1) The document summarizes Canada's management of health spending during an economic downturn from 1990-1999. It describes rising debt burdens, experimentation with regionalization, and national reform efforts. 2) Key statistics on health spending, surpluses/deficits, and debt are presented for Canada, as well as case studies of Ontario and Saskatchewan. Health spending growth slowed but outcomes did not suffer. 3) The document analyzes the recession's impact on GDP, revenues, transfers and spending on hospitals/institutions. Provinces recorded an aggregate surplus in 1999-2000 despite debt burdens.

1. NUFFIELD TRUST/CHSRF MASTERCLASS
CANADIAN 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

2. CURRENT PICTURE SASKATCHEWAN ONTARIO U.K.
Combined Life
expectancy at birth 79.5 81 79.7
(‘97)
Population (2011) 1M 13.2M 60.5M
Current Debt (2011) • 20 million • $16.7B deficit • £ 163B deficit
surplus • Net Debt: 37.6% • Net Debt: 59% of
• Net Debt: 7% of of Provincial GDP
provincial GDP GDP
Per Capita GDP (2009) C$45,718 C$43,847 US$32,798
2

3. Sources
Figure 1: Canadian Institute for Health Information; United
Kingdom Office for National Statistics
Figure 2/3: OECD Health Data 2010. 3

4. Important Context for Canada (1990-2000)
• 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
4

5. Total health expenditure per capita, US$ PPP
Source: Public Accounts and 2000 budgets.
5

6. Federal and provincial-territorial surplus/deficit(-)
Public Accounts basis
Source: Public Accounts and 2000 budgets.
6

7. Federal and provincial-territorial net debt
Public Accounts basis
Source: Public Accounts and 2000 budgets.
7

8. REAL PER CAPITA GDP, CANADA:
before, during and after the recession (1985 to 2000)
$50,000
$45,000
$40,000
$35,000
$30,000
$25,000
8

9. REAL PER CAPITAPUBLIC SECTOR HEALTH EXPENDITURE:
Canada, 1980 to 2010(f)
$4,500
$4,000
Trend (1980 to 1991)
$3,500
Trend (1992 to 1996)
$3,000
Trend (1997 to 2010)
$2,500
Actual
$2,000
$1,500
Source: Canadian Institute for Health Information
9

10. Provincial/Territorial Government Revenues
Constant 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

11. ONTARIO & SASKATCHEWAN
CASES
11

12. REAL PER CAPITA SPENDING GROWTH ON
HOSPITALS AND OTHER INSTITUTIONS:
Ontario, 1990 to 2000
10%
5%
Hospitals
0%
Other Institutions
-5%
-10%
Source: OECD Health Data 2010
12

13. REAL PER CAPITA SPENDING GROWTH ON
HOSPITALS AND OTHER INSTITUTIONS:
Saskatchewan, 1990 to 2000
10%
5%
Hospitals
0%
Other Institutions
-5%
-10%
Source: OECD Health Data 2010
13

14. Per Capita Physician Spending 1981-2010
14

15. Hospital beds per 1,000 population
8
7
6
5
4
3
2
1
0
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
Source: OECD Health Data 2010.
15

16. 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

17. QUESTIONS?
17

18. 18

19. Net Debt-to-GDP Ratio
Source: Department of Finance.
19

20. Source: 2000 Federal Budget
20

21. 21

22. The provinces and territories recorded an aggregate
surplus in 1999-2000
Federal and provincial-territorial budgetary balance
Public Accounts basis
Source: Public Accounts and 2000 budgets.
22

23. Federal and
provincial-
territorial
surplus/deficit(-)
Public Accounts basis
Source: Public Accounts and 2000
budgets.
23

24. Provincial-territorial revenues and program spending
National Accounts basis
Source: National Income and Expenditure Accounts.
24

25. Interprovincial comparison of taxpayer-
supported debt as a percentage of GDP
Source: Moody’s Investors Service Inc.
25