Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology

Issue 9 - Evidence, March 23, 2000

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 11:03 a.m. to examine the state of the health care system in Canada.

Senator Marjory LeBreton (Deputy Chairman) in the Chair.

[English]

The Deputy Chairman: Honourable senators, this is the third meeting with witnesses on our health care study. Our first witnesses this morning are from Health Canada. The committee has asked Health Canada to provide us with a general briefing on the population and health in Canada, including a current status report on the health of Canadians, long-term and recent trends and comparisons with other countries.

With us today are Dr. Wendy Watson-Wright, Mr. Sylvain Paradis, Ms Liz Kusey and Ms Monique Charron.

Honourable senators, the witnesses will show a short video before they make their presentation. You will hear the audio in English and French through your earpieces. Since this is relatively new technology, I ask for your patience.

Dr. Wendy Watson-Wright, Director General, Policy and Major Projects Directorate, Health Promotion and Programs Branch, Health Canada: Honourable senators, we are pleased to be with you today to speak about the health of Canadians and the underlying conditions which influence health.

We are tabling "Toward a Healthy Future: Second Report on the Health of Canadians." This report, as I believe most of you know, was produced by the Federal, Provincial and Territorial Advisory Committee on Population Health and certainly provides the most comprehensive information we have to date on the health of Canadians.

My colleagues have been introduced. I would like to say that we also have with us in the audience two other people from our Childhood and Youth Division, Julie MacKenzie and Mary Johnston, who can respond to any questions on our children and youth programs.

As you mentioned, Madam Chair, we will be showing a short video. We had not planned to give a presentation, but we can do so if you wish that in addition to the video. I will leave that up to you once you have seen the video.

Coming out of the report, the priority areas for action have been agreed to by all FPT Ministers of Health. The role of staff is to work with the other jurisdictions in promoting the messages which come from the report.

We are also distributing a presentation deck which more or less organizes the information you will be seeing on the video and reinforces the main points.

Again, we would be happy to answer your questions following the video.

(Video presentation.)

The Deputy Chairman: Dr. Watson-Wright, before we open the floor to questions, would you care to make any more statements in addition to the video?

Ms Watson-Wright: At this point, perhaps we could bring out more highlights from the report. I will ask Ms Kusey to do that. This information is contained in the deck that has been handed out to you.

Ms Liz Kusey, Policy Analyst, Policy and Major Projects Directorate, Health Promotion and Programs Branch, Health Canada: Honourable senators, the video gives a good indication of some of the status measures of the health of Canadians. The report answers three questions: How health healthy are we, what makes us healthy, and what can we do to improve our health? With your permission, I should like to talk briefly about those questions.

As mentioned, "Toward a Healthy Future: Second Report on the Health of Canadians" was developed by the Federal, Provincial and Territorial Advisory Committee on Population Health in collaboration with Health Canada, Statistics Canada and the Canadian Institute for Health Information.

The report provides a comprehensive picture on the health of Canadians and what makes us healthy. It does this by taking a population health approach in its organization and analysis. This means that it integrates traditional health status measures with data on the interrelated factors and conditions that make Canadians healthy. These factors or determinants include the socio-economic environment, physical environment, healthy child development, gender and culture, personal health practices, biology and genetic endowment and health services.

The goal of the population health approach is to maintain and improve the health status of the entire population as a whole and to reduce inequities in health status between groups.

When we look at the health of Canadians, you will see in the first slide of your briefing deck some key population health measures that have been used, one of which is life expectancy, where we have reached new highs. Another is the infant mortality rate, where we have reached new lows. As well, the United Nations continues to rank Canada as number one on its human development index, which takes into account life expectancy, educational attainment and adjusted income.

Canada continues to have an enviable health care system, despite continuing pressures in a period of reform. Access to insured health services has been safe-guarded for all Canadians, regardless of their income level.

More positive results include factors such as most older Canadians are independent and healthy, recent immigrants are in good health, and Canadians are taking action to improve their health and their declining death rates and potential years of life lost.

The graph on the fourth page relates to potential years of life lost. What you will see is heart disease and unintentional injuries, two of the major causes of death before age 70, continue to decline. Over the past 20 years, we have seen particularly impressive declines in childhood deaths. However, unintentional injuries that are virtually all preventable still remain the number one cause of death among children and youth.

Cancer, which is the principal cause of potential years of life lost, has declined somewhat in men but has only stabilized in women, largely due to increases in lung cancer deaths among women.

Unless there is a decrease in current smoking rates among women, we will see large increases in female deaths attributable to tobacco in coming years.

The video was very good in showing that high standards of health are not shared by all and disparities relate to age.

In 1990, one-in-five children were living in low-income families and this has changed to one-in-four children living in low-income families by 1995. It is a significant problem. That puts them at greater risk for infant death, for low birth weight, developmental delays and exposure to environmental contaminants.

The psychosocial health of our young people is of concern, as are high levels of stress, depression and suicide, and multiple risk-taking behaviours.

While women live longer than men, many are more likely to suffer from stress, depression, chronic conditions and injuries, and death related to family violence.

Aboriginal Canadians have made impressive improvements in educational levels, infant mortality rates and substance abuse; however, their life expectancy is still a full seven years less than other Canadians. They also suffer more chronic diseases than the general population, and there is evidence that some conditions are still on the rise.

Children and youth in aboriginal families have high rates of respiratory infections and unintentional injuries and early deaths from drowning, suicide and other causes. Many of the health concerns are linked to problems with housing and food affordability, unemployment and low incomes.

The UN, which rated Canada number one on the human development index, rated Canada tenth on the human poverty index for developed countries in 1998 and ninth in 1999. In explaining this, the U.S. suggests that Canada is not doing as well as we could on literacy, unemployment and income distribution.

I draw your attention to the graph on page 6, which shows self-rated health by income level. Only 47 per cent of Canadians in the lowest income group rate their health as excellent or very good, compared to 73 per cent in the highest group. You can see from this graph the persistent socio-economic gradient that affects health at every rung up the ladder. This holds true regardless of the cause of death and how much we spend on the health care system. These perceptions are backed up by hard data. Canadians with incomes below Statistics Canada's low-income rate suffer more illnesses and die earlier than Canadians with higher incomes.

The priority areas for action have been agreed on by all Ministers of Health at the federal, provincial and territorial levels. They include investing in the health of three key population groups -- children, youth and aboriginals -- improving health by reducing disparities in literacy, education and income, and renewing and reorienting health services.

Efforts to invest in health during early childhood are partially related to research which shows that experiences from conception to age six have the most important influence on brain development and, therefore, that all children and families can benefit from an integrated early child development strategy.

The second priority group is young people. Despite concerns raised about youth health, youth volunteerism is on the rise. As you see, the number of young women completing post-secondary levels of education is at its highest point ever. However, the report suggests the need to involve young people themselves in addressing challenges to their health and well-being. It also notes that personal lifestyle choices are linked to the capacities of homes, schools, communities, workplaces and governments to create environments for young people that make the healthy choices the easier choices for them to make.

The third priority group, aboriginal people, have the lead role in finding culturally appropriate ways to enable their people to improve their health, but in doing so they need the support of all Canadians.

Taking action to provide all Canadians with the opportunities they need to obtain a solid education, adequate literacy skills and a sufficient income to support themselves and their families would help foster healthy citizens and a prosperous, competitive nation. When we talk about renewing and reorienting health services, this is what we mean. Evidence shows that health promotion and injury and disease prevention activities have been working. In areas such as immunization, mammography and seat belt use, we have seen dramatic improvements, and prevention and promotion activities must be continued and broadened.

A number of concerns are noted in the report, including access to uninsured services, such as eye and dental care, prescription drugs, home care, and mental health counselling. Since many of the determinants of health that I am speaking of are outside the traditional health services system, building alliances with other sectors is a primary strategy for improving the health of the population. The ideal outcome of these collaborations would be healthy public policies in a variety of sectors, as well as the health sector. The health sector cannot do it all, and it cannot impose its agenda on others, but it can initiate dialogue and partnerships with others and act as a collaborator for change.

We need to increase our understanding about how the determinants of health influence well-being, and the report also points to the need for better data on effectiveness, accountability and quality of care. "Toward a Healthy Future" suggests a paradigm shift in the way we think about health, and it suggests that actions in the broad determinants of health are as important as efforts within the traditional health services system. It is clear that improving health must be a shared responsibility -- shared across organizations, disciplines and sectors. Honourable senators, we can give no greater gift to the next generation than a healthy future.

Senator Carstairs: I wish to deal with the youth issue and, in particular, the statements about the stress levels of those in the 18- and 19-year-old category. I think your data was that 37 per cent of them indicated they were suffering from some kind of stress.

My experience in working with kids that age is that "stress" has become a buzzword with them. If they are the least bit upset, they say, "I am stressed." I have heard that from both of my daughters at various times. Usually I suggest that they take a run, which might make them feel a little less stressed. I also recognize that with the increasingly high suicide rate, particularly among young men, stress is leading to clearly unhealthy behaviours.

What proof do we have or what analysis has been done about why these young people think they are suffering from stress? Rather than just telling us they have stress, have they told us in any studies what it is that makes them think they are under stress?

Ms Kusey: The report shows that the 18- and 19-year-old youth, particularly females, report that they are under stress. From observers outside the system, youth and particularly females between the ages of 15 and 19 are observed by others, by health professionals, to be exhibiting signs of distress and stress. Does that answer your question?

Senator Carstairs: Partly, although it seems to be an area in which we need to do more specific research and study.

According to your statistics, 9 per cent of youth suffer from some sort of depression. Are these young people getting treatment for that depression? My experience is that most people in this country who suffer from depression do not get adequate treatment. Is this also applicable to young people?

Ms Mary Johnston, Consultant, Childhood and Youth Division, Health Canada: In response to the first part of the question, we have done some work and other groups have done work and asked young people point blank what causes them stress. School is one answer -- pressure to achieve grades, pressure to be able to earn money so they can afford to go to school, pressure from parents to achieve grades, and, I guess very similar to adults, balancing work, family and school responsibilities.

Regarding treatment for depression, you are correct that the majority of youth with subclinical depression, and even many of them with clinical depression, are not getting the identification of the condition and the treatment that they need.

We know from work in the province of Ontario and work in other provinces that many of the provinces are looking for ways of integrating the services so that when young people are identified in one venue or in one setting as having a problem with mental health issues, they can be referred and get treatment faster.

Senator Carstairs: Is the ongoing discussion and debate about the stigma that is still attached to mental illness in this country, despite the fact that probably one-in-five people in Canada will at some time in their life suffer from some form of mental illness?

Ms Watson-Wright: Is your question in regard specifically to youth?

Senator Carstairs: Clearly for everyone, but particularly for youth, is the stigma still there for them?

Ms Johnston: I would say from work that we have done with school-based programs and with other youth programs that, yes, there is a stigma. There is also a difficulty with self-identifying or getting the actual identification and clinical assessment of clinical depression.

Senator Carstairs: My final question has to do with the reasons you have given us, including school achievement. In my other life, I was an educator.

What I have seen in almost a perverse way is that the expectations for young people today are so much greater than the expectations for my generation. For example, it recently required a higher academic average coming out of high school to get into dental hygiene than it did to get into dentistry; it required a higher average to get into physiotherapy than it did to get into pre-medicine. Many of these fields, coincidentally, are "female" fields.

It is not obviously in the mandate of the Department of Health, but when you talk about school achievement levels, is any of that feedback coming back to you?

Ms Johnston: Yes, the feedback is coming back to us. We are looking at and collaborating on indicators. As well, the ministries of education are looking at indicators of school achievement and indicators that are more pan-Canadian. They are looking at having those made broader than just academic achievement.

Senator Callbeck: My first question pertains to what a witness had to say yesterday. That witness indicated that they felt there was a lack of national data in the entire health care field. They spoke glowingly about the system in the province of Manitoba. Do you agree that we have a lack of data in the health care field? If so, what are we doing about it?

Ms Watson-Wright: I will ask Dr. Paradis to respond to that.

Dr. Sylvain Paradis, Acting Policy Group Manager, Policy and Major Projects Directorate, Quantitative Analysis and Research Section, Health Promotion and Programs Branch, Health Canada: Senator, there is actually a lot of data in the system already. It is not always the best data, and there is a lack of certain types of data to do certain types of assessment.

One of the big problems is how we attack all this data. For instance, if we look at mortality, hospital human resources and doctors and nurses, Statistics Canada carries a wide variety of surveys and the Laboratory Centre for Disease Control at Health Canada looks at diseases, mortality, morbidity, and other factors like this.

To be able to make all the assessments, we must link all this data to find the paths within the process. Money has been invested in a project called the Road Map Initiative, which is a link between Health Canada, the Canadian Institute for Health Information, Statistics Canada and the provinces to better focus on what is required, methods of data collection and stronger standards of data collection. It is a huge initiative.

As an example, the National Population Health Survey is conducted every two years on the same 20,000 people. We can actually track over time the same individuals, if they get better, if they get worse, what is their health status and if they are highly stressed.

In addition, we have just created a new survey called the Canadian Community Health Survey, which will actually go deeper in the communities with a larger sample of 150,000 households.

The problem is we could not do good assessments in small areas because we did not have enough numbers. Now we are increasing the size to be able to capture better what is taking place.

Similarly, the Advisory Committee on Population Health is looking at vital statistics, such as cause of death and the quality of the record. Hopefully we can improve the quality of reporting of this data. It is done systematically with all the organizations.

Senator Callbeck: In other words, we are working to come up with a better system.

Mr. Paradis: If we look at international comparisons, usually we provide data that meets international standards, compared to other countries that cannot meet some of these standards. Canada is developing many new indicators at the same time. We have a significant amount of information. The research shows there is much information at this time.

Ms Watson-Wright: In answer to your question, Senator Callbeck, yes, we are working on it.

Senator Callbeck: In 1974, a report was done by the Minister of Health at the time, Mr. Lalonde. In 1984, the then Minister of Health, Mr. Epp, did another report. I believe that they both dealt with a population health approach. Now we have another report, or is what you have just completed not as in-depth as the other two reports?

Ms Watson-Wright: No, this report is quite different from those reports. This is really bringing statistics together and addressing policy issues. The other two were much more intellectual pieces relating to how we can change what we have been doing and change the world. There were thoughts about doing another report similar to that, but the report we are speaking about today is quite different from the previous two.

Senator Callbeck: Those previous two reports dealt with the population health approach in Canada. Since those two reports, one in 1974 and one in 1984, what major initiatives has the federal government taken in that field?

Mr. Paradis: In fact, the first report was a broad brush report looking at four different sectors -- biology, personal behaviours, a health care system and the environment.

Mr. Epp's report dealt specifically with health promotion. If you remember, Dr. Glouberman yesterday spoke about four phases of the health system.

The new wave is the population health approach dealing much more with life conditions. The report that Mr. Epp put together related much more to people's behaviour, health education and community support. The new report addresses broader conditions, such as education, income, early childhood, culture and gender-oriented factors. That is the new direction. We are doing that jointly with the provinces. Most of the documents are coming out of the Advisory Committee on Population and Health.

Senator Callbeck: I read the report in 1974, but it was very much along the line of the population health approach, as was Mr. Epp's report. My question really was the following: What major thrust has the federal government taken in this area since that time?

Ms Watson-Wright: If I could attempt to answer that, there are some major approaches. Certainly, promotion of population health as a business line within Health Canada is a major factor. A number of smaller initiatives that have gone forth, not just within government but outside government.

In order to give you a good picture of that, it would be important to put all of this information together for you rather than my trying to pick out some of these initiatives for you.

The important thing, as you obviously know already, is to bring sectors other than the health sector together with health in order to address the determinants.

If you would like us to put together everything that has happened under a population health approach, we would be happy to do so.

Senator Callbeck: I wondered if there were any major initiatives that really stood out.

Ms Watson-Wright: Perhaps Dr. Paradis would like to talk about the Canadian Population Health Initiative.

Mr. Paradis: Under the Road Map Initiative I was talking about earlier, although Mr. Lalonde's report talked about the four sectors of social and environmental conditions, we did not have much evidence of that factor.

This report really shows discrepancies in the social economy. We thought it was important to look at new research to show these factors in terms of social condition.

A new initiative called the Canadian Population Health Initiative actually pulls together researchers from the CIAR. Dr. Fraser Mustard is one of them. They are looking at very specific connections between factors.

One of the areas they are addressing is the impact of a poor environment, as well as being poor. How does the environment, itself, affect people? We do not have a significant amount of information on this issue. That is where we are actualizing the proposals that were in the Lalonde report, proposals that have not been put in place over the years. That is the major initiative. We have started to look at the conditions we knew were there but had never assessed closely.

The Deputy Chairman: In your report you talk about asthma dramatically increasing among young children in the last decade. Can you can shed some light on this? The assumption or perception is that we have a more smoke-free environment. Do you have data to illustrate why asthma is on the increase? Is it related to the environment?

Mr. Paradis: This is not in the report, per se, but a study prepared by Health Canada a couple of years ago showed that when the temperature would rise, there were more hostile conditions for asthma in a geographic corridor running from the Midwest to Quebec City, including the entire Great Lakes region. That is certainly an important factor.

I think the potential for years of life lost is fairly flat, as all ages average out. However, if we take an approach that is age-group specific, we see consistent variations among these groups.

The Deputy Chairman: If there has been a dramatic increase of asthma among young children, then obviously that line will not remain flat. If asthma is in that particular age group, surely more data can be gathered. There must be some reason for this increase. We all think that the air we breathe and the air in buildings is less polluted, but obviously it is not.

Ms Watson-Wright: If I could, I would like Ms Johnston to respond to that question.

The Deputy Chairman: There may be other factors as well.

Ms Johnston: Health Canada is currently working on another report that looks at children's development from the perspective of each one of the determinants of health. The one on the physical environment collects quite a significant amount of data on air.

We know that there are increases in hospitalization for respiratory distress. The asthma rate in young children usually goes up when ground-level ozone rises in the Windsor-Quebec corridor. Ground-level ozone is a matter of air pollution.

As Dr. Paradis was saying, we need to work on many fronts simultaneously. We can work toward more smoke-free environments, but we need clean exterior air as a starting point. We need to reduce our pollution levels and our ground-level ozone in the exterior environment. Exterior and interior environments are interrelated.

Senator Cohen: Yesterday, Dr. Mustard explained to us the diseases of the elderly. Research has found that some diseases can be traced to the first five years of a child's life, even right back to conception. We know that children from low-income families are at a much higher risk when it comes to health. If the mother carrying the child does not get proper nutrition, the child does not. This impacts on the whole health picture.

Would the health of Canadians improve with early childhood intervention programs such as parenting centres or child care centres? I am not talking about daycare. I am talking about centres that could support low-income people and even some middle-class families, where both parents are working and there are no grandparents or extended family to offer the support that I knew growing up in Canada after the Second World War. I would like to hear some comments about how dollars spent on early childhood intervention can help the delivery of the childhood program.

Ms Watson-Wright: I will ask Julie MacKenzie, who works specifically on childhood issues within Health Canada, to respond to that question.

Ms Julie MacKenzie, Senior Research Analyst, Childhood and Youth Division, Health Canada: Honourable senators, that is a very good question and certainly one that officials are working on right now.

In terms of the cost benefit or dollars spent in early or intervention programs, several studies have been done, particularly in the United States where their expenditures on so-called head-start programs go back to the 1960s. They have been able to trace children up into adulthood. Right now, that is the richest overall source of data.

The programs that were started in the United States in the 1960s focus on high-risk, low-income children who obviously have a different cultural background than children in Canada. Many of the base-line indicators are quite comparable to children in Canada.

The Rand Corporation has found that for every $1 spent on early child intervention, $7 is saved down the road. That ratio relates to eventual costs in terms of crime prevented, welfare costs not incurred, et cetera.

Going back to what Dr. Mustard said yesterday, one of our concerns in Health Canada and in the provinces is trying to raise the low birth weight, which is a key expense to the system. Low birth weight is responsible for about 75 per cent of neonatal deaths. The children who do survive are quite expensive to the health care and social service system. The current figure is that approximately $200,000 is expended in the first year of life on a child who does survive. We hope to lower that rate by putting a relatively modest amount of money into prenatal care and nutrition and even pre-conception health. The video indicated that this rate has gone down, but it is certainly not as low as the rate in other OECD countries, particularly Japan and the northern countries. It is possible to further lower the rate, and the health care system and social services would save enormously.

Senator Cohen: I am more interested in the early intervention after birth. Are there any statistics on how effective this program could be, or is this a new phenomenon that is just being looked at now? Has it been proven in other jurisdictions?

Ms MacKenzie: In terms of early intervention, particularly in North America, the bulk of the activity has been on targeting high risk. Usually that means low-income children. The evaluation data and cost-saving studies are slightly skewed in that they are looking at this particular set of children. Your question was in terms of the broad level. You wanted to broaden that to middle-income families.

We have to look to evaluations and surveys that have been done in European countries because they have had broader systems of social support, child-care programs and parenting centres for a fair amount of time. I would not say it is universal, but it is broader than what exists here. They are finding positive outcomes across all socio-economic groups.

Senator Cohen: Does Health Canada have any of those studies available that we could look at?

Ms MacKenzie: We could probably access them for you. I believe Dr. Mustard has circulated his report on the early years, and he has mentioned the studies. He referenced them in quite extensive detail. We could try to get hold of them as well.

Senator Cohen: In travelling the country on behalf of poverty last spring and summer, many people complained that we have lowered our national standards in health care. I know that "national standards" is not a popular phrase in the provinces today. Do we need national standards in our health care system, or do we leave it to each province to develop their own? If so, what do you feel the role of the federal government should be vis-à-vis this area?

Ms Watson-Wright: There is actually a group in Health Canada working on the overall federal role in health, and they are scheduled to appear before this committee on April 5. With your permission, I would defer that question until that group appears.

Senator Keon: It is very encouraging to see the information that is being gathered on population health and the way the methodologies for data collection are being refined and the evolution of the Canadian Institute for Health Information. Hopefully the Canadian health information system will contribute a great deal to this.

I am concerned that we do not have any way of closing the loop. It is part of our Canadian mosaic that we have this federal-provincial grey zone in jurisdiction and communication. I compliment the current federal and provincial ministers and deputy ministers for the efforts they are making to get together regularly to work this out. Still, there is no feedback in the system.

We are getting a lot of information now on population health, but by the time that information is carried to the populations that are most adversely affected, a great deal of time will have transpired. There must be a better way of doing this.

How do you see that system unfolding? You have your information. It comes into the loop for intervention or feedback. You close the circle with the provinces and territories who are delivering health care and who are, to a large degree, responsible for environmental factors and some of the other determinants of health.

Ms Watson-Wright: That is quite a question. I am not sure if I fully understand exactly what you are asking for at this point. Obviously the ideal would be to have real-time data collection and real-time action on that data. Could I ask you to rephrase your question somewhat?

Senator Keon: I think one of the major problems we have in health research and in health care delivery, and indeed in public health, is fragmentation and gaps in communication. We have not been able to integrate these various services the way that they could be integrated to our tremendous advantage. I am not suggesting it would be easy, but I would like to hear your thoughts on that.

Mr. Paradis: You have captured the difficulty that we have. The fact that the Road Map Initiative and the CIHI project and the CPHI project is now reporting to the Advisory Committee on Population Health certainly creates a larger dynamic between the federal government and the provinces. StatsCan is coming out with a new report, as is the CIHI. The reporting capacity will be speeded up tremendously.

One difficulty we have in collecting all these data files is personal confidentiality. Many Canadians fear having government organizations and non-government organizations connecting the number of visits they make to their doctors and the number of drugs they take. They feel it is like Big Brother coming into their backyard. The Road Map Initiative is looking into the legal dimensions of individual rights and collective rights, and that certainly increases much of the difficulty you mention.

On the CPHI, there is a huge provincial representation. The growth of the health research institute is also a very good way to improve, smoothen and speed up the delivery. One of the ways we have tried to do that is through the Canadian Health Network. I do not know if you have had a chance to visit this Web site, but it pulls together about 400 high-quality Web sites on health information that will speed up this process.

I agree that some provinces are more advanced, such as Manitoba, in connecting the database. British Columbia has done that. In the last StatsCan survey, they increased their share of respondents on the surveys in an effort to gather better information. However, it is still quite difficult to connect these data files because of the confidentiality implications associated with it.

Senator Keon: It is something with which we have tried to grapple.

The Deputy Chairman: You may not have this at hand, but in the database, what percentage of health care costs are taken up by treating those individuals who fall into the unintentional injuries category? Do you know?

Mr. Paradis: I do not have it with me, but there is a report called the "Economic Burden of Illness in Canada." I think it is now the third or fourth report. We can provide that to you. It is unfortunate that I did not bring it with me today.

The Deputy Chairman: It seems to me that if people are more educated in that respect, it would free up more dollars to look after people who are ill because of a sickness and not because of unintentional injuries. It is something I would like to have at some point.

Mr. Paradis: Unintentional injury is an interesting phenomenon. It has decreased considerably in Canada, but it is still one of the highest causes of death for most of the younger age groups.

The Deputy Chairman: On television this morning, there was a report on young people driving and how the chances of them being seriously injured or killed goes up with the number of people in the car. It was an interesting report.

Mr. Paradis: The World Health Organization, with the World Bank and the Harvard Center for Population and Development Studies, has put together a book called The Global Burden of Disease. They are reporting that car accidents are a growing problem in industrialized countries and established market societies.

The Deputy Chairman: Thank you all very much for your presentations.

Senators, our second witness today is Dr. Keith Banting.

Please proceed, Dr. Banting.

Dr. Keith Banting, Director, School of Policy Studies, Queen's University: Honourable senators, I want to begin by commending this Senate committee for undertaking the review that it has launched. It is clearly an ambitious review and it will require stamina by the members of this committee to engage in such a sweeping and long-term review. It is highly appropriate. The Senate has often played an important role in setting the climate for debate on critical issues in this country. I wish you well.

When I was first approached about appearing before you, I demurred in the first instance because, although I have done work on Canadian social policy and federalism, I am not an expert in the particular area of health care, so I said that perhaps you should turn to others. However, it was agreed that in the context of your general discussion a retrospective view of some of the broad approaches to social policy in this country, and in particular federal-provincial relations and the role of different levels of government, may be helpful. It is there that I may have some limited contribution to make to your deliberations.

I shall speak in my opening remarks to the issue of the social union debate in Canada; that is to say, the debate about the relationship between our federal system and our approaches to social policy, the ways in which we have organized our relations in the past, why those relationships broke down in recent decades, and the kind of directions we seem to be setting with the Social Union Framework Agreement, and what the implications for the health care debate might be over the next few years. That is a big mandate and I have been asked to restrict my introductory comments to 10 minutes. When I mentioned that to my family, they laughed uproariously, thinking that I am programmed to speak in 50-minute bursts.

Given the breadth of the topic, I have circulated a handout with figures to highlight some of the points to which I will allude. We can revert to any of the specific points or other issues you would like to raise in the discussion because I will not have time to develop all of these points.

Whenever one raises the question of federalism and the relations between levels of government in a debate about social policy, eyes quickly glaze over. People would much rather focus on the real issues, such as health care and the types of intervention that will improve people's lives -- the sorts of things you were discussing most recently with a group of people from Health Canada.

The typical debate seemed to be about money and power, which appear to be perennials of our political life, but for many citizens they seem to get in the way of the real issues. At that level, I think that those citizens are right.

However, I do think that there are key issues underlying the debate about our federal system and social policy. In many ways, we work out our views on some of the fundamentals about life in Canada in a federal-provincial or an intergovernmental context. In the current context, we will be working out our social policy values -- to a large extent, although not exclusively -- through the mechanism of intergovernmental debates. It will be an important venue for the debate in the health care sector about the role of the public and private sector in the delivery of health care. Clearly, one of the ways we will work that out is debating it in federal-provincial terms and working through agreements such as the SUFA.

Many of our attitudes on the kind of democracy we have in this country are also worked out in the context of debates about federal-provincial relations: issues of accountability between citizens and their governments; issues of transparency and the openness of policy-making in this country; and issues of divisibility and the contribution different governments make to major programs that matter in the lives of individuals. These issues are often worked out, or at least set or constrained, by the intergovernmental relations we build in this country.

The extent to which the wider public and interested social groups can participate in the policy process is often shaped by the way we structure our federal-provincial agreements, or the process by which we work out intergovernmental relations. There is often a tension between our intergovernmental processes and our participation processes.

When we talk about our federal-provincial relations, we are talking most fundamentally about what kind of country we are. Is this a country in which there is a common community -- a community of Canadian citizens sufficiently strong enough to have a common approach to social policy and something as fundamental as health policy? Or are we, to use another phrase, a community of communities where what is really important is to be able to build a system that reflects the regional, linguistic and other differences of this country?

What is the balance between these two concepts of Canada? In many ways, the debate about these issues does produce a glazing over of the eyes and it is often difficult to keep people excited. When I talk to students at Queen's University, their hearts sink when I turn to this phase of debate. I actually think this is the way Canadians debate big issues. This is how we work out our attitudes towards the role of government. This is the way we work out our concept of democracy and the type of country we are. Therefore, I make no apology for being a bit of a federalism junky. I just hope I can convince people that it is an important way in which Canadians debate who they are.

What I thought I would do in that context today is talk about the mechanisms we have used historically to structure our relations in social policy and health policy. I want to talk about what I will call the post-war social union, the processes we put in place and why they broke down. I want to talk about the new agreement that has been put in place -- the Social Union Framework Agreement. As well, I want to talk about the implications for health care in that context. Perhaps a better way to put it is what are the implications of health care for the fate of the SUFA? I think that is probably more important than the reverse.

I will move on to the choices or the models of federalism.

The point I wish to make here is quite simple. A tidy mind is really a drawback when it comes to discussing Canadian federalism because we have always had a mix of models and a mix of ways of organizing our relationships. We have a menu of choices. There are basically four ways of dividing up relations between federal and provincial governments, and we have tended to use them all. The issue we face today is how are we rebalancing this menu? What is happening is that some mechanisms are fading and some are growing, and they have very different implications.

The classic model of federalism says that the federal government has its areas of jurisdiction here and the provincial governments have their areas of jurisdiction over there. The two levels of government make separate decisions in their own areas of responsibility. They are accountable directly to their citizens. They raise their own taxes. They deliver their own programs. They are accountable to their own electorate, and no priority is given to trying to integrate or coordinate the activities of the two levels of government.

Historically, we have used the phrase "watertight compartments" to describe this concept of federalism. If you believe in this concept, the important thing is to reduce overlap and duplication, get the two governments out of each other's hair, and let them be directly accountable to their citizens. It is a model which stresses flexibility of the system and the ability of different governments to respond to the diversity of the country. It says we are not looking in many areas for common Canadian approaches. What is important in a federal state is that we have diverse approaches.

The next three models actually say that interdependence is inevitable in a modern society, in a modern federal state. They relate to different ways of managing that interdependence between the levels of government.

The second model is what I call cooperative federalism. We relied heavily on this model in the post-war period. It said essentially that the federal government would establish cost-shared programs. The federal government would provide funding for programs operated within areas of provincial jurisdiction, by provincial governments, as long as those programs met conditions, principles or objectives established by the federal Parliament.

As I said, this mechanism was relied upon heavily. The important point for my purposes this morning is to underscore the fact that although there was an attempt to integrate the two levels of government, legally both levels of government remained free agents and could change their position, their level of participation and their commitment in a given area. Certainly the federal government, under the cooperative model, is capable of independent or, as critics would call it, unilateral action. The federal government is capable of changing the terms under which it provides funding and is capable of changing the level of funding provided, without legal constraint. It is free to make those changes.

It is important to note that under this model provincial governments can also take independent action. They can choose whether to opt into a program. Historically, many provinces took some time to opt into some of our programs. It took seven years for the provinces to opt into the Old Age Pension Program that existed in the 1920s and 1930s. Provinces could decide to make a change and accept federal penalties. For example, for a period, the Government of British Columbia chose to impose a residency requirement on people coming from other provinces who then sought social assistance or welfare from the Province of British Columbia. This was clearly an infringement of the terms of the Canada Assistance Plan at that time, but it was legally possible for the province to do this as long as it was prepared to accept the provincial penalty.

Politically, it was always hard for provinces to take independent action, but legally -- and this is the point I want to underline -- they could.

The third model is co-determination. The important thing about this model is that, legally, unilateralism is stripped out of the system. Legally, the federal government cannot move without the agreement of the provinces, and the provinces cannot move without the agreement of the federal government.

The only example we have in our system is the Canada Pension Plan. Under the terms of the plan, the plan cannot be changed without the approval of the federal Parliament and a majority of the provincial Parliaments. The CPP terms are very demanding. You need two-thirds of the provinces representing two-thirds of the provincial population. It is more demanding than the formula to change most parts of the Canadian Constitution.

This model is a way of managing interdependence. There are two levels of government with a stake in this area, but this model is different from cooperative federalism in that the federal government legally cannot act without the provincial governments' consent, and provinces cannot choose to deviate at the margin. I am setting aside the Quebec Pension Plan. We can discuss that if you are interested, but what I am interested in here is the idea of co-determination.

The final model is the interprovincial model. I will not linger on it because it is not a model that we rely upon heavily, except in the area of education policy.

The important point, for my purposes, is that the balance between these three models is shifting from the post-war period. The cooperative model has been fading and the real issue has been which way we are going to jump. Are we going to jump toward the classic model or toward the co-determination model as a way of managing our federal-provincial relations?

Let me say a word or two about how we have evolved between these models in the post-war experience. For brevity, I will underscore that both the federal and provincial governments had important jurisdiction in social policy in the post-war period. Provincial governments were generally deemed to have the predominant responsibility in a wide range of social policy areas, but the federal government also had independent jurisdiction, often as a result of constitutional changes, as in Unemployment Insurance or pensions. It also had, most importantly, the spending power, and this lies at the heart of our debate. Perhaps it is worth taking a moment to underscore its importance.

The spending power in our Constitution is assumed to lie with the federal government -- to make payments to individuals, to institutions, or to provincial governments, and to make payments even in areas of policy that it does not have the constitutional authority to legislate on or regulate. The federal government is assumed to have the constitutional power to make payments to individuals, such as family allowances or child benefits, or to make payments to institutions, such as research grants to universities, or payments to the provinces. This authority is not written formally into the Constitution but has been inferred constitutionally from a number of other jurisdictions. This power was core to the development of the welfare state in this country and core to the development of health policy. It is this power which has been most controversial.

Such a power exists in virtually every constitution of every federal state, but in the Canadian case, it has never been made explicit and it has never been made subject to any explicit controls. Much of the debate and struggle in this country has been around the question: Should there be an approval process for the exercise of the federal spending power other than decisions of the federal government and the federal Parliament alone?

In the post-war period, we had this mix of jurisdiction and mix of powers. We relied on a mix of those models I referred to a moment ago. We relied to some extent on the classic model of federalism, with governments doing their own thing in their own area of jurisdiction. For example, the federal government was making Old Age Security payments to citizens and direct transfers to persons, and the provincial governments were running their own programs without any relationship to the federal government. These were programs such as workers' compensation or primary and secondary education. As I say, certain aspects of our system were classical in nature.

There was also cooperative federalism -- that is, the shared-cost program mechanism to which I referred, which was critical to the big social services in this country: health care -- health insurance, certainly -- post-secondary education, social assistance and social services.

We also had a level of co-determination. I mentioned already the model of the Canada Pension Plan. The only area where we use interprovincialism is in health care, where provinces come together to help establish common standards and testing. The move toward common testing at the primary and secondary level and having tests that model international tests has primarily been an initiative of provincial governments coming together and developing a coordinated or joint approach. The federal government has played a role from time to time in this process, but it has primarily been led by the Council of Ministers of Education.

That post-war system had real strengths. If you wish to discuss those in greater detail, we can. It performed best in terms of social policy values. This mix of models performed well in allowing us to build a common, pan-Canadian framework for social policy. It allowed us to make a statement that there is a common approach here in general terms, and it also provided considerable flexibility on many programs for regional variations. I like to think that social policy was critical to the development of a common set of social benefits across the country, and I think we have a broader set of social benefits than we would have had if we had stuck with the more decentralized system of the inter-war years.

On the other hand, this mix of models has raised many issues relating to democracy and the democratic values I referred to in terms of confusion about who was accountable. It constrained transparency. We were less clear about who was doing what and who we should hold accountable if we did not like our health care system. It constrained participation because many decisions were made in closed meetings of federal-provincial officials.

With respect to democratic values, a critique was established. With respect to values of federalism, the system said that there is a community of Canadian citizens and there should be a set of benefits that citizens across the country can hold in common. There is no question that there were tensions between our federal and provincial governments. Although there are people who have critiqued the system for its constraints on democratic openness, federal-provincial tensions eroded the system.

I will not go through each of these crisis points in detail, but I would simply note two or three key turning points historically.

In some ways, the most important date is 1977 and the introduction of block funding, which did three things. First, it reduced the tension in the system. Until then, provinces had come forward to present detailed reports on their programming, and federal officials had to make decisions about whether this particular program -- for example, a particular home for the elderly -- fell inside or outside the terms of the shared-cost program. Many detailed decisions were being made in Ottawa, which, in effect, was a deeper intervention and deeper administrative control over provincial jurisdiction. The provinces found this very frustrating.

The federal government found the old 50-50 cost sharing frustrating because it could not control its budget. How much it spent on health care depended on how much the provinces spent. The provinces showed up and said, "We spent X millions of dollars last year and you have to match it." If you are the federal Minister of Finance, that is not much fun because a lot of your budget is controlled by decisions made elsewhere.

For this reason, the two governments agreed in 1977 to move to a new system. In many ways, we have been seeing the 1977 compact unfold. The new system, called block funding, said that the federal government would make a general contribution to the provinces to cover health and post-secondary education. There would no longer be an exact fit between expenditures and transfers -- that is, the federal government would make a general transfer that would not be based on what the provinces were spending but would grow over time with the rate of growth in the economy. The amount transferred would be unrelated to how much the province had actually spent.

Second, on the provincial side, the provinces did not have to come forward to get approval for each program, with all the irrationalities and constraints that were built into their program structure. It was a deal made in heaven. It took a lot of negotiating and there was a lot of conflict around it, but that was the deal.

In many ways, it was a slow-acting poison pill. It built into our system the potential for deep conflict between the federal and provincial governments because it separated expenditures from the policy role of the federal government. The federal government still could attach conditions to the transfer of funds. Nothing happened in 1997. The conditions attached to what then was the health insurance legislation remained intact and the provinces had to agree to meet those conditions to get the funding. However, the feds were not committed to 50-50 funding anymore. The federal government had an undiminished policy role, but there was not the same commitment on the financial side. Essentially, those financial transfers to the provinces declined, but the policy role remained in tact.

The other reason the 1977 compact was a slow-acting poison pill is that it introduced the big division between cash and tax points. Senators may be familiar with this, and perhaps I should just go over it. The 1977 decision to transfer some of the federal contribution in the form of a cash transfer and some of it in the form of tax points built into our politics an enduring conflict.

There is no single answer to the question as to what is the federal contribution to health care. The provinces have taken the view that the transferred tax points are simply part of the tax base of the provinces and that the federal contribution is therefore the cash contribution. The federal government says that, no, its contribution is both the cash transfer and the value of the tax points transferred in 1977, as escalated by growth in the economy. As a consequence, there are two answers to the question regarding the federal contribution to health care.

Both the provinces and the federal government are right. They both define the system differently and, in their terms, they are both correct. Again, there is no longer a single answer to the question. There is no agreement on the question. A lot of bitterness has been built into our federal-provincial relations because of the structure of the 1977 agreement.

Personally, I lean to the federal view that we should count the value of the tax points transferred. Politically, however, our citizenry will never fully grasp the complexities of that financial deal. In 1977, we built into our system slow-acting poison pill, which has now come to full fruition in the level of conflict we see.

These things unfolded quickly after 1977, as the federal government for a variety of reasons had to restrain its transfers because its deficits became a larger and larger problem. This began in the 1980s and accelerated in the 1990s. However, the federal government maintained its policy role and reinforced it in 1984 with the Canada Health Act, where it stiffened the terms and conditions attached to the transfer in the health care sector with provisions that effectively eliminated what was called balanced billing or extra billing and facility fees.

These trends came to a head in the 1995 budget, which introduced the CHST. It took the social assistance component, folded it into the block transfer and significantly reduced the federal cash transfer. There were no changes to the conditions attached on the health care side, but the aftermath of the CHST experience was to take these building tensions and just explode them. The result was a period of deep distrust in our federal-provincial relations, a distrust which remains deep and is not declining very quickly, if at all.

In effect, the provinces were beginning to say that the old, post-war model was gone and that they needed a new social union. The social union that emerged from the bargaining between federal and provincial governments was an attempt to re-establish the system. Of interest to me was to which of those four models would we jump?

If the old cooperative federalism model was no longer working well in the forum of the 50-50 conditional grants, with the possibility of unilateral action on either side, and if that model was not one with which people were willing to live, to which model would we jump? Would we jump to classical federalism where the idea was to avoid overlap and duplication, or would we jump to the co-determination model, where the idea was to build a deep set of joint controls over programs?

The provincial consensus, known as the consensus bargaining position that came out of the ministerial council established by the premiers -- the consensus position which the Quebec government joined at the last moment -- fundamentally said that we are not going to classical federalism. That is why it was very surprising that Quebec joined. The consensus was an acceptance that interdependence is the nature of the world and that both governments will be involved. What the provinces wanted, essentially, was joint decision-making. They wanted, in my language, co-determination. The provincial governments wanted joint decision-making over federal government transfers to individuals and to the provinces, as well as joint interpretation, implementation and enforcement of programs like the Canada Health Act.

The provincial position was the strongest assertion of what I am calling co-determination or the joint decision-making model; in other words, the CPP model exported to the whole sector.

The federal government was reluctant to get into negotiations and went into them slowly. When it did go in, its priorities were very different, having to do much more with mobility and accountability issues.

The deal that was struck in the end came closer to the federal model than to the provincial model, but there are elements of that provincial push in what we have established today.

The next model talks about the deal. I talk about the nature of the Social Union Framework Agreement. I do not know if senators have had a look at that in this context. We can talk in detail about the elements of the agreement, but it sets out principles.

The next two sections of the agreement are the ones the federal government was and is today still most interested in -- mobility and public accountability. Then there are sections dealing with the federal spending power and dispute avoidance and resolution.

This is where the provinces put their weight. They remain most interested in the agreement that was struck. I will not go into the financial components of the deal, but we can come back to that if you wish.

I suggest that we skip to the last chart I circulated. We can come back to whether any of this matters to the nature of our democracy in a moment, if you wish. Let me talk about where we ended up on the models of federalism that I suggested.

Under the Social Union Framework Agreement, we retained the mix of models. One of the refreshing things about Canada is that it has always refused to make up its mind about federalism. We do not have a single philosophy about what a federal state is about. We have always mixed different concepts of federalism. There has been a strength in that position in that it has allowed a flexibility. If one process is not working, we can shift to another. As I said early earlier, a neat and tidy mind is a serious deficiency in this area.

We continue to mix the three models, and elements of the classical model remain. In the federal spending power there is the capacity of the federal government to make payments to individual citizens and to institutions, such as research institutions, et cetera, through its granting councils. That is undiminished. The only requirement is that there be advance notice and consultation on such transfers.

In terms of transfers to the provinces, a much more elaborate agreement has been struck, which includes what one at this stage would have to call a faint element of joint determination. Although I say "faint", there is some. The federal government has agreed not to establish any new programs without the support of a majority of provincial governments. Thus, the federal government has bound itself not to move without a wider provincial consensus.

There are also provisions relating to the nature of the programs that can be built under the new system. Governments will negotiate objectives. In effect, they will build an array of ways of meeting those objectives. Provinces that already have programming in place will be able to receive funding, even for programming already in place. Any government that agrees to work on the objectives and agrees to the accountability mechanisms will receive its fair share of the funding.

In some ways, this is a weak form of joint decision-making. It certainly changes the rules that govern new initiatives.

In the agreement, there are also what the provinces regard as weak provisions relating to dispute avoidance and dispute resolution, which, fundamentally, were about the Canada Health Act. That is what the provinces were interested in when they pushed that area. By provincial standards, they are relatively weak. We can come back to that and discuss them in detail, if you wish.

I will end my comments with two points. First, one of the interesting things about the SUFA and the new federal-provincial relationship we have established is how general the rules are and how it is impossible to tell in detail how it will work out because the established rules and norms are quite general. Much will depend on the political will that federal and provincial governments pour into the agreement. What they want it to be will be as important as what is on paper.

Given the general nature of the terms, there have been wildly conflicting interpretations of what happened. In parts of Quebec, the SUFA has been seen as a centralizing document, with predictions that this instrument will lead to a major expansion of the federal role. This has come from the Quebec government and a number of sovereigntist intellectuals in Quebec who see this as the new face of centralism.

Elsewhere, people have argued that this is a major decentralizing device. For example, Tom Kent was an advisor to the Government of Canada in the days of the introduction of medicare. He was a principal advisor to Mr. Pearson. He has said that this is the end of shared-cost funding, period, and that we will never see it again. No government in its right mind, quote, unquote, would ever transfer funds to the provinces under these terms and that all that is left to the federal government is direct transfers to citizens.

Those are two diametrically opposed interpretations, each consistent with the details of what is written on paper.

Given these wildly conflicting interpretations, what has the experience been in the last 13 months since the agreement was struck a year ago in February? I say it is too early to tell, but it is clear that there are many tensions surrounding the agreement.

The Social Union Framework Agreement was never intended to end conflict. There will be conflict. You do not violate the SUFA if the provinces campaign for the federal government to raise its expenditures on health care. Similarly, I do not think it violates the SUFA for the federal government to speak politically about the intentions of the Government of Alberta in the area of private sector clinics.

The issue is whether the SUFA will provide rules that will help us manage those conflicts. My own sense is that we are a long way from having those rules fully worked out. The federal government is much more interested in the mobility and accountability provisions. The provinces want to strengthen the dispute-resolution portions of the agreement. They see those as weak and are working now to try and strengthen them, to get in place a more fully developed code that would indicate, in much more detailed terms, when a dispute is actually triggered and how it will be resolved. This code would be, by analogy, much like our international trade agreements. For example, how do we resolve disputes in international trade? That is the kind of formality they would like to see built into the agreement. They find the existing terms not sufficiently clear and defined to be triggered with clear ease.

The other big issue is whether, in the current context, governments, and particularly provincial governments, will actually want to use the terms of the SUFA to discuss the future of health care. The goal of the provinces, I believe, will be to increase the federal contribution through the CHST, which is relatively undefined, rather than enter into detailed negotiations about the future of Canadian health care where the process of defining will be a joint one.

In a strange way, although the provinces pushed hard for joint decision-making and joint rules, sometimes one must worry a little about what one asks for because one might get it. It is a little unclear whether they welcome the opportunity to sit down jointly with the federal government to define the new health care system of the future. They may prefer the maximum freedom to move on their own through the CHST transfers.

It is not clear to me whether the SUFA will actually constrain the way in which this issue is worked through. On the other hand, it is clear to me that the way it is worked through on the health care side will determine the weight of the SUFA. Child benefit improvements have been wonderful, but the reality is that future federal-provincial relations will turn heavily on the resolution of this question of how to resolve federal-provincial health relations in the next little while.

The Deputy Chairman: Thank you for an excellent presentation. You talk about the Canadian way and the retention of mixed models and going back to co-determination. Polling results released yesterday by Environics and by Goldfarb said that the Canadian public will not tolerate one level of government blaming the other. They are sufficiently concerned with this issue, but, again, they want an agreement. You talked about co-determination. In reading the provinces' comments, they seem to want to follow that model.

Senator Cohen: I repeat the question I asked of the previous group because I think the answer of national standards has already been given.

When I travelled the country as part of the task force on poverty, everywhere we went witnesses said they wanted to see national standards back on the public agenda. I know that "national standards" is a term that no one wants to hear anymore. The provinces really do not like the term.

Do you think the idea of national standards is completely out of the picture, or is there a place for national standards with the hook of transfer payments to the provinces? Your argument has already changed my viewpoint somewhat.

Mr. Banting: I am actually a supporter of the proposition that there should be a framework setting the broad parameters of core social programs, such as health care, in this country. I will come to the issue of national standards in a moment, but I think of it as a broad framework.

The argument can be made on two grounds. First, one can make the argument on efficiency grounds. It is economically inefficient to have a set of social benefits that are so diverse across the country that citizens who want a more expansive health care system actually must move from one province to the other to get it.

People who believe in the classical model of federalism say that it provides various levels of social benefits, where people who like a large social benefit package can gravitate towards the region that has the large benefit package and those who prefer a more modest benefit package with lower benefits and lower taxes can gravitate to another region of the country.

I am not an economist. I have many good friends who are economists, but I think only an economist would think that one would move one's family over issues such as those. I think it is economically inefficient and would lead to an irrational allocation of resources across the country if people were, in a sense, needing to move for those kinds of fiscal reasons.

Companies work not just nationally but internationally. To build a private company benefit package to compensate for variations across provinces in key areas like health care insurance strikes me as economically inefficient.

An economic case can be made for a broad framework of programs where there is broad comparability across the country. The strongest case, however, is the social case, which is rooted in the proposition that for all of our regional communities and cultures, for all of our differences, there is actually a community of Canadian citizens. Citizens in Canada have a broad common attitude or approach to these issues, and we should reflect that in our policy structures. There are no radical variations in the preferences of Canadians on health care from one region to another. There is actually a striking consensus across the country. Citizens may wish programs to be delivered locally if they believe their governments are more responsive, but on the broad structure of health care, there is a pretty solid consensus across the country.

I was quite heartened to see that this committee plans to look at other countries. I hope you will also look at other federal systems. We have been doing some work on this question. It is almost impossible to find a modern federation in which there are radically different levels of health benefits from one region to another. There is something inherent in democracies which says that citizens, wherever one lives, should have something like a common package.

That leads me to be in favour of a common framework. Does that mean I am in favour of national standards? I would say that as long as there is a common framework, there must be a lot of flexibility in how it is delivered.

I am quite comfortable with the language of the social union agreement, which says that what we need in common are objectives and a broad framework where we can have considerable variation in how people deliver them. I think the Canada Health Act is quite consistent with variation in delivery mechanisms and is designed so we can use community health services, and so on.

"National standards" as a term carries a lot of political baggage, but with a language of common norms, goals and objectives, as long as we keep it at that broad framework level, would be my preference.

Senator Cohen: I like the language and am very comfortable with it. I thank you for your explanation.

Mr. Banting: I apologize for the length of my explanation, but I do hope you will look at other federal systems.

The Deputy Chairman: Are there any examples you could give us?

Mr. Banting: We are part way through a project. We should have a book out at the end of this year. I would be happy to make it available, if senators would find it interesting. The countries we are looking at are Germany, Belgium, Australia and the United States. We are not looking at Switzerland only because our colleague from Switzerland became ill and was unable to complete the project, but that would be another country worth looking at.

It is striking in all of those systems that a common health care system exists. There is a broad similarity of approach. In some countries, there is a heavy public orientation. In some countries, as in the United States, there is a different approach with a different mix of government and markets. However, in each country there is a common approach across the country with, in many cases, local delivery. In Germany, there is a structured national system with local delivery and much smaller delivery systems than provincial governments.

The Deputy Chairman: That is interesting. If you were to ask Canadians about the United States, they would not believe that there is a common health care system in place there.

Mr. Banting: There is not a universal health care system in which all Americans are enrolled, but the mix of government and private sector health care is broadly the same across the states. There is variation at the state level, but it is not large. If you ask what proportion of the population is uninsured in the United States, there is a minor variation between states, but it is broadly a common picture.

Not many states have universal coverage. You will not find states with universal coverage on one hand and other states with virtually no coverage on the other.

The Deputy Chairman: Thank you for your comprehensive presentation and testimony.

The committee adjourned.