The problem with Canada’s middle-of-the-pack framing

On 17 October 2016, a day before Canadian health ministers’ meeting to discuss Canada federal health transfer, the Federal Health Minister Jane Philphott said again that it took more than just money to fix Canada’s middle-of-the-pack health system.


Studies have found again and again that Canada ranks in the middle-of-the-pack in terms of health outcome compared to its peer countries. A report recently published by Canadian Institute for Health Information (CIHI) found that not only Canada is, but has been, in the middle of the pack for 50 years in terms of Potential Years of Life Lost (PYLL).


The fact that it takes more than money to transform health systems into best performers could be learned from the United State’s spending on healthcare. The United States spends almost twice per capita compared Canada but ranks almost always at the end of the pack in which Canada remains in the middle. My interest, however, is in the framing of the middle-of-the-pack.

I see two problems with the framing.

The pack that Canada has created for itself is limited and needs to be expanded in order to learn lessons from many other countries in the world.

When we put ourselves in a pack, the pack becomes the field and the boundaries. The players in the pack are our comparators, they are the source of inspiration and learning, and they are the benchmark. They are called the ‘peer countries.’ The argument for comparing Canada to peer countries is that they have contextual similarities with Canada, and thus they are more comparable. And most often those peer countries are picked implicitly, without any rigorous method.

One study that conducted a cluster analysis based on many social, demographic and health indicators found that Canada’s comparator countries included most of the usual suspects (OECD countries) but also Argentina, Chile, Cuba, Malta, Republic of Korea, Singapore, Slovenia, and Uruguay. The second group of countries is almost always absent in the comparative studies. Cuba’s health system can be exemplary if one wants to integrate primary health care into the medicalized health care system. Singapore’s health system can be useful to learn about integrating new technology into health systems.

The second problem with the framing of the middle-of-the-pack is the notion of the middle. If there are 11 countries in a pack, we can have multiple middles for it. The rank 6 is a middle. The range of 5 to 7 is also a middle of the pack, and so is the range of 4 to 8, leaving three best performers and three worst performers. The notion of the middle creates a comfort zone. It is a safe zone for mediocre performers. It reminds the average performer that a number of countries are behind them, thus creating a sense of complacency.

While Canada constantly compares itself with its traditional peer countries, other countries are experimenting with innovative ideas that come from outside the pack. From a diffusion of innovation perspective, the best performers in the pack are the innovators or the early adopters, while Canada remains a late majority or even a laggard. In order to become the best performer or try to stay ahead of the pack, Canada needs to get outside the framing of the middle-of-the-pack, and look outside of the pack for innovations and excellence.


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