THE STANDING SENATE COMMITTEE ON NATIONAL FINANCE
EVIDENCE
OTTAWA, Wednesday, October 25, 2023
The Standing Senate Committee on National Finance met with video conference this day at 6:45 p.m. [ET] to study the Main Estimates for the fiscal year ending March 31, 2024.
Senator Éric Forest (Deputy Chair) in the chair.
[Translation]
The Deputy Chair: Good evening, honourable senators.
[English]
I wish to welcome all honourable senators as well as viewers across the country who are watching us on sencanada.ca.
[Translation]
My name is Éric Forest, senator for the Gulf senatorial division, Quebec, and deputy chair of the Standing Senate Committee on National Finance. Now, I would like to ask my colleagues to introduce themselves, starting on my left please.
Senator Gignac: Welcome to the witnesses. I am Clément Gignac, from Quebec.
Senator Galvez: Rosa Galvez, from Quebec.
Senator Loffreda: Good evening. Tony Loffreda, from Quebec.
[English]
Senator Pate: Kim Pate, and I live here on the unceded, unsurrendered territory of the Algonquin Anishinaabe.
Senator Smith: Larry Smith, Montreal.
Senator Marshall: Elizabeth Marshall, Newfoundland and Labrador.
[Translation]
Senator Dagenais: Jean-Guy Dagenais, from Quebec.
The Deputy Chair: Honourable senators, dear witnesses and all those listening, it is with deep regret that I inform you that the Honourable Senator Ian Shugart passed away earlier today. We will have the opportunity to pay tribute to him at a later date, but I would now like to offer my most sincere condolences on behalf of all senators — Senator Shugart sat on the Finance Committee with us — to his wife, Linda, son, James, daughters Robin and Heather, and to his entire family.
Honourable senators, I would ask you to rise and join me in a moment of silence.
(A minute of silence is observed.)
[English]
Honourable senators, today we will continue our study on the Main Estimates for the fiscal year ending March 31, 2024, which was referred to this committee on March 7, 2023, by the Senate of Canada.
[Translation]
Today, we have the pleasure of welcoming senior officials of Health Canada, namely, Serena Francis, Chief Financial Officer; Jocelyne Voisin, Assistant Deputy Minister, Strategic Policy Branch; Jennifer Saxe, Associate Assistant Deputy Minister, Cannabis and Controlled Substances Branch; Brigitte Lucke, Director General, Policy, Planning and Integration Directorate, Healthy Environments and Consumer Safety Branch; Ed Morgan, Director General, Policy, Planning and International Affairs Directorate; Daniel MacDonald, Director General, Drugs for Rare Diseases, Strategic Policy Branch; and Lindy Van Amburg, Director General, Policy and Programs, Oral Health Branch.
Welcome and thank you for accepting our invitation to appear in front of the Standing Senate Committee on National Finance.
I understand that Serena Francis, Chief Financial Officer, will make a short statement. Ms. Francis, the floor is yours.
[English]
Serena Francis, Chief Financial Officer, Health Canada: Good evening, Mr. Chair and all members of the Standing Senate Committee on National Finance. As mentioned, my name is Serena Francis, and I am the Chief Financial Officer at Health Canada.
I have with me today several colleagues. They were jumping to come and talk to you all today, so if you have any detailed program questions, we should be able to provide responses to most of those.
Thank you for inviting us today to discuss Health Canada’s 2023-24 Main Estimates. I welcome this opportunity to highlight some of the department’s priorities and to share with you the work the department is doing to support the health of Canadians.
In these Main Estimates, there is $4.1 billion in proposed spending, which consists of $1 billion in operating funding, $28 million in capital funding, $2.9 billion in grants and contributions and $181.2 million in statutory funding. Overall, this represents an increase of about $222 million over the Main Estimates from the 2022-23 fiscal year.
[Translation]
In addition to the information in the 2023-24 Main Estimates, significant investments have been announced in the 2023 budget. It is important to note that these investments are not reflected in the figures we’re discussing today, but will be determined in future supplementary and main estimates.
[English]
I will begin by providing a summary of the $4.1 billion in proposed spending followed by an overview of those budget items from 2023 that I mentioned.
Through these estimates, Health Canada will continue to provide national leadership to support the health care system. The department will remain focused on helping Canadians lead healthier lives by working to protect them from unsafe health, consumer and commercial products and substances and by continuing to take action to modernize regulations for food and health products.
Some significant areas of investment are as follows: In Budget 2017, the Government of Canada committed $11 billion over 10 years to support improved access to home and community care as well as mental health and addiction services for Canadians. In this fiscal year, Health Canada will spend approximately $1.2 billion by working with its provincial and territorial partners to fulfill this commitment. These funds will support a broad range of programs and services that will improve access to home and community care and mental health services for Canadians — from palliative care in rural communities, to integrated youth mental health services, to programs that will allow seniors to stay in their homes longer.
Budget 2021 announced funding of $3 billion over six years — from 2021-22 to 2026-27 — to support provinces and territories in ensuring standards for long-term care are applied and permanent changes are made. For this, Health Canada plans to provide $600 million to provinces and territories in 2023-24.
[Translation]
In March 2023, the department launched the first-ever National Strategy for Drugs for Rare Diseases. With an investment of up to $1.5 billion over three years, the strategy will help patients with rare diseases gain early access to treatments that improve their quality of life.
[English]
These Main Estimates also include $112 million for the implementation of the interim Canada Dental Benefit. This benefit is the first step towards fulfilling the government’s Budget 2022 commitment on dental care.
In parallel, the department is taking important steps to develop and launch the Canadian Dental Care Plan, which will help remove barriers to accessing needed dental care and support Canadians in improving their oral health.
[Translation]
Budget 2021 provided Health Canada with $198 million over three years in new funding starting in 2021-22, to continue Canada’s Chemical Management Plan for assessing and managing the risks chemicals pose to human health and the environment, and to support domestic and international engagement with stakeholders and partners. For 2023-24, this amounts to $85 million.
[English]
The opioid overdose crisis is a top priority of the government. Budget 2022 provided an additional $99.7 million over three years to support the Substance Use and Addictions Program by providing funding to support a range of innovative approaches to harm reduction, treatment and prevention at the community level to reduce substance use-related harms and increase evidence for action. In total, for 2023-24, Health Canada plans to provide almost $137 million through this program to address critical gaps and support initiatives that address existing system barriers.
In addition, Health Canada is continuing to work with other federal partners to implement and administer the federal Framework for the Legalization and Regulation of Cannabis in Canada and follow through on the objectives set out in the Cannabis Act to protect public health and public safety. The estimated cost to Health Canada is $131 million in 2023-24.
[Translation]
Budget 2023 was tabled in Parliament on March 21, 2023, and announced additional investments in key priority areas for Health Canada. As mentioned, these are not included in the Main Estimates, but have been or will be identified in future supplementary and main estimates.
[English]
This includes $195.8 billion over 10 years for health system priorities, with the following relating to Health Canada — $25 billion over 10 years to support bilateral agreements for patient‑centred integrated care addressing family health services, health workers and backlogs, mental health and substance use and a modernized health system; $1.7 billion over 5 years to support personal support workers; $505 million over 5 years to the Canadian Institute for Health Information, Canada Health Infoway and other federal data partners to build a world-class data system, including the creation of a Centre of Excellence on Health Workforce Data and Planning; and $350 million over 10 years to the Territorial Health Investment Fund.
[Translation]
In addition, Budget 2023 announced $13 billion over five years, starting in 2023-24, and $4.4 billion thereafter to Health Canada to implement the Canada Dental Care Plan, and $359.2 million over five years, starting in 2023-24, $5.7 million thereafter to support a renewed Canadian Drugs and Substances Strategy.
[English]
In conclusion, this proposed spending will ensure the government can continue to focus on important health priorities that are designed to result in better health outcomes for all Canadians.
Thank you, once again, for inviting us before the committee today. We are pleased to answer any questions that you may have.
The Deputy Chair: Thank you very much for your statement.
[Translation]
We’ll now move on to the question period. I’d like to point out to honourable senators that you have up to seven minutes for the first round of questions and three minutes for the second round. I would request that you ask your questions directly and that the witnesses keep their answers succinct. The clerk will let me know when the time is up.
[English]
Senator Marshall: Thank you to all our witnesses for being here.
My question is very general in nature, because I notice all the money there, including the $4 billion to the Department of Health, and I know that there is $47 billion in the Department of Finance. The intent under the Public Health Act is that we have a universal health care system, and I think you referenced it in your opening remarks, but we no longer have a universal health care system. Because every time I read the news — just about every day — there is something there about private health care in Canada.
I know in Quebec I recently read an article about all the doctors opting out of the public system; they’re going to the private system. I know that there are people mortgaging their houses, so they can go to the United States or another province for private surgery.
I saw an article about Marda Loop Medical Clinic in Calgary and that they were going to provide comprehensive health care to their clients for $4,800 a year for their families. There are private health clinics now all over the country. In Newfoundland and Labrador, where I’m from, there are about 150,000 Newfoundlanders without a primary health care provider.
Where is the Department of Health going with regard to a universal health care system, because it’s not really universal anymore. People keep referring to our universal health care system, which I now say no longer exists. It’s great for the people who can afford private health care, but there are a lot of people that can’t afford private health care, and they have no health care provider.
I see all this new money going into the health care system, and I feel we are too far down the road to go back to a universal health care system.
I’d really like it if somebody could just respond to that, because it is a big issue. Generally speaking, where are we going with our system?
Jocelyne Voisin, Assistant Deputy Minister, Strategic Policy Branch, Health Canada: Thank you very much for the question.
I would say, first of all, that the government is steadfast in protecting and strengthening a public health care system through the Canada Health Act. Indeed, with the funding that was announced as part of Budget 2023 and the agreements that we are negotiating with the provinces and territories, there is a commitment from all of them to respect the principles of the Canada Health Act and ensure that people have access to health care without having to pay for medically necessary services.
Senator Marshall: It’s not happening.
Ms. Voisin: We are concerned about the reports that we’re seeing, like you, about private clinics that are popping up across the country. The former Minister of Health actually sent a letter and issued a statement that confirmed that there was a concern about the issues, especially related to private clinics that offer virtual care services for a fee or for nurse practitioners that are charging fees for patient services that are medically necessary.
We are actively discussing that issue with the provinces and territories and plan to see how we can address that. We want to make sure that the health system evolves with Canadians, that they can get care, however that is delivered or by whom, if that’s really the same care in that same basket of services.
Senator Marshall: The problem is if you now cut off all those private health care facilities or services. The reason people go to the private health care facilities is because they have no other choice. People try to scrape together the money to go to the private services. They can’t access services. You can’t go to a hospital and be assured that you’re going to access the services within 24 hours. If you’re in a waiting room and you’re having a heart attack and you tell them, they say, “Go wait your turn.” It is very concerning.
For the additional money that’s provided to the provinces and territories, what kind of accountability mechanism is built into that money? Some of the provincial medical associations are saying that even with the additional money, it’s not going to do the trick. It’s not going to repair our universal health care system.
We call them performance indicators, but how will the Department of Health and Health Canada monitor, just for compliance, the spending as outlined in the agreement?
Ms. Voisin: Thank you for that question. First, let me address the comment you made about access to care.
We would agree that access to care is a significant concern for Canadians and is actually one of the priorities that we’re trying to address with this funding to the provinces and territories. That’s essentially getting at if people have better access to care through their public health system, then there won’t be as much pressure on them to use these other services and to spend, as you say, out of pocket for those services.
In terms of the accountability for the spending, we’re doing that in several ways. First, there are common indicators. When the funding as announced, we also announced eight common indicators that the Canadian Institute for Health Information is working on with experts and the provinces and territories so that there is a reporting to Canadians on those common indicators. One of them, for instance, is the percentage of Canadians that can access a family health provider in their community.
We want to see these indicators move as we provide the funding to provinces and territories.
Senator Marshall: Just as an example, would there be a certain percentage? Right now, say 15% of Canadians don’t have access to a primary care provider. Do you want to see that reduced to 10% in two years’ time, numbers like that?
Ms. Voisin: Yes. In addition to those common indicators, which are reported on at the national level, we are negotiating action plans with each of the provinces and territories to access their share of the money. They need to provide us with a detailed action plan that says how they’re using federal funds incremental to their own investments. In that action plan, we’re asking them to set targets for the common indicators, what they are going to do in their province about that percentage and if they have specific initiatives that are tied to that, some specific targets tied to those initiatives.
The first action plans are three years. Those will be made public, and then we will be able to see if they’re actually reaching those targets. Of course, we have annual reporting in terms of how they’re using the funding as well.
[Translation]
Senator Gignac: Once again, welcome to the witnesses.
I have two topics: dental benefits and pharmacare. Let’s start with dental benefits. We had the Parliamentary Budget Officer here, and according to his latest estimate, when we move from a dental benefit to a dental insurance plan, we’re talking about $10 billion over five years.
Is this within the order of magnitude that you think is reasonable? Are your calculations the same as the Parliamentary Budget Officer?
[English]
Lindy Van Amburg, Director General, Policy and Programs, Oral Health Branch, Health Canada: Thank you for the question. I am Lindy Van Amburg, Director General responsible for Policy and Programs for the new Oral Health Branch, so my job all day, every day, is implementing the dental care commitment. I’m happy to answer that question.
You’re citing a $10 billion over five years number. The amount that’s included in Budget 2023 is $13 billion over five years, actually, and $4.4 billion ongoing. That’s an estimate that we have worked on with the Department of Finance and are comfortable with at this stage. We think that will be sufficient for the plan as it’s launched, which we think might serve up to 9 million Canadians.
[Translation]
Senator Gignac: We’re talking about dental benefits now, before the dental insurance plan. Basically, parents don’t need to have a dental appointment to qualify for this dental benefit, if I understand correctly.
[English]
Ms. Van Amburg: Sorry for my misunderstanding there. You’re talking about the interim Canada Dental Benefit for children that is currently in place.
The estimate there — I have the number right in front of me — is significantly less than the amount that you’re talking about from the Parliamentary Budget Officer. I have the number of the payments we’ve made under that so far.
There are two benefit years. The first one has completed as of July in the second benefit year. To date, we’ve paid out about $315 million in benefits and that will run until the end of June. We’re about on track for what we were hoping to see for uptake, but it’s significantly less than the number that you used.
[Translation]
Senator Gignac: The next topic will be pharmacare.
We know that the New Democratic Party, the NDP, is lobbying hard for a public pharmacare program. However, as a government representative, I certainly don’t want to take you into the political arena. That’s not my objective.
However, we know that the NDP wants a 100% public program. What options are you considering, and what can you tell us now about pharmacare? What are you considering?
Would it be a system similar to the one in Quebec, because in Quebec, we still have a hybrid system with a role for the private sector and a role for the public sector? Are those options being considered by Health Canada, and what can you tell us at this point?
[English]
Daniel MacDonald, Director General, Drugs for Rare Diseases, Strategic Policy Branch, Health Canada: Thank you for the question. The government remains fully committed to introducing a Canada Pharmacare bill and then tasking the Canadian Drug Agency to develop a national formulary of essential medicines and a bulk purchasing plan.
In terms of options, the minister has been speaking publicly about where we are at with respect to that commitment. He has spoken to a framework. He’s making reference to a lot of the considerations that we’re going to have to take into account as we move forward from that framework legislation. To list a few, there is, obviously, the Canadian current context; the health commitments and Pharmacare commitments that we’ve made; the current fiscal environment, which has been clear, and the PBO came forward with a report very recently which was adding to that information base that we’re dealing with; and the perspective of stakeholders.
To get to your question, there is, obviously, a great deal of complexity in the environment here. A lot of Canadians are benefiting from private drug coverage and the complexity of the public drug plans.
You referenced the system in Quebec, and we’re well aware of that. The systems in other provinces are different and complex in their own ways as well.
I think the minister is saying all of this has to be taken into account before we develop those options, and there are a lot of interests that have to be balanced before we get there.
Senator Gignac: You think the next amount will be enough to find a solution; this is what I understood too. Just kidding.
Back to Ms. Francis, and pardon me if I’m wrong but, according to the figure, the budget expenditure in 2021-22, it’s a pass for Health Canada.
[Translation]
For Health Canada, it was $6 billion. For 2022-23, the estimates are now $6.3 billion. These are the main estimates: $4.1 billion and last year it was $3.8 billion. We understand that it will be even more than that.
Compared to the years before the pandemic and COVID-19, Health Canada’s budgets were much lower. Will we go back to pre-pandemic budgets? What part is historical, and what part is recurring and will stay there?
[English]
It’s 10,000 feet. It is a difficult spot.
Ms. Francis: It is a 10,000-foot question, yes.
Senator Gignac: There are some things, non-recurrent, that you have here. Could you provide some hope that we will be back closer to the pre-pandemic level?
Ms. Francis: You’re already seeing it’s starting to go back a bit. However, there’s been a lot of announcements of investments in the health care piece, things such as we were talking about the $2.5 billion this year that already came in Supplementary Estimates (A). So like your 4.1, you are right; add 2.5 to that because Supplementary Estimates (A) has already brought that in. That’s good for 10 years.
The big-dollar programs are predominantly now in the grants and contribution space and moves to transfers to provinces and territories through negotiated bilateral agreements. In terms of the rest of the department, there’s a decline coming with respect to the COVID spending. Obviously, that’s now going away. You’ll see less in that space. Then the rest of the programs are stabilizing.
I would add that in Budget 2023, there was a reduction exercise announced. All departments are now grappling with how to implement those cuts within their organizations, or those reductions, over the next three years, so that work is under way right now as well, with a focus on trying to streamline and ensure that the dollars are going to the highest priority items as well. That’s under way.
There is stabilization to the core, regulatory programming pieces. Things like the transfers to the provinces and territories, obviously there’s 10 years there. Then we’ll see what happens from there.
Senator Smith: One of your department’s top priorities as part of its mandate is to ensure Canadians have access to appropriate and effective health care services, a focus on retention and recruitment as well as integrating internationally trained health care professionals. How exactly is the department undertaking this initiative? Could you provide the committee with data on how many internationally trained health care professionals have been integrated into the Canadian system?
Ms. Voisin: Thank you for the question. Given that hiring health professionals is really the domain of the provinces and territories, we are working closely with them to advance this priority.
In fact, we just had a health ministers meeting in P.E.I. in October where all the health ministers — federal, provincial and territorial — agreed to a statement on how we’re going to advance these priorities together, especially on the health workforce. One is in terms of retention. The federal government is supporting a nursing retention tool kit that has been developed with nurses across the country by our chief nursing officer.
In terms of recruitment of internationally educated health professionals, Immigration has taken some measures to support the immigration of international health professionals. The real issue is about those professionals, as you noted, getting credentials to work in Canada.
Senator Smith: That is the issue, is people coming over here who are doctors and nurses in other countries but can’t have those jobs because they’re not getting proper accreditation or recognition of their credentials.
Ms. Voisin: Yes.
Senator Smith: That’s getting to the bottom line. I am trying to understand what are you going to be able to do other than say it’s a provincial responsibility?
Ms. Voisin: We’re working with the provinces and the national regulatory organizations that actually work with those health workers. It’s a very challenging and complex issue.
For doctors, for instance, we are working with the Royal College, the Medical Council of Canada, the College of Family Physicians of Canada, for instance, in how they can streamline their processes to ensure that they’re much quicker to allow doctors to work in Canada and to recognize doctors from other countries, so they can be streamlined to work in Canada more quickly so that they can do practise-ready assessments and work under another doctor. There are several measures being taken.
In the nursing area, it is much more complex. There are about 23 different nursing regulators across Canada in different provinces and territories; we need to work with them to look at how we can streamline that. There are many initiatives under way. The provinces and territories are taking initiative as well, but we want to see some consistency.
Senator Smith: Do you have any stats showing any results in terms of doctors and nurses?
What we hear all the time is that people come over and, if you’re a doctor, then you can become an orderly. You work as an orderly. Then you have to go back to school and get your Canadian accreditation, because I guess we know more in Canada about how to be good doctors than some people in other countries.
I’m trying to understand. The system itself is flawed. If you throw money at it, it is like throwing money against a wall; how much of it sticks?
What has been achieved through the immigration system to this point? How many doctors have you been able to add through immigration, or how many people have qualified to be doctors and nurses in the last year so we can see some statistics? What’s really happening?
Ms. Voisin: I’m afraid I don’t have statistics from Immigration. They wouldn’t have statistics about credentialing because, as we know, the issue is really about that credentialing.
We did recently work on a report with Statistics Canada about internationally educated health professionals who are in Canada, and how many are working in their field. We can send you the link to that statement.
Senator Smith: That would be great if you could send us a link or a one-page summary, key bullet points. Everything else is conjectured until you see the results. You talked about $10 billion here, $4 billion here or $5 billion here. As a businessman, when I heard those types of numbers, I used to go crazy and say what are your results?
It’s great to talk about throwing money out the door, but you have to have results that are tied to a specific plan. You’ve got some plans. We would love to hear more. If there was a one‑pager you could give us with your top three priorities or plans that would be helpful.
Ms. Voisin: Certainly. We’ll follow up with the statement issued at the health ministers meeting with concrete actions that they are taking, including a 90-day service standard from regulatory bodies for physicians, and that report I mentioned on internationally educated health professionals.
Senator Smith: What are some of the barriers to integration for international doctors, nurses and support staff to get into our hospitals and clinics? What are your biggest top two or three barriers?
Ms. Voisin: I would say the top barrier is getting that practical experience in the Canadian context, which is required by many of the colleges for physicians.
In some cases, language is a significant barrier. To operate in the health care system, especially in cases like Quebec, they want French-speaking physicians or doctors.
Essentially, making sure that their equivalency is the same in the education that they are coming from, from another country, and that it meets the standards in Canada.
I would say our biggest barrier is those standards are different in all the colleges across the country in terms of nursing.
Senator Smith: And in other countries.
Ms. Voisin: We need more consistency.
Senator Smith: Right. I’m not sure you really answered the question, but that is okay.
[Translation]
The Deputy Chair: I would like to welcome Senator Woo, who is joining us.
[English]
Senator Pate: Thank you to all of our witnesses for being here.
My questions are along the same lines, although a bit different than Senator Marshall’s. I know many of us are concerned about inequitable access to health care, but also inequitable access to other services.
In 2020, the Yukon issued the results of its review of the health care system in a report entitled Putting People First. It included a recommendation to pilot implementation of a guaranteed livable basic income, noting in particular the physical and mental health benefits reported during the Ontario pilot. Then, two years later in 2022, Newfoundland released the results of a similar review, and similarly recommended implementing a guaranteed livable basic income and securing federal funding to do so. In the absence of that funding, however — and I note Prince Edward Island has also requested to embark on such an initiative — Newfoundland in particular moved forward with the basic income in 2023, but only for one group. It’s the priority group that you’ve also mentioned, and that’s youth leaving care.
Health Canada’s website includes a strong statement that the department is working in a number of ways to reduce health inequalities and address the social determinants of health. We also know that the government has committed to implementing the Sustainable Development Goals, number one of which is poverty, and which contributes to all the others.
We know that income and social status is number one on the list of the determinants of health. I’m curious to know what steps your department is taking to work with other departments to consider the benefits of a guaranteed livable basic income of the sort that has been highlighted and tried in this country as well as elsewhere. Also, I’d like to know what kind of analysis, if any, you have done of how that might result in improved health care as well as cost savings in the health care system, which is, of course, what they found in Manitoba and Ontario.
Ms. Voisin: Thank you for the question. I will try to answer that as best I can.
I would say that we recognize that social determinants of health are a significant contributor to people’s health. We do work closely with other departments, including Employment and Social Development Canada, or ESDC, which has responsibility for social services and funding issues. A lot of our work with them is really focused on seniors. As you know, the National Seniors Council is examining ways to provide an aging-at-home benefit — how people can age better. I think a lot of that discussion is really centred around financial sustainability for seniors and supports, so we’re waiting to see the recommendations from that report.
In terms of the funding we’re providing to the provinces and territories, you know about that announcement of the $200 billion. There is also the Canada Health Transfer — a $2 billion top up in addition to the 5% guarantee over five years. As well, of course, we’ve been discussing here the $25 billion in bilateral health agreements.
One of the real priorities under those bilateral agreements is mental health and substance use. All the provinces and territories will need to tell us how they’re using their funding to support mental health and substance use priorities, because part of that funding from 2017 that Serena talked about at the beginning is also being rolled into these agreements.
All the action plans will by default be talking about those priorities, with a focus on youth. I would say that provinces have really advanced integrated youth services for mental health, which is being shown by the evidence to be one of the best ways to serve that youth population.
Senator Pate: You mentioned that the health ministers met in P.E.I. recently, and you’ve also talked about the focus on health and mental health and addictions. I’m not certain whether you’re aware of the research being done out of the University of British Columbia by Dr. Jiaying Zhao, who has led a team on cash transfers with the Vancouver homeless, including young homeless people. What they found was that substance use was reduced. They haven’t been doing it long enough to show long‑term savings in terms of social, economic and health systems, but certainly in terms of the use of substances, there were remarkable changes within a year with folks who previously had been using quite heavily.
Again, I’m curious — in the context of your ongoing collaboration with provincial and territorial governments and partners — whether you’ve looked at any of those measures. If not, how would you go about examining some of the work that is being done around income supports and the benefits those provide?
You mentioned seniors, and that’s great because the guaranteed income supplement as well as the Canada child benefit are two of the early sort of limping toward that type of guaranteed livable income. Now some of the measures in provinces to focus on other groups will also do that.
I’m just curious how that intersects with the work and research you’re doing.
Ms. Voisin: I might turn to my colleague Jennifer Saxe who works in our substance use area.
Jennifer Saxe, Associate Assistant Deputy Minister, Cannabis and Controlled Substances Branch, Health Canada: Thank you very much for that question. Certainly, we do work closely with a variety of different partners, provinces, municipalities and local organizations in the substance use area. One of our programs in particular, the Substance Use and Addictions Program, really looks at providing funding for innovative approaches in terms of harm reduction, treatment and prevention — really looking at that full continuum.
You’ve given us a good example of one kind of innovative approach. We certainly look at that research, and we do work with community partners to try and get other types and similar innovative approaches to look at what some of the best practices are and what kind of evidence can be built from that.
As well, we fund a variety of different things. These could be community-based supports, it could be actual guidance or it could be the research around some of that. Since 2017, there has been over $500 million committed to over 380 projects, so it’s a large financial contribution program. We have collaborated and exchanged information with partners as well, like our partners at Infrastructure Canada who work on the homelessness strategy. So we work with a variety of different partners to be able to address and build those innovative practices that are so important, and then share them.
[Translation]
The Deputy Chair: Thank you.
Senator Galvez: Many thanks to our guests this evening.
[English]
I want to shift the conversation to new stressors of mental health. The Canadian Mental Health Association has raised concerns that Budget 2023 doesn’t go far enough in funding the mental health supports that are needed right now — today — by Canadians because of new stressors. For example, they are saying that inflation is making people feel higher rates of anxiety and depression. There are higher rates of diagnoses of mood disorders and even higher suicidal ideation. The rates are 30% plus.
On top of that new stress, we also have the stress of extreme weather events that are causing psychiatric disorders and worries. For example, just this year, the smoke produced by Canadian wildfires impacted air quality and threatened the physical and mental health of Canadians.
Did this allocation for the budget take into consideration these new stressors for mental health?
Ms. Voisin: Thank you for the question. The budget measures were announced in February and then confirmed in Budget 2023 in terms of funding for improving access to health care services, including mental health services. I think a lot of these issues were ongoing at that time, so indeed, they did come into play in terms of considerations as we were looking at those policy decisions.
I just want to reiterate that mental health services and substance use services is one of the four priority areas for health funding that we agreed upon with provinces and territories. The agreements that we’re negotiating right now with provinces and territories also bring in the funding that was announced from 2017 over 10 years for mental health and substance use. All the action plans that the provinces are developing include at least how they are spending that money in terms of those priorities.
Senator Galvez: Thank you.
The other stressor is with respect to the legalization of cannabis. When Canada legalized the use of cannabis in 2018, the goals were to improve safety and public health and reduce access by youth, crime and illegal markets. However, health experts are saying it hasn’t created any health benefit — it’s almost the opposite. It is now linked to very serious concerns. For example, 27% of Canadian adults say they have raised their consumption of cannabis. There has been hospitalization data published wherein nearly 7 million people aged 15 and up in Ontario, Quebec, Alberta and British Columbia were hospitalized.
By the way, talking about the cost of private versus public, detoxification in Ontario from any of the substances, whether it is cannabis, opioids or cocaine, is $3,000 for 28 days. In Quebec, it’s $10,000. There is a difference if you go for these treatments.
With respect to private doctors, in Quebec it’s $3,500 per year to access a private doctor. If you talk to a private doctor who came from France — because he must know how to speak French — and you ask him how long it took him to do all the paperwork, he will say seven years.
How many programs or projects related to cannabis health risks, physical or mental, abuse or intervention, have been funded?
Ms. Saxe: Thank you. I may get you to repeat your final question, but I’ll start by responding to the first two parts, if that works. I appreciate your questions. Excellent points.
Certainly, it’s been five years since cannabis legalization has come into play, and the intent and objective is for a robust public health and public safety approach. Last year, back in 2022, the government launched an independent legislative review. An expert panel of five people was convened, and they have been doing extensive consultation and looking into quite a number of pieces in terms of that cannabis frame. That includes looking at things like impacts on public health, young people, First Nations, Inuit and Métis and progress on adult access. Many of these key points —
Senator Galvez: What have they found?
Ms. Saxe: What they’ve published so far is a what-we-heard report. They’ve undertaken over 500 consultations. Just last week, they published a what-we-heard report, and they will be tabling a final report with advice and recommendations in March. I can mention some of the key things that they’ve highlighted and maybe on some of the points that you’ve noted.
In terms of impacts on public health, public health stakeholders support a precautionary approach, arguing that it’s premature to loosen key restrictions. Conversely, industries have seen more flexibility to increase competitiveness with the illicit market, which is also a key consideration in these pieces.
For young people, which is another area where you’ve noted particular interest, there has been no apparent change in the rates of use among youth, and there are some signs that adolescents are initiating cannabis at older ages. There is also recognition that fewer youth are interacting with the justice system, and that means that they’re avoiding those negative consequences with respect to their futures.
Certainly, it’s a comprehensive what-we-heard report. I’m happy to touch on other pieces, but we’re reading through, looking at that report and the key pieces from it and what’s been observed to date. Then we will be looking for advice and recommendations from the expert panel that will be tabled in March.
Senator Loffreda: Thank you to Health Canada for being here this evening.
Health care is a major concern in Canada. I’m concerned with the backlogs and resources to health care, such as a lack of doctors and nurses and wait times. Although health care is predominantly held by provincial governments, the federal government does play an important role in the health of Canadians, and provincial governments do rely on federal funding to provide essential health care services. I would like to address the $2.6 billion in Supplementary Estimates (A) that will be used for new bilateral agreements with the provinces and territories to address health system needs.
Regarding the use of these funds, can you provide our committee with an update on these agreements, such as the allocation formula used and consistency across the country? Does the federal government have any say on how and where these funds will be spent by the provinces and territories? Considering the extent of these funds, I think Canadians would appreciate knowing how they will be used and how they may benefit from this large injection of federal money.
I’m particularly interested, like I said from the start, on the backlogs, the lack of resources and how we’re addressing those concerns and those issues.
Ms. Voisin: Thank you for the questions. In terms of the bilateral agreements, I’ll try to get at the different elements of your question. Let’s start with backlogs and access to health professionals.
Let me say first that with the $25 billion and the bilateral agreements, there are four priorities: Access to family health services in your community, backlogs and health workers, mental health and substance use, and modernizing the health system. Those are the four priorities that we developed in collaboration with the provinces and territories and they have agreed to as the parameters for those bilateral agreements.
Then, as I said, in negotiating those agreements, we are asking all the provinces and territories to develop a detailed action plan on how they will use the federal funds incrementally to the funds that they’re already investing in these areas. They need to tell us how they are going to use that money in addition to things they’re doing already in family health services or in the health workforce, for instance.
Also in those action plans, we’re asking them to set targets against the common indicators where they’re investing federal funds. For instance, if they’re investing some of their federal funds to support better access to family health services in the community and their action plan, they need to tell us in British Columbia, for instance, or in Newfoundland, we’re increasing access to family health services by X%. That’s our target in three years. They have a special initiative. They will tell us how many extra physicians or professionals they will hire in those three years with the federal money.
We are getting really granular in terms of how much we’re asking provinces to tell us about how they’re using those federal funds. Then as well, the Canadian Institute for Health Information is gathering all the data from the provinces and territories on those common indicators to report to Canadians from a pan-Canadian perspective what that looks like.
Those action plans are transparent and online. We recently announced the agreement with British Columbia, so that agreement is now available publicly and there’s also a press release. We can send that link, if you’d like.
Senator Loffreda: Thank you. Just looking at the overall picture on a best-case/worst-case scenario and looking at the sustainability of our universal health care system going forward, what percentage of our overall budget will be health care once the dental program is fully implemented? And if we go a step further, what percentage of our total budget will health care be if Pharmacare, which is being contemplated, comes into the picture? Maybe you can answer one question or the other.
Ms. Francis: When you say what percentage of the total budget, do you mean the total budget of the Government of Canada?
Senator Loffreda: I sponsored the last Budget Implementation Act. I just wanted to know, based on the new dental care numbers and the projections you do have, is it sustainable going forward? What percentage would it entail going forward?
Ms. Francis: I don’t know that I have the answer to that. That’s probably a question for officials from the Department of Finance in terms of the overall government spending in this space.
Senator Loffreda: Or globally?
Ms. Francis: A percentage annually?
Senator Loffreda: Over 50%?
Ms. Francis: I honesty couldn’t guess.
Ms. Voisin: It’s difficult for us to answer that question right now, especially because we don’t know yet. You mentioned Pharmacare. We don’t know yet what that will look like.
Senator Loffreda: Or the incremental cost on dental care, for example?
Ms. Van Amburg: We know the annual ongoing cost is $4.4 billion on dental care. What I’m not sure is what number I’m adding that to to then provide a percentage of overall spending. I think that’s what I’m struggling with in terms of how to add that and do the math for you.
Do you mean Health Canada spending on health care related things? There’s a whole bunch we would have to add up into that number to come back with a percentage.
Senator Loffreda: As Health Canada, don’t you look at those figures and projections going forward and determine you’re taking up a certain percentage of the total budget and have those discussions at different government levels and determine that it will be sustainable or not going forward based on projections and based on what is being used up currently?
Ms. Francis: The Canada Health Transfer part is all managed by the Department of Finance. When we do our financial resources, it’s very much focused on what does our department spend — Health Canada — within our reference levels. That’s where our focus is versus the bigger health care system.
Senator Loffreda: The Department of Finance takes care of that?
Ms. Francis: Yes, the Department of Finance does that direct transfer to the provinces and territories, and that percentage is clearly growing and growing.
Senator Loffreda: Growing and growing.
Ms. Francis: But I couldn’t tell you what it is. It really is a question for the Department of Finance.
Senator Loffreda: I was just curious on that.
Ms. Van Amburg: This is not a direct financial answer, but it is something we take into account. As we’re designing the long‑term Canadian dental care plan, for example, we are looking at performance measures and indicators and how we will know that it’s making a difference. We’re keenly aware that we should be looking at things that aren’t just the change in people’s mouths, but also are we seeing fewer visits to the emergency department for dental care needs? There is a high percentage of emergency department use right now for dental needs. We would expect that would come down as people are getting their dental care needs met in a dentist office through preventive care and other things.
It’s not a financial measurement that we’ll be able to look at there, but we do take into account how the various pieces of the system interact with each other in hopes that each area of improvement has an impact on the sustainability of other areas of improvement, in the same way you would hope with more access to family physicians you would see fewer visits to an emergency department for something that could have been dealt with in a family physician’s office if you had access to it when you wanted it.
I know you’re asking a financial question but we do, from a policy perspective, look at all the pieces and how they interrelate.
Senator Loffreda: I’m asking because I always did my budgets bottom up and say what do you need and tell me, rather than top down and here is what you get. You have to know the overall picture to know on a micro level if it is sustainable over the long term or whether we are shooting blanks here.
[Translation]
The Deputy Chair: I presume that you can probably check and send us a written response.
Ms. Voisin: Yes, we can provide you with an answer.
The Deputy Chair: You have our full confidence. We look forward to receiving your written answer.
Senator Dagenais: My first questions are for Mr. MacDonald. Can you give us an overview of the decision‑making process that gives critically ill Canadians access to drugs for rare diseases? Will your budget expand that access for Canadians in the short term?
By the way, I have a little joke: Don’t follow Canada Life’s example when it comes to drug reimbursement. The service is dismal. I’d like to hear your response.
[English]
Mr. MacDonald: Thank you for that question. I would be happy to walk through the process that has been under way for the National Strategy for Drugs for Rare Diseases since then Minister Duclos announced the program in March 2023.
We initiated discussions with provincial and territorial officials the same day as Minister Duclos made the announcement, and that was to initiate the discussion of bilateral agreements that he identified in his announcement as the critical next step. These discussions are taking place in three areas.
The first is to identify a common set of new and emerging drugs that will be identified and covered in common across all provinces and territories in Canada who come forward and sign a bilateral agreement with the Government of Canada, and those will be cost shared using the funds provided through the bilateral agreement.
The second piece is allowing provinces and territories the flexibility to address unique circumstances within their own province with a part of their funding, recognizing it is their jurisdiction and founder effects and different things like that.
Then the third is to achieve an element of national consistency in the area of screening and diagnosis.
I go through that and just identify that the first step that we took with the Government of Canada was to pull together that conversation with provinces and territories. Now the deputy ministers of the federal government, the federal health department and the provinces and territories have assigned an officials group to look at this question of what will go into the bilateral agreements in terms of the common list of drugs.
That conversation is not bounded by any specific definition of what a rare disease is. It’s very much the public plans coming together with the federal government with this opportunity on the table to discuss what it is that we wish to achieve in common. That discussion has been ongoing. It was a continuation of a discussion that was under way during the consultation phase that we did for the national strategy for the two years prior to the announcement, so that group of people was already in place and that conversation had essentially already begun, so it was a continuation.
In terms of what this is going to mean for Canadians, it’s linked to the rest of the strategy. There were three other elements of the strategy which had to do with how we collect evidence so that we can support decision making on reimbursement and listing. We have provided money to the health technology agency, CADTH, to do a series of work about how we support that decision-making process. We face a common challenge with rare diseases; the challenge is that there are many rare diseases in Canada, and for each rare disease, very few people have it.
It’s a very large problem, but when you try to use the standard methods for more common diseases to assess what evidence there is that this drug will actually be effective, that it can be cost-effective and that it can be listed and we know what the results are going to be, we have a great deal of difficulty in common across all of those.
So the conversation is not just, “Okay, the money will go to this disease treatment or that one.” It’s about how can we, in concert with the rest of the investments in the strategy, improve the manner of decision making so that we have consistency across the country so that a patient in one area of the country is receiving more closely the same care as in another part of the country, and that we’re sharing information so that with the limited information that we do have, we’re making consistent decisions across the country and we’re making the best use of the information. We’re looking at what information can be made available to make decisions.
We’re looking beyond the common set that is identified in those bilateral agreements. It’s how can the system be improved continuously, keeping pace with ongoing innovation and so many diseases we don’t have treatment for. Research is under way. We know the pipeline of treatments for diseases are coming. It is growing in terms of specialty treatments that are coming and will need to be evaluated. How do we structure the system such that it is better able to produce the best decisions for those?
I hope that has addressed the element as to what Canadians can expect from the national strategy.
[Translation]
Senator Dagenais: My next question is for Ms. Saxe. I’d like to follow up on Senator Galvez’s questions about cannabis.
I’m a little surprised when you say that we have to wait for the findings of a government-created expert panel to address the health problems caused by cannabis. Are the costs associated with this politically created expert panel borne by your department? If so, how much will it cost?
After five years of cannabis legalization, have there been any significant changes in your responsibilities to ensure the health of Canadians who use cannabis?
Ms. Saxe: Could you repeat the second question?
Senator Dagenais: I would like to know whether, after five years of legalization, there have been significant changes in your responsibilities to ensure the health of Canadians who use cannabis. It’s been said that there are a few more Canadians using cannabis now.
Ms. Saxe: Thank you very much for the questions.
I just want to clarify something. It’s not that we need to wait to take action. We’re still taking action on public health and public safety. It’s important to review our framework and have a panel of experts to give us advice. We’re continuing our work, and we plan to direct our actions to move forward with the panel.
As for the costs of the panel and whether those costs are borne by the department, the answer is yes. I don’t have that data with me, and I’ll have to follow up on that.
Senator Dagenais: Of course.
Ms. Saxe: As for the second question, I’ll continue in English.
[English]
Five years after legalization, whether there are changes in our roles and responsibilities in terms of the actions that we are taking, this is exactly why we are looking at a legislative review. And the expert panel is looking quite broadly at a number of things, as I mentioned, from public health — young people, the impact on the economic side of things, public safety, medical access, criminal activity. It is looking at quite a number of different things. That advice and the recommendations that they put forward will be important in terms of informing our way forward.
We continue to take action in terms of public education and awareness. There continues to be action in terms of the public safety piece. There has been a big displacement in terms of the illegal market. I don’t have the number right now, but I think it’s 72% that is now purchased through the legal market. We have seen some important shifts, but it’s important that we take stock of that, and that is why there is a legislative review happening that will inform the way forward.
Senator Woo: Thank you, witnesses. Can you tell us a bit more about the mechanisms by which provinces and territories are kept to their promises in the action plans that they provide to the federal government? Is there a mechanism for external auditing of the deliverables that have been promised, or is the evaluation and monitoring process based solely on self-reporting on the part of the provincial ministries? If, in fact, some of these deliverables have not materialized over a certain period of time, what recourse or what kind of penalties will the federal government impose?
Ms. Voisin: Thank you for the question. A large part of the accountability that we’re placing on the provinces and territories is tied to transparency, making them report to their own residents on the targets that are in their action plans, so it is holding them to account to their own residents and then holding them to account to Canadians through the common indicators that I spoke about.
In addition to that, we’ve embedded in the bilateral agreements the other commitments that were made as part of that Working Together to Improve Health Care for Canadians Plan. That includes commitments on improving how health data is shared and used in the health system so that Canadians have access to their own health data. It also includes commitments related to the health workforce — we talked about that a little earlier in the committee — to support labour mobility and accelerate foreign credential recognition.
We have embedded those clauses in the bilateral agreements along with the action plan, which is amended to the agreement, and they are required to report to us on an annual basis on how they’re using the federal funding. Should we find that they are not using the federal funding appropriately, if they are not meeting the targets that they set out in their action plan, we do have the means to withhold funding for the next payment on an annual basis.
Obviously, that’s a big stick. We would like to ensure that provinces and territories are held to account by their own residents and the transparency that is inherent in posting those action plans on their own websites.
Senator Woo: On the transparency mechanisms that are data-based, is there a possibility of them being audited in some way and verified by third parties, or is this already built into the system that there is a trusted partner that can be relied on to provide data that the government will accept?
Ms. Voisin: The Canadian Institute for Health Information, or CIHI, is the arm’s-length pan-Canadian organization that is responsible for health data in this country. It is a very integral approach to collecting data from the provinces and territories, securing that data and protecting the privacy of Canadians. We rely on CIHI to play that role in terms of collecting data and then, of course, the provinces are reporting on their own targets.
Also built into the plan is a review that federal, provincial and territorial governments have committed to, in terms of health funding, to work together on a review of how this health funding is working and what the path forward should be.
Senator Woo: The hard data on numbers of waitlists and the number of families doctors, in particular, can be measured quite easily. CIHI is a very reputable organization and it would be appropriate and adequate for them to provide that basis for assessment, but are there some more qualitative targets and goals in the action plans that are a little harder to measure? It’s not about the number of bodies or heads or beds; that requires some sense of judgment. How will those kinds of promises be assessed?
Ms. Voisin: Yes, that’s a very good question.
You’re right that the indicators that we’ve launched — those eight headline indicators — are focused on percentages and numbers, but provinces and territories have also committed to working with CIHI on a broader set of common indicators for each of those priority areas.
Some of those are more nebulous and challenging in terms of what the definitions are, what that looks like, what more efficient care means and what quality care is. Those are the really difficult questions. They’re working with the experts, the provinces and territories, and notably with Indigenous partners as well to get some disaggregated data about Indigenous health outcomes related to those priorities, as well as for other racialized priorities. They’re working to come up with a broader list of indicators.
[Translation]
The Deputy Chair: Thank you. That concludes our first round of questions. For the second round, I remind you that you have three minutes. I ask you to try to be concise, honourable senators, and I’d ask the witnesses to summarize their answers as much as possible.
[English]
Senator Marshall: I have two questions, and I’m going to start with Ms. Voisin. When you were responding to Senator Woo, were those measurement criteria? Does that also apply to the base funding or do those measurements just apply to these new programs that got approved in the budget?
Ms. Voisin: As part of the Working Together to Improve Health Care for Canadians Plan — which is a mouthful — provinces and territories agreed to work with CIHI on the headline indicators and the broader list of indicators. That is to access the entire pot of money.
Senator Marshall: It applies to the whole $47 million.
Ms. Voisin: Yes, that is the HT increment. In order to access all of that, they had to agree in principle to the parameters of the plan. We did that through an exchange of letters with the Minister of Health and the provincial ministers of health.
Senator Marshall: Ms. Francis, this is a question I have asked other departments, and I can’t seem to get an answer, so I’m going to ask you and maybe you can help me.
I understand the distinction between the funding for your department and the funding that is for the Department of Finance, but when the budget came down last year, there was a graph provided with regard to the federal government funding. The graph actually shows the funding for this year to be $56 billion, but the verbiage talks about $49.4 billion. That $49.4 billion is in the Department of Finance. I’m wondering what the difference is.
I don’t expect you to have an answer, because I saw the look on your face.
Ms. Francis: Are you suggesting that $49.4 billion is in the Department of Finance, and $56 billion —
Senator Marshall: Yes, but the graph on page 55 of the budget actually shows $56 billion. I was looking at all the components because the incremental funding is different packages. There’s so much for this and so much for that. I was trying to add it up. I’m trying to make sense of the money.
Can I leave that with you? Could you get back —
Ms. Francis: It’s in the budget? Do you have a page?
Senator Marshall: On page 55 of the budget there’s a graph, and it shows $56 billion in 2023-24.
Ms. Francis: Okay.
Senator Marshall: That’s for federal health transfers to provinces and territories. However, when you look at page 53, two pages back, it talks about $49.4 billion.
Ms. Francis: In the health transfer?
Senator Marshall: Yes. What is the difference? That’s my question and I’ll leave it there. Hopefully, you’ll be able to get back to the clerk. If you can come back with an answer, that would be marvellous, because nobody has been able to give me an answer and I’ve been going around with this for five months.
Ms. Francis: It’s like a $6- or $7-billion difference.
Senator Marshall: The chair will indicate a date by which we need the answer.
[Translation]
The Deputy Chair: You can’t say that the question isn’t specific. So we’re waiting for an equally specific answer.
Senator Gignac: I would like to continue with Ms. Voisin. I thank my colleague Senator Woo for his questions. I have a better understanding of the discussions and negotiations that took place with the provinces.
I’d like some clarification to make sure I’ve understood correctly. It varies from province to province, depending on the objectives and negotiations. We’re not talking about copying and pasting province by province; there are differences. Is that what you said?
Ms. Voisin: Yes.
Senator Gignac: Can you confirm that all the provinces, including Quebec, have agreed to a penalty clause if they don’t achieve the expected results in terms of negotiations? Do penalty clauses apply to all provinces, including Quebec?
Ms. Voisin: All provinces and territories, except Quebec, have indicated that we have an agreement in principle within the parameters of the overall plan. We’re still in discussions with Quebec to reach an agreement in principle.
Senator Gignac: Quebec hasn’t yet signed an agreement, but to date, how many provinces have accepted the parameters of the plan?
Ms. Voisin: To date, 12 provinces and territories have agreed to the parameters of the plan, and we’ve signed and announced a more specific agreement with British Columbia.
Senator Gignac: How much of a budget envelope are we talking about? We’ve seen this in other files such as housing — we were talking about $900 million at the time — but what’s the size of the envelope currently being discussed with Quebec?
Ms. Voisin: I’ll have to get back to you with an exact figure for the Quebec portion.
Senator Gignac: Thank you very much.
[English]
Senator Smith: I want to talk a bit about virtual care, if we could. I’m not sure to whom I should address the question but the organization is looking to expand the use of virtual health care as a result of over $150 million that has been allocated for this program over the past two years. There are, however, risks associated with virtual care. The level of adequacy and effectiveness of virtual care compared to seeing a health care provider in person is called into question.
Is your department tracking the effectiveness of virtual care across the country? How are you measuring whether or not the needs of Canadians are being properly addressed through virtual care?
Ms. Voisin: Thank you for the question. The funding that you’re referring to was provided to provinces and territories during the pandemic years. As you probably know, there has been a huge growth in virtual care over the course of the pandemic. I think that was of great benefit to Canadians in terms of allowing them to continue to access health services they would not otherwise have been able to access. There are many benefits to virtual care for people in rural and remote communities, or to those who have issues relocating, et cetera, but there are issues that you also point out in terms of quality of care.
This is a very live issue of discussion with the provinces and territories and with organizations like the CMA and the OMA, for instance, who are also very much seized with the issue. Provinces and territories are considering what policies they need to put in place in terms of billing for virtual care. Do they need to put policies in place where they favour in-person care? Do they leave that decision to the professionals? These are all the questions they’re grappling with right now to ensure that Canadians can continue to get the care that they need. They also know there are many benefits to virtual care, especially in the mental health sphere, for instance.
We know that there are many ways to provide mental health supports to Canadians in care where they don’t need to necessarily be in person, but there are other cases where you need a physical exam for something like a skin issue, for example, and you need to see a doctor in person. Those are live questions that are in discussion with provinces and territories. We’re discussing it with them and with other professional associations.
Senator Smith: Are there specific measurements within the provinces in terms of the relationship with the centre versus the provinces? If so, what would be two or three key examples of key measurements that you would be able to discuss so that you’re on the same wavelength with the provinces who become your particular clients?
Ms. Voisin: That’s a challenge in terms of how you track the benefits. Say we wanted to track how many virtual care visits there are compared to how many in-person visits. That’s not really getting at the question that you want in terms of is that visit appropriate.
The provinces are coming up with different frameworks in terms of how they want to measure that quality, so we don’t have common measures yet.
Senator Smith: Have they shared any of these measurements with you so that you can create something basic that could be used possibly throughout Canada?
Ms. Voisin: This is part of the work that the Canadian Institute for Health Information is doing with the provinces and territories, namely, coming up with different indicators and talking to the experts about how we define and develop an indicator that will get at the issue that we want to capture here, which is what modality is providing appropriate care to that Canadian.
[Translation]
Senator Dagenais: My first question is for Ms. Francis. Ms. Francis, I’d like to come back to the dental care program. As you know, it’s essential to have an idea of the number of beneficiaries in order to draw up a budget.
Have you budgeted for 100% of Canada’s children, or do your figures also take into account the number of people who won’t qualify? Since we know that some parents don’t file income tax returns, how many children are excluded from the dental care program?
[English]
Ms. Van Amburg: Are you talking about the interim Canada Dental Benefit for children, which is in place, or the longer term plan, because my answer will differ.
[Translation]
Senator Dagenais: I’m obviously talking about the long-term plan up to age 12, if I’m not mistaken. Obviously, people who don’t file taxes can have two or three children. Are they eligible for dental care? How do you keep track of them?
[English]
Ms. Van Amburg: The plan currently in place, the interim Canada Dental Benefit, is for children up to the age of 12; you are correct. Our estimates for that included the best data that we have in place. We have good data on the income of the family and on how many children are in those families.
In order to get that benefit, you need to also get the Canada Child Benefit. We have solid information on that. That reduced the number of children. If you’re in a family earning under $90,000 a year, if you’re a child under 12 years of age, we took that estimate. On top of that, we layered on the data we have from Statistics Canada about how many report that they have access to dental benefits. We know that if you have access to dental benefits, you’re not eligible for the interim Canada Dental Benefit, so we built our estimates off that. It was not estimated that it would be all children in Canada. We know many of them have good access through their parents’ coverage.
There are two answers to that. We would be very pleased if 500,000 children in each of the benefit years took advantage of the benefit. We’re tracking very well towards that this year.
On the financial side, we wanted to make sure we had sufficient funding if we’re pleased and more children apply, so the upper limit of the children, we think, who don’t have access to dental coverage, who are in the right income range and are in the right age range is pretty close to 700,000 children a year. We also know that not everybody will hear about the benefit and not every child will have a dental issue in that year that their parent needs to treat, so we think it’s realistic to estimate 500,000 children could benefit.
[Translation]
Senator Dagenais: Ms. Voisin, I’d like to hear what you have to say about two points that Senator Marshall mentioned earlier. Is the failure of universal access due to the federal government’s underfunding of the provinces, which must provide health services, or is it mismanagement of these funds, or both? Have you ever looked at whether private services are less expensive than what’s currently offered by the government?
Ms. Voisin: This service issue has been exacerbated by the pandemic. It’s really an issue around health care workers; there aren’t enough of them, and then the pandemic has also greatly affected health care services, as well as surgery and diagnosis backlogs. I think that’s what we’re seeing in the health care system.
As for your other question, we haven’t done a comparison between the private costs and the public services costs at the present time.
Senator Dagenais: Thank you very much.
[English]
Senator Loffreda: Substance abuse is becoming an increasingly pressing issue. Just like homelessness, municipalities are struggling to find solutions, and I noticed in Health Canada’s Departmental Plan for 2023-24 that Health Canada has committed, through its Substance Use and Addictions Program, to provide approximately $10 million per year to the Canadian Centre on Substance Use and Addiction “to address substance use at a coordinated, national level.” This is on page 35.
How does Health Canada monitor the effectiveness of that $10 million, and can you elaborate on how this money is being used specifically by the Canadian Centre on Substance Use and Addiction? Most research does show that around one third of people who are homeless have problems with substance abuse, and approximately two thirds have a lifetime history of such.
And substance abuse doesn’t necessarily lead to homelessness, but with the homelessness, the research shows that those are the numbers.
Ms. Saxe: Thank you very much for that question, senator. Certainly, through the Substance Use and Addictions Program, there are, as I mentioned, a number of different contributions that are made. One of them is to a pan-Canadian organization called the Canadian Centre on Substance Use and Addiction.
We have a long-standing collaboration with the Canadian Centre on Substance Use and Addiction where we transfer funds. They develop a work plan annually that itemizes and is very clear in terms of the work that they are doing. Then they provide a report in terms of how they are doing or what they have delivered on, according to that work plan each year. There is an actual contribution agreement, which is very clear in terms of what is going to be the work that they do.
There is a broad range of work, obviously, over that $10 million, and certainly I can follow up. There are a number of different actions that they take, particularly in this field, as you were mentioning, and so that includes work in terms of —
Senator Loffreda: Targets that have to be reached, or how is it monitored?
Ms. Saxe: There’s a variety of work. They undertake a lot of knowledge translation work for Canadians. They’ve undertaken work in terms of alcohol, cannabis, public awareness in terms of substance use, so there’s a broad range of different work that they undertake.
Ms. Voisin: If I can add on the issue of targets and indicators, in terms of the agreements, again, some of those headline indicators are for mental health and substance use, so they’re measuring things such as how many Canadians are coming to the emergency room for substance use issues. Those kinds of indicators are being developed as part of the overall indicator process that is tied in with the health funding, because one of those priorities, again, is mental health and substance use.
So the Canadian Centre on Substance Use and Addiction, or CCSA, is a partner that really galvanizes stakeholders on the ground but also works with provinces and territories to advance those issues.
Senator Loffreda: Thank you.
Senator Galvez: In the years 2021-22 and 2022-23, there were no funds allocated to the Environmental Health Research Contribution Program. There was not. I’m happy to see that in 2023-24, the Main Estimates include a contribution of half a million dollars — a little bit higher — but that’s a very low amount. I would like to know how this amount was set and to what it is directed. What are the objectives, and how is it going to be allocated?
Brigitte Lucke, Director General, Policy, Planning and Integration Directorate, Healthy Environments and Consumer Safety Branch, Health Canada: Thank you for the question. I just wanted to confirm, the Environmental Health Research Contribution Program?
Senator Galvez: Yes.
Ms. Lucke: This program is a new contribution program that’s been put in place, so that’s why we are only seeing new funds come through in 2023-24. It’s a brand new contribution program.
The purpose of this program is really to support our overarching initiative on the circular economy in dealing with plastics, so it’s very specific to increase and communicate knowledge on plastics to Canadians and review and conduct internal and external research.
The main issue from an environmental health perspective is the microplastics. We breathe them. They’re in our food. They’re in our water. We anticipate that there are health effects, and we need to do a lot more research. It’s an emerging issue, so the contribution funds are really targeted to be able to advance —
Senator Galvez: Who is going to conduct this research?
Ms. Lucke: Proponents can apply, and they can come from non-governmental organizations, not-for-profits, professional associations, different government agencies, and regional health authorities can also contribute.
Senator Galvez: Thank you.
Ms. Lucke: You’re welcome.
Senator Pate: In the Main Estimates, $1.8 billion is included in terms of payments to provinces and territories for the purpose of home care and mental health. Budget 2023 indicates that since 2015, the government has provided $10 billion to provinces and territories for home care, community care and long-term care for seniors, as well as $5 billion to increase community-based mental health care.
The Prime Minister’s website, in February of this year, indicated that Budget 2023 amounts were building on $7.8 billion over five years that had yet to flow to provinces and territories for mental health and substance use, home and community care and long-term care.
I’m hoping that you can clarify how much in total, including the Main Estimates, the government has committed to provinces and territories that is earmarked for each of the categories — home care, community care and long-term care for seniors, and community-based mental health care — since 2015. How much of this has and, conversely, how much has not yet flowed to provinces and territories?
If it takes too long during my time, if you can provide it in writing, that would be great.
Ms. Voisin: I’ll try to be concise. I think what is happening here is they’re bundling different parts of announcement funding.
Let me just start with the basics. In 2017 there was $11 billion over ten years provided for home and community care and mental health and addictions, and $6 billion of that was for home and community care, and $5 billion of that was for mental health and addictions. That goes until 2027.
In addition to that, in Budget 2021 there was $3 billion over five years for long-term care, and so that is bundled in one of those descriptions that you had, as well.
The $3 billion for long-term care is starting this year, so those are agreements that we’re also going to negotiate with the provinces and territories on aging with dignity. And in terms of the money that was announced from 2017, the remaining four years of that funding is being rolled into two sets of agreements. The mental health money is being rolled into what we’re calling the “Working Together Agreements,” which are the four priorities I’ve been talking about all night with this mental health money. Then the home care and community care money, and the long-term care money, so the $3 billion, that’s being rolled into what we’re calling Aging with Dignity agreements so that they’re thematic and really focused. In many provinces and territories, there’s a different minister for seniors, so we negotiate with that ministry instead. Was that helpful?
Senator Pate: It was very helpful. Is it possible to get that in writing so we can see? I am madly trying to scribble.
Ms. Voisin: Yes.
Senator Pate: I’d like to go back now and look at the figures again. Great. Thank you very much.
[Translation]
The Deputy Chair: I’d like to ask a question about artificial intelligence, which has enormous potential in the health care field.
I met with representatives of the Canadian Association of Radiologists, who told us that one of the reasons for the current bottleneck was the waiting lists for imaging exams, and that it could be reduced by around 12% if we had adequate equipment and good management of our fleet, which is very aging.
When it comes to monitoring and assessing artificial intelligence technologies in the health care field, can Health Canada enforce rules, or does it have a role to play?
I’ll ask you a second question, as well: Are there any funds earmarked for deploying these new technologies and upgrading our equipment?
Ms. Voisin: I’ll try to answer your questions. I, too, met with the Canadian Association of Radiologists this week. I think they were on tour. We had a very interesting discussion.
The use of artificial intelligence in the health care system is a very important issue for the provinces and territories. We recently spoke with the various provincial and territorial deputy ministers of health and saw examples of how technologies are being used to improve patient outcomes and system operations in hospitals.
Health Canada plays a role in regulating technologies to ensure they’re safe for the health care system.
Health Canada’s role is also to work with the provinces and territories. For example, if the Association of Radiologists wants to examine standards or norms for the application of technologies in health care systems, Health Canada will work with them and with the provinces and territories to promote a consistent approach across the country.
The Deputy Chair: Thank you very much.
We’re going to conclude the meeting. Thank you for all your answers and for the answers we’ll be waiting for. It’s been very enlightening and much appreciated by all our colleagues.
I’d like to remind you to submit your written answers to the clerk before — and we’re giving you plenty of time — the end of the day on Wednesday, November 8, 2023.
[English]
Before adjourning, I would like to remind senators that our next meeting will be next Tuesday, October 31 at 9 a.m. to continue our study on the Main Estimates 2023-24.
[Translation]
Before we adjourn, I’d like to thank this committee’s entire support team, those in the room as much as those working behind the scenes. Thank you to our interpreters, who contribute enormously to the success of our work as senators.
On that note, good evening.
(The committee adjourned.)