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Richard Shimooka: We are witnessing the future of war on the battlefields of Ukraine

Commentary

Historically, certain wars have stimulated the development of future defence thinking. The 1905 Russo-Japanese War previewed many features of the Great War a decade later, including the lethality of machine guns and howitzers, as well as the ubiquity of trench warfare. The 1973 Yom Kippur War between Israel and its Arab Neighbours was particularly influential for present wars—the Arab combatants’ use of new anti-tank guided missiles challenged many existing doctrines. This is not to say that all groups absorb the lessons directly or effectively. Many of the great powers, including Russia (who fought in the 1905 war), failed to adopt the lessons laid bare in that conflict and suffered grievous casualties in the first years of World War I as a result. 

Approaching two years since the invasion, the war in Ukraine has the potential to have an outside impact on the future of war for a variety of reasons. Its timing comes as a number of new technologies have emerged, many of which have come from the civilian space. These include the proliferation of drones, low-cost satellites, and high bandwidth networking—all of which to date have had major effects on the outcome of the war.While earlier conflicts, such as the Armenian-Azerbaijan war of 2021, or the war against ISIS from 2014 onwards, featured these systems, they were not employed in such a comprehensive fashion as they are currently in Ukraine. This was partly the result of one or more of the combatants’ lack of resources, but the scale and length of the conflict are also important. Over the past two years, both sides have adapted their doctrine and capabilities to reflect a cycle of learning and adaptation which gives a clearer understanding of where these technologies are headed. 

Some of these trends are a validation of overriding trends in warfare, particularly around the collection and use of data afforded by networked systems. This is evident in the maturation of the “reconnaissance-strike” complexes in Russian and Ukrainian doctrine. Essentially, this is a streamlining of the process of identifying and attacking targets with precision fire, usually from some form of artillery. The United States and NATO have been pursuing a roughly similar—but much more advanced and all-encompassing—concept known as “multi-domain operations.” There are several common denominators between both doctrines, including the effort to expand detection over wider areas, as well as hastening the decision-making process which can improve the lethality of any weapon system attached to it. While it may not be able to employ traditional airpower, the use of long-range artillery (including the recently provided ATACMS missile system) shows the effectiveness of this approach to war. It also allows for a greater economy of force—a critical consideration for Ukraine due to its disadvantageous economic and strategic situation facing a state three times its size. 

A key feature of progress in this area is its organic nature. Since the start of direct hostilities in 2014, Ukraine has done well to build up some of these connective capabilities adapting civilian systems for military purposes, such as the Starlink satellite network and apps for mobile devices. A large portion are ground-up approaches, developed even by military units to suit their particular operational needs. This was part of the total war approach that the Ukrainian government has instituted, often leveraging their emerging tech industries to develop new capabilities to fight against the Russian Federation. Many allies have similar efforts, but too often focus remains on a very centralized, top-down approach, which has led to substandard outcomes. Some balance between the two poles is likely ideal. 

Another major consideration is the revolutionary impact of drones on air warfare. Traditional manned airpower, like F-16, Mig-29s, and even attack helicopters, remain as relevant as ever in Ukraine. While no side possesses true air superiority, some localized control has been established for short periods, resulting in potentially decisive consequences. However, the war has followed the trend of other recent wars with low-cost, attritable drones playing an important role. While this has been evident in the strike-reconnaissance doctrine discussed above, the so-called kamikaze loitering drones, such as the Russian Lancet and armed first-person view commercial drones, have played an important role as well.

One important aspect is what is known as the “mass” of these capabilities—not individually, but as a collective system or swarm of multiple individual units that can be lost without a major degradation of their lethality. At present, the link between traditional and emerging airpower domains is fairly disjointed over the battlefield in Ukraine, perhaps due to lingering service parochialism. But once combined they will only multiply each other’s lethality. 

There is, however, one question concerning this new frontier of airpower’s ultimate influence in the future. It hinges significantly on the efficacy of new anti-drone systems, like those being developed by the United States Army and NATO allies. These potentially may blunt or even remove the deadly threat these UAVs pose to modern ground forces. But as of now they are in their infancy and very few are present in Ukraine today. If they are unable to make a major impact, then the future of conflict will be radically different.

Over the past thirty years, Canada, the United States, and its allies have often been able to deploy troops abroad to many stabilization and peacekeeping missions, in part due to the relatively benign threat environment they were entering. There was confidence that deployed soldiers would not incur significant casualties, which would arouse domestic opposition to the missions themselves. If the lethality of these unmanned drone systems remains unchecked, then, considering their greater ubiquity, it may drastically constrain the ability of Western countries to intervene and assert their muscle abroad, even in low-risk environments. 

Finally, and perhaps most critically, is the need for an adaptive defence industrial base (another word for military supply chains) with the capacity to meet a wide need for war. The Russian Federation, for example, faced wide-ranging and intrusive sanctions from the start of the conflict that precluded them from obtaining a number of key resources for their war effort, ranging from raw materials to advanced technology components. They have been able to weather these challenges due to a combination of factors: a deliberate effort to develop an autarkic industrial base that started after 2014, a less technologically advanced military, and sanctions-avoiding policies such as smuggling and diversifying their foreign supplier base to more reliable allies.

While Western allies are unlikely to face the same restrictions in a potential future conflict on the scale that Russia has, in some ways they have greater challenges. These countries rely on much more sophisticated military capabilities that have levels of complexity far in excess of Russian systems. The sheer diversity in all of the raw materials inputs and various subcomponent providers, as well as the networks to make them all work, means that they are actually much easier to disrupt. Shades of this were evident during the initial months of the COVID-19 epidemic when the production of civilian goods was affected by shortages and supply chain disruptions.

Furthermore, underinvestment in the defence industrial base has left the capacity to ramp up production in most areas perilously slow, even two years after the conflict started. 

More effort must be spent on creating a much more resilient industrial base that has the capacity to ramp up production to meet the needs of modern war. This requires significant front-end investment by governments in capacity building as no private firm is willing to spend money in that fashion without any guarantee of a return. At the same time, building capacity must be targeted and appropriate to the actual needs of Canada and its allies—taking lessons from Ukraine without understanding their context would be a mistake. That war and its material demands are unique to it.For example, the first several months saw a massive need for man-portable anti-tank guided missiles like the Javelin and N-LAW, because that was the only system available at the time. Allied states, on the other hand, possess a wide diversity of different systems available to fight such a conflict. While more production capacity for anti-tank systems is necessary, it may not be as much as the conflict in Ukraine suggests. Discerning the actual needs and developing accordingly should be done through careful analysis and wargaming, much like the recent Center for Strategic International Studies analysis on U.S. missile needs in a potential war against China has done.

In the end, a clear trend that seems to bind all of these areas is the need for adaptability and critical thinking. Warfare is fast becoming more lethal and decisive. Modern armies must be able to respond to those changes as quickly as they occur—or better yet, lead those changes against their adversaries. That, for one, cannot occur in an organization that is continually starved for funding like the Canadian Armed Forces is today.

But it may also require a radical reorganization and re-think of how defence policy, strategy, operations, and doctrine are developed and implemented—not to mention personnel and industrial policy. As the conflict in Ukraine has laid bare, bringing in the brightest minds and giving them greater leeway to develop responses is key, as is harnessing the potential and building the capacity of domestic industrial bases. These are essential and urgent lessons we must learn. They have been hard won by the sacrifices of the Ukrainian people for our benefit. It would be a shame to waste them.

Livio Di Matteo: Health spending continues to be a paradox of simultaneous feast and famine

Commentary

In the post-pandemic world, health spending in Canada continues to be marked by the paradox of simultaneous feast and famine, according to the Canadian Institute for Health Information (CIHI) release of the National Health Expenditure Trends 2023.

Total health spending in Canada for 2023 is projected at $343.8 billion, up 2.8 percent from 2022. The lingering effects of the pandemic contributed to growth in hospital expenditures of 11 percent in 2022 and 4 percent in 2023. Meanwhile, physician spending grew almost 10 percent in 2022 and nearly 7 percent in 2023. As a share of GDP, health spending’s projected share of GDP in 2023 is approximately the same as the previous year, at about 12 percent which is still above the pre-pandemic figure of 11 percent.

However, despite what seems to be robust overall growth numbers, once one factors in population growth as well as inflation, it turns out that real per capita health spending in Canada is expected to be down for the second year in a row. Indeed, for 2023, the change in real total health spending per capita is -0.5 percent which comes after a nearly 2 percent decline the previous year. However, it remains that real per capita spending is still substantially higher than it was going into the pandemic.

Graphic credit: Janice Nelson.

Figure 1 provides some historical perspective on the long ascent of real per capita health spending in Canada providing a plot not only of total spending but also provincial government and private sector health spending. The pre-pandemic period saw a slowdown in the growth rate of real per capita spending, which was more pronounced at the provincial government level.

From 2010 to 2019, the average annual growth rate for total real per capita spending was 1.2 percent, but provincial government spending grew at 1.1 percent while private spending grew at 1.6 percent. By way of comparison, during the heyday of the federal transfer escalator, the 2000 to 2010 period saw average annual growth in real per capita total health spending of 3.2 percent—3.3 percent for provincial government and 3.1 percent for private.

The pandemic, fueled by emergency federal health transfers, saw real per capita public sector health spending surge, but also a decline in private sector. Figure 2 dramatically illustrates the 2020 surges in real per capita health spending for total and provincial government health, which each clocked in at about 8 percent respectively, but this was accompanied by a nearly 8 percent drop in private spending. The next year, provincial government spending grew at a slower but still robust rate at 4.7 percent, but real per capita private health spending rebounded at 8 percent and total health spending at 4.9 percent. For the subsequent two years however, decline sets in for real per capita total health spending at -3.9 and -0.5 percent driven mainly by declining provincial government spending at -2.2 and -0.5 percent given that private spending rose at 1.8 and 2.2 percent. However, this decline in per capita spending was partly driven by the wind-up of COVID-19 supports as well as other public health spending.

Graphic credit: Janice Nelson.

It should be noted that for 2023, real per capita provincial government health spending is projected at $5,723. If after 2019 spending had continued to increase at the same average rate from 2010 to 2019, then 2023 would clock in at approximately $5,450 which means that real per capita health spending in 2023 is still projected at several hundred dollars above what the previous trends might have placed it at. Indeed, compared to 2019, real per capita provincial government health spending in Canada is 10 percent higher. Overall, despite the recent declines due to both a winding up of pandemic-specific health spending as well as robust population growth, it would appear that there has been an enrichment of per-person health spending.

However, performance varies across health spending categories. In the case of provincial government health spending, for 2023 the largest components are hospitals (36 percent), physicians (20 percent), other institutional care including LTC homes (14 percent), and provincial drug plan spending (7 percent). If one looks at a comparison of real per capita provincial government spending between 2019 and 2023 for these key categories, hospital spending is up 6 percent, other institutions is up 25 percent, physicians is up 1.3 percent, but drugs is down nearly 2 percent. As for some of the other categories, real per capita provincial government public health over the same period is up 29 percent, other professionals at 10 percent, administration is up 9 percent, and home care/community care is up 14 percent.

So, what is one to make of all this in the current context of waiting lists and health care shortages that continue to plague health systems across Canada? Despite the post-pandemic decline in emergency health spending and the resulting slowdown in real per capita health spending growth for 2022 and 2023, it remains that real per capita health spending is up substantially. But two areas still lag the others: physician spending and drugs. Drug spending by provincial drug plans is linked to physician spending: if people cannot access physicians because of shortages in family doctors, then they are also going to find it more difficult to fill their prescriptions.

Of course, the Canadian health spending paradox of more spending and yet growing issues of access and timely service delivery is not a new one. It has, however, entered a more concerning phase given that physicians are the primary gatekeepers when it comes to health care access. If large proportions of provincial populations are not able to access physician services and get in line for care, how exactly are all these spending increases going to meet the health-care needs of Canadians?

For the time being, provincial health-care systems appear to be dealing with access issues by changing the access rules to some health services. Take the case of Ontario. Pharmacists in Ontario can now prescribe treatments for nineteen health services including diaper rashes, canker sores, and yeast infections. And most recently, Ontario has expanded the ability to self-refer for screening tests by lowering the age for women’s breast screening without a doctor’s referral to 40. One expects that eventually you may be able to self-refer for other routine screening tests in order to free up scarce physician time.

While such measures are a way of dealing with current physician shortages by reducing some of their gatekeeping requirements, it remains that they are short-term stop-gap measures. Eventually, once results from self-referred tests come back and short-term pharmacy treatments are exhausted, people will still need to see a doctor. Expect to see within a year or two complaints that despite a test result requiring follow-up, people cannot get in to see a physician. The next health-care accessibility crisis is already taking shape.