The Health of Canadians – The Federal Role
Interim Report
Volume Four – Issues and Options
Chapter: Twelve, Thirteen, Fourteen
Issues and Options for the Population Health Role
In 1974, the then federal Minister of Health, Marc Lalonde, released a working document entitled A New Perspective on the Health of Canadians. This report was extremely influential in shaping approaches to health both in Canada and internationally. The report recognized the impact of individual behaviour on health outcomes, and stressed that individual Canadians should assume greater responsibility for their health. But more importantly, the Lalonde report put forward the idea that a good health care system is only one of numerous factors that help keep people healthy. In recent years, some experts have suggested that 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.
In fact, as mentioned in the Phase One report of the Committee, there is agreement that multiple factors – called "determinants of health" – influence individual health status. These include: income and social support; education; employment and working conditions; social environment; physical environment; personal health practices and coping skills; early childhood development; health care; gender; and culture.
The term "population health" is used to refer to the overall state of health of a population that is brought about by all these determinants of health. 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 policies and programs that focus on these broader determinants of health.
The objective of a population health approach is to ward off potential health problems before they require treatment within the health care system. It is therefore oriented toward preventing a problem from arising as opposed to the health care system which focuses on fixing a problem once illness or injury has occurred.
At the same time, it is important to recognise that a population health approach does not advocate the replacement of traditional health care — rather, in working out how best to improve health outcomes, a population health approach attempts to take into account all determinants of health, as well as their interaction. Population health advocates believe that investing more human and financial resources in a population health approach would improve the health outcomes for a given population, and, in the end, reduce demand for the services required to treat illness.
One of the key attractions of a population health approach is that it widens the framework for understanding why health status is not uniform for all Canadians. Our universal health care system has ensured equitable access to insured services, but not necessarily to good health for everybody. A wide range of health status indicators show significant disparities among Canadians in terms of geographical location, demographic factors, socio-economic conditions, gender differences and so on.
Therefore, population health strategies encompass a broad range of activities, ranging from health promotion and disease prevention to overall policies and programs that influence income distribution, access to education, housing, water quality, workplace safety, and so on, which all have an impact on health status.
The 20th century revolution in health care has significantly altered the pattern of diseases, with the causes of mortality shifting away from infectious diseases and towards non-communicable diseases. Chronic diseases, such as cancer and cardiovascular disease, are now the leading causes of death and disability in Canada, while unintentional injuries are the third most important cause of death. However, some infectious diseases once thought to have been conquered – like tuberculosis – are re-emerging and antibiotics are becoming increasingly ineffective against them. Rapid international transport of foods and people also increases the opportunities for infectious diseases to spread.
During Phase Two of its study, the Committee was informed that the total cost of illness was estimated at $156.4 billion in 1998. Direct costs (such as hospital care, physician services and health research) amounted to $81.8 billion, while indirect costs (such as lost productivity and lower quality of life) accounted for $74.6 billion. The diagnostic categories with the highest total costs were cardiovascular diseases, musculoskeletal diseases, cancer, injuries, respiratory diseases, diseases of the nervous system, and mental disorders.
According to witnesses, many diseases, and most injuries, can be prevented. In their view, the only way to reverse disease trends and reduce the burden of illness is by investing more in health promotion, disease prevention and population health. More importantly, however, they pointed to a strong tendency for government to focus on curing diseases, rather than on preventing them. For example, clinical treatment has been the most common chronic disease strategy and there has been only a limited political will to expend resources on health promotion and disease prevention. Outcomes from such programs are generally visible only over the longer term, and are therefore less attractive politically than money invested in health care facilities, such as hospitals.
12.2 Some Disturbing Trends
While it is perhaps trite to observe that today’s youth represent the future of the country, a number of health trends that affect Canadian young people in particular are of great concern.
A recent study has raised the alarm with regard to overweight and obese children in Canada. Researchers found that the body mass index of Canadian children between the ages of 7 and 13 has increased dramatically in recent years. In 1981, 15% of boys and girls were overweight, but by 1996 the percentages of overweight children had grown to almost 29% of boys and 23% of girls. Childhood obesity also more than doubled over the same period and research suggests that children and adolescents with excessive body mass are more likely to experience health problems as adults.
Eating disorders such as bulimia and anorexia nervosa remain a serious problem, especially among young women. Approximately 90% of those with eating disorders are women, and these disorders usually develop between ages 14 to 25. In Canada, over 38,000 women suffer from anorexia nervosa, and more than 114,000 women suffer from bulimia. While the majority of physical complications in adolescents with eating disorders can be remedied over time, some may be irreversible. Although the full extent of the long-term consequences remain unclear, among the medical complications that are potentially irreversible are pubertal delay or arrest, impaired acquisition of peak bone mass later in life, and increased risk of osteoporosis in adulthood.
According to Statistics Canada, the vast majority of Canadians are aware of the risks associated with smoking – only 4% of Canadians 12 and over in 1996-97 felt that there were no smoking-related health risks for those who light up. Despite the widespread knowledge of the dangers of smoking, over a quarter of Canadians age 12 and up still smoke daily or occasionally, putting them at risk for lung cancer, heart disease and other health problems, and significant numbers of young Canadians start smoking each year.
A number of other broad trends among the Canadian population are also worth noting. Work prepared for the Federal/Provincial/Territorial Advisory Network on Mental Health estimated that about 3% of Canadians suffer from severe and chronic mental disorders, such as manic depression and schizophrenia, that can cause serious functional limitations and social or economic impairment. This translates into approximately one in every 35 Canadians over 15 years of age. The National Population Health Survey of 1994/95 found that some 29% of Canadians had high levels of stress; 6% of Canadians felt depressed; 16% of Canadians reported that their lives was adversely affected by stress; and 9% had some cognitive impairment such as difficulties with thinking and remembering. Canadian youth, in particular, report the lowest levels of psychological well-being.
Approximately 42% of adult Canadians do not possess sufficient literacy skills to allow them to deal with everyday reading tasks, including reading about health matters. Canada is rather unique in that there is a rapid deterioration in literacy skills in mid-life, rather than in later life, as is the case in Sweden, for example. The Committee was told that a number of factors could help explain this difference. Swedes read twice as much in the workplace as Canadians do and they also tend to read more at home. Swedes participate in adult education at a level that is twice the average for Canadians, and they do so throughout their working lives, whereas we see the same kind of reduction in adult education participation in midlife as we see in literacy levels in Canada. The Committee was also told that, despite increasing education, literacy levels in Canada over the coming decades are likely to remain stable, unless there is an extraordinarily large investment in enhancing literacy skills. This is a major concern, given that about 15% of today's literacy is determined by the previous generation's literacy. Since literacy is an important determinant of health, there is a vector for the intergenerational transmission of inappropriate health behaviours.
12.3 Determinants of Health: Some Evidence
Disease issues are complex, in large part on account of the immense diversity of determinants of health, and this complexity is further compounded by the interaction among these various factors.
According to many experts, socio-economic status constitutes the most powerful influence on health. Whether we look at how people rate their own health, at premature mortality, at psychological well-being or at the incidence of chronic disease, socio-economic status remains strongly correlated with health status. Differences in health status are readily evident in a comparison of the highest and lowest income groups. Canadians with low incomes and low levels of education (which are often related) are more likely to have poor health status, no matter which measure of health is used, and people’s health improves on virtually all measures and in all of the factors that influence health as levels of income and education increase.
In other words, high-income Canadians are more likely to be healthy than middle-income Canadians, who are in turn healthier than low-income Canadians. Indeed, it is estimated that if the same death rates as for the highest income earners applied to all Canadians, over one-fifth of all potential years of life lost before age 65 could be prevented. The Committee was also told that:
- 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;
- Despite reductions in infant mortality rates, improvements in education levels, and reductions in substance abuse in many Aboriginal communities, Aboriginal Canadians remain at higher risk than the Canadian population as a whole for illness and early death.
12.4 The Role of the Federal Government
The federal government’s role with regard to health promotion, disease prevention and population health is a well established one. Following the public release of the Lalonde report in 1974, the federal department of health created community programs and issued specific social marketing campaigns aimed at health promotion (such as ParticipAction, "Dialogue on Drinking" and the Canada Food Guide).
The report, Achieving Health for All, released in 1986 by the then federal Minister of Health, Jake Epp, broadened federal policy to encompass both health promotion and disease prevention. The Epp report also placed a particular emphasis on the determinants of health. Programs that were initiated during that period include Canada’s Drug Strategy, the Heart Health Initiative, Healthy Communities, a National AIDS strategy, etc.
In the 1990s, the concept of population health was officially endorsed by the federal, provincial and territorial Ministers of Health. This prompted the publication of three major reports that provided data on the determinants that affect the health status of Canadians and set out frameworks to guide the development of population health policies and strategies.
The findings of all these reports offered the federal government a way of participating in the elaboration and implementation of policies and programs that affect the health of Canadians from outside the traditional health care sector (which is, essentially, a provincial/territorial responsibility). In 1997-98, Health Canada formally adopted a population health framework for its programs and initiatives. Other federal department and agencies are also involved in population health strategies. For example:
- Population health is one of the four pillars of health research at the Canadian Institutes of Health Research (CIHR). Moreover, the CIHR Institute of Population and Public Health specifically supports research into the complex interactions (biological, social, cultural, environmental) which determine the health of individuals, communities, and global populations.
- The Canadian Institute for Health Information (CIHI) is responsible for the Canadian Population Health Initiative. This initiative also provides support to research oriented towards advancing our understanding of the determinants of health that affect the Canadian population, and towards the formulation of policies that will improve population health and reduce health inequities.
- The National Children’s Agenda involves a variety of healthy child development initiatives, including the Canada Prenatal Nutrition Program, Aboriginal Head Start, the Community Action Program for Children, the National Child Benefit, as well as maternity and parental leave benefits that are covered under Employment Insurance.
It is clear that the longstanding federal role in health promotion and disease prevention should be maintained and strengthened. Moreover, the federal government has been recognized as a leader worldwide in elaborating the concept of population health. It could, once again, show leadership in implementing a population health strategy for all Canadians. This is a feasible task, given the federal government’s role in many areas that affect health, such as the environment, economic policy, health research, workplace safety, etc.
12.4.1 Health Promotion and Disease Prevention
Witnesses stressed that it is necessary to continue encouraging people to make smarter choices with regard to their own health. Eating healthy food, exercising regularly and not smoking are certainly important messages that must be reiterated on an ongoing basis.
Although there was some initial resistance to a number of preventive campaigns, many nonetheless proved to be very successful. A good example is the law requiring people to wear seatbelts. Prior to the passage of legislation, only an estimated 15% to 30% of Canadians wore seatbelts, whereas, the rate of seatbelt use is currently about 92% among drivers. This has resulted in an impressive reduction in motor vehicle fatalities in Canada.
However, witnesses suggested that, to date, a number of other strategies that attempted to prescribe ‘good behaviour’ have not been very successful, and noted that part of the challenge lies in creating an environment that allows people themselves to make the right choices.
Prevention efforts have to be tailored and flexible. There is no ‘one size fits all’ strategy. For example, sexually transmitted disease trends change as sexual practices change and therefore will always require new prevention and promotion strategies. In this regard, it is important to ensure that health information is always up-to-date. Witnesses pointed to the Canada Food Guide as an example of a good initiative, but one that has not been marketed effectively or updated and adapted over time.
One difficulty that arises with regard to the elaboration of strategies for health promotion and disease prevention is that many diseases usually have several risk factors associated with them. Comprehensive prevention and promotion strategies must therefore address the linkages between risk factors, as well as between health status and socio-economic, demographic, and environmental factors.
Strategies must also recognize the link between healthy communities and healthy citizens. For example, people may be less inclined to bike or jog if the streets are unsafe. Successful community-based programs combine an understanding of the community, with the participation of the public, and the co-operation of community organizations. Approaches that address several risk factors can produce multiple benefits. These include support for families at risk, comprehensive school health promotion programs, and comprehensive work health and safety programs.
Furthermore, since disease and injury are not uniformly distributed across populations, strategies must also look at the linkages between health status and demographic and environmental factors, such as age, race, region of residence, and gender. Strategies must therefore address disease and injury trends among specific demographic groups, such as youth and Aboriginal peoples. For example, motor vehicle accidents predominantly affect young men, and Aboriginal youth have high rates of suicide. Adults over 65 are most affected by falls, and injuries are the leading cause of death in children. Strategies must be tailored to the situations of each affected group, and need to be targeted to the groups that will derive the most benefit from prevention.
12.4.2 Population Health Strategies
The Committee is of the view that there are several key issues with regard to population health strategies that largely revolve around the difficulties associated with how to translate research evidence concerning the importance of population health strategies into policies and programs that can be implemented. There can be little doubt that these strategies could result in improved health outcomes, but there remain significant practical obstacles to moving beyond the expression of pious good wishes to the design of concrete programs that are sustainable over the long haul.
In the first place, the multiplicity of factors that influence health outcomes means that it is exceedingly difficult to associate cause and effect, especially since the effects are often only felt many years after exposure to the cause. This time lag also means that the timeframe for judging the impact of policy in this area is a long-term one. Because political horizons are often of a shorter term nature, this can constitute a serious disincentive for the elaboration and implementation of population health strategies.
Furthermore, as noted earlier, there is already a massive infrastructure that is in place to deal with the treatment of illness, and this creates many entrenched interests within the system. It is not necessarily that people who treat illness have anything against promoting population health strategies — the contrary is no doubt the norm. Rather, it is simply that massive resources must be deployed simply to sustain the existing health care infrastructure, making it difficult to find sufficient time, energy and capital to devote to the preventive side of the equation.
Moreover, because of the diversity of the factors that influence health outcomes, it is very difficult to co-ordinate government activity in this regard. Given that the health care system itself is only responsible for a relatively small percentage of the actual determinants of health, the responsibility for population health cannot reside exclusively with the various ministries of health. Yet the structure of most individual governments does not easily lend itself to inter-ministerial responsibility for addressing complex problems, and this difficulty is compounded several times over when the various levels of government, along with the many non-governmental players, are taken into account, as they must be if population health strategies are to be truly effective.
For example, the evidence concerning the existence of gradients of health that correlate with socio-economic levels is quite conclusive. The implication of this fact is that the promotion of population health requires a strong focus on the reduction of poverty. But there are clearly a great number of government policies that have an impact on the levels of poverty in Canada and it would be impossible to ask a ministry of health to take charge of all the policy tools that are involved, if for no other reason than this would be rightly seen as a form of ‘health imperialism’ by other ministries. It is also somewhat perverse, as one witness pointed out, to argue for the reduction of poverty exclusively because of the impact which poverty has on the health status on individuals. Any such initiative would have to come about as a result of the overall social policy orientation of government, something that is considerably broader than health policy alone.
The evidence suggests that population health strategies in general must be carefully thought through so that they take into account the realities facing specific communities. This implies that rigidly designed programs applied in a uniform and highly centralized fashion are unlikely to succeed. Some combination of co-ordination and decentralized implementation therefore would seem to be required.
Although there are many difficulties associated with the development of an effective population health approach, the Committee believes that it is important for the federal government to continue to try to set an example by exploring innovative ways to turn good theory into sound practice that will contribute to improving health outcomes in Canada. There are two broad options the Committee would like to put on the table and to solicit comments from readers on them.
The first of these options is developed in more detail in the following chapter, as it concerns the federal responsibility for the delivery of health care services to Aboriginal Canadians. The key idea, however, is that in an area of clear federal responsibility it should be possible for the government to adopt an explicit population health approach that would recognize the many factors that contribute to the deplorable health outcomes that are still the norm in many Aboriginal communities. There would have to be close co-ordination of the activity of the different departments that each have some responsibility in this area (Health, Indian and Northern Affairs, Finance, etc.). Ways would also have to be found to work effectively with the Aboriginal communities themselves, as well as with other levels of government that also deliver services to these communities. This approach would also provide an opportunity for the development of effective accounting mechanisms with regard to measurable health outcomes. This is an important, and often neglected, element of population health programs.
The second option would involve an even wider federal undertaking. Because of the very broad focus required to implement population health strategies, it is essential that a way be found to break down the ministerial silos that compartmentalize responsibility for policy outcomes. One way of doing this, as was already suggested in Chapter 10 of this report, would be to give responsibility to a ‘Health Commissioner’ for monitoring and reporting on the health impact of all government policy.
Regardless of the exact nature of the office that assumes this responsibility, the important point, however, is to devise a mechanism that enables all government policy to be screened through a population health lens. This would permit an ongoing analysis of health outcomes and provide some measure of overall public accountability. An annual report from such an office that focused on the broad determinants of health could complement the work already being done by CIHI, but also include prescriptions for how to ensure that all government policies have as positive an effect as possible on the health of Canadians.
Many witnesses told the Committee that greater research is needed, particularly in certain areas. Often, money is spent without sufficient epidemiological research to guide where it is invested. In terms of chronic disease research, witnesses told the Committee that there is a lack of knowledge on how to use that information in the implementation of preventive strategies. In this respect, research is needed to determine how best to share health information with both providers and individual Canadians and, in particular, how best to target that information to those in lower socio-economic groups or those with poor literacy skills.
Issues and Options for the Service Delivery Role: Aboriginal Health
A major role played by the federal government is its direct provision of a variety of health services to particular population groups. The federal government is responsible for the provision of health care, including primary care, to First Nations and Inuit communities, and some health services to the RCMP, Correctional Services, the Armed Forces and veterans. Indeed, the federal government delivers health services to more Canadians than several provinces do. In this chapter, the Committee raises specific issues with respect to the delivery of health care to Aboriginal Canadians and suggests potential public policy options for addressing those issues.
The Constitution Act, 1982 recognizes three groups of Aboriginal peoples: Indians, Inuit, and Métis. The Indian population includes both status and non-status Indians. The Indian Act sets out the legal definitions that apply to status Indians (First Nations) in Canada; that is, Indians who are registered under the Indian Act. Non-status Indians are those who are not registered under the Act. The Inuit population of Canada lives primarily in communities in the Northwest Territories, Nunavut, Nunavik and Labrador. About 6% of the Inuit live in southern Canada. the Inuit are not specifically covered by the Indian Act but still receive certain benefits from the federal government. Métis people are of mixed Indian and European ancestry. The Métis are not covered by the Indian Act and do not receive Métis-specific benefits from the federal government.
The Aboriginal population was estimated at 1,399,300 in 2000, or about 3% of Canada’s overall population. Of this total, 28.5% were status Indians living on reserve, 30.6% were non-status Indians, 20.8% were status Indians off reserve, 15.6% were Métis, and 4.5% were Inuit.
Currently, 12 federal government departments offer programs and services for Aboriginal peoples. These programs and services are numerous and include health care and social services; elementary, secondary and post-secondary education; water and sewer services; housing; environmental remediation; business development, etc. Total expenditures for these programs are estimated at $7.3 billion for 2001-2002.
Despite this large federal investment toward the health and well-being of Aboriginal peoples, very significant health and socio-economic disparities persist between the Aboriginal population and the general Canadian population. In fact, the state of health of Aboriginal Canadians and the socio-economic conditions in which they live remain deplorable. Furthermore, during the Committee hearings, status Indians living off-reserve, non-status Indians and the Métis stressed that they often fall between the cracks of public policy with respect to meeting their unique health and health care needs.
13.1 Health and Socio-Economic Profile of Canada’s Aboriginal Population
There are significant health and socio-economic disparities between Aboriginal peoples and the general Canadian population. During Phase Two of its study, the Committee heard some very disturbing testimony.
Aboriginal peoples suffer from chronic diseases to a much greater degree than do other Canadians. For example, current evidence suggests that heart problems, hypertension and diabetes are over three times as prevalent in Aboriginal communities as in the general population. The prevalence of tuberculosis and HIV/AIDS is much higher among Aboriginal peoples than among other Canadians. The rate of deaths due to injuries and poisoning is 6.5 times higher for First Nations and the Inuit than for the total Canadian population. The suicide rate among Aboriginal youth is five to six times higher than the suicide rate of the general Canadian youth population. Alcohol, substance and solvent abuse is a major problem in Aboriginal communities. Foetal Alcohol Syndrome (FAS) and Foetal Alcohol Effects (FAE) are much more prevalent in some Aboriginal communities than in other parts of Canada. Approximately 75% of Aboriginal women are victims of family violence and up to 40% of children in some Northern communities have been physically abused by a family member.
Aboriginal peoples are less likely to be in the labour force and unemployment rates are higher than for the general population. Average annual income from all sources for Aboriginal Canadians is far behind that of non-Aboriginal peoples. Some 44% of the Aboriginal population and 60% of Aboriginal children under six years of age live below Statistics Canada’s low income cut-off line. Some 54% of the Aboriginal population do not have a high school diploma, compared to only 16% for the general population.
Crowded housing conditions are found much more frequently among the Aboriginal population than among Canadians in general. Mold growth has recently been identified as a critical issue in Aboriginal housing, but its full impact on health is not yet known. Access to clean, safe drinking water and adequate sewage disposal is an issue for many Aboriginal communities.
In the view of the Committee, the health of our Aboriginal peoples is a national disgrace. If the Aboriginal population was enjoying a state of health similar to that of the overall Canadian population, Canada would probably stand as the healthiest country in the world. We certainly need to do a better job. The federal government must take a leadership role in working to immediately redress this situation.
13.2 Health Service Delivery to Aboriginal CanadiansHealth care to Canada’s Aboriginal peoples is delivered through a complex array of federal, provincial and Aboriginal-run programs and services. Who delivers what to whom depends on a number of factors such as status under the Indian Act, place of residence (on or off-reserve), the location of one’s community (non-isolated or remote) and whether Health Canada has signed an agreement to transfer the delivery of certain health services to an Aboriginal community or organization.
During Phase Two of its study, the Committee was told that the federal government has particular and special responsibilities for status Indians under the Indian Act. The provision of hospital and physician services, however, is a provincial or territorial responsibility. Status Indians who reside on reserves are entitled to the general health services provided by the provinces and territories that fall under the Canada Health Act such as hospitals, physician services, and other insured services covered by provincial and territorial health plans. Health Canada, however, provides direct primary care and emergency services on reserves in remote and isolated areas where no provincial services are available. More precisely, the department operates 4 small hospitals, 77 nursing stations and 217 health centres.
Health Canada also provides community-based health promotion and prevention services or funding for such services for status Indians living on reserves. Regardless of residence (on or off–reserve), status Indians receive non-insured health benefits (NIHB) funded by the federal government. These benefits include drugs, medical supplies and equipment, dental care, vision care, medical transportation, provincial health care premiums and crisis mental health counselling.
Provincial and territorial governments are responsible for delivering health services to the Inuit; thus, delivery of health services to Canada’s Inuit population varies with jurisdiction of residence. In 1988, the federal government transferred responsibility for health administration to the Government of the Northwest Territories. With the creation of Nunavut, the Nunavut government assumed this responsibility for the Nunavut region. The federal government provides funds to the territorial governments to deliver health programs for status Indians and the Inuit. The federal government continues to fund non-insured health benefits for status Indians and the Inuit.
As a result of the James Bay and Northern Quebec Agreement, the federal government transferred responsibility for Inuit health services in northern Quebec to the government of Quebec then to Nunavik. The Nunavik Regional Department of Health and Social Services administers federal and provincial programs in that region.
In Labrador, the province provides health services to all residents and the federal government provides funding to the Labrador Inuit Health Commission through a transfer agreement and contribution agreements for specific projects and for a range of federal programs including non-insured health benefits.
Métis and non-status Indians are not eligible for federal health programs. They receive medical services from provincial and territorial governments on the same basis as other Canadians.
13.2.1 A National Action Plan on Aboriginal Health Services
Overall, jurisdictional barriers to the provision of health services to Aboriginal peoples exist on two levels. The first barrier arises from the division of powers between the federal and provincial governments. Provincial governments provide equitable access to health care under the Canada Health Act for all residents including status Indians living on reserves and the Inuit, but take the position that the federal government is responsible for certain health services (e.g. prescription drugs or home care) to Aboriginal persons who are Indians under the Indian Act (status Indians). As a result, witnesses told the Committee that health services not covered by the Canada Health Act but otherwise provided by the provinces may or may not be provided to status Indians and Inuit communities.
Other consequences of having two jurisdictions involved in delivering health services include program fragmentation, problems with co-ordinating programs and reporting mechanisms, inconsistencies, gaps, or possible overlaps in programs that prevent the rationalization of services and block the development of a holistic approach to health and well-being.
The second jurisdictional barrier stems from the divisions among Aboriginal peoples that arise as a result of the Indian Act. Because Métis and non-status Indians are excluded from the legislation, they are not eligible for most federal programs. In the view of witnesses, this lack of recognition leaves the Métis and non-status populations in a jurisdictional void.
The Committee agrees with the witnesses that these barriers must be overcome rapidly and that all levels of government – federal, provincial, territorial, municipal, band and settlement – should develop a comprehensive plan that could meet the health care needs of all Aboriginal peoples in Canada. The federal Minister of Health should play a leadership role in co-ordinating such a plan.
Therefore, the proposed option is for the federal government to undertake, in collaboration with the provinces, territories and Aboriginal representatives of all groups, the development of a National Action Plan on Aboriginal Health to improve inter-jurisdictional co-ordination of health care delivery. The special contribution of the federal Minister of Health would be to facilitate such co-ordination.
13.3 Ensuring Adequate Access to Culturally Appropriate Health Services
Accessibility to health care is one of the four patient-oriented principles of the Canada Health Act. However, access to adequate health services remains a challenge in remote and isolated Aboriginal communities. Most health care is provided by community health clinics or nursing stations staffed by nurses and only offering basic services. Patients with serious health problems are treated in the major urban centres. A lack of appropriate infrastructure and shortages in key health care providers contribute to this problem.
13.3.1 Aboriginal Health Care Providers
Witnesses suggested that the federal, provincial and territorial governments should address the shortage of health care providers in Aboriginal communities by developing a long-term strategy to increase the number of Aboriginal health care providers. As part of this strategy, the federal government could provide the necessary resources to train Aboriginal Canadians across a wide range of health sector disciplines. In 1996, the Royal Commission on Aboriginal Peoples made a similar recommendation. More precisely, the Commission called upon the federal and provincial/territorial governments, along with the academic community and health professional groups, to implement a program to train 10,000 Aboriginal health care workers. A long-term strategy should also address issues that relate to the training, recruitment and retention of qualified personnel in emerging areas of importance such as home care workers, early childhood educators, diabetes prevention workers, telehealth and systems development technicians, etc.
Tele-medicine can also play an important role in improving access to health services in Aboriginal communities. In the context of remote and isolated Aboriginal communities, telemedicine offers the following advantages: it addresses the shortage of health care providers and the lack of medical training; it improves the health care infrastructure; it enables conformity with the accessibility principle of the Canada Health Act; and it ensures a more equitable development of health information systems across all regions of the country.
13.3.3 Culturally Appropriate Health Services
Perhaps most importantly, witnesses stressed the need to provide Aboriginal peoples with "culturally appropriate" health services. This means that their cultural experience and traditions must be taken into account when designing and implementing services. For some witnesses, culturally appropriate services are those that can be accessed through the use of an interpreter or provided by Aboriginal workers. For others, culturally appropriate care involves the combination of both western medicine and traditional healing approaches. Witnesses also emphasized to the Committee that Aboriginal peoples are not a homogeneous group. They called for this distinctiveness to be recognized in the delivery of health programs and services. The Committee welcomes opinions on how adequate access to culturally appropriate health services can be best achieved for all Aboriginal Canadians.
People from all of Canada’s Aboriginal groups do not simply define health as the absence of disease. They talk about "wellness" and adopt a broader view of the concept of health that encompasses the spiritual, physical, mental and emotional aspects of the individual. For them, the various components of the overall state of health may be influenced by the social, cultural, physical, economical and political environments in which a person lives. Aboriginal wellness emphasizes that solutions to health will not be effective until all factors having an impact on a problem are considered. Witnesses suggested that federal Aboriginal health policy must develop a greater focus on illness prevention, health promotion and a holistic approach to population health.
13.4.1 A Population Health Strategy for Aboriginal Canadians
During its Phase Two hearings, the Committee heard about the various federal health strategies co-ordinated by Health Canada and the multiple programs managed by Indian and Northern Affairs Canada and other federal departments. Still, an enormous amount remains to be done if Canada is to reduce disparities in health status and socio-economic disparities between Aboriginal peoples and the general population. Given the wide range of programs that the federal government currently manages and given its specific constitutional responsibilities, it is in a unique position to develop population health strategies aimed specifically at Aboriginal Canadians.
The federal government has been recognized as a leader worldwide in developing the concept of population health, and this option urges it to once again show leadership in implementing a population health strategy designed specifically for Aboriginal Canadians. Such a strategy should include dealing with economic conditions, environmental issues such as clean and safe drinking water, high quality and culturally appropriate health care, healthy lifestyle choices, etc. Investing in such activities will improve the health status of Aboriginal peoples and reduce the suffering and costs that result from poor health. This option would require extensive and ongoing inter-departmental collaboration. The federal Minister of Health could, once again, assume a role of leadership and co-ordination.
13.4.2 Federal Accountability for Programs aimed at Aboriginal Health
As discussed in Chapter 10, the federal government could set a valuable example by establishing a permanent mechanism for reporting to the Canadian public on the impact of all its policies affecting health and health care. Federal accountability for programs aimed at Aboriginal health is of paramount importance and could be the first step towards federal accountability for its overall health policy. We welcome any suggested options for an effective federal accountability mechanism with respect to Aboriginal health.
13.5 Aboriginal Health Research
During the hearings on Aboriginal health, witnesses pointed out the importance of undertaking research on the health of Aboriginal peoples as a means to improve health service delivery and health outcomes. They welcomed the new Institute on Aboriginal Health within the Canadian Institutes for Health Research (CIHR) and stressed that it is essential that it be provided with a sufficient level of funding.
Witnesses underlined the importance of recognizing the diversity of the various groups within the Aboriginal population. In their view, this diversity must be reflected in health research activities. It was also recommended that more funding be allocated to health research that explores a range of models in order to assist with the design and delivery of programs that affect Aboriginal health.
13.6 Involvement of Aboriginal Communities
Witnesses stressed that, given the diversity of Aboriginal peoples and given their unique health and health care needs, it is essential to involve them directly in the renewal of federal policies and programs that affect Aboriginal health. In their view, it is only with significant input from the members of the concerned community that successful programs leading to healthier outcomes can be implemented. The Committee would like to obtain suggestions on the best way to involve Aboriginal Canadians in designing, developing, implementing and assessing federal programs and policies aimed at Aboriginal health.
For Canadians, our publicly funded health care system is a key distinguishing characteristic of our country. In fact, it has achieved iconic status. It is perceived to reflect Canadian values and these are seen to stand in sharp contrast to the values of our American neighbours.
Medicare is based on the belief that Canadian society should collectively share the risks, and the consequences, of illness and injury to individual Canadians. Before Medicare, these were largely borne by the sick or injured themselves, their families, or various charitable organizations. Canadians’ attachment to a sense of collective responsibility for the provision of health care has remained largely intact despite a shift towards more individualistic values that has, in recent years, led to broader changes in society.
Health care is also seen in Canada as very much a public good, in spite of the fact that more than 30% of total health care costs are paid out of private funds. It is a public good also in the sense that Canadians look to government, both federal and provincial, to guarantee the services to which they feel entitled.
One might expect that given the importance of the health care issue in the collective psyche of Canadians, and in the political life of the country more generally, that an ongoing, thoughtful, discussion of health care issues would be the norm. Unfortunately, the opposite is true. The health care debate in Canada is characterized by :
- The repetition of myths (as documented in the Committee’s first and second reports). The most common of these are the notion that the Canada Health Act prohibits the delivery of health care services by the private sector, and the assertion that all medically necessary health care services are publicly funded in Canada;
- Ideological statements by the right and the left. The right claims that all our health care woes would be solved by introducing competition and private sector delivery into the system and by having patients pay for part of the service they receive. The left claims that the introduction of any element of competition, private sector delivery or having patients pay for part of the service they receive, would destroy our current system;
- Politicians of all parties and all levels of government passing the buck for the current troubles in the system. The federal government blames the provinces; the provinces blame the federal government; and all opposition parties, both federal and provincial, blame their respective governments;
- A reluctance on the part of the various organizations representing health care professionals to embrace systemic change. They tend, rather, to argue for more money to be put into the system (presumably on the assumption that money alone will solve the system’s problems).
Faced with this situation, the Committee decided from the outset that it would provide a useful public service if it could produce a report that outlined the major issues facing Canada’s health care system and presented a set of potential options for addressing them. Moreover, it envisaged this report as being factual and non-ideological. Also, the Committee strongly believes that it was essential not to foreclose discussion of any option a priori. This is what the Committee hopes it has achieved with this report.
We recognize that our set of issues is not exhaustive, and that many readers of this report will want to add to the issues list. Similarly, there are those who will feel that our set of options is not complete, and they will want to add new options of their own. We very much welcome these additions to our work. We believe that they will help to further the Committee’s objective of being a catalyst for informed public debate on health care issues.
Above all, we hope that individual Canadians – the people who most benefit from Canada’s Medicare system and the people who will be most affected by any changes made to it – will take the time to write to the Committee, and give us their views on which options they prefer, and why. We very much look forward to receiving the guidance of Canadians as we prepare our final report and our own set of recommendations.
Please write to:
The Standing Senate Committee on Social Affairs, Science and
Technology
The Senate
Ottawa, Ontario
K1A OA4
health@sen.parl.gc.ca
fax: 613-947-2104