Canada remains poor performer among countries with universal health care

Canada reported far fewer physicians (ranking 28th of 30) and hospital beds (23rd of 29) per 1,000 people in 2021. And ranked low for the availability of MRI machines (25th of 29) and CT scanners (26thof 30) per million people in 2019

Earlier this year, the Trudeau government announced it will increase health-care spending to provinces and territories by $196.1 billion over the next decade. But patients hoping for improved access will likely be disappointed. In reality, Canada’s health-care system already ranks as one of the most expensive systems in the world, but only has mediocre results to show for it. In other words, the problem isn’t the amount of money we spend, it’s the poor value we get for our health-care dollars.

A new study compared the spending and performance of Canada’s system with 29 other universal health-care systems worldwide. According to the study (after adjusting for population age in each country), Canada was the highest spender on health care as a share of the economy (at 12.6 per cent) and ninth-highest on a per person basis in 2021, the latest year of available data.

And yet, compared to other universal countries, Canada reported far fewer physicians (ranking 28th of 30) and hospital beds (23rd of 29) per 1,000 people in 2021. And ranked low for the availability of MRI machines (25th of 29) and CT scanners (26thof 30) per million people in 2019 (the latest year of available data).

Unsurprisingly, scarce health-care resources are accompanied by long wait times. Using data collected in 2020 by the Commonwealth Fund, the study found that only 38 per cent of Canadians reported waiting less than four weeks for a specialist appointment—a much smaller percentage than countries such as Switzerland (68 per cent) and Germany (67 per cent). On this indicator, Canada ranked 10th out of 10 countries. Canada also ranked dead last (10th) on timely access to elective surgery—with 62 per cent of Canadians reporting waiting less than four months—compared to 99 per cent of Germans and 94 per cent of Swiss.

While these results were disappointing, Canada reported mixed results in other areas of performance. For example, although Canada performed poorly on safety indicators such as obstetric trauma during birth (23rd of 23 countries), it performed above the OECD average on other indicators including heart attack survival rates (9th of 25 countries). But while the Canadian system has in some areas performed in line with its high spending levels, overall it’s struggled to meet many of its basic obligations—especially timely access to care.

With its latest increase in health-care spending, the Trudeau government again ignores the fact that Canada already has one of the most expensive universal health-care systems in the world. And although some of this new spending is predicated on provinces tracking progress and demonstrating improvement on certain indicators, international data reveal a simple truth—Canadians do not receive commensurate value for their health-care dollars. Without fundamental reform, it’s unlikely the new spending promised by the Trudeau government will produce improved performance for Canadian patients and their families.

Authors:

Mackenzie Moir

Policy Analyst, Fraser Institute

Bacchus Barua

Director, Health Policy Studies, Fraser Institute

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Addictions

Why B.C.’s new witnessed dosing guidelines are built to fail

Published on July 14, 2025

Todayville

Photo by Acceptable at English Wikipedia, ‘Two 1 mg pills of Hydromorphone, prescribed to me after surgery.’ [Licensed under CC BY-SA 3.0, via Wikimedia Commons]

By Alexandra Keeler

B.C. released new witnessed dosing guidelines for safer supply opioids. Experts say they are vague, loose and toothless

This February, B.C pledged to reintroduce witnessed dosing to its controversial safer supply program.

Safer supply programs provide prescription opioids to people who use drugs. Witnessed dosing requires patients to consume those prescribed opioids under the supervision of a health-care professional, rather than taking their drugs offsite.

The province said it was reintroducing witnessed dosing to “prevent the diversion of prescribed opioids and hold bad actors accountable.”

But experts are saying the government’s interim guidelines, released April 29, are fundamentally flawed.

“These guidelines — just as any guidelines for safer supply — do not align with addiction medicine best practices, period,” said Dr. Leonara Regenstreif, a primary care physician specializing in substance use disorders. Regenstreif is a founding member of Addiction Medicine Canada, an advocacy group that represents 23 addiction specialists.

Addiction physician Dr. Michael Lester, who is also a founding member of the group, goes further.

“Tweaking a treatment protocol that should not have been implemented in the first place without prior adequate study is not much of an advancement,” he said.

Witnessed dosing

Initially, B.C.’s safer supply program was generally administered through witnessed dosing. But in 2020, to facilitate access amidst pandemic restrictions, the province moved to “take-home dosing,” allowing patients to take their prescription opioids offsite.

After pandemic restrictions were lifted, the province did not initially return to witnessed dosing. Rather, it did so only recently, after a bombshell government report alleged more than 60 B.C. pharmacies were boosting sales by encouraging patients to fill unnecessary opioid prescriptions. This incentivized patients to sell their medications on the black market.

B.C.’s interim guidelines, developed by the BC Centre on Substance Use at the government’s request, now require all new safer supply patients to begin with witnessed dosing.

But for existing patients, the guidelines say prescribers have discretion to determine whether to require witnessed dosing. The guidelines define an existing patient as someone who was dispensed prescription opioids within the past 30 days.

The guidelines say exemptions to witnessed dosing are permitted under “extraordinary circumstances,” where witnessed dosing could destabilize the patient or where a prescriber uses “best clinical judgment” and determines diversion risk is “very low.”

Holes

Clinicians say the guidelines are deliberately vague.

Regenstreif described them as “wordy, deliberately confusing.” They enable prescribers to carry on as before, she says.

Lester agrees. Prescribers would be in compliance with these guidelines even if “none of their patients are transferred to witnessed dosing,” he said.

In his view, the guidelines will fail to meet their goal of curbing diversion.

And without witnessed dosing, diversion is nearly impossible to detect. “A patient can take one dose a day and sell seven — and this would be impossible to detect through urine testing,” Lester said.

He also says the guidelines do not remove the incentive for patients to sell their drugs to others. He cites estimates from Addiction Medicine Canada that clients can earn up to $20,000 annually by selling part of their prescribed supply.

“[Prescribed safer supply] can function as a form of basic income — except that the community is being flooded with addictive and dangerous opioids,” Lester said.

Regenstreif warns that patients who had been diverting may now receive unnecessarily high doses. “Now you’re going to give people a high dose of opioids who don’t take opioids,” she said.

She also says the guidelines leave out important details on adjusting doses for patients who do shift from take-home to witnessed dosing.

“If a doctor followed [the guidelines] to the word, and the patient followed it to the word, the patient would go into withdrawal,” she said.

The guidelines assume patients will swallow their pills under supervision, but many crush and inject them instead, Regenstreif says. Because swallowing is less potent, a higher dose may be needed.

“None of that is accounted for in this document,” she said.

Survival strategy

Some harm reduction advocates oppose a return to witnessed dosing, saying it will deter people from accessing a regulated drug supply.

Some also view diversion as a life-saving practice.

Diversion is “a harm reduction practice rooted in mutual aid,” says a 2022 document developed by the National Safer Supply Community of Practice, a group of clinicians and harm reduction advocates.

The group supports take-home dosing as part of a broader strategy to improve access to safer supply medications. In their document, they say barriers to accessing safer supply programs necessitate diversion among people who use drugs — and that the benefits of diversion outweigh the risks.

However, the risks — and harms — of diversion are mounting.

People can quickly develop a tolerance to “safer” opioids and then transition to more dangerous substances. Some B.C. teenagers have said the prescription opioid Dilaudid was a stepping stone to them using fentanyl. In some cases, diversion of these drugs has led to fatal overdoses.

More recently, a Nanaimo man was sentenced to prison for running a highly organized drug operation that trafficked diverted safer supply opioids. He exchanged fentanyl and other illicit drugs for prescription pills obtained from participants in B.C.’s safer supply program.

Recovery

Lester, of Addiction Medicine Canada, believes clinical discretion has gone too far. He says take-home dosing should be eliminated.

“Best practices in addiction medicine assume physicians prescribing is based on sound and thorough research, and ensuring that their prescribing does not cause harm to the broader community, as well as the patient,” he said.

“[Safer supply] for opioids fails in both these regards.”

He also says safer supply should only be offered as a short-term bridge to patients being started on proven treatments like buprenorphine or methadone, which help reduce drug cravings and manage withdrawal symptoms.

B.C.’s witnessed dosing guidelines say prescribers can discuss such treatment options with patients. However, the guidelines remain neutral on whether safer supply is intended as a transitional step toward longer-term treatment.

Regenstreif says this neutrality undermines care.

“[M]ost patients I’ve seen with opioid use disorder don’t want to have [this disorder],” she said. “They would rather be able to set goals and do other things.”

Oversight gaps

Currently, about 3,900 people in B.C. participate in the safer supply program — down from 5,200 in March 2023.

The B.C. government has not provided data on how many have been transitioned to witnessed dosing. Investigative journalist Rob Shaw recently reported that these data do not exist.

“The government … confirmed recently they don’t have any mechanism to track which ‘safe supply’ participants are witnessed and which [are] not,” said Elenore Sturko, a Conservative MLA for Surrey-Cloverdale, who has been a vocal critic of safer supply.

“Without a public report and accountability there can be no confidence.”

The BC Centre on Substance Use, which developed the interim guidelines, says it does not oversee policy decisions or data tracking. It referred Canadian Affairs’ questions to B.C.’s Ministry of Health, which has yet to clarify whether it will track and publish transition data. The ministry did not respond to requests for comment by deadline.

B.C. has also not indicated when or whether it will release final guidelines.

Regenstreif says the flawed guidelines mean many people may be misinformed, discouraged or unsupported when trying to reduce their drug use and recover.

“We’re not listening to people with lived experience of recovery,” she said.

This article was produced through the Breaking Needles Fellowship Program, which provided a grant to Canadian Affairs, a digital media outlet, to fund journalism exploring addiction and crime in Canada. Articles produced through the Fellowship are co-published by Break The Needle and Canadian Affairs.

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Brownstone Institute

Net Zero: The Mystery of the Falling Fertility

Published on July 11, 2025

Todayville

From the Brownstone Institute

By Tomas Fürst

If you want to argue that a mysterious factor X is responsible for the drop in fertility, you will have to explain (1) why the factor affected only the vaccinated, and (2) why it started affecting them at about the time of vaccination.

In January 2022, the number of children born in the Czech Republic suddenly decreased by about 10%. By the end of 2022, it had become clear that this was a signal: All the monthly numbers of newborns were mysteriously low.

In April 2023, I wrote a piece for a Czech investigative platform InFakta and suggested that this unexpected phenomenon might be connected to the aggressive vaccination campaign that had started approximately 9 months before the drop in natality. Denik N – a Czech equivalent of the New York Times – immediately came forward with a “devastating takedown” of my article, labeled me a liar and claimed that the pattern can be explained by demographics: There were fewer women in the population and they were getting older.

To compare fertility across countries (and time), the so-called Total Fertility Rate (TFR) is used. Roughly speaking, it is the average number of children that are born to a woman over her lifetime. TFR is independent of the number of women and of their age structure. Figure 1 below shows the evolution of TFR in several European countries between 2001 and 2023. I selected countries that experienced a similar drop in TFR in 2022 as the Czech Republic.

***Figure 1.*** *The evolution of Total Fertility Rate in selected European countries between 2000 and 2023. The data corresponding to a particular year are plotted at the end of the column representing that year.*

So, by the end of 2023, the following two points were clear:

The drop in natality in the Czech Republic in 2022 could not be explained by demographic factors. Total fertility rate – which is independent of the number of women and their age structure – dropped sharply in 2022 and has been decreasing ever since. The data for 2024 show that the Czech TFR has decreased further to 1.37.

Many other European countries experienced the same dramatic and unexpected decrease in fertility that started at the beginning of 2022. I have selected some of them for Figure 1 but there are more: The Netherlands, Norway, Slovakia, Slovenia, and Sweden. On the other hand, there are some countries that do not show a sudden drop in TFR, but rather a steady decline over a longer period (e.g. Belgium, France, UK, Greece, or Italy). Notable exceptions are Bulgaria, Spain, and Portugal where fertility has increased (albeit from very low numbers). The Human Fertility Project database has all the numbers.

This data pattern is so amazing and unexpected that even the mainstream media in Europe cannot avoid the problem completely. From time to time, talking heads with many academic titles appear and push one of the politically correct narratives: It’s Putin! (Spoiler alert: The war started in February 2022; however, children not born in 2022 were not conceived in 2021). It’s the inflation caused by Putin! (Sorry, that was even later). It’s the demographics! (Nope, see above, TFR is independent of the demographics).

Thus, the “v” word keeps creeping back into people’s minds and the Web’s Wild West is ripe with speculation. We decided not to speculate but to wrestle some more data from the Czech government. For many months, we were trying to acquire the number of newborns in each month, broken down by age and vaccination status of the mother. The post-socialist health-care system of our country is a double-edged sword: On one hand, the state collects much more data about citizens than an American would believe. On the other hand, we have an equivalent of the FOIA, and we are not afraid to use it. After many months of fruitless correspondence with the authorities, we turned to Jitka Chalankova – a Czech Ron Johnson in skirts – who finally managed to obtain an invaluable data sheet.

To my knowledge, the datasheet (now publicly available with an English translation here) is the only officially released dataset containing a breakdown of newborns by the Covid-19 vaccination status of the mother. We requested much more detailed data, but this is all we got. The data contains the number of births per month between January 2021 and December 2023 given by women (aged 18-39) who were vaccinated, i.e., had received at least one Covid vaccine dose by the date of delivery, and by women who were unvaccinated, i.e., had not received any dose of any Covid vaccine by the date of delivery.

Furthermore, the numbers of births per month by women vaccinated by one or more doses during pregnancy were provided. This enabled us to estimate the number of women who were vaccinated before conception. Then, we used open data on the Czech population structure by age, and open data on Covid vaccination by day, sex, and age.

Combining these three datasets, we were able to estimate the rates of successful conceptions (i.e., conceptions that led to births nine months later) by preconception vaccination status of the mother. Those interested in the technical details of the procedure may read Methods in the newly released paper. It is worth mentioning that the paper had been rejected without review in six high-ranking scientific journals. In Figure 2, we reprint the main finding of our analysis.

***Figure 2A.*** *Histogram showing the percentage of women in the Czech Republic aged 18–39 years who were vaccinated with at least one dose of a Covid-19 vaccine by the end of the respective month.* ***Figure 2B.*** Estimates of the number of successful conceptions (SCs) per 1,000 women aged 18–39 years according to their pre-conception Covid vaccination status. The blue-shaded areas in Figure 1B show the intervals between the lower and upper estimates of the true SC rates for women vaccinated (dark blue) and unvaccinated (light blue) before conception.

Figure 2 reveals several interesting patterns that I list here in order of importance:

Vaccinated women conceived about a third fewer children than would be expected from their share of the population. Unvaccinated women conceived at about the same rate as all women before the pandemic. Thus, a strong association between Covid vaccination status and successful conceptions has been established.
In the second half of 2021, there was a peak in the rate of conceptions of the unvaccinated (and a corresponding trough in the vaccinated). This points to rather intelligent behavior of Czech women, who – contrary to the official advice – probably avoided vaccination if they wanted to get pregnant. This concentrated the pregnancies in the unvaccinated group and produced the peak.
In the first half of 2021, there was significant uncertainty in the estimates of the conception rates. The lower estimate of the conception rate in the vaccinated was produced by assuming that all women vaccinated (by at least one dose) during pregnancy were unvaccinated before conception. This was almost certainly true in the first half of 2021 because the vaccines were not available prior to 2021. The upper estimate was produced by assuming that all women vaccinated (by at least one dose) during pregnancy also received at least one dose before conception. This was probably closer to the truth in the second part of 2021. Thus, we think that the true conception rates for the vaccinated start close to the lower bound in early 2021 and end close to the upper bound in early 2022. Once again, we would like to be much more precise, but we have to work with what we have got.

Now that the association between Covid-19 vaccination and lower rates of conception has been established, the one important question looms: Is this association causal? In other words, did the Covid-19 vaccines really prevent women from getting pregnant?

The guardians of the official narrative brush off our findings and say that the difference is easily explained by confounding: The vaccinated tend to be older, more educated, city-dwelling, more climate change aware…you name it. That all may well be true, but in early 2022, the TFR of the whole population dropped sharply and has been decreasing ever since.

So, something must have happened in the spring of 2021. Had the population of women just spontaneously separated into two groups – rednecks who wanted kids and didn’t want the jab, and city slickers who didn’t want kids and wanted the jab – the fertility rate of the unvaccinated would indeed be much higher than that of the vaccinated. In that respect, such a selection bias could explain the observed pattern. However, had this been true, the total TFR of the whole population would have remained constant.

But this is not what happened. For some reason, the TFR of the whole population jumped down in January 2022 and has been decreasing ever since. And we have just shown that, for some reason, this decrease in fertility affected only the vaccinated. So, if you want to argue that a mysterious factor X is responsible for the drop in fertility, you will have to explain (1) why the factor affected only the vaccinated, and (2) why it started affecting them at about the time of vaccination. That is a tall order. Mr. Occam and I both think that X = the vaccine is the simplest explanation.

What really puzzles me is the continuation of the trend. If the vaccines really prevented conception, shouldn’t the effect have been transient? It’s been more than three years since the mass vaccination event, but fertility rates still keep falling. If this trend continues for another five years, we may as well stop arguing about pensions, defense spending, healthcare reform, and education – because we are done.

We are in the middle of what may be the biggest fertility crisis in the history of mankind. The reason for the collapse in fertility is not known. The governments of many European countries have the data that would unlock the mystery. Yet, it seems that no one wants to know.

Author

Tomas Fürst

Tomas Fürst teaches applied mathematics at Palacky University, Czech Republic. His background is in mathematical modelling and Data Science. He is a co-founder of the Association of Microbiologists, Immunologists, and Statisticians (SMIS) which has been providing the Czech public with data-based and honest information about the coronavirus epidemic. He is also a co-founder of a “samizdat” journal dZurnal which focuses on uncovering scientific misconduct in Czech Science.