Hockey and the beaver, the maple leaf and the RCMP, the Rockies and Niagara Falls – all made the list when the Dominion Institute conducted a national survey a few years ago, asking citizens what defined Canada. Amidst the people, places and things, one ideal finished high up the rankings too. It was the principle of universal health care.

To many people, our health care system symbolizes Canadian values. The Canada Health Act (CHA) clearly lays out the vision for universality and accessibility. But is the system as equitable as Canadians would like to think?

The CHA sets the conditions for federal funding to support provincial and territorial health insurance plans. The question is whether all Canadians receive equal health care or equal capacity to receive that care. By many measures, the answer is clearly no.

Take the issue of “reasonable access” to health services. The CHA says that one of the primary objectives of federal health care policy is “to facilitate reasonable access to health services without financial or other barriers”.

Whether we’re doing so depends in part on how you define “reasonable access”? Across Canada, for instance, there are very different concentrations of health care providers. Can people who live in urban and rural centres each have the same “reasonable access”?

That disparity is a reality of Canada’s geography, but it is not the only inequity when it comes to health care services.

While the CHA is concerned with how the system is financed, it does not specify how health care should be organized and delivered. Which means standards of care across the country can differ greatly.

The fact is that health care delivery is a provincial and territorial responsibility. As federal legislation, the CHA outlines broad objectives and principles, and the requirements that jurisdictions must fulfill in order to qualify for federal contributions.

Still, different jurisdictions can have significantly varying results in areas such as key health indicators for their population, or wait times, or health care spending per capita.

Jurisdictions have their own benchmarks, and many are exemplary. But health care standards simply are not the same throughout all parts of Canada.

Should they be?

In effect, we do not have a national health care system; we have a series of individual health care systems. Think of what would happen if we were to have a single national standard of care.

What if, for example, federal funding was tied directly to health status and health outcomes?

Perhaps it’s time to revisit the method of transfer payments. Imagine if, under the CHA, the financial levers were used to ensure a uniform standard for access to physicians, or for spending on health prevention and promotion. Reforms like that could have a profound impact on countless health indicators.

Is it time for the federal government to adopt a “pay for performance” model when it comes to financing the health system? Basically, the different jurisdictions would still operate their own health care – but with funding linked to the ability to meet national standards for that care, and to certain efficiencies.

Whatever changes are needed to improve our health system, and to achieve a sense of equilibrium in care delivery, one thing is clear: no province or territory can do it alone.

The public health care system is seen as a sacred trust in Canada – a sacred national trust. The emphasis on national also means that none of these changes can be made without not only the participation but the leadership of the federal government.

By developing a consensus on health care standards – essentially, by emphasizing the “Canada” in the Canada Health Act – we could move closer to achieving the main goal of our health care policy. And that, as set out in the CHA, is “to protect, promote and restore the physical and mental well-being of residents of Canada”.

Whether or not this is feasible, it certainly seems fair. And it’s probably what all those Canadians surveyed were thinking about when they named universal health care as a national symbol.

Kim Furlong is Director, Federal Government Affairs and Mo Amin is Director, Health Economics and Payer Planning for Amgen Canada.