private Practice,
May 1982, Annex B.
Governments in some provinces
also imposed user charges for patients receiving insured hospital services.
Once again, fee levels varied greatly from one province to another. As
shown in the data for 1982,(4)
British Columbia and Newfoundland charged patients in general hospitals
a daily co-payment of $7.50 and $3 respectively, whereas in Alberta patients
were required to pay a $5 hospital admission fee. In 1982, four provinces
imposed daily fees for long-term chronic care hospital patients. These
fees were: British Columbia, $11.50; Alberta, $7.00; Ontario, $12.60;
and Quebec, $12.33. British Columbia hospitals also charged a co-payment
of $4 for each emergency service visit, and $7 for outpatient surgery.
The provinces that imposed co-payment charges for hospital costs offered
exemptions for certain groups, such as welfare recipients, the elderly
and children. Only one province, Saskatchewan, imposed co-payment for
doctors' services. Between 1968 and 1971, patients in this province paid
$1.50 per doctor's office visit, and $2 per house call.
The 1984 Canada Health
Act ended the authorization of user charges and extra-billing. The
federal government's justification for this initiative was based on studies
evaluating the impact of the various formulae for user charges.(5)
These analyses indicated that user charges for insured medical and hospital
services reduce use of the system by low-income earners, and in fact act
as a regressive tax. The results of these studies also showed that user
charges do not reduce the overall rate of health care service use, and
that they are ineffective in controlling total health care costs.(6)(7)
At present, the federal
government makes transfer payments to the provinces for "medically
necessary services" insured under their respective health insurance
plans. These services include the full range of care provided by hospitals,
doctors and dental surgeons in institutions. These transfer payments are
made on condition that the provinces do not extra-bill or charge user
fees. The federal government also makes additional payments for supplementary
health services such as intermediate care in nursing homes, adult institutions,
or at home. These payments are not subject to any conditions, and such
services may therefore be subject to charges. In addition, the provinces
may impose user charges for other supplementary services insured under
their respective health insurance plans, such as optometry, dental and
pharmaceutical services. Some provinces insure 100% of supplementary health
service costs, while others impose co-insurance, co-payment or a deductible
amount. In their most recent budgets, some provinces decided to de-insure
Newfoundland and Prince Edward Island do not insure optometry services,
while Ontario covers eye examinations for all residents. The remaining
provinces cover eye examinations and prescriptions for certain groups,
usually young people and the elderly, and require a financial contribution
from recipients of other optometry services, either through a 20% co-insurance
fee or a deductible of about $500. Similarly, four provinces (New Brunswick,
Ontario, Alberta and British Columbia) do not insure children's dental
services; the rest of the provinces cover insured services for children,
with three requiring a co-payment of between $5 and $25. Ontario, Manitoba
and British Columbia insure some prescription drugs, but with a deductible
and co-insurance fee. Only Ontario covers the full cost of prescription
drugs for the elderly; the other provinces insure prescription drugs,
but impose user fees from which welfare recipients are usually exempt.
While user charges are in
limited use in Canada, they are widely used in some OECD countries. France,
for example, has a complex user fee system in place. Medical services
are subject to a 25% co-insurance fee and some doctor's visits may also
be subject to extra-billing. Prescription medicines are subject to co-insurance,
which varies from 30 to 60% depending on the product's degree of necessity.
Hospital services are also subject to user fees. A co-payment of 55 FF
($12 CDN) a day is required for hospitalization; to this is added a 20%
co-insurance fee for hospital stays of less than 30 days. A 30% co-insurance
fee is applicable to laboratory tests and dental care. There are exemptions
for low income earners and the chronically ill.(9)
The Swedish health insurance
system covers an extensive range of health services, and also includes
a variety of user charges. A co-payment of 55 Crowns ($11 CDN) is required
for services provided by a public sector doctor; between 60 and 70 Crowns
($12 to $14 CDN) are paid for services provided by doctors in private
practice. Co-payment does not apply to some medical services, such as
birth control consultations. Hospital care is virtually free. For dental
treatments, there is a user fee of 60% on the first 2,500 Crowns ($480
CDN), and 25% on the balance. A co-payment of 25 Crowns ($5 CDN) is charged
for physical, occupational and speech therapy when prescribed by an authorized
medical practitioner. In addition, a 30-Crown ($6 CDN) co-payment is charged
for transporting a patient. Finally, prescription drugs are subject to
a 65-Crown ($13 CDN) co-payment; life-sustaining drugs are free.(10)
Charges are also authorized
in other countries, but their use is more limited. For example, Germany
applies a co-payment system which exempts children and low-income earners.
A fee of 2 DM ($1.34 CDN) per person is levied on prescription drugs and
hospital patients must pay 5 DM ($3.35 CDN) each day for a stay of up
to 14 days, and a fee of 5 DM ($3.35 CDN) for transportation by ambulance.(11)
In the United Kingdom, user charges apply only to prescription drugs,
and individuals may choose between co-payment, from which certain groups
are exempt, and a deductible amount. Patients must pay £3.05 ($7 CDN)
for each prescription. Those not eligible for the exemption may opt for
a deductible amount of £43.50 ($97 CDN).(12)
Studies of user charges
in some of these countries draw conclusions similar to the Canadian studies.
Analysis has revealed that user fees do not enable governments to control
health costs, that they risk leading to under-consumption of medical services
by those who are the most ill, and that they are frequently ineffective
when patients have supplementary insurance.(13)
In addition, in a report published recently, the World Health Organization
emphasized that user fees are liable to make a health care system less
effective and to jeopardize equality of health care.(14)
Furthermore, a Rand Corporation study of the United States found that
there was a decrease in the consumption of services when patients are
required to pay fees directly. The authors of the study noted that this
decrease in consumption affected both essential and non-essential services,
that it affected low income individuals most, and that it had undesirable
effects on the health of the patients who use the services less frequently.
These authors concluded that the existence of user charges has no effect
on the total cost of services.(15)
In summary, Canadian and
foreign studies would appear to show that user fees affect health care
equity and do not seem to be the most appropriate solution for resolving
the financing problems of health care systems. Although some countries
continue to apply a policy of user fees, the problem of financing the
health care system remains a major concern for their governments. For
instance, a number of them are studying the systems of other countries
in their quest to improve the effectiveness of their own systems and to
control health care costs. Canada decided less than a decade ago to forgo
user fees, but it would appear that there is now a desire to take a step
AND PRIVATE FUNDING OF HEALTH
In spite of past experience
and the criticisms levelled at user charges, some provincial governments
in Canada are currently studying the possibility of increasing private
participation as a way of reducing public expenditures on health care.
For a number of years, the public has been hearing about "spiralling"
health costs and the need for governments to control their expenditures
in this sector. Far from being casual remarks, these comments reflect
the current reality.
Table 2 shows the trend
for total health costs over the last three decades. It is true, on the
one hand, that health care expenditures have grown continually in real
terms, and are consuming an increasing share of our national income. In
1960, health care expenditures totalled $2.1 billion. In 1991, they totalled
$66.8 billion, or $183 million per day and $7.6 million per hour!
Expressed in constant 1986 dollars, total health care expenditures rose
from $8.9 to $54.8 billion over three decades. The substantial real growth
of expenditures in the 1960s and early 1970s was due primarily to the
establishment of hospital and medical insurance plans by all the provinces
in 1961 and 1975 respectively. Subsequently, while total expenditures
have continued to rise in real terms, they have done so at a slower pace.
obtained from the Health Information Division, Health Policy, Planning
and Information Branch, Health and Welfare Canada, Ottawa, April 1993.
It is also true that Canada
is spending an increasing proportion of GDP on health care. Between 1960
and 1991, the proportion of GDP allocated to health rose from 5.4 to 9.9%.
This percentage increased between the 1960s and 1970s, as the universal
health insurance plans were introduced, then remained relatively stable
until the early 1980s, since when it has increased consistently. Internationally,
Canada is among OECD countries spending a large percentage of their economic
output on health care. Available data show that in 1990, the percentage
of GDP expended on health care was 9.4% in Canada compared to 9.2% in
Sweden, 8.8% in France, 8.1% in Germany, and 6.2% in Great Britain.(16)
Furthermore, Canada's provincial
governments are an important source of financing for the health sector.
In 1991, the public sector as a whole (combined federal, provincial and
municipal governments) financed 71.4% of total expenditures on health
care. Individuals assumed 27.8% of the total cost, either directly when
receiving a service, or indirectly through private supplementary insurance
plans. As is evident from Table 3, the distribution of funding between
the public and private sectors varies considerably by type of service.
The public sector covers 87.6% of hospital services and 95% of medical
services. This large public contribution reflects the Canada Health
Act, under which medically necessary services are universal and free
of charge: patients are not required to pay anything when using them.
For other services, on the other hand, the public plans offer more limited
coverage, and the private sector therefore provides a larger share of
Finally, health sector expenditures
are currently the largest provincial government budget item, representing
approximately one-third of total expenditures.(17)
Furthermore, in recent years health care expenditures have taken up an
increasing proportion of provincial budgets.
and Welfare Canada, Health Expenditures in Canada - Summary Report,
1987-1991, Health Information Division, Health Planning and Information
Branch, Ottawa, March 1993.
In sum, total health care
expenditures continue to rise in real terms, and are consuming an increasing
share of GDP. Furthermore, the proportion of GDP spent on health care
is higher in Canada than in other OECD countries. Since governments are
the primary source of financing, control of health care expenditures is
a major challenge for public finances, particularly in the present context
of budgetary restraint. This seems to justify governments' review of the
fairness of how health care financing is shared. However, a detailed examination
of the distribution of funding will be required prior to any decision
on the appropriateness of implementing user fees.
Indeed, a study of the changes
in amounts paid towards health care by the various financing sectors shows
that the public sector's share has decreased in recent years, while the
private sector share has steadily increased. As Table 4 illustrates, as
a result of the implementation of the national health insurance plan,
public sector financing of health care services rose overall from 43%
in 1960 to 76% in 1975. Since then, however, the public sector share has
declined slowly, reaching 72% in 1991. The federal share rose from approximately
16% in 1960 to almost 33% in 1980. Because of budgetary restraints, however,
the federal government has limited the rate of growth of transfer payments
to the provinces for health care several times; as a result, the proportion
of federal government expenditures was down to 24% in 1991. Provincial
government expenditures on health care as a percentage of total expenditures
increased rapidly until the mid-1970s, then declined marginally. They
have, however, recently begun to increase again, in order partly to counterbalance
the decrease in federal funding.
supplied by Health Information Division, Health Policy, Planning and Information
Branch, Ottawa, March 1993.
In the same way, the percentage
of health care expenditures financed by the private sector has grown in
recent years, to 28% in 1991, a level higher than in the period when extra-billing
and user charges were permitted.
Although the use of user
charges is limited in Canada, the private share of health care costs is
larger than in other OECD countries. Furthermore, private financing of
health care is higher in Canada than in countries with user charges in
effect for a wider range of services. For example, data for 1987 show
that the private sector financed 26% of total health sector expenditures
in Canada; for the same period, private sector financing was 25% in France
and 10% in Sweden.(18)
The use and types of user
charges vary from one country to another. Overall, in Canada as elsewhere,
user fees seem to be common for such services as drugs. However, some
countries use charges more extensively than is done in Canada. As we have
seen, user charges apply only to supplementary health services in this
country, whereas they are imposed for a wide range of services, including
medical and hospital services, in other OECD countries.
The desire to reduce or
to stabilize the deficit is probably responsible in large part for the
rebirth of the user fee debate in Canada. Governments must impose budgetary
restraint and make difficult choices in all the sectors in which they
are involved, including health care. It should not be forgotten, however,
that one of the basic objectives of introducing a public health insurance
plan in Canada was to eliminate the financial obstacles to obtaining hospital
and medical care. At present, the health insurance system permits the
financial burden to be distributed fairly between those who are well off
and those living in poverty, and those in good health and those who are
ill. Various studies suggest that user charges might compromise this principle
The desire to reduce government
deficits is acting as a constraint on public financing of health care
and how costs are shared between levels of government and between the
public and private sectors. Although it appears necessary to contain growth
in Canadian health care expenditures, before implementing a user charge
policy, governments should consider carefully whether the private sector
-- the individual, household or family -- is able to assume a larger share
of these costs.
Badgley, R.F. and R.D. Smith.
User Charges for Health Services. Ontario Committee on Health Services,
Barer, M. L., R.G. Evans
and G.L. Stoddart. Controlling Health Care Costs by Direct Charges
to Patients: Snare or Delusion? Ontario Economic Council, Occasional
Paper No. 10, 1979.
Beck, R.G. "The Effects
of Co-payments on the Poor." Journal of Human Resources, 1974,
Beck R.G. and J.M. Horne.
An Analytical Overview of the Saskatchewan Copayment Experience in
the Hospital and Ambulatory Care Settings. Report for the Ontario
Committee on Health Services, 1978.
Creese, A.L. User Charges
for Health Care: a Review of Recent Experience. Division of Strengthening
of Health Services, World Health Organization, SHS Paper No. 1, 1990.
Government of Canada. Preserving
Universal Medicare: a Government of Canada Position Paper. Ottawa,
Government of Quebec. Ministère
de la santé et des services sociaux. Un financement équitable à la
mesure de nos moyens. 1991.
Government of Quebec. Ministère
des Finances et Conseil du Trésor. Les finances publiques du Québec:
vivre selon nos moyens. 19 January 1993.
Government of Saskatchewan.
Report on Utilization Charges. Department of Public Health, 1979.
Health and Welfare Canada.
Health Expenditures in Canada - Summary Report, 1987 - 1991. Health
Information Division, Health Policy, Planning and Information Branch,
House of Commons, Standing
Committee on Health and Welfare, Social Affairs, Seniors and the Status
of Women. The Health Care System in Canada and Its Funding: No Easy
Solutions. Ottawa, May, 1982.
Hurley, J. and N. Arbuthnot
Johnson. "The Effects of Co-Payments Within Drug Reimbursement Programs."
Policy Options, Vol. 17, December 1991, p. 473 - 489.
Majnoni d'Intignano, B.
"Financing of Health Service Systems: Recent Developments and Reforms."
International Social Security Review, Vol. 44, No. 3, 1991, p.
5 - 21.
National Council of Welfare.
Medicare: The Public Good and Private Practice. Ottawa, May 1982.
OECD. "Health Care
Systems in Transition: The Search for Efficiency." Social Policy
Studies, No. 7, Paris, 1990.
OECD. The Reform of Health
Care: a Comparative Analysis of Seven OECD Countries. Paris, 1992.
Rochon Commission. Rapport
de la Commission d'enquête sur les services de santé et les services sociaux.
Government of Quebec, 1988.
Stoddart, G.L. and R.J.
Labelle. Privatization in the Canadian Health Care System: Assertions,
Evidence, Ideology and Options. Health and Welfare Canada, October
The Swedish Institute. "Health
and Medical Care in Sweden." Fact Sheets on Sweden. 1990.
Data were provided by the Health Information Division, Policy, Planning
and Information Branch, Health and Welfare Canada, April 1993.
Quebec, Ministère de la santé et des services sociaux, Un financement
équitable à la mesure de nos moyens, 1991, p. 78-82.
The advantages and disadvantages of increased privatization of health
care were discussed extensively in a study by G.L. Stoddart and R.J. Labelle,
Privatization in the Canadian Health Care System: Assertions, Evidence,
Ideology and Options, Health and Welfare Canada, October 1985.
National Council of Welfare, Medicare: The Public Good and Private
Practice, May 1982, Annex C.
Government of Canada, Preserving Universal Medicare: A Government of
Canada Position Paper, Ottawa, 1983.
References are as follows: R.F. Badgley and R.D. Smith, User Charges
for Health Services, Report of the Ontario Committee on Health Services,
1979; Government of Saskatchewan, Department of Public Health, Report
on Utilization Charges, 1979; National Council of Welfare, Medicare:
The Public Good and Private Practice, Ottawa, May 1982; R.G. Beck,
"The Effects of Copayments on the Poor," Journal of Human
Resources, 1974, p. 129-142; R.G. Beck and J.M. Horne, An
Analytical Overview of the Saskatchewan Co-payment Experience in the Hospital
and Ambulatory Care Settings, Report for the Ontario Committee on
Health Services, 1978; M.L Barer, R.G. Evans and G.L. Stoddart, Controlling
Health Care Costs by Direct Charges to Patients: Snare or Delusion?,
Ontario Economic Council, Occasional Paper 10, 1979.
Today, studies of the impact of user charges for drug insurance program
beneficiaries are coming to similar conclusions. For a summary of these
studies, see J. Hurley and N. Arbuthnot Johnson, "The Effects of
Co-Payments Within Drug Reimbursement Programs," Policy Options,
Vol. 17, December 1991, p. 473-489.
Source of 1992 data: Government of Quebec, Ministère des Finances et Conseil
du Trésor, Les finances publiques du Québec: vivre selon nos moyens,
Government of Quebec, 19 January 1993, Annex 3.
1991 data. The rate of exchange at 31 December 1991 was: $1 CDN =
4.483FF. OECD, The Reform of Health Care: A Comparative Analysis of
Seven OECD Countries, Paris, 1992, p. 47.
Data for 1988. The exchange rate at 31 December was: $1 CDN = 5.1622
Crowns. The Swedish Institute, "Health and Medical Care in Sweden,"
Fact Sheets on Sweden, 1990.
Data for 1988. The exchange rate at 31 December 1988 was: $1 CDN
= 1.4927 DM. OECD, The Reform of Health Care: A Comparative Analysis
of Seven OECD Countries, Paris, 1992, p. 59.
Data for 1990. The exchange rate at 31 December 1990 was: $1 CDN
= £0.447. OECD, The Reform of Health Care: A Comparative Analysis of
Seven OECD Countries, Paris, 1992, p. 115.
B. Majnoni d'Intignano, "Financing of Health Service System: Recent
Developments and Reforms," International Social Security Review,
Vol. 44, No. 3, 1991, p. 5-21.
A.L. Creese, User Charges for Health Care: A Review of Recent Experience,
Division of Strengthening of Health Services, World Health Organization,
SHS Paper No. 1, 1990.
See summary in: Rochon Commission, Rapport de la Commission d'enquête
sur les services de santé et les services sociaux, Government of Quebec,
1988, p. 653.
These data were obtained from the following sources: Canada: Health and
Welfare Canada, Health Expenditures in Canada - Summary Report, 1987-1991,
March 1993, Table I; Sweden: The Swedish Institute, "Health
and Medical Care in Sweden," Fact Sheets on Sweden, 1990,
p. 3; France, Germany and the United Kingdom: OECD, The Reform
of Health Care: A Comparative Analysis of Seven OECD Countries, Paris,
1992, Table 10.1.
House of Commons Standing Committee on Health and Welfare, Social Affairs,
Seniors and the Status of Women, The Health Care System and Its Funding:
No Easy Solutions, Ottawa, June 1991.
OECD, Health Care Systems in Transition: The Search for Efficiency,
Social Policy Studies No. 7, Paris, 1990.