4.1 Global Trends – From 1975 to 2000

Graph 4.1 depicts the evolution of total health care spending in Canada over the last 25 years. Expressed in current or nominal dollars (bold line), total health care expenditures grew steadily from $12.2 billion in 1975 to $95.1 billion in 2000. In fact, the growth in nominal health care expenditures exhibited double digit rates in the 1970s and early 1980s, but it did slow considerably to single digit growth rates in the latter part of the 1980s and the 1990s(55). Abby Hoffman from Health Canada told the Committee:

We must be careful how we interpret the extent and the significance of the slowdown because raw numbers are a little misleading. We need to take into account the much higher levels of inflation in the 1970s and early 1980s, compared with single digit inflation in the latter part of the 1980s and the 1990s, and our current very low levels.(56)

The second line in Graph 4.1 represents total health care expenditures adjusted for inflation and converted into constant (1992) dollars(57). Even after removing the effect of inflation, which makes it possible to measure real growth rates, health care spending rose steadily from 1975 to the early 1990s. However, the real rates of growth throughout the 1975-2000 period were much lower, in the range of less than 1% to about 5%.(58)

According to CIHI, sustained growth in health care spending in the last four years reflects primarily increased investment in health care by governments.

A number of witnesses who appeared before the Committee suggested that, in order to properly interpret trends in health care spending, the data should also be adjusted to the size of the population. Total health care spending per capita is presented in Graph 4.2.

 GRAPH 4.1

GRAPH 4.2

The fine line, which represents per capita expenditures adjusted for both inflation and population, indicates that health care spending in Canada increased from 1975 to the early 1990s. However, there were small annual declines in real expenditures per capita from 1992 to 1996. This trend was reversed in 1997 and real annual rate of growth in spending per capita is expected to average 3.6% between 1997 and 2000.

GRAPH 4.3

Another way to measure how much Canada spends on health care is to calculate health care expenditures as a percentage of gross domestic product (GDP)(59). This indicator, which is referred to as the "health care to GDP ratio", reflects the extent to which Canada devotes productive resources to health care. In 1975 (see Graph 4.3), health care expenditures in Canada amounted to 7.0% of GDP. This percentage increased for the most part of the 1970s and the 1980s, and it peaked at 10% in 1992. Then, the health care to GDP ratio decreased continually from 1992 to 1996, when it reached 9.0%. The latest forecast by CIHI suggests that this downward trend has been reversed: the share of the GDP devoted to health care rose to 9.3% in 1998 and it has remained at this level in 1999 and 2000.

4.2 Public versus Private Spending

While the public sector is currently the main source of health care funding in Canada, this was not the case forty years ago, when over half of health care spending came from the private sector(60). Graph 4.4 provides information on the sources of health care financing in Canada. In 1960, private sector funding accounted for over 57% of total health care expenditures. Throughout the next decade, as universal health care insurance was introduced in the provinces, health care expenditures by the public sector grew at rates that were much higher than the growth rates in private sector funding. As a result, the private sector share dropped dramatically. By 1975, the public sector share had increased to over 76%, while the private share accounted for the remaining 24%.

GRAPH 4.4

Between 1975 and 1985, the private and public shares remained relatively constant. Then, governments initiated restraints in funding for hospitals and physician services and introduced measures to enhance efficiencies in the health care system. This resulted in a levelling off of public expenditures. As the same time, the private sector share began to increase and, in 1997, it peaked at 30%, higher than at any time since 1970. The private sector share has decreased slightly in recent years, to reach 29% in 2000. In that year, the public sector share amounted to 71% of total of health care spending.

GRAPH 4.5

Once again, it is useful to consider trends when expenditures are adjusted for both inflation and population size. Graph 4.5 shows that public sector expenditures per capita in constant dollars increased continuously from 1975 to 1992. Between 1992 and 1996, public sector expenditures on health care on a per capita basis decreased in real terms. In other words, growth in public spending on health care did not keep up with either economic growth or population growth. This downward trend was reversed in 1997 and, in 1998, public spending on health care, per capita, in constant dollars, came back to its 1992 peak. This was followed by a real growth of 4.4% in 1999 and 4.8% in 2000:

When one adjusts spending for overall population growth and general inflation, the slowdown in public spending – indeed the decline in the mid-1990s – becomes more apparent. In other words, the mid 1990s was clearly a period when public health expenditures did not keep pace with overall, albeit low, inflation rates and population growth. However, with the rebound in public health expenditures in the late 1990s, the overall level of public spending regained its peak of the early 1990s in terms of real per capita expenditures, even after adjusting for population growth and the general rise in price levels.(61)

4.3 Categories of Expenditures

In 2000, Canada spent $30.2 billion on hospital care. Hospital care is the largest category of health care expenditures, accounting for 31.8% of total health care spending in 2000. The share of total health care spending allocated to hospitals has seen a downward trend over the last 25 years, from a high of 45.0% of total health care expenditures in 1976 (see Graph 4.6).

GRAPH 4.6

Spending on physician services amounted to almost $12.8 billion in 2000, representing 13.5% of total health care expenditures. Between 1975 and 1985, the share of total health care spending on physician services remained relatively constant. It declined slightly from 1985 to 2000.

Since 1997, expenditures on drugs have been the second largest category of total health care spending, overtaking spending on physician services. The share of total health care spending allocated for drugs has grown continuously over the last 25 years, from 8.8% in 1975 to 9.5% in 1985, 13.4% in 1995 and 15.5% in 2000.

GRAPH 4.7 

Public spending by category ranges from 100% of expenditures on public health to 10% of expenditures on health care providers other than physicians (see Graph 4.7). More than 70% of total expenditures in all categories, except drugs and other professionals, is publicly funded. Public sector spending on hospitals accounts for some 91% of total spending on hospitals, while just under 99% of total physician services is financed by public sector sources. Private health care spending in Canada is generally concentrated in areas such as drugs, dental services, vision care and home care, items for the most part not covered under the Canada Health Act.

4.4 International Comparisons

International comparisons are another way of evaluating our health care system. Indeed, in attempting to determine the optimum size of the health care sector, international comparisons are essential to gaining a better understanding of the volume of expenditures and the factors causing them to increase. There is a variety of indicators for health care spending that can be used when comparing countries. As Professor Deber pointed out during her presentation to the Committee, it is important to give a precise definition of what is measured by each indicator because Canada’s ranking changes depending upon the indicator used to measure health care spending.

There are three types of indicators that are most commonly used to compare the level of health care expenditures among countries. The most frequently used indicator is the ratio of health care expenditures to GDP, which measures how much of the total economy each country is devoting to health care.

As shown in Table 4.1, in 1998, Canada ranked fourth (9.5%) among the OECD countries, after the United States (13.6%), Germany (10.6%) and Switzerland (10.4%), in terms of the ratio of total health care expenditures to GDP. The United States spent the highest proportion of GDP on health care, while Turkey spent the least. Japan ranked 18^th, with a relatively low proportion of GDP devoted to health care (7.6%). On average, OECD countries spent 7.9% of GDP on health care. This indicator suggests that Canada spent more on health care than the OECD average in 1998 and is one of the top spenders on health care.

TABLE 4.1

Another international indicator is "nominal spending per capita": it involves converting national currency units into a common unit (usually US dollars) and then dividing by its population. This indicator is therefore adjusted for population size. The third column in Table 4.1 indicates that Canadian health care spending in 1998 amounted to $1,828 US per capita. Using this measure, Canada slipped to 14^th place, far behind the United States ($4,178 – 1^st place), Switzerland ($3,834 – 2^nd place), Norway ($2,836 – 3^rd place) and Germany ($2,769 – 4^th place). Canada’s spending on health care was comparable with that of Sweden, the Netherlands and Finland. By comparison, Japan ranked 9^th, spending $2,283 US per capita. Using this indicator, Canadian spending on health care is in line with the average OECD amount and we are not among the countries that spend the most on health care. Japan’s showing is not nearly so impressive: while it ranked 18^th in terms of health care expenditures as a percent of GDP (among the lowest spending levels), Japan’s comes in 9^th place in terms of US dollars per capita (among the highest levels of health care expenditures).

A more sophisticated indicator uses purchasing power parity (PPP) per capita; it is computed by comparing the prices of identical products in various countries and dividing by population(62). The conversion into PPPs eliminates price disparities between countries. With this indicator, Canada remains among the top, ranking 5^th ($2,312 per capita), following the United States ($4,178), Switzerland ($2,794), Germany ($2,424) and Norway ($2,330). Japan ranked 14^th, in the middle of all the OECD countries ($1,822).

Regardless of the measurement used, the United States clearly spent the most on health care in 1997, followed by Germany and Switzerland. Although Canada’s spending was high, it was proportional to that of several other countries.

Table 4.2 provides the OECD ranking with respect to public health care spending. In 1998 in almost all countries, the best part of health care spending came from the public sector. In Canada, 69.6% of total health care expenditures were publicly financed, a proportion lower than the average among OECD countries (73.6%). The United States and Korea were the only two OECD countries where more health care spending came from the private sector than from the public sector, with approximately 45% of total health care spending coming from public sources. At the other extreme was Luxembourg, where 92.3% of total health care expenditures were publicly financed. Compared with other OECD countries, Canada had the 9^th highest public health care expenditures measured as a percentage of GDP. Interestingly, Canada’s level of public health care spending as a proportion of GDP was close to that of the United States.

TABLE 4.2

Have different countries experienced similar trends in health care expenditures over the last four decades? Graph 4.8 depicts the evolution of health care expenditures as a percentage of GDP in selected OECD countries from 1960 to 1998. It can be seen that the United Kingdom has consistently devoted far less of its GDP to health care than either Canada or the United States has done. Trends in health care to GDP ratio in Canada and the United States looked virtually identical until about 1971 – when Canada instituted universal health care insurance, while the United States did not.

GRAPH 4.8

The health care spending to GDP ratio in Canada remained relatively stable throughout the 1970s. Then it peaked at 10.2% in 1992, second only to the United States. Many observers have argued that Canada now had one of the most expensive health care systems among OECD countries. This result was widely discussed and interpreted as meaning that the Canadian model was inherently inflationary. As in Canada, most OECD countries experienced growth in health care expenditures as a percentage of GDP during most of the 1975-1990 period. Increases also occurred in the early 1990s, during periods of low GDP growth and recession, and then were followed by stabilization or slight declines in the ratio of health care spending to GDP. However, Canada is the only country to have experienced a five-year decline (from 1992 to 1997).

4.5 Health Care is a Priority in the Provinces

During her testimony, Raisa Deber contended that health care is the priority for provincial governments and that spending on education and social assistance has been cut rather drastically in the provinces. Graph 4.9 depicts provincial government spending on health care, education and social services as a percentage of total program spending; while provincial governments have increased the proportion of public spending devoted to health care and social assistance, spending on education has been declining steadily. The 2000-01 Performance and Potential report of the Conference Board of Canada shows similar trends: in the last three years, 62% of the increase in provincial government spending went to health care, while 25% was devoted to education, 3% to social services, 5% to interest and 5% to general spending.(63)

GRAPH 4.9

4.6 Committee Commentary

We hope that this chapter will contribute to a better understanding of the past and current trends in health care spending, of the relationship between public and private health care expenditures, and of the Canadian situation in terms of international comparisons. There remain, however, gaps in the information about health care expenditures. In a recent report, CIHI indicates what we do not know about health care spending in Canada:

• How do changes in health care spending affect the health status of the population?
• How does health care spending differ between regions within provinces?
• What are the costs of treating specific diseases?
• What are the costs of rehabilitation, health promotion and other community-based services?
• How much do Canadians spend out-of-pocket on complementary and alternative medicine (e.g. massage therapy, homeopathy, herbs and other similar remedies, etc.)?(64)

Moreover, there are still other difficult questions. For example, how much of its GDP should Canada devote to health care? What would be an appropriate level of public health care spending? What role should the private sector play in the financing of health care? What should be the role of the federal government in health care and, more specifically, how much money should it earmark for health care? What factors could explain the disparities in health care costs among OECD countries? Are there important lessons for future public policy in Canada that can be learned from a close examination of the international experience? These questions and others will be debated when the Committee examines a set of options for the future of Canadian health care system in Phase Four of its study.

Health Status and the Concept of Population Health

Canadians are extremely interested in health. Personal health status, the health of family members and that of our friends are all important. Good health enables us to lead productive and fulfilling lives. For the country as a whole, a high level of health contributes to increased prosperity and overall social stability. Therefore, the overall level of health enjoyed by Canadians is an important indicator of the success of our society and our quality of life.

5.1 Health Status of Canadians

There is a variety of health status indicators. Life expectancy, for instance, is a widely used, internationally accepted measurement of the health of a population. It is defined as the average number of years an individual of a given age is expected to live if current mortality rates continue.

Over the past century, life expectancy has increased steadily (see Graph 5.1). Based on current mortality patterns, a baby girl born in Canada in 1996 can expect to live 81 years on average, while a baby boy will live 76 years. This is a new high in Canada. At all ages, women have a greater life expectancy than men. The gap in life expectancy at birth between men and women has been narrowing, however, since the early 1980s.

Life expectancy measures years of life only. Related indicators are being developed to tell us whether those years of life are spent in good health. One example is disability-free life expectancy, which measures the years of life spent in various states of independence. In this regard, a Canadian child born in 1991 could expect to spend on average 69 years – almost 90% of his or her total life span – free from disabling health problems. Other measures such as quality-adjusted life expectancy and health expectancy are still evolving, and long-term trends are not available.

GRAPH 5.1

Life expectancy and related indicators do not evolve very quickly, however, so it is not expected that significant changes will be observed from year to year. For example, between 1986 and 1991, disability-free life expectancy increased by 1.2 years for men and by 0.6 years for women.

The age-standardized mortality rate (ASMR) is another useful health status indicator. The ASMR is a measure of the death rate that is adjusted to take into account the age distribution of the population. Graph 5.2 depicts the evolution of the ASMR for both males and females over some 47 years. It can be seen that the ASMR for both sexes improved continually during this period. Specifically, the ASMR fell from 1,375 deaths per 100,000 males in 1950 to 848 deaths in 1997, and from 1,089 deaths per 100,000 females to 524.

GRAPH 5.2

Another internationally recognized indicator is called "potential years of life lost" (or PYLL). It refers to the number of years of life lost when a person dies before a specified age, say age 75. A person dying at age 25, for example, has lost 50 years of life. PYLL helps to identify causes of deaths which occur in younger age groups and which could, in theory, be prevented or postponed.

Long term trends in PYLL by major causes of death are presented in Graph 5.3. In 1997, there were over one million PYLL due to all causes, the most important being cancer, accidents and heart disease. As the graph indicates, cancer has been the leading cause of PYLL since 1984, and is the only major cause of PYLL to have continually increased. PYLL due to accidents have declined dramatically since 1979. The PYLL of heart disease, respiratory conditions and strokes has also declined over the past two decades. This suggests that Canada has been successful in reducing premature mortality over the past thirty years.

GRAPH 5.3

GRAPH 5.4

Infant mortality is often used as a basic indicator of social and economic development. The rate of infant mortality – deaths within the first year of life – has declined substantially over the last 20 years in Canada (see Graph 5.4). In 1997, the rate of infant mortality was about 6 out of every 1,000 newborns, down from 15 deaths per 1,000 births in 1974.

Overall, the health status of Canadians has improved continuously over the past decades. Canadians live longer with fewer disabilities in old age. Fewer babies die in the first year of life and premature deaths from major causes, except cancer, continue to decline. Where does Canada stand internationally in terms of health status?

5.2 How Does Canada Compare to Other Countries?

In 1998, life expectancy at birth for Canadians was 79 years. Canada ranked second only to Japan (80 years) among the 25 countries with the longest life expectancy (see Graph 5.5). By contrast, the United States ranked the lowest, along with Luxembourg.

GRAPH 5.5

Canada ranked fourth in 1996 in terms of age-standardized mortality rates among 20 OECD countries (see Graph 5.6). Japan had the lowest rate, followed by France and Sweden. By comparison, Germany ranked 10^th, the United Kingdom 11^th and the United States 13^th.

GRAPH 5.6 

Compared to five other industrialized countries for which figures are available, Canada ranked second lowest in PYLL per 100,000 population for males and third lowest for females (see Graph 5.7).

Like Canada, other industrialized countries have seen a decline in their infant mortality rates over the past few decades (see Graph 5.8). In 1960, the rates ranged from a low of 22 per 1,000 in the United Kingdom to a high of 44 per 1,000 in Italy. By 1996, the rates had fallen to a low of 4 in Japan and a high of 7 in the United States. Canada’s infant mortality rate remains far above that of Japan which is the lowest in the world.

GRAPH 5.7

GRAPH 5.8

Overall, a variety of health indicators show that Canadians enjoy a standard of health that is among the highest in the world. Canada ranks second in life expectancy, behind only Japan. Canadian mortality rates are among the lowest in OECD countries, behind only those of France, Sweden and Australia. And Canada has the second lowest premature mortality rate among industrialized countries. While Canada’s infant mortality rate is still higher than Japan’s, it is well below the American rate.

5.3 Health Care Expenditures and Health Status

Somewhat surprisingly perhaps, there is no definitive relationship between a country’s spending on health care and the health status of its population (see Graph 5.9). For example, the Japanese have the longest life expectancy; yet their health care expenditure as a percentage of GDP is the second lowest among the industrialized countries. By contrast, the Americans have the highest ratio of health care spending to GDP, but their life expectancy is one of the lowest and their infant mortality rate one of the highest. While Sweden and Italy have similar levels of health care expenditures, the life expectancy of their respective populations differs. In addition, Canada spends less on health care than the United States, but the overall health status of Canadians is much better.

GRAPH 5.9

It is obvious that there is no clear relationship between a country’s health care spending and the health status of its population. In other words, the health status of a population depends on many factors of which health care is only one.

5.4 The Concept of Population Health

It is clear that the state of the health care system affects our health. Services such as childhood immunisation, medications to reduce high blood pressure as well as heart surgery all contribute to health and well-being. But a good health care system is only one of numerous factors that contribute to good health. Graph 5.10 reproduces a chart prepared by the Canadian Institute for Advanced Research available on Health Canada’s website. This graph suggests that only 25% of the health of the population is attributable to the health care system, while 75% is dependent on factors such as biology and genetic endowment, the physical environment and socio-economic conditions.

 GRAPH 5.10

The term "population health" is used to describe the multiplicity and range of factors which all contribute to health. "Determinants of health" is the collective label given to the multiple factors which are now thought to contribute to population health. While there is no agreement on a finite set or the relative importance of the determinants of health, a certain degree of consensus has developed over the past decade. The list of health determinants presented in Table 5.1 was provided by Health Canada. It must be pointed out that the population health approach does not detract from the impact of the health care system, but it includes additional factors or determinants of health and takes the interaction between and among the determinants into consideration.

Unlike traditional health care, which deals with individuals one at a time when they become ill, population health strategies aim to improve the health of an entire population through broadly based preventive approaches that take determinants of health into account. Such preventive approaches ward off potential health problems before they have an impact on the health care system.

The concept of population health is not new. In 1974(65), the then federal Minister of Health, Marc Lalonde, released a working document entitled A New Perspective on the Health of Canadians. This report put forward the idea that good health is not the result of medical care alone. For example, it proposed that changes in lifestyles or to social and physical environments would likely improve in the health status of Canadians more than would spending more money on health care delivery. The Lalonde report identified four major health determinants: human biology, environment, lifestyle and health care organization.(66)

KEY DETERMINANTS OF HEALTH

Source: Health Canada, Towards a Common Understanding: Clarifying the Core Concepts of Population Health, Discussion Paper, December 1996, pp. 15-16; F/P/T Advisory Committee on Population Health, Strategies for Population Health: Investing in the Health of Canadians, Ottawa, 1994, pp. 2-3.

The Jake Epp report, Achieving Health for All: A Framework for Health Promotion, released in 1986 when he was federal minister of health, gave us new insight into the field of population health by focusing on the broader social, economic and environmental factors affecting health.(67)

The Epp report viewed health promotion as a complement to the health care system and a means to reduce health inequities between the various socio-economic population groups, to prevent the occurrence of injuries, illnesses, chronic conditions and their resulting disabilities, and to enhance people's ability to manage and cope with chronic conditions, disabilities and mental health problems.

In 1989, the Canadian Institute for Advanced Research (CIAR) argued that individual determinants of health do not act in isolation, noting instead that it is the complex interaction among the various determinants that can have a far more significant effect on health. These types of interaction can help explain why some groups of Canadians are healthier than others in spite of the fact that all Canadians have equal access to the health care system.

In 1994, the population health approach was officially endorsed by the federal, provincial and territorial Ministers of Health in a report entitled Strategies for Population Health: Investing in the Health of Canadians.(68) This report summarized what was known at the time about the broad determinants of health and set out a framework to guide the development of policies and strategies to improve population health.

In 1997, the National Forum on Health furthered the discussion of the determinants of health. It stressed the importance of working, not only with health departments, but with various sectors, to take action on the determinants of health. It proposed the establishment of a "Population Health Institute" as an instrument to improve decision-making in the field of health by contributing and promoting a population health perspective in health research and policy-making.

In response to the Forum’s recommendation, the federal government launched the Canadian Population Health Initiative (CPHI) in 1999. Established within CIHI, the initiative is designed to bring together researchers and analysts from across the country. It builds on existing databases and aims at creating a statistical infrastructure that will form the foundation of population health research. It will aggregate and analyse data, develop data standards and common definitions, report to the public on the national health status and health system performance as well as act as a resource for the development and evaluation of public policy. The first CPHI Council was announced on February 3, 2000. It is now developing a research agenda, and dissemination and communication strategies.

Again in 1999, the Federal/Provincial/Territorial Advisory Committee on Population Health released a report entitled Intersectoral Action… Towards Population Health which stressed that improving the health, well-being and quality of life of the population requires the involvement of many sectors(69). It stated that intersectoral action – cooperation and collaboration within and between organizations and sectors – must involve the public and government sectors, the voluntary sector, the private sector, businesses, professionals and consumers in the fields of health, justice, education, social services, finance, agriculture, environment, and so forth.

Following the release of the Second Report on the Health of Canadians (September 2000), all federal, provincial and territorial Ministers of Health have agreed to the following priority areas for action on the broader, underlying conditions that make Canadians healthy or unhealthy in the first place. These are:

• renewing and reorienting the health care sector;
• investing in the health and well-being of key population groups;
• improving health and reducing disparities in literacy, education and income distribution in Canada.

5.5 What Makes Canadians Healthy or Unhealthy?

Health status in Canada does not extend evenly to all Canadians. Our universal health care system has ensured equitable access to insured services, but not necessarily to good health for everybody. There are variances in terms of many different health status indicators between the affluent and the poor, and these cannot only be explained by unequal access to health care services. Disparities in health status exist in terms of geographical location, demographic factors, socio-economic conditions, gender differences and so on.

A copy of the Second Report on the Health of Canadians was tabled with the Committee(70). This comprehensive report provides valuable information and comments on the health status of Canadians using a population health approach. Among other things, it points out that:

• Low-income Canadians are more likely to die earlier and to suffer more illnesses than Canadians with higher incomes;
• Large disparities in income distribution lead to increases in social problems and poorer health among the population as a whole;
• Canadians with low literacy skills are more likely to be unemployed and poor, to suffer poorer health and to die earlier than Canadians with high levels of literacy;
• Canadians with higher levels of education have better access to healthy physical environments and are better able to prepare their children for school than people with low levels of education. They also tend to smoke less, to be more physically active and to have access to healthier food;
• Studies in neurobiology have confirmed that experiences from conception to age 6 have the largest influence of any time in the life cycle on the connecting and sculpting of the brain’s neurons. Positive stimulation early in life improves learning, behaviour and health right into adulthood;
• Ageing is not synonymous with poor health. Active living and the provision of opportunities for lifelong learning may be particularly important for maintaining health and cognitive capacity in old age;
• Despite reductions in infant mortality rates, improvements in education levels, and reductions in substance abuse in many Aboriginal communities, First Nations and Inuit people remain at higher risk than the Canadian population as a whole for illness and early death;
• Men are more likely to die prematurely than women, largely as a result of heart disease, fatal unintentional injuries, cancer and suicide. Women are more likely to suffer from depression, stress overload, chronic conditions, and injuries and deaths resulting from family violence;
• Older Canadians are far more likely than younger Canadians to have physical illnesses, but young people report the lowest levels of psychological well-being.

A recent study by Statistics Canada shows that chronic conditions and activity limitation are more prevalent among individuals aged 45 to 64 with lower education or lower income. In 1998-99, arthritis or rheumatism, high blood pressure, heart disease, diabetes, bronchitis or emphysema and activity limitation were more prevalent among those who had not graduated from high school (see Graph 5.11). These conditions, as well as asthma and migraine headaches, were also more prevalent among those with a low or lower-middle income than among those with a higher income (see Graph 5.12).

There are also great disparities in infant mortality rates between income groups. For example, Statistics Canada reports that infant mortality rates are highest in the poorest urban neighbourhoods, and lowest in the richest urban neighbourhoods. Graph 5.13 shows that, while there has been progress in reducing this disparity, the infant mortality rate in Canada’s poorest neighbourhoods (6.5 per 1,000) in 1996 was still two-thirds higher than that of the richest neighbourhoods (3.9 per 1,000). Statistics Canada estimated that if the rate for all Canada had been as low as that of the richest neighbourhoods, there would have been about 500 fewer infant deaths in 1996.(71)

GRAPH 5.11

5.6 Committee Commentary

While many Canadians enjoy high levels of health and although Canada ranks well above other countries in terms of most of the major health status indicators, there is definitely room for improvement. There are disparities in health associated with age, socio-economic conditions, gender and so on. Many witnesses told the Committee that it is imperative to reduce these disparities if we want to improve the overall health status of Canadians. In their view, this can be best achieved through a comprehensive population health approach.

GRAPH 5.12

GRAPH 5.13

Witnesses also stressed that there is a need to better understand the links between health status and the various determinants of health. We do not know how changes in health care spending affect the health of a population. We do not know much about the impact of other public policies on health status as a recent report clearly indicated:

We have large gaps in our understanding of the factors affecting individuals’ health over the medium to long term. For example, what is the longer-term effectiveness of sometimes competing procedures or interventions – such as coronary bypass surgery and balloon angioplasty? In the case of prostate cancer, what are the relative merits of drug therapy, surgery, or simply waiting and seeing? How do psychological interventions affect outcomes? What are the special health risks of different occupations? What are the long-term effects of many environmental hazards? To what degree, if at all, do people with low incomes or educational levels benefit from "equal access" provisions in the Canada Health Act?(72)

During his testimony, Sholom Glouberman raised the following question: given that health care is only one factor among a variety of health determinants, what role can or should the health ministers play in establishing population health strategies? Specifically, he told the Committee:

The Ministry of Health has a problem because the most critical contributors to health are not health-related by this account. They have to do with social status, control over work, level of education, and the Ministry of Health has no authority over these matters. If they take responsibility for this, they risk being viewed by other government departments as "health imperialists". How do you deal with those kinds of problems?(73)

Since a multiplicity of factors determines the health of a population, there is clearly a need for collaboration and intersectoral action. According to Marc Lalonde, the federal Minister of Health should act as a leader. He also stressed that new initiatives to improve the health of the Canadian population are needed, particularly in the areas of health promotion and disease prevention:

We need the type of action wherein the Minister of Health can be a leader, but he cannot be the only actor. There must be action that will take place on the basis of a collective action by the government, because in almost every instance it involves action by a number of departments of the government. Money is not the problem. A program of public education on obesity, for instance, is insignificant compared to what you spend on the health budget. What we need is a determination to go ahead with programs and do it consistently.(74)