Canada's often-lauded health-care system has an unusual and unfortunate distinction. Physician care and hospital stays are universally publicly funded, but medicines are not. Canada is the only country in the world with public health care and no universal public system for providing prescription drugs (pharmacare). In the run-up to the country's federal election on Oct 21, the harms to Canadians, and the costs to the health-care system, of the absence of national pharmacare are again in the spotlight.

How Canadians pay for their prescriptions is variable: federal or provincial plans provide public coverage of medicines used outside of hospitals for some groups, such as people receiving social assistance, those older than 65 years, and Indigenous peoples on reserve. About half of the country's 35 million residents have employer-based private insurance, often requiring a copayment. One in five Canadians has to pay out of pocket for medicines that amounted to CAN$30 billion for 600 million prescriptions in 2016, four times what it was 20 years ago . This medley—over 100 different public drug plans and thousands of private ones—has left millions of Canadians struggling to afford their medications.

Worse, the fragmentation means that Canadians pay the highest drug costs in the world, behind only Switzerland and the USA, according to an advisory council report . With a national system, the federal government would be in a powerful bargaining position to bulk-purchase drugs and drive down costs. And removing out-of-pocket expenses would improve patient adherence and health outcomes, reduce avoidable hospital admissions, and provide a net saving to the public purse.

Implementing national pharmacare won't be easy. Funding, administration, and jurisdictional negotiations will be difficult, and creating the requisite national drug agency, formulary, and strategy will take time. But after multiple reports, advisory councils, and political pledges, together with high public expectations, the delivery of the pharmacare promise is long overdue. After Oct 21, a first order of business needs to be a universal system to ensure that Canadians can equitably access medicines.

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Article Info Publication History Identification DOI: https://doi.org/10.1016/S0140-6736(19)32324-4 Copyright © 2019 Elsevier Ltd. All rights reserved. ScienceDirect Access this article on ScienceDirect