Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 66 - Evidence - September 11 (Morning)
OTTAWA, Wednesday, September 11, 2002
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 10:13 a.m. in order to examine the document entitled ``Santé en français — Pour un meilleur accès à des services de santé en français.''
Senator Yves Morin (Acting Chairman) in the Chair.
[Translation]
The Acting Chairman: To begin, it would be appropriate to note the anniversary of one of the darkest days on the continent and to have a thought for the families of victims of the events of September 11.
I would now like to welcome Ms Pierrette Guimond, from the Faculty of Health Sciences of the University of Ottawa, Rector Yvon Fontaine, from the University of Moncton, and my colleague, co-worker and student, the Assistant Vice-Dean of the Faculty of Medecine of the University of Sherbrooke, who is the coordinator of the francophone Faculty of Medecine of the University of Moncton, in New Brunswick.
Madam Guimond, you have the floor.
Ms Pierrette Guimond, Assistant Professor, Faculty of Health Sciences, School of Nursing, University of Ottawa: I shall attempt to limit my presentation to the seven minutes which have been allocated to me. I have five slides for you.
Some documents which have been prepared have to do with professional training. One of them has been prepared by the Network of French Language Health Services for Eastern Ontario. It is an in-depth report on the training needs of professionals. The report raises a number of issues which were raised in the document entitled ``Santé en français,'' prepared by the Fédération des communautés francophones et acadiennes du Canada. The report has to do with career promotion in the field of health, as well as financial and human incentives which should be offered by francophone institutions with regard to the recruitment and retention of health professionals.
The documents are well prepared and comprehensive, and they provide a very good description of training needs for professionals at the present time. I will not repeat what has already been dealt with in these documents. However, I would like to add another dimension with regard to professional training, one which has to do more specifically with its fundamental aspects or foundations.
Let me first give you an overview of professional training in the field of nursing. I am a professional nurse and my studies at the doctoral level involved, among other matters, the subject of professional training in the field of nursing. This is why I shall be dealing more specifically with this profession. However, the same issues apply to a number of other health professions. They do not concern nursing alone, with the exception of the first criterion, that of entry standards for nursing practice.
We are at present reviewing the academic program in an effort to cooperate with colleges. As you know, the bachelor in nursing sciences will henceforth be required at the entry level to practice nursing. This brings us to our first issue with regard to professional training in nursing. The problems encountered not only have to do with language but also with culture at the collegiate and university levels.
It may seem that my presentation today does not deal specifically with issues relating to the francophone population. In fact, the issues I shall be raising have to with professional training in general, and also apply to training that takes place in English. These problems are made more acute however because of the language issue, which adds yet another dimension to an existing problem in the area of professional training.
We have seen that there is an important need for change in professional training programs in order to bring about an improvement in this training. At the present time, and this has been the case for a number of years, each academic program review is focused essentially on reorganising content. It is therefore a never-ending exercise.
However, training programs must undergo in-depth changes. Teaching relationships must be re-conceptualized and this means that the philosophical basis of training must be seen in a new light. This new thrust must be based on research results in the field of professional training. New data is available, but it seems that it is practically not taken into account when academic programs are revised.
There is also a need to strengthen the teaching function and to enhance the quality of teaching. I will dwell further on this subject in the next slide but please note that it is a very important factor, given that if the quality of teachers is not as high as it should be, then the entire training program is jeopardized.
It would also be useful to implement new learner-based teaching models which will favour the development of critical, independent thinking. The new trend with regard to health professionals is toward training them to be able to make critical judgments, well-founded clinical judgments, and away from the mainly technically-based philosophies and models previously used in training.
With regard to nursing sciences, more specifically, we aim to train people who will be able to make enlightened clinical judgments and to develop a sound critical thinking process.
This brings us to the issue of the insufficient number of nurses trained in French. With regard to universities, I have already mentioned the fact that the teaching function is insufficient valued. It is the practical component that distinguishes a professional discipline from a university discipline. In nursing sciences, this practical component has been recognized for sometime as the central element in the training of our future professionals. The importance given to practical training for nurses is well reflected in the number of hours provided for practical training courses as opposed to that provided for theory courses.
Practical training gets twice the amount of time. Whatever the time provided, however, the problem of undervaluation is a real one. It has to do mainly with the fact that institutional conditions do not favour teaching. In the university context, promotions are based on the publication of research reports and the teaching is not well recognized.
Professionals and practical training are even more undervalued. Given that situation, professors, and more specifically university professors, become less and less willing to take part in teaching or practical training activities. It is also extremely difficult for teachers to stay current in their field. The trainer must not only be competent in his or her discipline, but also competent as a teacher.
University professors are competent as teachers, but it is difficult for them to remain competent in their discipline if they are away from their work environment for any length of time.
Teachers of theory are required to hold a master's degree or a doctorate but in the case of practical training, the bachelor degree is still the norm. For practical training, teachers or teaching nurses do not need to hold a master's or a doctorate. Most teaching nurses have no training as teachers and have never taught before. They teach in the way they themselves were taught.
To overcome problems relating to competency in the discipline as opposed to competency in teaching, we could rely more and more on the services of practising nurses, given that they master the subject matter required in the training. This is what we are attempting to do. Theses nurses would simply need to acquire the necessary teaching skills.
There is a shortage of nurses in the hospital environment. New graduates must often be supervised by experienced nurses, and this means an extra workload for nurses who are already overburdened with patients. In such a context, nurses who are presently practising are overworked and they have no interest in taking on the training of new nurses.
To resolve these issues, a number of avenues are open and should be examine. First, we should build a shared vision between universities and health care institutions with regard to the development of new academic and practical training programs. Second, we should establish conditions which would be favourable to the training of trainers. Third, we should revisit present teaching strategies, stressing, for example, training models which favour continuous training of trainers. Fourth, we should establish cooperative programs.
Cooperative programs exist in a number of other disciplines, but not in nursing. This possibility is well worth exploring. With regard to the French-speaking population, it will be necessary to decentralize training programs. Students could be given theorical training in a centre over a period of months, following which they would be working in their environment or region. After that, they would take part in training sessions for several more months. This would accelerate training, given that cooperative programs are more concentrated. Nurses could therefore be trained more rapidly. As these nurses would already be in their work environment during their training for a relatively lengthy period, this would contribute to lessening the shortage of nurses.
The last recommendation would be to create specialized centres which would not only provide training services in French, but could also be used for training and research more generally. Montfort Hospital would provide an excellent environment in this respect. Efforts could be structured under a theme. There are, for example, a number of themes which would combine health services and services in French. Nurses could help develop research through health education tools, teaching tools, the production, adaptation and validation of evaluation tools, through planning and through health care practices. The idea here would be to bring together the three practical components of training and research within a single centre.
The Acting Chairman: Thank you, Ms Guimond. I now give the floor to Mr. Yvon Fontaine, Rector of Moncton University.
Mr. Yvon Fontaine, Rector and Chairman of the National Health Training Consortium of Moncton University: I wish to thank the Senate Committee for being interested in this important problem having to do with university institutions outside of Quebec and all across French-speaking Canada. I hope that my contribution will shed some light on the issue.
Of course, members of the committee will be interested more specifically in the study of the report prepared by the consultative committee which Mr. Rock had set up at the time as Minister of Health. I have been told that some of you asked controversial questions yesterday concerning the capacity of communities and institutions to absorb funding and obtain results, in the event that the plan was financed as provided for in the committee report.
I would like to make a number of statements which have to do with a concern which I see as all together legitimate, given my knowledge of education in Canada in minority language environments. It would have been impossible to envisage the creation of an infrastructure for French-language schools outside Quebec and, later on, to establish school boards to manage these schools, and to have teaching specialists build curricula appropriate for the communities concerned, if the federal government had not acted. If it had not, at one time, been confident that universities had to be financed and that professionals had to be trained in the field of education to allow for the creation of a pool of human resources, in order to establish a plan and an education infrastructure for French speaking minorities in Canada, this will not have happened.
There is also something to be said concerning the field of law. In the seventies, there was a debate in Canada concerning this issue. At Moncton University, some had come up with idea of creating an entirely francophone faculty of law to teach common law. We had been told that this was impossible, given that common law was an Anglo-Saxon institution related to the Commonwealth. It may be noted also that, at that time, it was not possible to obtain legal services in French. The practice of law was done entirely in English outside of Quebec. We can see, 25 years later, that through an act of faith an entirely francophone faculty of law was established at the University of Moncton, and later on, at the University of Ottawa, to the common law program — which already existed a french language program was added. So we now see, 25 years later, with judges, lawyers, all those who must serve within the legal system outside of Quebec, that there has been a tremendous evolution. I thought that this analogy would be appropriate given that, today, when we look at the question of health, we see that there are exceptions concerning the health services network outside of Quebec. The rector mentioned Montford Hospital. I am less familiar with the situation in Ontario, but I do know what the situation is where I come from. Some hospital organizations are able to provide health services in French. Given the situation at the present time, and if this is what can be expected in the future, it is certain that the plan you have presented today is beyond the present capacity to provide health care services in the French language. The basic idea here is allow us to build the required infrastructure, so that French speakers have greater access to health services in their language.
To me, the timing of it all seems right. First of all, because we are well aware that the government has reiterated its intention to modify a number of government programs to fulfil its responsibilities under the Official Languages Act and because it has created a committee, chaired by Mr. Dion — made up of several ministers — and that this committee must over the next few weeks present a proposal that the government will consider. For communities and universities outside Quebec, the health care sector is the best suited for implementing a vision of what we want to do. This is because the health care sector has been a major priority for us for the last three or four years and we have put a lot of thought into it.
For all of these reasons, the time is right and we must consider the report's relevance and conclusions. In fact, this report should be studied in conjunction with the report that was produced by the Fédération des communautés francophones et acadienne, which was released in the summer of 2001 and the results of which were used by the advisory committee created by Minister Rock at the time. A number of our conclusions were based on that data. These conclusions are quite close to reality and communities, aspirations, which is not always the case for all departments and programs. We must admit that we have gone over the health care sector with a fine-tooth comb.
Immediately following the tabling of the report co-chaired by Ms Marie Fortin and Mr. Hubert Gauthier, the university set up the Consortium pour la formation en santé. This consortium is made up of nine college or university institutions outside Quebec and has an agreement with Acadie-Sherbrooke for medical training. In four or five months, we have successfully put together a very detailed file on how to implement the conclusions of the report prepared by Ms Fortin and Mr. Gauthier on training for health care professionals.
The report that we produced and that was analyzed by the government...
The Acting Chairman: I am sorry to interrupt you, but we would really like to see this report.
Mr. Fontaine: You will receiving a copy in the next few minutes. There is an executive summary.
The Acting Chairman: We would like to see it in detail.
Mr. Fontaine: There is a longer version of the report. There is also a report for each institution, but I do not have them with me.
The Acting Chairman: We would like to see them.
Mr. Fontaine: I can get them for you. Essentially, the consortium is targeting a complete training program for health care professionals; Ms Guimond told you about the challenges involved in training nurses. This is one of the major components of the proposal currently being considered by the government. All health care professions are being considered, including doctors.
We have developed a five-year plan. One of the next questions that will be come up is whether or not we have to develop an ongoing long-term plan. We started by preparing a five-year plan, but we are very much aware that this plan will not address all of the needs with respect to francophone people outside Quebec. The consortium, if you look at the conclusions of the committee chaired by Ms Fortin and Mr. Gauthier, felt that an annual budget envelope of approximately $15 million would be required for the training component. The government is currently analyzing a proposal for an envelope of about $20 million a year. It is not $20 million multiplied by five. It is about $100 million. That may seem high. I think that $100 million over five years, considering that there are one million francophones outside Quebec, means $100 per person; divide that amount by five, and it is $20 per year per person, and divide that again by 365 days. This is not an exorbitant amount when we are talking about health care and when we know that it is the most costly service in Canadian society. It is a fraction of the cost of infrastructure for delivering health care services and training for health care professionals. It is a way of inviting decision-makers to study the matter. We must not look at these figures as absolute, but as relative. In that sense, this proposal is necessary. We estimate that we will have to triple the number of francophone health care professionals to achieve that result. This is the challenge facing the institutions.
The cost of what is being proposed is just a fraction of the cost of current registrations to train health care professionals. At our university, we have 1,750 full time students who are interested in the programs covered by the proposal. Imagine the cost for our institution. It represents 20 per cent of the full time population, and an annual budget of $90 million. Calculate what the institution is already putting into training for health care professionals. I think that this budget envelope as proposed is quite realistic.
My last conclusion shows that the process that gave rise to this vision by university institutions is very interesting. You know, Mr. Chairman — you are a career academic — that universities are highly autonomous and highly individualistic. The fact that we are able to bring together nine college and university institutions around the same table and develop a consensus on a complementary role for each of them in identifying priorities is, to my mind, a major achievement. I have the honour of co-chairing this committee with the rector of the University of Ottawa, Ms Gilles Patry. The atmosphere is excellent. We must continue in the same direction. There is a wealth of experience in each of our institutions that must be used in preparing the plan to carry out the wishes expressed by this committee.
I could go on about this at length, but I would not want to take too much of your time, as I know that you will have questions. I will conclude by saying that consolidating the universities and their ability to train health care professionals will help all communities in terms of delivering health care. In our communities, universities, like the Church in the past, have always been long-standing. When we consolidate these institutions and when they look after their communities' priorities, they represent an absolutely essential foothold for community development.
Dr. Aurel Schofield, Assistant Vice-Dean, Faculty of Medical Sciences, and Coordinator of francophone health training in New Brunswick: It is an honour for me to make this first presentation to a Senate committee, and I must tell you that I have been taking health care to heart since my first year of practice in New Brunswick. I am involved in medical training. I hope that my background information on how the program was implemented in New Brunswick will enable you to measure the importance of this type of program there, and nationally, in the health care sector for the future.
In New Brunswick, in the 1960s, two commissions looked at setting up a faculty of medecine. The first, the Hall commission, had advocated setting up a francophone faculty of medecine at the University of Moncton. Later on, the second commission decided that it would not be possible because of the costs and the presence of two linguistic communities in New Brunswick, and it preferred, that New Brunswick enter into an agreement with Quebec for training in French and with Dalhousie University for training in English.
That is the origin of the agreement between Quebec and New Brunswick for medical training as well as for training in other health care professions, like rehabilitation sciences. During the first 10 years of this agreement there were very few benefits. Very few doctors returned to New Brunswick, and the number of students accepted into medecine was well under what was expected. People obtained their training in Quebec, got married and stayed in Quebec, as all other health care professionals did. Ten years later, the situation had not changed.
That is when Jean Bernard Robichaud came out with a study showing that the health of francophones in New Brunswick was well below that of anglophones. This fact was attributed to socio-economic factors, the lack of accessibility to services in French, and a lack of resources in the health care field. The most striking was the shortage of doctors.
In 1980, the University of Moncton and the Ministry of Health and Education joined forces. This was a wake-up call for French medical training in New Brunswick. Admissions were coordinated in the three faculties of medicine in Quebec, a medical training program was set up in the francophone community in New Brunswick, and that is what got the ball rolling. In fact, we had to build the medical program and develop services.
Twenty years ago, there were very few health services in French in New Brunswick. Today, 30 per cent of pre- clinical training is done in New Brunswick, and 100 per cent of all family medicine training is done in the province, in decentralized francophone communities.
Our professors are for the most part students we trained thanks to the program but has been in place for the past twenty years. This has had a major impact on health care services, along with the organization of group practice models.
Models for obstetrics clinics created by groups of francophone doctors also had a major impact on health care services, while the program was being implemented. Twenty years later, there is a 90 per cent return rate for family physicians and a 75 per cent return rate for specialists. They are well distributed throughout the province and we are retaining approximately 100 per cent of our students who are completing these programs.
As for the cohort of our students who are studying in Quebec and not doing my practical training in New Brunswick, fifty per cent are staying in Quebec. Our conclusions, in terms of recruitment and retention of doctors, have shown statistically that the origin of the candidate is a deciding factor in the candidate's decision to return to practice in his or her region. Clerkships in the community also ensure an ongoing link with these communities. There is a 4/3 return factor to the community. Moreover, if we could concentrate these clerkships, as is done in family medicine, there would be a sevenfold increase in the potential return of for medical students.
The Acting Chairman: Could you repeat what you just said with respect to origin?
Dr. Schofield: When we consider a candidate's origin, New Brunswickers are twice as likely to return to New Brunswick. When we guarantee an ongoing clerkship, they are four times as likely to return and when we offer a series of clerkships one after the other, as in family medicine, they seven times more likely to return to the province.
The Acting Chairman: The clerkships are more important than the place of origin?
Dr. Schofield: Exactly.
The Acting Chairman: The location of the clerkships is more important than the place of origin?
Dr. Schofield: These are significant statistics. An international study conducted by the World Health Organization and Wanka revealed the same predictive values.
In New Brunswick today, 30 per cent of doctors are practising in French, whereas 20 years ago, it was only 18 per cent. Twenty years ago, the ratio of doctors to the general population was one doctor for every 1,742 francophones. Twenty years later, it is one doctor for every 791. So there has been a significant improvement, but there is still a deficit in comparison with the province and the national standard. New Brunswick is one of the poorest provinces in terms of the doctor-to-people ratio.
The Ministry of Health and the Government of New Brunswick seem very happy with the success of our recruitment campaign. We had to fight to prove that we could train high quality students and meet the program's objectives, which were to recruit and retain as many doctors as possible in New Brunswick.
The partnership with the institutions and the role that the University of Moncton has played in training at the health sciences degree level and the coordination of admissions in the three faculties of medicine have all been very important. I must also highlight the role the Ministry of Education has played by providing us with the budget that enabled us to administer locally. This budget enabled us to put in place a structure for medical sciences in the province and to evolve. The three faculties of medicine in Quebec have always supported this approach. I must say that the University of Sherbrooke has been our guardian angel. It gave us the confidence to develop this program. Thanks to everyone, we have succeeded in putting in place an effective structure that meet medical students' needs in an optimal way. This structure required financial resources and a lot of time. The debate over the past 15 years has been difficult and slow. In the end, we have gained ground thanks to the structure that we set up and the funding we received.
We must continue trying to increase the number of medical students. The Government of New Brunswick is currently funding 25 spaces per year. We could really use some 40 francophone spaces per year and 40 anglophones spaces. The Government of New Brunswick has always planned its medical force by taken into account the fact that it would have to pay to train 50 per cent of these health care professionals and that it would recruit the other 50 per cent from other universities.
This was always more realistic in the anglophone side, because there are English medical schools. The number of French universities is limited to the University of Ottawa and to the universities in Quebec. That is why there are fewer francophone doctors in New Brunswick than there are anglophone doctors. We must try to increase the number of medical students as part of the Quebec-New Brunswick agreement. Based on the experience we have gained over the past 20 years, we would be prepared to play an Atlantic francophone role by helping neighbouring provinces develop similar programs.
Our objective is to continue decentralizing the program for New Brunswick, which would help meet the province's needs. We would also like to add interdisciplinary training. We must examine these training programs in order to integrate training for doctors and nurses and that of other health care professionals. That is the future direction for the discipline. As educators and professionals, I think we must move in that direction. Training professors is also important.
Research and front-line health care services, the organization of services, the health of the general population are extremely important in developing these programs. That is done from the ground up in order to decentralize and obtain a more comprehensive project.
The francophone medical training program can serve as a model for any other training program in health care disciplines. We must propose cooperation with anyone willing to work with us to develop decentralized programs that are as close to the regions as possible, in order to maximize training, recruitment and retention of medical professionals.
To conclude, the health care file that we have presented with respect to training is part of a host of initiatives that the advisory committee wanted to put in place. It is very important for training to be closely linked with other levers, because training will definitely have an impact on how health care professionals practice and how services are organized. So these links are very important. I would like to see the committee and the Senate throw their support behind all of these health care issues so that we can get the most out of integrating these five approaches. Training must be decentralized and as close to the regions as possible, and must take into account criteria for successful recruitment and retention of health care professionals.
We can achieve that with adequate long terms budgets. The budgets are tabled for five-year periods. However in five years, health care professionals will not have completed their training. Training programs take from six to ten years, and this where the needs are. We have a lot of catching up to do. There is a lot of work ahead for those who want to get involved. The matter has been presented in a very user-friendly way with all of the five approaches and we hope that it will be based on a very solid foundation. Our francophone communities will be able to benefit enjoy equity in the area of health care services.
The Acting Chairman: Thank you very much, Doctor Schofield, Ms Guimond, et Mr. Fontaine for you presentations which were very clear.
Senator Pépin: Ms Guimond, I want to see if I fully understood the points you raised. Overall, you were saying that we must re-emphasize the importance of teaching, because there is a real problem in this regard for people who are currently teaching?
Ms Guimond: Yes.
Senator Pépin: You also said that co-op programs must be put in place for these training and research practices, and that people who are currently teaching say that many of them do not have pedagogical training. Do you feel that is a major shortcoming? The teaching corps may not have all of the necessary knowledge.
Ms Guimond: They do not have the pedagogical approaches, but they master the practical side. We rely heavily on the mentoring approach. The problem with university professors in clinical environments is one of maintaining skills in the discipline. To offset that, we ask nurses who are already practising and who have a good mastery of their work — they work in the field every day and they have excellent skills in their discipline — to help us. However, they are not teachers.
We are favouring the mentoring approach more and more, where we pair a student nurse with a nurse practitioner. However, from one day to the next, the nurse who is paired with a student is often asked to become a teacher.
These nurses are at a loss as to how to pass on their knowledge, as they do not have the teaching skills. The student nurses learn by observing, which means that employers are not always satisfied with their performance when they start working. Employers find that they do not have enough skills to take on the responsibilities they are required to because they lack experience.
Senator Pépin: If I understand correctly, nurses study nursing at cégep or in college, and they practice only once the theory courses have been completed.
Ms Guimond: That is correct.
Senator Pépin: Several years ago, students took their courses in a hospital. Students practised eight hours a day in a hospital environment in addition to devoting four additional hours to their studies each day. The material was assimilated more quickly. The current system should be based on that model.
Ms Guimond: Absolutely. We cannot teach all of the theory. I will give you a practical example. I thought a fourth year surgery class. Students only had four days of practicum to apply this theory. That is not very much. That is why employers are not satisfied with the results. To offset that, we organized consolidation practicums, in other words, intensive eight-week practicums at the end of the program. Students are paired with nurses who have disciplinary skills. However, this is an additional responsibility for these nurses who, although they are experienced, do not necessarily have teaching skills. It would be a good idea to give these nurses some teacher training to help the students.
Senator Pépin: Is the training you are describing offered to everyone or simply francophones?
Ms Guimond: It is the same for everyone.
Senator Pépin: I would be in favour of going back to the old system. It would also give students an opportunity early on after the start of classes to see whether the profession suits them.
Ms Guimond: That is where we have the problem with retention.
Senator Pépin: What would we need to develop a more practical patient-focused system?
Ms Guimond: We should emphasize practical training, which is not sufficiently done at present. We should also increase the length of the internships. To do so, we need people in the field who are able to provide this training. There should also be some teacher training for nurses who are already practising. The problem at present is that they are already overworked.
Mr. Fontaine: I am not aware of the details, but there are perhaps some differences with respect to the curriculum. In Ontario, a transition is currently underway. College training programs lead to a B.A., which is a new requirement to enter the profession. For us, it has been a requirement for the past five years. College or two-year programs no longer exist. Students must have a B.A. to practise the profession.
Professor Guimond is raising a real difficulty. In our university, we have been forced to hire teacher practitioners who are simply monitoring students during their practicum in the hospitals. These are not nurses from the Hospital Corporation; they are university employees, professional nurses who have a graduate degree. They are training as practitioners, but they work exclusively for the institution, in the hospital. The problem is finding enough of these trainers, as there are not enough of them.
The Acting Chairman: That system is coming quite universal.
Senator Losier-Cool: Mr. Chairman, I do not know if you want to continue on the topic of nurses.
The Acting Chairman: You should be specifically examining the francophone situation.
Senator Losier-Cool: Mr. Fontaine, I would like to thank you for using your examples to illustrate the level of maturity that has been reached with regard to health care issues by talking about education and justice.
Ms Guimond, you have highlighted the shortage of nurses. You even said: ``produce nurses quickly.'' The word ``produce'' struck me. Are there any orientation programs designed to interest young men in the nursing profession? With the women's movement, many women have opted for medicine. However, we do not see the same among men. Is it because there are not enough role models?
Ms Guimond: It is true that we have very few male students from year to year. Some years, there are three or four young men out of 30 students on the francophone side, and the same problem exists on the anglophone side. There are no specific incentives or recruitment programs to attract men to the profession. I do not think that there is anything specific being done in that regard. I made a presentation in the high school. The only advertisement for the presentation was a poster on the bulletin board. Not a single man attended the presentation.
Senator Losier-Cool: Mr. Fontaine, if the federal government were to tie its transfers to the provinces to a condition or obligation to provide training in French, would it again be accused of interference? Remember what happened with the Millennium Scholarships.
Mr. Fontaine: We think about that when we work on matters like this for several reasons. In the longer term, we cannot see how provinces cannot be involved in this initiative for a long period. Initially they are not. In many cases, when francophone universities outside Quebec offer courses in the health care field, operational budgets for these universities come from the provinces. So the provinces are already funding French training for health professionals. It is, obviously, not universal. It is more less important based on the jurisdiction and the university.
From our experience, if we want to be successful in attracting candidates to the health care professions who will become health care professionals, and who will stay in the communities, part of the training must be done in these institutions, and another part in the communities where the services of these professionals will subsequently be required.
Today, some provincial jurisdictions are providing partial funding, Ontario, the University of Ottawa, Laurentian, et cetera, and New Brunswick. Elsewhere, there are very few or no professional training programs in the area of health care. These are not the most reluctant provinces, but the ones with which it would take more time to conclude agreements.
This is not unlike other matters that we have dealt with. I spoke about education and law. During the crisis in the 1980s, I think Senator Pépin was a politician at the time, is that not correct? The crisis in the 1980s in the west was resolved for the most part when the federal Cabinet stated that it would inject funds through a special agreement for schools board management and for developing francophone schools in the West and elsewhere. The federal government did it. For the next five years, there were negotiations and agreements and the provinces gradually followed suit. If the federal government is not prepared to get directly involved in the short term with the institutions and the communities to put this type of approach in place, we will have difficulty moving quickly. We do not have much time to lose.
If we cannot train health care professionals, they will go elsewhere, and the phenomenon described by doctor Schofield will occur. They will go to Quebec. I like going to Quebec. The problem is that if people do not come back, there will be more Acadians living in Quebec than in Acadia, in that causes a problem in Acadia.
That is the issue, but at the moment, I think the federal government needs to show significant leadership in this regard if we want to see some results.
Senator Losier-Cool: I would like to ask Dr. Schofield a question about francophones in the Atlantic Region. I know you are very familiar with this part of the country. The FCFA report stated clearly that francophones living in Newfoundland had no access to health care services in French — and this applies to francophones of, again, both Labrador City and Cap Saint-Georges. Would you agree that we need an isolated post allowance?
Dr. Schofield: For professionals?
Senator Losier-Cool: Yes, for professionals, for the doctors. This is a question that comes up in the case of northern Quebec, and many other regions.
Dr. Schofield: I can tell you what I think about isolated post premiums. I think they are helpful, but I do not think they are a long-term guaranty of success. The studies on isolation premiums show that they are good, but they have relatively little impact on recruitment and even less on retention. People go to these remote locations on contract, they get their pay, and at the end of their contract, they leave. So we are constantly having to start over again. Isolated post premiums concern me a little, because we are in a competitive market.
At the moment, health care professionals in Canada are worth their weight in gold. We are looking for health care professionals and the richest provinces are paying them salaries in keeping with high demand. But this leaves out the poor provinces and rural regions. I fear that getting involved in a competitive market is going to take us where we do not want to go. Such advantages may be helpful, but their usefulness is limited.
Senator Losier-Cool: This often comes to a question of principle and a matter of personal opinion. You spoke about positions. You are well aware of the situation, because you are the director of the agreement involving Acadia and Sherbrooke. Are the University of Moncton and the Beauséjour Corporation not mature enough to offer a full medical training program in Acadia?
Mr. Fontaine: Is the question for me or for him?
Dr. Schofield: I think that this is definitely not a decision for which I am solely responsible. However, if we look at all the success we have had with the medical training program in its present form, I think we have put in place all the criteria for successful recruitment and retention within the decentralized medical training program. It is true that we deal mostly with the Beauséjour Corporation, but we deal with others as well. I have students who go to the Edmundston and Bathurst region. They work on the Acadian Peninsula in Bathurst and Edmundston, and they go to the Grand-Sault region as well. We have a sort of decentralized education network in the province.
What we should perhaps have in New Brunswick is better cooperation among the four hospital corporations so as to develop this decentralized program in partnership with the University of Moncton and the University of Sherbrooke. If, some day, everything is in place for the faculty of medicine, then we should proceed, but that is not my decision to make.
Senator Losier-Cool: Would that be helpful to francophones in other Atlantic provinces?
Dr. Schofield: I think a francophone training facility in the Atlantic region would be helpful to Nova Scotia, Prince Edward Island and Newfoundland. I think we could be influential in that regard. I do not agree that we need a faculty of medicine to achieve this objective. I think can get there in a different way. This may be a long term vision. However, I think that what we have done so far has enabled us to provide many services, and the system is working well. We have to capitalize on what works well. Let us continue in the same direction. If, someday, there is the political will to establish a French-language faculty of medicine in the Atlantic region, that will be fine with me.
The Acting Chairman: That is a very diplomatic answer. For a doctor, that is most diplomatic.
Senator Gauthier: I have a few questions. First of all, you doctors should not be upset to hear that lawyers are about 25 years ahead of you in the practice of law in French throughout Canada. One of the reasons for that is that the federal government is involved into criminal code and the law.
The delivery of health care services comes under provincial jurisdiction. Do you agree, Doctor Schofield?
Dr. Schofield: Yes.
Senator Gauthier: To a large extent, the problem is the responsibility of the provinces. Have some provinces or territories expressed any support with respect to the recommendations made by the FCFA in its report on health care in French?
My concern is for patients, people who want service in their own language. I am familiar enough with the system to tell you that in Ontario, doctors and nurses are trained in English. In Ottawa, there is one hospital, the Montfort, where services are provided in French. There is also the Georges-Dumont in New Brunswick; so we have two institutions that provide service in French. Otherwise, services are usually offered in English.
I am thinking about my grandparents and my uncles and aunts. The could not speak French in lowertown, in Ottawa. Imagine that. We could not speak our own language when we were sick and wanted health care services in our own language.
Senator Gauthier: There was an attempt to close down the Montfort Hospital, but we managed to keep it. The provinces have decision-making authority. However, the federal government has some persuasive power and definitely a spending power that it uses when it must. Consequently, 10 million dollars was provided to Ottawa for training purposes.
The consortium is calling for 20 million dollars a year for the years ahead. What a lot a catching up we have to do. I agree that it will be appropriate to invest more time and energy in decentralizing and regionalizing training.
You are right to say that in order to interest young people in coming to our French-language institutions, we have to offer them training in both close and distant locations. Telemedecine exists and the technology for it exists. It is now possible to have both centralized and decentralized training centres connected by means of telemedecine.
Dr. Schofield: Your question has a number of parts. Your first point was about provincial jurisdiction over health care services. When we look at the work done by the consultative committee, we see that from the outset, there were three representatives of provincial departments of health on the committee. The approach of the consultative committee was to incorporate its objectives into provincial objectives.
Health care has become such a priority in all regions that it is difficult to believe that bringing more health care professionals — whether anglophone or francophone — into the province would displease anyone. The fact is, of course, that our francophone professionals will also offer their services to English-speakers. Telemedecine and other systems are beneficial in this regard for provincial departments.
The objective of the federal government and the provincial government is to further the health of the population. That is the ultimate goal of this entire initiative. To that we have added a very important element: the health of francophones. There is a question of equity as regards access to health care services, and that is the focus of our efforts.
Four provinces have sent letters to the Department of Health in support of this initiative. New Brunswick, Nova Scotia, Alberta and Manitoba have expressed their interest in being part of these offers. We have an opportunity now that we have not had for a long time. We must avoid errors. The greater the participation we have, the better our chances of success for all. So, we have to be careful not to step on anyone's toes and to work together toward a common vision and objective.
There is more than one hospital corporation that offers services in French in New Brunswick. Beauséjour is the largest, and the most important one, but Edmunston operates in French, Bathurst operates in French to a large extent, and Campbellton operates partly in French. The situation in New Brunswick has changed a great deal in the last 20 years. As a result of changes in health care services, and the training programs established at the University of Moncton and the agreement between Quebec and New Brunswick, we have been able to bring health care professionals to the province and to build a health care system in French.
To take the example of the francophone medical training program in New Brunswick, 20 years ago, we started with two teaching doctors and one student. Why not do the same thing in Alberta, and Manitoba, with a training centre in each province? There are definitely some small communities where we can start to introduce French-language health care services with one doctor and perhaps one student.
It is necessary to get into the small communities. There are communities, cultural centres, education centres and health centres throughout virtually all of Canada. Why not include a health clinic in the small locations? Establishing a health centre requires resources and infrastructure. I think the will exists, across the board. If we can bring a national vision into the small communities and start building quickly, I sincerely believe that we can change things.
Senator Gauthier: A number of problems have been raised. I have two brief questions. Are you familiar with the sixth principle? When Georges Arès appeared before the committee, he suggested that we add to the five existing principles a sixth one on linguistic duality. What do you think about that, Rector Fontaine?
Mr. Fontaine: I think this is an issue that is part of the whole discussion. Is it necessary to include this as an official principle in the Health Act? I have not looked at the issue in this light. We have to ensure that the principle is reflected in federal programs, in transfers to the provinces for health care and in direct initiatives by the federal government for the official languages communities. The fundamental thing is that the language requirements of the Government of Canada and the Constitution must be respected.
I chaired the Treasury Board Minister's committee on government transformations and their impact on official languages. Some administrative procedures have been introduced since that time by the federal government. That was the point we emphasized the most. It is difficult to provide for everything. Not providing for something often means that it is not mandatory.
I think this is a mandatory issue and a question of vigilance on the part of the federal government. When it delegates its responsibilities to one province or another, it must ensure that language requirements are part of this delegation of authority.
Senator Gauthier: Would you like to comment, Dr. Schofield?
Dr. Schofield: A principle is a principle. I prefer actions to principles. A principle may be written down, but not implemented.
The Acting Chairman: That is the difference between a doctor and a lawyer. Do you have a final question, Senator Gauthier?
Senator Gauthier: You spoke about outside recruitment. Do you have a 50 per cent policy in New Brunswick?
Dr. Schofield: New Brunswick calculates its training needs as follows. The province finances 50 per cent of the recruitment for training, and we expect that the other 50 per cent will come from outside sources. This is the way in which the department's basic calculation is always done. As you know, it is never easy to calculate medical labour force requirements. New data on labour force planning come out every two years, and they must always be taken into account. The province now realizes that it definitely must fund more training in health care.
Senator Gauthier: Is it difficult for immigrants from Africa, Europe or other countries to get professional accreditation here?
Dr. Schofield: It is very difficult. Foreign doctors arriving in New Brunswick, or any other province, have a hard time getting a licence to practice medicine. However, a restricted licence may be granted in certain situations. In recent years, we have integrated foreign physicians into our training programs to provide them with an equivalent Canadian degree and given them service contracts in specific regions. This has proven successful. These are candidates with a great deal of potential. We have to take a little more time to integrate them harmoniously into the Canadian health care system and into our way of doing things. This initiative has produced excellent results at a minimum cost, if we compare three years of training to six or ten years.
Senator Gauthier: Is it possible to take a professional examination from the professional Order of Physicians or Physiotherapists in French in New Brunswick? Do the professional orders accept examinations in French? That was very difficult and took a very long time in Ontario. I am very familiar with the problem.
Dr. Schofield: In the case of the medical training program, everything is in French — no course, no training or clinics are given in English. The examinations are set by the University of Sherbrooke and the University of Montreal, the Collège des médecins du Québec and the College of Family Physicians of Canada. The examinations are all translated into French.
Mr. Fontaine: In New Brunswick, we have a choice. Candidates must pass an examination to become a member of a professional order, and they may do so in the language of their choice.
Senator Gauthier: You are not familiar with the situation in the other provinces, are you? Can that be done in Manitoba or in Ontario?
Mr. Fontaine: I could not say.
The Acting Chairman: Can everything be done in French for nursing in Ontario?
Ms Guimond: Candidates may take the examination in the language of their choice. Students taking the course in French are not required to write the examination set by the order in French. They may write it in English if they prefer. The texts and documentation are in English, and even though we teach in French, they are accustomed to reading in English. There are a limited number of clinical postings in French and when they do their training in an English- speaking context, they learn all the technology in English. Consequently it is difficult for them to do their exam in French. Despite the fact that a number of students are francophone, they often decide to write the examination in English.
Senator Gauthier: The problem is always placed on francophones in English-speaking institutions.
Ms Guimond: Yes.
Senator Gauthier: Does the College of Nurses of Ontario recognize the examination in French?
The Acting Chairman: These are university examinations, not government examinations. Perhaps we should have the difference explained.
Ms Guimond: Students write their university examinations in French when they get their degree. If they are registered in the French-language program, they must write their examinations in French. However, when they write the provincial examinations set by the College of Nurses of Ontario, they can register to write in English if they prefer.
Senator Pépin: Does that happen often?
Ms Guimond: Yes, it does.
Senator Gauthier: My question is rather indiscreet. Do you have a doctorate in nursing?
Ms Guimond: In education.
Senator Gauthier: Did you do it in French?
Ms Guimond: I did my doctorate in Montreal in French.
Senator Gauthier: You are lucky. You could afford to do that!
The Acting Chairman: Do you have any other questions, Senator Gauthier?
Senator Léger: Ms Guimond, you said that more emphasis needed to be placed on practical training. I think practical training is essential in any field.
Ms Guimond: Yes.
Senator Léger: What has been de-emphasized? Practical training? For patients, practice is all that counts. Has there been a shift in this direction in all professional fields? Some nurses' aids have told me that they were almost going crazy because they no longer knew how to look after patients. I think it is incredible that we find ourselves in a position of saying that we have to place more emphasis on practical training.
Ms Guimond: It is mainly a question of funding. It is rare that funding is provided to support training for instructors, for example.
Senator Léger: This practical training means with patients?
Ms Guimond: That is training in a practical setting.
Senator Léger: Patients are the ultimate objective of all this, are they not?
Ms Guimond: Yes, that is correct.
Senator Léger: You also said that you wanted a new pedagogical model that would include judgment. That is the essential component of basic training. Judgment is more important than technical matters.
Mr. Fontaine, thank you for your confidence with respect to health care, as was the case of education and law earlier. This all reflects a vision. Everything that has been said for New Brunswick also applies to Prince Edward Island. I imagine the same is true of Newfoundland and the Yukon. Do your schools serve all francophones in Canada?
Dr. Schofield: Our unique feature is that we have included other criteria for success in our training program. That is what we wanted to promote when we asked our students to do some of their practical training in New Brunswick. Thanks to the agreement between Quebec and New Brunswick in its present form, there is already a position in medicine for Nova Scotia and Prince Edward Island.
We could add other health care professionals to this program. We could implement these programs and have an impact on our neighbouring provinces. We could also play a role for francophones in Newfoundland, because they have no services whatsoever. This will be done at different levels, using different resources. We spoke about information technologies. Distance education programs could always be included into these programs. We have to be innovative, but we must keep these students as close as possible to their home communities, while at the same time offering them high quality training. We also have to help them develop the infrastructure that we will welcome them once they finish their education. This can all be done in a beneficial manner.
Senator Léger: I appreciate your use of the conditional tense. Should this committee not invite representatives from the University of Sherbrooke, because it is the centre, but also representatives from the other provinces, in order to respond to the needs of francophones throughout the country?
Dr. Schofield: I mentioned the partnership between Acadia and Sherbrooke as a model, but it could be adapted to all the provinces. If we could develop a national vision and partnership, I think we could be innovative and meet some very specific objectives. But it does take some resources. In New Brunswick, it took us 20 years to get established and to prove ourselves, when practically everyone was saying that what we were trying to do could not be done. We want to be a model that could be applied elsewhere, throughout Canada, and in other fields as well as medicine.
Mr. Fontaine: There was a little applied intelligence in all of that, and some carefully calculated opportunism as well. We could make a significant effort to train health care professionals under agreements such as those mentioned by Dr. Schofield — mainly the Acadia-Sherbrooke agreement or the one in Ottawa with the Montfort Hospital. I have no inferiority complex about my community's ability to train the labour force it needs. If there is enough political will, there would be no reason not to have a faculty of medicine to train francophones outside of Quebec. Once we have this political will, we will be able to do that and we will find the resources we need. They exist, they have simply not yet been assembled and organized. It is a question of means, not capacity. We have to look at the medium term. If Newfoundland has a faculty of medicine at Memorial University, I think the francophone communities of Canada could have a French-language faculty of medicine.
We have to be sure that all the essential components are brought together in order to act. I know that a law faculty is not as complicated as a faculty of medicine, but in the 1970s, we were told that it was not possible to have French language law faculties outside Quebec. Once the political will was in place and people got down to the job, this faculty never brought dishonour on anyone. It would be exactly the same in the medium and long term in the case of the faculty of medicine. It is a question of timing, of picking the right moment.
As the rector of the University, I am not saying that this is going to happen tomorrow, but once there is a will to do that, there will definitely be a will to work to move things forward.
The Acting Chairman: It is good to see a rector getting involved in this way. I think Dr. Schofield is pleased to hear that.
Senator Losier-Cool: I do not have to ask the question!
[English]
Senator LeBreton: Dr. Schofield, when you talked about the New Brunswick experience, you said that 30 per cent of doctors practice in French now as opposed to 18 per cent 20 years ago and that the doctor-patient ratio is now approximately 1 for 700. I did not hear the actual figure. How long did it take to get to that level of practice? In a realistic world, with all things working out properly, what are your short- and long-term goals in terms of providing medical service to francophones in their own language? I want to get a sense of how long it has taken to get to this point and what the ideal ratio is in terms of servicing the population in relation to the rest of the country.
Dr. Schofield: One for one.
[Translation]
Actually, this ratio has changed over a 20-year period. We had a ratio of one doctor to 791 inhabitants in 1980, and of one doctor to 742 inhabitants in 1999-2000. It took 20 years to change this.
In 20 years, the number of students per year admitted into medicine in French has not changed, nor has the number of students who complete the program. We cannot expect that the ratio will improve because the number of admissions has remained stable, and consequently the number of students who complete the program will not be higher and the ratio will remain the same.
The disturbing thing is the factors that will have an impact on the number of doctors. There is the fact that more women are becoming doctors, as well as the lifestyle changes for everyone. Both male and female doctors want a better- organized practice. They want to work 40 to 60 hours a week, rather than 80 to 90 hours a week. The aging population will make for a huge increase in workload for doctors, as well as the fact that physicians are retiring early. In the past, doctors practiced until the age of 60 or 70. This will happen less and less often. Physicians have been a little wiser and have accumulated pension funds. We will see them retiring early, perhaps between age 55 and 60. They may also reduce their work hours in order to pursue other activities. It is therefore very difficult to calculate our future needs.
The figures produced by the New Brunswick Department of Health for medical training requirements, for example, refer to the year 2014. Taking into account some of the factors I just mentioned, the projection is that we would need forty francophone physicians and forty anglophone physicians in our training programs. These figures are conservative. It is very difficult to put a number on our needs, and this is always a dilemma, because we draw conclusions based on the figures we have.
As we know, the commission headed by Barry Stoddart recommended a reduction in the number of students admitted into medicine and nursing a few years ago. We are seeing the consequences of that today. The change of lifestyle was not taken into account, and this will certainly result in a significant reduction in health care resources.
If there is some input today, the consequences will not be apparent tomorrow, but in five or ten years. We should not be conservative in our projections, but rather very generous, and set high targets in order to correct the mistakes in five or ten years, as the phenomenon develops.
We will experience a significant shortage over the next ten years. If we do not solve the problem today, what can we expect in the future? Have I answered your question?
The Acting Chairman: Senator Keon is a cardiac surgeon and the Director of the Heart Institute in Ottawa.
[English]
Senator Keon: Even before the language issue, the entire question of training health professionals needs a tremendous amount of evolutionary change. We really have not addressed the kind of health professional we want to turn out to provide the ideal integrated team for our given circumstances.
Having a faculty of medicine for francophones somewhere to meet the needs of the francophone population would be a mistake. I think that if a faculty were to be created, it should be a health science faculty. That faculty should address the need for physicians — both primary care physicians and specialists — nurses, a new category of health professionals that can work somewhere between physicians and nurses, and the need for all the categories of the other 35 to 38 health disciplines, depending on the province.
Perhaps this is an opportunity to not only contribute to solving the problem of providing health professionals for the francophone population across the country, but it might also be an opportunity to construct a health science faculty that would provide the proper evolutionary changes in the entire field of health education. I would like to hear your comments.
Mr. Fontaine: At least two of our universities, which are part of this consortium, already have health science faculties. You are a professor at the Faculty of Health Sciences at the University of Ottawa. They have a number of disciplines and programs in that faculty that are taught in both French and English.
My university, the University of Moncton, is a French-speaking university. We have a health science faculty. There are 12 disciplines represented in that faculty. Disciplines include nursing, psychology, nutrition, kinesiology and social services. It is partly health, partly not health. We do not have a medical school; therefore, we do not have that program at the university. We do not have some programs in health sciences, such as dentistry or other kinds of professions.
Yes, we have health science faculties. We are looking at establishing health science bachelor degrees that would provide a universal program to prepare students for admission to graduate schools for health professions or medical schools in jurisdictions where these prerequisites are required.
In Quebec, you only need two years — cégep. We have the two-year program in Moncton so that our students may go to Sherbrooke University.
I would have a different point of view than you on the capacity of a university outside Quebec to establish a medical school. If governments were to finance such a venture, there is no reason it could not be successful. We have seen that in other professions.
I am not a doctor, and I am sure there are complexities that are different than the complexities of training for other professions. However, we do have engineering, law, forestry and all types of professional faculties. It is always a challenge to build a school like that, but if the Government of Ontario were to announce that it would build a new faculty at Laurentian University, it could be done. The infrastructure of Laurentian University is not any bigger than some of our universities. My feeling is that this could be achieved.
We are not about to launch this unless there is cooperation among governments, universities and health service providers.
Dr. Schofield: An objective that we would like to pursue in the francophone teaching program is interdisciplinary teaching, as you mentioned. I agree with you that we need to model, not only in practice but also in teaching, the health services of the future. It is known that when students go into a certain organizational system, they have a tendency to adapt that organized approach and practise it afterwards.
We have seen that in New Brunswick. When I started to practise in New Brunswick in 1980, there were no teams of family physicians. Everyone worked solo. We were the first team of doctors to get together and work as a group. Our practice was limited to family medicine. Other physicians would ridicule us by calling us UMF, which stands for United Maritime Fishermen. We were bucking the trend by doing something different.
Our team has grown to 10 physicians. We do all sorts of services in the region, including obstetrics, emergency care, hospital care, home care, long-term services, palliative care, adolescent care and many other things. We have each developed little specialties. Most of our students who graduated are working in group practice. They do not want to work solo because they trained with us in a group practice and have adopted the group practice concept.
The future is more than group practice. The future is interdisciplinary teams, nurse practitioners, psychologists and dieticians working together. All those people need to work with doctors because it is will make the system much more efficient.
We are putting together a project very similar to that of Ms Guimond, which we call ``Centre de santé communautaire universitaire.'' This centre will offer services and interdisciplinary clinical teaching because we need to get those specialists to work together in the clinical setting. Upon having all those people together, we hope to do research on the organization of service and health status for the population.
That approach could be brought up to a health science faculty level. I certainly would agree with that.
We need to look at where we want to go. We need to be somewhat innovative and build that into the system if we want to move ahead. I agree completely with that. People are hoping that this will happen worldwide. I work sometimes with the World Health Organization, WHO, to push the concept of partnership and interdisciplinary teams, and we try to build health resources within that context. We are sure that it will create a much more efficient system.
[Translation]
The Acting Chairman: We do not have enough time for any more questions. It is now noon. I know that a number of colleagues would have liked to ask you some questions. Perhaps you would agree to answer some of their questions individually after the meeting.
Before closing, I would like to congratulate you. Unfortunately, we did not have an opportunity to talk about the national health care training centre. Senator Gauthier referred to it. We consider it a model, and we would have really liked to hear your comments on it. I know that as a result of some funding from Heritage Canada, you have been able to increase your recruitment. We would have been interested to hear about the results of this experiment, because it could serve as a model for federal government funding for health care. In any case, I am sure we will have an opportunity to hear about the centre some other time.
Rector Fontaine, your university can serve as a model for smaller universities. You show the dynamism I noticed when I visited your university a year ago. I congratulate you and wish you every success in your work.
Dr. Schofield has established a model, and I very much like his approach, which is to work regionally and not set objectives that are too ambitious. He is building in his own region. If his efforts are successful, others will be able to imitate what he has done. You refer to the tragic situation regarding the Professional Training Act in Manitoba. Unless I am mistaken, there is absolutely nothing at all there.
Yesterday we were told that the third largest francophone community in Canada was in British Columbia. There was a reference to the complete lack of any training facilities. Saint-Jean University in Alberta is an excellent institution that offers no programs in health care. There is definitely work to be done in this area, but I think you sketched out a solution when you said that we should start with small facilities in certain places and then build on them. Once again, I would like to offer my congratulations, because we realize that you work under difficult conditions.
The meeting is adjourned.