Relatively expensive and underperforming. These words describing Canada's health-care system are now widely accepted in political and medical circles – in contrast to what we heard as recently as a decade ago, when "experts" and politicians still insisted that Canada had one of the best systems in the world.

But is Canadian health care underperforming as badly as the Commonwealth Fund believes? We can only hope not, because if the U.S.-based foundation is even remotely correct, Canada's system needs even more work than had been feared.

Recently, the foundation released a comparative scorecard of 11 health-care systems in advanced industrial economies. The United States ranked 11th. Canada ranked 10th, its worst standing in the comparison since it began in 2004.

Story continues below advertisement

The Commonwealth Fund focuses on U.S. health care but keeps an eye on other systems, if only to show Americans the weaknesses of their own system. If it has an agenda, apart from solid research, it's to push for more public health care. It does not promote or favour an extension of private medicine. It's not a right-wing group blasting away at "socialist medicine." In this study, as in previous ones, it argues that "the most notable way the U.S. differs from other industrialized countries is the absence of universal health insurance coverage."

Philosophically, therefore, it is in the same corner with countries having largely public systems, such as Canada. So when Canadians knowledgeable about health care read Commonwealth Fund reports – and they do – they pay less attention to its criticisms of the U.S. system and focus on Canadian comparisons to the other largely public systems. That's the apple-to-apple comparison. Alas, the comparison is discouraging: Canada stands dead last among them.

Until this year's report, the Commonwealth Fund had compared just seven countries: the United States and six others, including Canada. Canada had previously ranked fourth, fifth and sixth, with the U.S. always last. This time, the Fund added four more countries: France, Norway, Sweden and Switzerland. Not surprisingly, Canada ranked below them, plus the five other public health-care countries: Australia, Germany, the Netherlands, New Zealand and Britain.

No single international comparative study is definitive. Each one – and there are many – asks different questions, uses different methodologies, weights answers differently. Some are highly technical. Some focus on crunching numbers. Some focus on patient or provider surveys, which are by definition more subjective. Some try to blend approaches.

The Commonwealth Fund leans toward satisfaction surveys by health-care providers and patients. So it's more subjective, for instance, than reports from the OECD, which are heavy on details of what services are provided, outcomes from medical procedures, the number of doctors, nurses, beds, long-term care facilities and the like. In the OECD survey, Canada scores high on cost but at least average in overall performance.

The Commonwealth Fund examines 80 indicators of performance, many of them based on patient surveys. Canadian respondents were by far the most numerous of any country, which suggests a somewhat greater accuracy than the results for other countries.

Of course, Canada was ranked last of the 11 for "timeliness of care." Canada always comes at or near the bottom in many studies for long wait times – at all levels of service, from family doctors to specialists to surgeries to long-term care. In none of the categories does the Fund put Canada at the top. In very few categories is Canada even near the top.

Story continues below advertisement

We'll see if Canada improves in future surveys. Some of the Fund's survey questions were highly subjective. To their credit, provincial governments are pursuing long-overdue reforms. Without the false fix of more money and the phony rhetoric about Canada being No. 1, people in politics and the health-care system are thinking about new and better ways of doing things. Measurable progress is evident in some places.

But other countries aren't standing still. The Commonwealth Fund study illustrates how much work remains for Canadians, and how other systems do work better.