Dalla Lana School of Public Health

A Canadian first: Country-​wide study shows primary care transformation is slow, incremental, fragmented

November 20/2023

Prof. Monica Aggarwal led a team in a decade-long study that observed and assessed changes in primary care delivery across 13 Canadian jurisdictions. The results show that progress was limited, slow, and sometimes missing altogether in many attributes of high-performing primary care in Canada’s splintered system.  

Despite significant efforts and investments, Canada’s primary care system is not meeting the standards of a high-performing system, says a new study.  These standards are crucial to improving health outcomes and health equity, lowering mortality rates, and reducing costs. Researchers, including lead author and principal investigator PHS Prof. Monica Aggarwal, co-authors IHPME Prof. Ross Baker, research assistant Reham Abdelhalim, and Prof. Brian Hutchison of McMaster University – with support and input from PHS Prof. Rick Glazier – published the results of a 10-year review (2012-2021) of Canada’s primary care performance in The Milbank Quarterly.  

“The study found that Canada’s primary care transformation has been slow, piecemeal, and incremental, with limited changes to the overall organization and delivery of primary care,” says Aggarwal.  

This study is the first in Canada to compare and evaluate primary care transformation across all Canadian provinces and territories. The researchers conducted qualitative interviews with experts in each jurisdiction and a literature review of each region’s policies and innovations. The data was then analyzed and assessed using the features of high-performing systems, originally identified by Prof Aggarwal and Dr. Brian Hutchison in 2012. 

Aggarwal says challenges to transformation include the country’s “decentralized health systems, pre-existing policy legacies, inadequate accountable investments in primary care innovations, resistance to change among health care providers, limited evidence on the impetus of change, and insufficient performance measurement and accountability.”  

Based on the assessment of the key features, the authors noted 10 areas that require significant reflection and action. 

1. Explicit policy direction – More jurisdictions have defined an explicit policy direction for primary care, but the aims and approaches of reform initiatives differed across jurisdictions.
2. Governance mechanisms – More jurisdictions have developed governance mechanisms with structures and processes that oversee primary care at the local levels in the last decade, but overall, change has been slow. 
3. Patient enrollment – Various initiatives have been implemented to attach a patient to a primary care provider or team, but formal patient enrollment is limited.
4. Patient engagement – Actively involving patients in decisions about their healthcare and the planning of health services is an area that requires significant improvement across Canada.
5. Funding and provider payment arrangements – More jurisdictions have experimented with the implementation of funding and provider payment arrangements that support health system goals, but widespread change has not occurred.
6. Ongoing performance measurement – Ongoing performance measurement that enables accountability at multiple levels to inform and assess the impact of health services planning, management, and improvement activities has been slow across Canada, and no jurisdiction monitors performance at all levels.  
7. Leadership development – Investments in leadership development in primary care have been minimal across Canada.
8. Coordination, integration and partnerships – Few jurisdictions have developed initiatives to enable collaboration with other health care and social services.
9. Systematic Evaluation – Investments in the systematic evaluation of new approaches and innovations have been limited across jurisdictions.
10. Research capacity – Building research capacity and productivity in primary care remains an area of underinvestment across Canada.

While the researchers found that progress was slow in many areas, some areas showed improvements over the course of the decade. 

1. Health Information Technology – The adoption of electronic medical records is where Canada has made the most significant change. However, the shift toward integrated health records remains slow.  
2. Quality improvement training and support – Significant progress has been made through investments in quality improvement training and support for primary care providers.
3. Inter-professional teams – More jurisdictions have launched inter-professional teams or networks; however, the degree of spread is variable.

Although these improvements should be celebrated, the study’s findings show that the country still has a lot of work to do to build high-performing systems. The authors suggest that to accelerate transformation in Canada and abroad, a national strategy and performance measurement framework based on meaningful engagement of patients and other stakeholders is needed. This must be accompanied by targeted funding investments and building strong data infrastructure for performance measurement to support rigorous research. Considering the current primary care crisis, Aggarwal says, “Canada and the world have waited long enough for high-performing primary care.” She calls for “national and international leaders to “walk the talk.” 

“The benefit of our study is that it is the first to collect data on the degree of progress on the key features of high performing primary care systems over the last decade. This information will allow us to continue to monitor progress over years to come,” says Aggarwal. “I plan to identify best practices and lessons learned in Canada and internationally and hope to create forums by which this knowledge can be available to policymakers so that leaders across the country can learn from each other and work together to build high-performing primary care systems in Canada today and in the future.”