Recently the World Health Organization rated the health care systems of 191 countries, and contrary to what the public in Canada is often told by our politicians, our country did not get a stellar grade: Canada was pegged at the 30th spot. As a WHO official bluntly put it, "Canada does not have the best health care system in the world." Yet, as a country, we are still reluctant to embrace or adapt the best practices (financing, organization and/or service delivery) of those countries that finished ahead of us.

Demographic pressures are already upon us and by 2020, almost 60% of health care expenditures will be consumed by those aged 65 or older compared to 45% today. Moreover, technological advances while welcome usually just improve upon existing technology instead of replacing it (i.e.: x-ray, CT scanner, and MRIs), thereby driving costs further in an upward spiral.

Pharmaceuticals consume more resources than physician billings. With new and aggressive drug therapies around the corner, costs will only escalate. Amidst these pressures, patient demands and expectations for "right here, right now" services will also magnify.

Taken together, demographic, technological, pharmaceutical and patient expectation pressures can be termed as the "gang of four."

To date, reforms in Canadian health care have been supply-side driven, from regionalization of service delivery to province-wide disease networks to cost containment to structural integration. While some economies have been found, patient demand, patient responsibility and perverse incentives have been ignored as focal points for reform.

Health care is complex and it is clear that there are no magic bullet solutions. However, key principles do exist that should be employed both in legislation and in restructuring service delivery, which would put Canada on the proper road toward patient-focused, sustainable reforms.

At the legislative level, a modernization of the Canada Health Act is long overdue. Its current five principles should be replaced in with the following six principles:

Public governance;

Universality;

Quality;

Accountability;

Choice; and

Sustainability.

At the structural level, guiding principles for reform include:

Individual accountability and responsibility (this could include co-payment);
Intergenerational fairness (pre-funding of health care is key which could include health care savings allowances or accounts); and an

Embrace of innovative approaches (including flexible and workable public-private partnerships in capital construction, service provision and technology renewal as well as provincial experimentation in financing and service delivery).

The principal and laudable aim of medicare was to provide health services without hindrance. Now the greatest hindrance to reform is the intransigence of those who refuse to accept that the problem with health care is the system itself.

Its present global funding configuration is unsustainable and its orientation must change to place the patient at the centre of every interaction. An honest, open and thorough debate on the future of health care is needed.

This debate must go beyond the hearings of the Romanow royal commission or the deliberations of the Kirby Senate Committee; it's time for citizens and taxpayers to take ownership of this debate.