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April 28, 2023

From: Dr. Danielle Martin

To: Canadian healthcare observers

Date: April 28, 2023

Re: Collaboration, not Competition, Will Get Us Through Our Healthcare Crisis

In the real world of health service delivery, the last three years have taught us a great deal. The pandemic has been a test of endurance for healthcare workers for sure, but it has also tested our ability as a collective system to do something we don’t do enough: work together.

Here is an incomplete list of the results:

  • We procured massive quantities of supplies and distributed them across the country: Personal protective equipment; swabs; hand sanitizer; ventilators.
  • We massively ramped up testing capacity; stood up assessment centres, drive-through clinics, mobile outreach teams.
  • We trained and retrained healthcare workers; instituted billing codes and protocols for COVID@Home clinics and virtual care for people with acute and chronic medical problems.
  • We opened field hospitals and tents in parking lots. We participated in clinical trials to determine which drugs to use and at what doses.
  • On the basis of data about who was most affected by the virus, and only because of unprecedented collaboration, we allocated resources accordingly when they were scarce – like testing, drugs and vaccines.
  • We moved patients out of hospitals that were overwhelmed, whether that meant from Scarborough to University Avenue or from Saskatchewan to Ontario.
  • We sent teams of workers into long-term care facilities to try to stem the impact of decades of poor design, understaffing, and under-resourcing on our elders.
  • And we created one of the world’s most successful vaccination campaigns, learning from early design mistakes and adopting community-based strategies that were unprecedented at that scale.

The result was a world-class pandemic response, built entirely on collaboration and co-ordination. Resolving to eliminate competition and work together was the key to every success we had.

Competition, on the other hand, is what happened in New York City where, in the first wave, hospitals were overwhelmed with COVID patients while for-profit facilities up the street stood empty.

Competition is also what happens in the most dysfunctional parts of our Canadian health systems, where value for money is most elusive and frustration is highest.

Pharmaceuticals: where we have competition between multiple public and private insurers, among the highest drug prices in the world, and millions of Canadians not taking their medicine because of cost.

Long-term care: Where for-profit homes in Ontario competing to care for our elders had a 78-percent higher mortality rate from COVID-19 than not-for-profits.

Electronic records: where vendors compete for our business but have seemingly no incentives or requirements to be interoperable with each other.

Competition, in a true market for any good or service, requires a set of conditions, including a large number of buyers and sellers making homogenous products; perfect knowledge among buyers and sellers; and mobility of the factors of production.

None of these exist in healthcare, in Canada or anywhere else. Patients are not savvy consumers choosing between near-identical products on the basis of price or the bells and whistles. They are sick people in need of compassionate care close to home.

And providers are not in endless supply, able to move freely around the market. They are highly trained, expensive resources, who need to be marshalled to areas of greatest need. The World Health Organization is projecting a global shortfall of 10 million health workers by 2030, and in Ontario alone, there will be a shortage of about 33,000 nurses and personal support workers by 2027-28. Where exactly will the supply come from for competition?

We have a long road to recovery ahead. To suggest that other countries have it better is to ignore the reality plaguing us all: nurses are on strike for the first time in the history of the NHS in England, and President Emmanuel Macron has declared that he’ll be completely overhauling the French healthcare system. Healthcare workers have been on strike over working conditions and wages in the Netherlands, Spain, Germany and more. There is no system, no matter the mix of payment and delivery, that is not struggling today.

We are in tough times in Canadian healthcare and there are more tough times ahead. Service backlogs. Human resources shortages. Mental health impacts. The coordinated effort required to manage recovery will probably dwarf what we have just achieved. More competition and fragmentation is the last thing we need. Collaboration is our only hope.


Dr. Danielle Martin is a professor and chair of the Department of Family and Community Medicine at the University of Toronto. This Memo is drawn from her argument at the C.D. Howe’s latest Regent Debate: Be It Resolved, Competition Will Save Canada’s Broken Healthcare System.

To send a comment or leave feedback, email us at blog@cdhowe.org.

The views expressed here are those of the author. The C.D. Howe Institute does not take corporate positions on policy matters.

A version of this Memo first appeared in the Toronto Star.