When someone sneezes, we say Gesundheit – a small cultural habit meaning health. In Germany, under the Gesundheitfonds, they have quietly built one of the most functional healthcare systems in the developed world, while Canada continues to struggle with access, waits, and outcomes.
This article is not about admiration for Germany, nor condemnation of Canada. It is about diagnosis – because if we misdiagnose the problem, we will never treat it.
Canada’s Healthcare Problem Is Not Underfunding
For years, the dominant narrative in Canada has been simple: Healthcare is in crisis because it is chronically underfunded. That story is emotionally compelling – and factually wrong.
According to OECD data, Canada spends roughly 12.5–12.7% of GDP on healthcare, well above the OECD average of ~8%. We spend more, as a share of our economy, than countries like Australia, the Netherlands, and many European peers.
Yet when outcomes are compared, Canada consistently performs poorly on:
- Timely access to care
- Specialist and diagnostic availability
- Avoidable (amenable) mortality – deaths that should not occur with effective healthcare
Independent international comparisons from the Commonwealth Fund routinely rank Canada near the bottom among high-income nations on access and timeliness – despite our high spending and strong clinical workforce.
This combination – high spend, weak outcomes – is the hallmark of inefficiency, not austerity. The uncomfortable truth is this – Canada is not underfunding healthcare. We are incorrectly funding it.
Unfortunately, the broad consensus across Canada is that we need to spend more on the system that is failing and not attempt to change it. Until there is broad consensus on the diagnosis, we will never be able to treat the underlying problem.
When Spending More Makes Things Worse
Calls for “more funding” are understandable. Hospitals are crowded. Clinicians are exhausted. Infrastructure is aging. But pouring more money into a structurally inefficient system does not fix it – it often makes it worse. Why?
Canada has built an institution-centric, activity-based funding model. In practice we fund healthcare by:
- Allocating global budgets to hospitals and institutions
- Paying fee-for-service to physicians per visit, test, or procedure
- Funding home care, long-term care, and community services separately
- Measuring performance primarily by volumes and utilization, not outcomes
Money flows to buildings and budgets, not to outcomes across a patient’s life. The result is a system that intervenes late, expensively, and often too slowly.
A Useful Comparison: Germany
Germany spends a similar share of GDP on healthcare as Canada – slightly more in some years, slightly less in others. Yet the lived experience of patients is dramatically different. Germany does not achieve this through miracle drugs, superhuman doctors, or unlimited spending. It achieves it through design. Germany operates a population-based, risk adjusted funding model across the patients full spectrum of healthy living.
The Gesundheitsfonds: Funding People, Not Buildings
At the heart of Germany’s system is the Gesundheitsfonds – a national health fund that finances care per person, not per institution. Instead of one monolithic payer like OHIP, Germany has over 100 non-profit insurers (“sickness funds”). That sounds chaotic until you understand how it works.
- Coverage is mandatory and universal – no one is uninsured.
- Benefits are defined by federal law – insurers cannot cut care.
- Funding is risk-adjusted:
- Older patients receive more funding
- Patients with chronic illness receive more funding
- Insurers are rewarded for managing complexity well, not avoiding it
This creates something Canada largely lacks: financial responsibility for the full health trajectory of real people. Insurers compete on service quality, care coordination, and prevention – not on denying care.
In contrast to Canada’s system of competing institutional budgets, Germany’s Gesundheitfonds are actively measured by how well they keep their members well, at the lowest total cost, over time.
Canada pays for ambulance rides and ICU stays after an injury or illness. Germany invests to prevent the injury — and still responds quickly when one happens.
The Capacity Question Canada Avoids
Here is where the comparison becomes most uncomfortable. Germany does not design its healthcare system to run at 100% utilization. Hospital beds, diagnostics, and operating rooms are deliberately planned with buffer capacity. Typical utilization sits closer to 70–80%.
Canada, by contrast, often operates well above 95%. This difference in Germany is not waste. It is resilience.
We accept this logic everywhere else. Power grids are not designed to run at full load, because uncertainty is inherent. Healthcare is the only critical system expected to function perfectly while permanently overloaded.
This is not efficiency – it is massive fragility in our system.
The ALC Paradox: A Canadian Logic Failure
This flawed thinking shows up clearly in Canada’s treatment of ALC (Alternative Level of Care) patients. Consider this common scenario:
- A patient occupies a hospital bed at $800–$1,200 per day
- That patient could be safely cared for at home for $200 per day
- The objection? “If we free the bed, someone else will fill it – so now we’re paying for both.”
This argument is absurd – but revealing. Because it ignores the person “waiting in the wings.” Under the current logic:
- One person gets care (expensive)
- One person waits – untreated, unseen, deteriorating
Under the proposed logic:
- Two people get care
- At lower total cost than hospitalizing both
Germany’s system implicitly understands this. Canada’s does not. Germany plans for flow. Canada optimizes for occupancy.
What Germany Gets Right – and Canada Must Face
Germany’s success is not ideological. It is mechanical. It works because:
- Funding follows people across settings
- Capacity is treated as safety, not waste
- Prevention and early intervention are financially rewarded
- Care shifts easily between home, outpatient, and hospital
- Data continuity supports longitudinal care
Canada’s system, by contrast, unintentionally punishes:
- Keeping people well, because avoided hospitalizations generate no funding signal
- Moving care out of hospitals, because savings in one silo create costs in another
- Reducing institutional dependence, because hospitals are funded to be full, not to empty safely
This is not a failure of intent — it is a failure of design.
The Real Choice Ahead
Canada can continue insisting that more money will fix what is fundamentally a design problem. Or we can acknowledge a harder – and more hopeful – truth: Our healthcare system is not failing because it is incapable. It is failing because it is organized around the wrong incentives.
Germany shows that universal healthcare does not require rationing by time, permanent crisis conditions, or clinician burnout. It requires something more pragmatic: designing the system around people rather than institutions, and around prevention rather than rescue.
This is not theoretical. This shift is already starting, and we can choose to accelerate it.:
- Growing momentum for a universal health record to provide better use of data across time and settings – this is the keystone for almost everything else
- Care delivered safely at home
- Earlier detection and intervention
- Funding models that reward keeping people well
- Capacity planned for uncertainty, not perfection
If we start with an accurate diagnosis, we can finally have an honest conversation about treatment. That treatment will not be a single reform or a single technology. It will be a shift – toward predictive, preventative, and person-centred care, delivered as close to home as possible, and supported by data and modern system design.
Nothing about this is easy. But it is achievable.
And the alternative – continuing to fund a system that punishes the very behaviours we say we want – is not conservative, compassionate, or sustainable. It is simply institutional inertia.
About the Author
Robert Stanley is the Founder and CEO of Stay at Home Nursing and CHAH Technology, where he is focused on advancing Comprehensive Healthcare at Home — a model designed to shift care from reactive, institution-centric delivery toward predictive, preventative, and person-centred care delivered closer to home.
His work explores how modern data, workforce redesign, and home-based care models can address many of the structural inefficiencies described in this article. A more detailed discussion of these ideas is outlined in the white paper Comprehensive Healthcare at Home: An Industry Call to Action.
