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Figuring out precisely what people perceive as "just pay" is complicated, but there are social standards and patterns. People who feel paid appropriately experience a balance of investments and rewards. Investments such as education, skill, effort and seniority are on one end of the scale - that is, how much have you put in? Rewards are on the other. When the scale tips toward investments, you feel underpaid; when it tips toward rewards, you feel overpaid. We all have internal standards, but we also rely on social comparisons: "Why does so-and-so earn more than me? I have better credentials, work harder and have more seniority!" Getting less than you deserve It hurts to feel under-rewarded - to get less than what (you think) is just - on a cognitive, emotional and even physical level. Perceived underpayment and job dissatisfaction go hand in hand. A recent Accenture study of 3,600 entry- to managementlevel business professionals across 30 countries found that feeling underpaid is the top reason for worker dissatisfaction.

Likewise, in the CANWSH and GSS studies, roughly one-quarter of those who feel severely underpaid are "very dissatisfied" with their job, while about 6 per cent of those who feel appropriately paid are "very dissatisfied." Feeling underpaid doubles the probability that a worker will report experiencing "stress, depression and problems with emotions" on a majority of days in any given month. Physiological reactions are common, too. Perceived underpayment raises the risks of rating oneself as having poor health, headaches, and stomach, back and chest pain. All this affects sleep quality: Those who feel severely underpaid have more difficulty falling or staying asleep. Perceived underpayment also hurts because it amplifies other stresses, such as interpersonal conflict, work interfering with non-work life, and having too much work and not enough time. That's a lot of suffering - and it isn't equally distributed in the population. In collaboration with Atsushi Narisada and Sarah Reid, our research shows that the pain of feeling under-rewarded hurts more among those who earn less, mostly because of the link with greater financial insecurity.

Everyone has a stake in understanding the social causes and consequences of perceived underpayment. We need to talk about it and address it collectively as departments, organizations and institutions. The conditions that surround unjust earnings are ripe with chronic stress. Ultimately, that makes this a public health concern. If monkeys aren't cool with getting less than they deserve, why should we be? Health Advisor contributors share their knowledge in fields ranging from fitness to psychology, pediatrics to aging. Dr. Scott Schieman is a Canada Research Chair (Social Contexts of Health) and professor of sociology at the University of Toronto. His research focuses on the causes and health consequences of social stress. You can follow him on Twitter @ScottSchiemanUT.

Canada is in or close to the top 25% of OECD countries on many measures of quality of care.

Sarah Gregory is a researcher in health policy at The King’s Fund.

published in the journal Health Affairs

stark differences in payment between nations, and between private and public payors in those places that have two-tier systems

Provincial medicare agencies pay an average fee of $652 to surgeons in Canada for a hip replacement. Government programs like Medicaid in the States reimburse almost triple that, while U.S. private insurers offer an average of just under $4,000 per hip operation

Primary-care physicians include family doctors, pediatricians, internal-medicine specialists and obstetriciangynecologists. Those in the U.S. earned an average after expenses in 2008 of $186,582, versus $125,000 in Canada, $159,000 in Britain and just $92,000 in Australia

allow people to buy health insurance from a choice of up to 180 private insurers

Though there is a shortage of empirical evidence in any of the countries on what works, evidence suggests that such a system encourages patients and doctors to better manage their health, curbing the likelihood people will end up in an emergency ward or pricey acute-care hospital bed, the report said.

Antibiotics are likely being overused in some nursing homes in Ontario - and that misuse is putting all residents of these facilities at risk, a study suggests. With most drugs, inappropriate use only threatens the health of the person who takes the medication. But with misuse of antibiotics, the problems that arise - drug-resistant bacteria, C. difficile infections - are not restricted to the people who have been taking the drugs. "[Nursing] homes with higher use put patients at hig

These people often live in close quarters and are cared for by staff who move from resident to resident. It's a situation that makes for efficient spread of bacteria and other pathogens that cause infections. For this study, Daneman and his co-authors looked at antibiotic use in 110,656 residents of 607 nursing homes in Ontario in 2010 and 2011. The nursing homes studied were divided into low, medium and high antibiotic-use categories. The differences were stark: antibiotic prescribing in high-use facilities was 10 times that of low-use homes. If high-use homes had residents who were significantly sicker and more frail, that might explain their heavy reliance on antibiotics. But the authors also did a comparison of the residents of the various facilities and found there were not major health differences among them. That suggests the increased use of antibiotics in the high-use homes likely is a result of the doctors who are prescribing at those facilities, said infectious diseases expert Dr. Andrew Simor, who was not involved in this study. Simor is head of microbiology at Sunnybrook.

He suggested this information could help change prescribing behaviours; facilities where antibiotic use is higher than the norm could be targeted with programs aimed at minimizing misuse of these critical drugs. The article, which Simor praised, also drew a line between high antibiotic use and higher rates of negative consequences of antibiotic use. Those side-effects included allergic reactions to antibiotics, developing antibiotic-related diarrhea, contracting C. difficile infection, or becoming infected with a drug-resistant bacteria. Daneman said the adverse events were generally serious enough to send these people to hospital. "If you live in a high antibiotic-use home versus a low antibiotic-use home, you had 25 per cent increased risk of one of these serious antibiotic-related adverse events," he said. Because of the way the study was designed, the authors could not tell if the antibiotics used were needed in each setting. So they cannot say that the low-use homes had hit the sweet spot for antibiotic use - not too much, but enough.

Still, Simor observed that when hospitals started to develop programs to cut back on unneeded use of antibiotics - it's called antibiotic stewardship - concerns were raised that some people who needed the drugs might not get them. That hasn't proven to be the case, he said. "So if you feel comfortable translating those findings into a nursing home setting, I think you'll find the same situation is true - that stewardship will not place patients at increased risk for not getting an antibiotic when they need it."

Has a doctor   85.1% Heavy drinkers          17.9% High blood pressure 17.7% Overweight or obese adults 54.0% Overweight or obese youth (12-17)          23.1% Physically active (leisure time)       53.7%

In 2014, roughly 3.4 million Canadians aged 12 and older (11.2 per cent) reported that they did not receive health care when they felt they needed it. Overall, females (12.4 per cent) were more likely than males (10 per cent) to have reported an unmet health-care need. Among age groups, unmet health-care needs were lowest for those aged 12 to 19 and those aged 65 or older, and were highest for those aged 20 to 54. Source: Health Canada

Top 10 Causes of Death in Canada (2012) Ischaemic heart disease       13.8% Alzheimer’s and other dementias   9.5% Trachea, bronchus, lung cancers     8.1% Stroke             5.4% Chronic obstructive pulmonary disease     4.5% Colon and rectum cancers   3.7% Diabetes mellitus      2.7% Lower respiratory infections           2.3%

Breast cancer             2.2% Falls    1.9% Source: World Health Organization International Comparison of Health Spending  Canada           OECD Average           Canada’s OECD Ranking Total Health expenditure as a percentage of GDP            10.2    8.9       10/34 Total Health expenditure per capita           $4,351            $3,453            10/34

Public expenditure on health per capita   $3,074            $2,535            13/34 Public share of total health expenditure   70.60%          72.70%          22/34 Hospital expenditure per capita     $1,338            $1,316            15/29 Physician expenditure per capita   $720   $421   27-Apr Drug Expenditure per capita          $761   $517   2/31 Source: OECD Health Statistics 2015           

But many medical tourists are returning home with potentially catastrophic complications, including anastomotic leakages, where intestinal contents leak through surgical staples into the abdominal cavity, increasing the risk of life-threatening sepsis. "It's almost like your stomach ruptures," says Dr. Shahzeer Karmali, an associate professor of surgery at the University of Alberta and one of the authors of the newly published paper.

Millions of taxpayer dollars are being spent in Canada repairing botched stomach-shrinking surgeries performed outside the country, suggests new research into the growing phenomenon of "bariatric medical tourists." Researchers who surveyed Alberta surgeons estimate that province alone is spending a minimum $560,000 annually treating complications in people who have travelled to Mexico and other destinations for cut-rate bariatric surgery. Doctors say abysmally long wait lists in Canada for virtually the only obesity treatment proven to provide long-term weight loss is driving people out of the country for surgery. Yet most don't receive co-ordinated, long-term post-surgery care.

many patients turn to medical tourism despite potentially severe complications," the Alberta researchers write in the Canadian Journal of Surgery. Earlier work by the same group estimated a complication rate of 42 to 56 per cent for out-of-country weight loss surgery. In Canada, unplanned readmission to hospital within 30 days of bariatric surgery was 6.3 per cent in 2012-2013, according to the Canadian Institute for Health Information. Karmali says Canadians living with obesity are being shortchanged because of lingering stigma and bias. "The stigma is that these people just eat too much and don't exercise enough and they can fix themselves," he said.

"The reality is, it's a significant problem and when people become severely obese it is very hard to 'fix.'" Surgery not only improves weight and overall life expectancy, it helps reduce the drain on the health-care system and economy. A Senate committee report released this month pegged the cost of obesity at upwards of $7.1 billion a year in health care and lost productivity. The committee made 21 recommendations to combat obesity, from overhauling Canada's food guide to banning food advertising to children. But it was silent on reducing wait times for bariatric surgery. Karmali and colleagues surveyed Alberta general surgeons to estimate the cost of revision surgery, ICU stays and other interventions to treat complications in "BMTs" - bariatric medical tourists.

In all, 25 doctors responded to the survey. Together they treated 59 out-of-country surgery patients in 2012-13. Complications included slipped bands, leaking, abscesses and blood clots. The estimated average cost per medical tourist was just under $10,000 - an "extremely conservative estimate" that doesn't include total hospital stay, blood work, nursing care and other costs. By comparison, the average cost of bariatric surgery performed in Alberta public hospitals was just under $14,000. "Alberta does not seem to save much money by limiting the annual volume of bariatric surgeries," the authors write. Studies suggest bariatric surgery accounts for a growing proportion of Canadian medical tourism, with Mexico one of the most popular destinations. According to Statistics Canada, one in four adults in Canada - more than six million people - are obese. skirkey@postmedia.com

Canadians appeared to experience higher rates of some hospital errors or adverse events, including trauma during delivery of babies

Canada has higher rates of foreign bodies being left in incisions after surgeries but that may be because Canada does a better job collecting adverse events data than some other countries

wait times to receive care were highest in Canada in an 11-country survey cited in the OECD report

While survival rates for breast cancer and colorectal cancer are among the highest in the OECD, the country has a relatively high rate of cancer compared to other countries, the CIHI report says.

As well, the country's self-reported obesity rate is the second-highest in the G7 countries.

lower smoking rates in Canada today may mean fewer lung cancer cases in the future — but some of this progress could be offset by higher obesity rates

The OECD report says Canada spent 11.4 per cent of its gross domestic product on health in 2009, more than the OECD average of 9.6 per cent. The United States spent the most, at 17.4 per cent of GDP, with the Netherlands, France and Germany spending slightly more than Canada.

Health spending per person in Canada was also higher than the OECD average. Canada spent $4,363 (U.S.) per person on health care in 2009; the OECD average was $3,233 (U.S.).

53 per cent of those who took prescription medication for a chronic condition – and therefore would have recently used the services of a health-care professional such as a physician or pharmacist – feel the system is either in or heading to a state of crisis.

those users of the health-care system are less likely than others to believe that our system does a good job of caring for the health of the more vulnerable in society (55 per cent compared to 65 per cent of other Canadians) and less confident services will always be there when they need them (62 per cent compared to 69 per cent of other Canadians.)

Overall, Canadians still prefer their government-funded system, with 77 per cent of them saying so.

Of the G8 nations that took part in the survey, Canada was the only country where a majority (52 per cent) held a positive view of their health system.

for those Canadians who use the health system more frequently and have chronic medical conditions, solutions are more likely to rest with better management (63 per cent) rather than increased spending (31 per cent).