I will first review some of the Israel’s natural advantages that have allowed it to so outperform Canada in terms of the roll out of COVID-19 vaccination. These factors are mentioned by Rosen and colleagues but I will try to put them in rough order of importance in terms of Canada. The first and most obvious is the fact that Canada’s population is dispersed over a vast geography that poses acute challenges in distribution. Although this factor is attenuated by an urban population concentrated near the US border, there remains a large number of Canadians living in rural and remote areas that are distant from these urban centres. When this factor is combined with the highly decentralized nature of the Canadian federation, this results in time lags in distribution.
While the Government of Canada has taken on the responsibility of procuring vaccines, it is the provincial and territorial (PT) governments which actually administer vaccinations to the residents in their respective jurisdictions based on independently determined criteria for priority. This means that the federal government has a central point in each of the 13 provinces and territories which it delivers the vaccines. The PT governments must then distribute the vaccine to countless points within their own geographies thereby creating a chronic gap between the doses delivered by the federal government and the doses actually administered to Canadians by PT governments: as of 25 January 2021, this meant that slightly less than 75% of the doses delivered to the PTs had actually been injected into the arms of Canadians [6]. Due to the storage and logistical challenges of administering the Pfizer-BioNTech vaccine because of the extremely low storage temperature, the federal government has only distributed the Moderna vaccine to the three territorial governments responsible for residents in Canada's far north.
Canada has far less experience than Israel with emergency preparedness and response. As a consequence, the muscle memory exhibited by professionals, government public servants and the general public in Israel when engaging in emergency efforts is almost non-existent in Canada on any regional or national basis. Again, due to Canada’s decentralized federation, most of the emergency planning has been done at the PT level of government. While many PT governments have done creditable jobs, they have limited incentive to collaborate on pan-Canadian emergency planning, and no formalized intergovernmental agency responsible for national emergency planning. In fact, there are significant legislative and procedural limitations on the federal government’s use of its Emergencies Act and, thus far, the federal government has not declared a state of national state of emergency in the face of the pandemic [7].
There are also important health system differences. Unlike Israel, Canada has a fragmented and under-developed electronic medical record (EMR) system. This prevents national (and even individual PT) tracking to allow for effective identification and contact of priority individuals for vaccination with follow-up tracking afterwards. However, this challenge goes well beyond EMR infrastructure. Public health surveillance data are collected and used by the 13 PT governments using differing protocols and standards. These data are then stored in 13 individual PT databases defying efforts to track vaccination progress on a more national basis and to conduct more probative statistical analyses based on consistently defined data [8].
Another health system difference is Israel’s use of its well-developed primary care system to deliver vaccines. Except in Canada’s far north where publicly-managed primary health centres are the norm, the administration of vaccines has overly relied on hospitals because the majority of primary care physicians are independent contractors paid on a fee-for-service basis raising issues of coordination and cost. Canada has ended up relying on a more hospital-centric administration of vaccines for the general population due to the fragmented nature of primary care. To vaccinate residents living in long-term care (LTC) homes, Israel had relied on a single organization – Magen David Adom (MDA) – the country’s national medical emergency services organization [1]. Nothing similar exists in Canada. Instead, each PT has assembled its own approach and its own task teams to go into LTC facilities and administer vaccinations in the process sacrificing some speed in the process.