Despite progressive universal drug coverage and pharmaceutical policies found in other countries, Canada remains the only developed nation with a publicly funded healthcare system that does not include universal coverage for prescription drugs. In the absence of a national pharmacare plan, a province may choose to cover a specific sub-population for certain drugs. Although different provinces have individually attempted to extend coverage to certain subpopulations within their jurisdictions, out-of-pocket expenses on drugs and pharmaceutical products (OPEDP) accounts for a large proportion of out-of-pocket health expenses (OPHE) that are catastrophic in nature. Pharmaceutical drug coverage is a major source of public scrutiny among politicians and policy-makers in Canada. In this editorial, we focus on social inequalities in the burden of OPEDP in Canada. Prescription drugs are inconsistently covered under patchworks of public insurance coverage, and this inconsistency represents a major source of inequity of healthcare financing. Residents of certain provinces, rural households and Canadians from poorer households are more likely to be affected by this inequity and suffer disproportionately higher proportions of catastrophic out-of-pocket expenses on drugs and pharmaceutical products (COPEDP). Universal pharmacare would reduce COPEDP and promote a more equitable healthcare system in Canada.

Equity in healthcare is an important policy objective of the Canadian healthcare system. Out-of-pocket payments for healthcare (OPPH) by Canadian households account for a substantial share of total healthcare expenditures. Using data from Statistics Canada's Survey of Household Spending (SHS, n = 33,367), this study examined the progressivity and catastrophic effect of OPPH in Canada over the period 2010 to 2015 inclusive. The Kakwani Progressivity Index (KPI) was used to measure the progressivity of OPPH for each year of the study period. The catastrophic effect of OPPH was calculated using a threshold of 10% of total household consumption. The computed KPI indicated that OPPH are a regressive source of healthcare funding in Canada and the regressivity of OPPH has increased over the study period. This indicates that the distribution of OPPH in Canada is not equitable and the percentage contribution of households from their total consumption to healthcare as OPPH decreases as their consumption increase. The results also suggested that 7% of Canadian households face catastrophic outof-pocket payments for healthcare (COPPH) over the study period. The proportion of households with COPPH was higher in rural areas compared with urban areas over the study period. Policies to enhance financial risk protection among low-income and rural households are required to improve equity in healthcare financing in Canada.

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