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Issue The Canadian healthcare system is defined by universality, but unfortunately that does not extend to drugs outside of hospitals. Access to medication remains an area of inequity, fragmentation and system failure, with millions struggling with cost related non-adherence. This has created major implications for public health, limiting the health status of populations. Canada's inequitable system and the recent pursuit to fix it, provides an opportunity to examine ways of balancing public health goals and health systems reform in a country with established public and private care services. Background The government mandated the creation of a plan to improve access to medications. Stakeholder consultations ran from June -September 2018 and the Heart &amp; Stroke Foundation (H&amp;S) aimed to create policy recommendations that would improve population health outcomes and inequities. Research review and analysis determined the scope of the problem and viable solutions. Questions arose around whether a solution could improve equity and lower health care costs without dismantling the existing private system. Results Visionary principles led to the recommendation of a universal pharmacare program, designed to improve access to cost-effective medicines for all people in Canada regardless of geography, age, or ability to pay. A hybrid -program would include a robust common formulary for which the public payer is the first payer creating cost efficiencies. Top-up private insurance would result in less strain on the public system and maintain the presence of the existing private industry. Lessons Health charities have a unique role to play in creating innovative policy solutions that also serve patient interests. In order to advance public health, health charities need to maintain focus on equity and avoid policy development that is biased with conflict of interest. Key messages Canada is primed to implement a unique universal pharmacare program that addresses healthy inequities. Varied stakeholder interests can block public health goals.

When universal health care isn’t truly universal: Beyond filling gaps in access to medicines