On January 31, 2011, the Minister of Health requested that the Standing Senate Committee on Social Affairs, Science and Technology initiate the second parliamentary review of the 10-Year Plan to Strengthen Health Care (10-Year Plan), an agreement reached by First Ministers on September 16, 2004 that focuses on federal/provincial/territorial (F/P/T) collaboration in the area of health care reform. The committee’s study is undertaken pursuant to section 25.9(1) of the Federal-Provincial Fiscal Arrangements Act, which requires that a parliamentary committee review progress towards the implementation of the 10-Year Plan on or before March 31, 2008 and three years thereafter. The committee’s review also includes an examination of the separate Communiqué on Improving Aboriginal Health, which was released by First Ministers and Leaders of National Aboriginal Organizations1 on 14 September, 2004.2
This report presents the committee’s findings regarding progress towards the implementation of the 10-Year Plan and the Communiqué on Improving Aboriginal Health and identifies further actions that could be taken in support of the objectives outlined in these documents. It reflects the testimony presented by witnesses over the course of 13 hearings and one roundtable discussion, as well as many written submissions received from interested organizations and individuals.
The key themes raised by these witnesses provide the basis and spirit of the recommendations outlined in this report. Witnesses emphasized to this committee the central importance of adopting a holistic understanding of health that sees physical and mental wellbeing as inextricably linked and equally important to the efficiency and quality of health care systems. This holistic concept of health has become a framing principle for this report.
Witnesses also stressed that many of the factors that influence the health outcomes of Canadians lie beyond health care systems and are located in the social determinants of health, a point that is reflected most clearly in the poorer health status of Aboriginal peoples and the challenges children and youth face with respect to mental health and obesity.
Throughout the course of this study, witnesses were emphatic that health care reform could only be achieved by breaking down the different silos within health care systems. They insisted that different health care sectors such as primary, acute, continuing care and mental health services be integrated through common governance structures and funding arrangements and supported by seamless information systems. The integration of different health care professionals into primary health care teams requires the adoption of different methods of remuneration that allow for different health care professionals to work together. Furthermore, they underscored the vital importance of making patients’ needs and perspectives central to these reform efforts.
Witnesses provided exciting examples of reforms occurring at the front lines of health care delivery in Canada. However, they indicated that systemic change had stalled. When compared internationally, they noted that Canada is no longer seen as a model of innovation in health care delivery and financing. They therefore identified the need for specific mechanisms to promote the implementation of new practices in health care systems across the country. Otherwise, they feared that health care reform in Canada would never evolve beyond a pilot project.
Finally, many witnesses said that resources currently committed to federal, provincial and territorial health care systems are sufficient to provide Canadians with a high standard of quality health care, but they also told the committee that innovation-based transformation is needed to achieve and sustain these systems. These witnesses were unequivocal in their insistence that any increases in health care funding be used to promote change rather than maintain the status quo. They therefore argued that governments need to focus on creating incentives to transform health care systems. The committee heard that there is a real appetite among health care professionals to truly transform the way that they do business and achieve lasting reform. The committee believes that the time for this transformative change is now. It therefore recommends:
That the committed annual increase in funding transferred from the federal government to the provinces and territories, through the Canada Health Transfer, be used by governments in great part to establish incentives for change that focus on transforming health-care systems in a manner that reflects the recommendations outlined in this report, and the overarching objectives of the 2004 10-Year Plan to Strengthen Health Care, including the need for measurable goals, timetables and annual public reporting through existing mechanisms.
Progress in Implementing the 10-Year Plan to Strengthen Health Care
An agreement between First Ministers, the 10-Year Plan to Strengthen Health Care identified ten main priorities for health care reform in Canada:3
- reducing wait times and improving access;
- strategic health human resource (HHR) action plans;
- home care;
- primary health care reform, including electronic health records and telehealth;
- access to care in the North;
- National Pharmaceuticals Strategy;
- prevention, promotion and public health;
- health research and innovation;
- accountability and reporting to citizens; and
- dispute avoidance and resolution.
In support of these objectives, the federal government provided provinces and territories with additional long-term funding amounting to $41.3 billion from 2004 to 2014.4 The bulk of the funding would be provided through the Canada Health Transfer (CHT)5, as a conditional cash transfer that would escalate by 6 per cent per year, amounting to $35.3 billion in total by 2014. In addition to funding provided through the CHT, the federal government allocated $5.5 billion over a 10-Year period to reduce wait times. A further $500 million was earmarked for enhanced investments in medical equipment. Finally, $850 million was allocated to Aboriginal health programs and the Territorial Health System Sustainability Initiative (THSSI). The following sections examine how jurisdictions have used these funds to meet the specific commitments under each component of the 10-Year Plan.
1. Reducing Wait Times and Improving Access to Care
As part of the 2004 10-Year Plan, First Ministers agreed to achieve reductions in wait times for procedures in five priority areas: cancer, heart, diagnostic imaging, joint replacements and sight restoration by March 31, 2007. In order to demonstrate meaningful progress in reducing wait times in these areas, First Ministers agreed to:6
- Establish comparable indicators of access to health care professionals, diagnostic and treatment procedures with a report to their citizens to be produced by December 31, 2005;
- Establish evidence-based benchmarks for medically acceptable wait times starting with cancer, heart, diagnostic imaging procedures, joint replacements, and sight restoration by December 31, 2005 through a process developed by Federal, Provincial and Territorial Ministers of Health;
- Establish multi-year targets to achieve priority benchmarks by December 31, 2007; and
- Report annually to their citizens on their progress in meeting their multi-year wait-time targets.
In their evaluation of progress towards achieving these objectives, the committee found that governments had, for the most part, met their obligations in relation to the establishment of benchmarks in four of the five priority areas (cancer, heart, sight restoration, and joint replacement) and reporting on progress. In addition, the committee heard that targeted funding had resulted in an increase in the number of surgeries in the priority areas, as well as the number of diagnostic imaging services performed. Moreover, the committee heard that eight out of ten Canadians were indeed receiving treatment within the established time frames. However, the committee also heard from witnesses that there were significant variations among provinces in meeting the benchmarks in some of the priority areas and considers this to be a concern.
The committee also heard that the wait time agenda had certain limitations, including that the benchmarks established were not based upon sufficient research, which in some cases, led to questioning of their appropriateness by health care providers and policy makers. Moreover, they were not patient-centred in that they did not reflect the complete wait times experienced by patients across the continuum of care, with witnesses emphasising the lack of timely access to primary care physicians as being of particular concern.
The committee also heard from witnesses that further meaningful reductions in wait times could best be achieved through reforms to health care systems and increasing efficiencies through management practices, rather than by increasing funding alone. With respect to moving the wait-times agenda forward, the committee recommends:
That provinces and territories continue to develop strategies to address wait times in all areas of specialty care, as well as access to emergency services and long-term care, and report to their citizens on progress.
That the federal government work with provinces, territories and relevant health-care and research organizations to develop evidence-based pan-Canadian wait-time benchmarks for all areas of specialty care that start when the patient first seeks medical help.
That the federal government provide the Canadian Health Services Research Foundation7 or the Canadian Institutes of Health Research with funding to:
- commission research that would provide the evidence base for the development of pan-Canadian wait-time benchmarks for all areas of specialty care; and
- commission research to evaluate the appropriateness of existing pan-Canadian wait-time benchmarks related to cancer, heart, sight restoration, and joint replacement.
That the Health Council of Canada examine best practices in reducing wait times across jurisdictions, through improvements in efficiency, focusing in particular on management practices such as pooling waitlists, the adoption of queuing theory and the development of referral guidelines and clinical support tools.
That the federal government work with provincial and territorial governments to develop a pan-Canadian vision statement that would foster a culture of patient-centred care in Canada through the establishment of guiding principles that would promote the inclusion of patient needs and perspectives in an integrated health-care-delivery process.
That the federal, provincial and territorial governments ensure accountability measures be built into the Canada Health Transfer agreement, to address the needs of disabled persons.
2. Health Human Resources
In the 10-Year Plan, First Ministers agreed to increase the supply of health care professionals in Canada, as shortages were seen as particularly acute in some parts of the country.8 They also agreed to ensure an appropriate mix of health care professionals and to make their health human resources (HHR) action plans public by December 31, 2005. In addition, the federal government committed to:9
- Accelerating and expanding the assessment and integration of internationally trained health care graduates for participating governments;
- Targeting efforts in support of increasing the supply of health care professionals for Aboriginal communities and Official Languages Minority Communities;
- Take measures to reduce the financial burden of students in specific health education programs; and
- Participate in health human resource planning with interested jurisdictions.
Overall, the committee heard from witnesses that there have been significant increases in the supply of health professionals in Canada since the 10-Year Plan was signed in 2004, including in areas of federal responsibility such as Official Language Minority Communities and First Nations and Inuit communities. However, the committee heard that shortages remained an ongoing concern, particularly in rural and remote areas and Aboriginal communities. The committee also heard that there is a need to make greater efforts to promote the inter-professional education and training of health professionals in order to promote ongoing efforts towards the development of multi-disciplinary health care teams across Canada. In addition, the committee heard that current efforts to support the integration of Internationally Educated Health Professionals (IEHPs) into health care systems need to be accelerated. The committee is also of the view that the federal government needs to play a greater leadership role in promoting pan-Canadian collaboration HHR planning with interested jurisdictions. As witnesses articulated, this is necessary in order to support jurisdictions in identifying which health professionals need to be trained to meet and reflect the differing needs of their populations. The committee therefore recommends:
That the federal government take the lead in working with the provinces and territories to:
- evaluate the impact of health-human-resource observatories in other jurisdictions;
- conduct a feasibility study, and determine the benefit of establishing a pan-Canadian health-human-resource observatory and report on the findings.
That the Canadian Institutes of Health Information include linguistic variables in their collection of data related to health human resources and populations served by health-care systems across Canada.
That the federal government work with the provinces and territories and relevant health- care organizations to reduce inequities in health human resources, such as rural and remote health care, vulnerable populations, and Aboriginal communities.
That the federal government, through its Foreign Credential Recognition Program, take the lead in working with provincial and territorial jurisdictions and relevant stakeholders to accelerate their efforts to improve the assessment and recognition of the foreign qualifications of internationally educated health professionals and their full integration into Canadian health-care systems, in line with the principles, obligations and targets agreed upon in the Federal/Provincial/Territorial Pan-Canadian Framework for the Assessment and Recognition of Foreign Qualifications.
That the federal, provincial and territorial governments work with universities and colleges to increase inter-professional training of health-care practitioners to continue the development of multi-disciplinary health-care teams in Canada.
3. Home Care
Under the 10-Year Plan, First Ministers recognized the importance of home care as an essential part of an integrated patient centred health care system and10 they agreed to provide first dollar coverage11 for certain home care services by 2006:12
- short-term acute home care for two-week provision of case management, intravenous medications related to the discharge diagnosis, nursing and personal care;
- short-term acute community mental health home care for two-week provision of case management and crisis response services; and
- end-of-life care for case management, nursing, palliative-specific pharmaceuticals and personal care at the end of life.
The 10-Year Plan further required that jurisdictions report on progress towards the implementation of these services with Health Ministers providing an additional report to First Ministers on the next steps in fulfilling home care commitments by December 31, 2006.
The committee’s review found that jurisdictions had made progress in improving access to acute home care services; acute community mental health home care services; and end-of-life care. However, the review also found that governments did not meet their reporting requirements relating to home care due to a lack of agreement regarding developing indicators and targets for progress in this area. The committee also shares the concerns of witnesses related to the increased costs of drugs and supplies experienced by patients and families as a result of being treated out-of-hospital, as well as the reduction of chronic home care services currently being offered, given the increasing burden of chronic diseases in Canada. The committee also heard from witnesses that overall, the 10-Year Plan adopted a narrow approach to addressing home care that did not include ensuring access to a broad range of services that were considered by witnesses to be important parts of home care. In addition, the committee heard that home care needs to be better integrated with the acute and primary care sectors, mental health services, as well as the full range of continuing care services that includes palliative care and facility based-long term care. Finally, the committee agrees with witnesses that governments need to take further action to promote access to high quality palliative and end-of-life care in Canada, as well as raise awareness among Canadians regarding the importance of planning end-of-life care. The committee therefore recommends:
That the federal government work with provincial, territorial governments and other relevant stakeholders to develop indicators to measure the quality and consistency of home care, end-of-life care, and other continuing care services across the country.
That where necessary, jurisdictions expand their public pharmaceutical coverage to drugs and supplies used by home care recipients.
That the Mental Health Commission of Canada work with the home care sector to identify ways to promote the integration of mental health and home care services.
That Health Canada, taking the lead, work with provinces and territories to create and implement an awareness campaign for Canadians about the importance of planning end-of-life care.
That the federal government work with provincial and territorial governments to develop a pan-Canadian Homecare Strategy, which would include a focus on reducing the burdens faced by informal caregivers.
That the federal government work with the provinces and territories to increase access to palliative care as part of end of life health services in a broad range of settings including residential hospices.
That the federal, provincial, and territorial governments develop and implement a strategy for continuing care in Canada, which would integrate home, facility based long-term, respite and palliative care services fully within health care systems. The strategy would establish clear targets and indicators in relation to access, quality and integration of these services and would require governments to report regularly to Canadians on results.
4. Primary Care Reform
The 10-Year Plan highlighted timely access to family and community care through primary health care reform as an ongoing priority; and therefore, First Ministers committed to ensuring that 50% of Canadians have 24/7 access to multidisciplinary health care teams by 2011.13 They further agreed to establish a best practices network to share information and find solutions to barriers to progress in primary health care reform. The committee’s study revealed that though there were many innovations occurring in primary care to ensure that 50% of Canadians had 24/7 access to a multi-disciplinary health care team, jurisdictions have yet to meet this goal. The committee heard from witnesses that key challenges relating to achieving systematic primary care reform are: current remuneration models; the lack of governance mechanisms to manage and steer reform efforts; and the need for targeted conditional funding arrangements. The committee is of the view that jurisdictions need find ways to address these key challenges and re-commit to meeting the goal established in the 10-Year Plan. The committee heard from witnesses that there was also an ongoing need to share best practices in primary health care reform and jurisdictions should work together to address their common challenges. Witnesses felt that the federal government could play a leadership role by promoting the sharing of best practices in these areas. The committee therefore recommends:
That the federal, provincial and territorial governments share best practices in order to examine solutions to common challenges associated with primary-care reform, such as: the remuneration of health professionals; the establishment of management structures to guide primary-care reform; and the use of funding agreements linked to public health goals.
That the federal government work with the provinces and territories to re-establish the goal of ensuring that 50 per cent of Canadians have 24/7 access to multi-discliplinary health-care teams by 2014.
5. Electronic Health Records and Tele-health
In the 10-year Plan, First Ministers recognized the development of Electronic Health Records (EHRs)14 and tele-health as integral parts of health care renewal, particularly in rural and remote areas.15 They therefore agreed to accelerate the development of EHRs across the country, as well as tele-health in rural and remote areas. Consequently, the federal government agreed to invest an additional $100 million in the development of electronic health records through Canada Health Infoway Inc.16 During the course of the committee’s study, the importance of the development of electronic health records to health care reform in Canada was stressed by almost all witnesses. The committee heard that EHRs would promote the integration of different sectors of the health care system by allowing patient information to be seamlessly transferred from primary care to acute, home and long-term care. EHRs would also promote patient safety through drug information systems and allow for increased accountability within the system, as information systems would enable better monitoring of patient outcomes.
However, the committee also heard the frustrations of health practitioners related to EHRs, in particular, how local systems between doctor’s offices and nearby hospitals did not have the same standards and could therefore not communicate. For policy makers, low up take among physicians, a lack of harmonization in privacy laws across the country, and the overall cost of the system remained key concerns. Tele-health was also seen as a key resource promoting innovations and reducing costs in health care delivery in the North, though it remained unclear how many Canadians have access to these services. All witnesses agreed that both EHRs and tele-health were areas in health care reform that called for federal leadership and on-going investments. The committee therefore recommends:
That the Government of Canada continue to invest in Canada Health Infoway Inc. to ensure the realization of a national system of interoperable electronic health records.
That Canada Health Infoway Inc. target its investments to:
- projects aimed at upgrading existing components to meet national interoperability standards set by the organization; and
- promoting the adoption of electronic medical records by health professionals in Canada, including working with stakeholders to identify effective incentives in this area.
That Canada Health Infoway Inc. work with provinces and territories and relevant stakeholders to:
- establish a target that would outline when all existing components of the EHRs would be upgraded to meet national interoperability standards;
- establish a target that would outline when at least 90 per cent of all physicians in Canada will have adopted electronic medical records;
- ensure that electronic health record systems are currently being designed and implemented in a way that would allow for secondary uses, such as health system research and evaluation; and
- develop a systematic reporting system in relation to access to tele-health services in Canada.
That the federal government work with provinces and territories to examine approaches to addressing differences in privacy laws across jurisdictions in relation to the collection, storage and use of health information.
6. Access to Care in the North
The 10-Year Plan also recognized the importance of improving access to health care services in northern communities. As a result, the federal government provided $150 million over five years to the Territorial Health System Sustainability Initiative (THSSI) in order to: facilitate long-term health reforms; establish a federal/territorial working group to support the management of the fund; and enhance direct funding for medical transportation costs.17 The federal government also agreed to develop a joint vision for the North in collaboration with the territories.18
The committee’s study found that funding provided through the THSSI had enabled the territories to introduce numerous initiatives that addressed their unique challenges related to health care delivery, including: the high costs of medical travel, addressing the burden of chronic diseases and mental health issues; collaborating across jurisdictions; improving the recruitment and retention of health human resources; and addressing the broader social determinants of health. However, the committee heard that these challenges still remained and some, such as the cost of medical travel, were increasing due to demographic changes in the region and the nature of health care service delivery. The committee therefore heard that future funding arrangements needed to reflect these ongoing unique needs and be provided in a predictable manner. The committee also heard that territorial jurisdictions needed to focus their efforts on continuing to develop accountability measures and enhancing collaboration in addressing jurisdictional barriers related to health care delivery and dealing with the broader social determinants of health. The committee therefore recommends:
Recognizing the ongoing unique challenges associated with health and health care delivery in the North, that the federal government extend its funding of the Territorial Health System Sustainability Initiative beyond 2014 in a manner that is both sustainable and predictable.
That the Federal/Territorial (F/T) Assistant Deputy Ministers’ Working Group work with relevant stakeholders and communities to:
- improve accountability measures to evaluate the performance of health care systems in the North; and
- address jurisdictional barriers as they relate to health care delivery and addressing the broader social determinants of health, including potable water and decent housing.
7. The National Pharmaceuticals Strategy
As part of the 10-Year Plan, First Ministers agreed to establish a National Pharmaceutical Strategy (NPS), which would address common challenges associated with pharmaceutical management in Canada. First Ministers agreed that the NPS would include nine elements19 and agreed to establish a Ministerial Task Force, which would be responsible for the development and implementation of these nine elements and report on their progress by 30 June 2006. The committee heard that after the signing of the 10-Year Plan in 2004, jurisdictions began advocating for a more focused agenda for the NPS, which would include five priority areas: costing models for catastrophic drug coverage; expensive drugs for rare diseases; the establishment of a common national formulary; real world drug safety and effectiveness; and pricing and purchasing strategies.20 The committee heard that the Ministerial Task Force released its progress report in 2006 which identified recommendations for future action in these areas. Though no further collaborative work was currently being undertaken by the Ministerial Task Force, the committee heard from witnesses that its recommendations formed the basis of further work undertaken by individual jurisdictions.21
Overall, the committee’s review of the implementation of the NPS found that progress towards its five main priorities was mixed and that F/P/T collaboration had slowed substantially after 2006. Though some jurisdictions had moved forward in the provision of catastrophic drug coverage, the committee heard that disparities and inequities in the provision of pharmacare continue to persist and there was a need for governments to work together to develop a national pharmacare program. Meanwhile, the committee heard that the Common Drug Review (CDR) had helped jurisdictions contain costs and achieve harmonized drug formularies through its formulary recommendations, but other witnesses suggested that a national formulary was still necessary. The committee heard that the efforts of the CDR were being supplemented by the federal government`s establishment of the Drug Safety and Effectiveness Network (DSEN), which conducts research evaluating the safety and effectiveness of drugs in real world settings. Witnesses articulated that there was a need to engage private drug insurance companies in these cost saving efforts to ensure the sustainability and affordability of the drug coverage programs that the majority of Canadians currently rely on. Witnesses highlighted the rising costs of newer specialized drugs as a key threat to the sustainability of both private and public drug coverage programs in Canada. Meanwhile, the committee did not receive testimony as to whether Health Canada intended to develop a regulatory framework for expensive drugs for rare diseases. The committee therefore recommends:
That the federal government work with the provinces and territories to develop a national pharmacare program based on the principles of universal and equitable access for all Canadians; improved safety and appropriate use; cost controls to ensure value for money and sustainability; including a national catastrophic drug coverage program and a national formulary.
That governments, acting together, work with private health insurance companies to encourage their adoption of best practices in cost containment strategies.
That Health Canada report on progress towards the development of a regulatory framework for expensive drugs for rare diseases as part of its annual performance report to Parliament.
8. Prevention, Promotion and Public Health
In the 10-Year Plan, First Ministers recognized the importance of public health efforts, including health promotion, disease and injury prevention, in improving health outcomes for Canadians and ensuring the sustainability of the health care system. First Ministers therefore committed to accelerate their ongoing work towards the establishment of a pan-Canadian Public Health Strategy that would set goals and targets for improving the health status of Canadians and focus on common risk factors for diseases. They further agreed to collaborate on developing coordinated responses to infectious disease outbreaks and other public health emergencies through the F/P/T Pan-Canadian Public Health Network. In addition, the federal government committed to increasing its investments in the National Immunization Strategy (NIS), which was to provide new immunization coverage for Canadian children.
The committee found that the objectives outlined in the 10-Year Plan relating to the development of a Pan-Canadian Public Health Network and increasing investments in the National Immunization Strategy had been met, though there is also an on-going need to fund and elaborate on the NIS to address the risks posed by communicable diseases. The committee’s study also found that efforts towards the development of a pan-Canadian Public Health Strategy had been unsatisfactory. Though witnesses recognized the importance of addressing current priorities such as chronic diseases, promoting healthy lifestyles, and preventing childhood obesity, they explained that the public health agenda needed to be broader, including focusing on widening health disparities by addressing the social determinants of health and recognizing that addressing mental health issues represent a key component of overall health and well-being. They also identified the need to reduce the number of injuries in Canada and their associated burden on the acute care system as another priority. The committee recognizes the importance of these issues, as well as the fact that important work has already been undertaken in these areas by the Mental Health Commission of Canada and this committee’s own Subcommittee on Population Health. The committee therefore recommends:
That the Public Health Agency of Canada continue its efforts to renew the National Immunization Strategy, including the establishment of goals, objectives and targets.
That the federal government work with provincial and territorial, and municipal governments to develop a Pan-Canadian Public Health Strategy that prioritizes healthy living, obesity, injury prevention, mental health, and the reduction of health inequities among Canadians, with a particular focus on children, through the adoption of a population-health approach that centres on addressing the underlying social determinants of health.
That Health Canada, upon receipt of the Mental Health Commission report, use data developed on pan-Canadian child and youth mental-health issues to inform policy and program decisions relating to child and youth mental health.
9. Health Innovation
In the 10-Year Plan, the federal government committed to continuing its investments in science, technology and research to promote the adoption of new, more cost-effective approaches to health care, as well as facilitate the adoption and evaluation of new models of health protection and chronic disease management.22 The committee’s study revealed that the federal government was making significant investments in health research that was allowing for discoveries, which were reducing adverse reactions and mortality rates, and were cutting costs across health care systems. However, the committee heard that there were concerns among witnesses that insufficient resources were being dedicated to health services research. The committee also heard that the Canadian Institutes of Health Research (CIHR) had developed a new Strategy for Patient Oriented Research that would provide funding for health innovations in different areas of health care service delivery over ten years. The committee heard that the federal government, in collaboration with provincial and territorial governments, could enhance these efforts through the creation of a specific mechanism dedicated to promoting health innovation in Canada, which would be established to promote collaboration among governments in identifying, disseminating, and implementing leading practices in health care service delivery across health care systems. The committee therefore recommends:
That the federal government, taking the lead, work with provincial and territorial governments to establish a Canadian Health Innovation Fund to identify and implement innovative and best practice models in health care delivery and the dissemination of these examples across the health system.
That the Canadian Institutes of Health Research provide an interim report in five years evaluating the implementation and impact of its Strategy for Patient Oriented Research, including its findings related to new primary care models.
That Health Canada create a network between federally funded pan-Canadian health research organizations, and other interested stakeholders that would focus on identifying leading practices in health care delivery and work together to promote their dissemination in health care systems across Canada.
That the federal government ensure that there is ongoing funding dedicated towards health services and systems research either through the Canadian Institutes of Health Research or the Canadian Health Services Research Foundation
10. Accountability and Reporting to Citizens
In the 10-Year Plan, all governments committed to report to their residents on the performance of their health care systems, as well as on its key components such as wait times, health human resources, and home care through the development of common indicators and benchmarks.23 The committee heard from witnesses that accountability and reporting requirements of the 10-Year Plan had led to enhanced collection of data and the development of health indicators measuring health system quality and performance. However, they explained that there was a need to develop a pan-Canadian health indicator framework to allow for common measurements of health care system quality and performance, inter-jurisdictional comparisons and pan-Canadian reporting. The committee heard that ongoing efforts in these areas were necessary to promote health care reform and quality improvement. The committee also heard that these efforts were being reinforced by the establishment of health quality councils in different jurisdictions across Canada. The committee heard that health quality councils should be established across Canada and be given a mandate focusing on dimensions of quality beyond those outlined in the 10-Year Plan, including patient safety, effectiveness, patient-centeredness, efficiency, timeliness, equity and appropriateness. The committee therefore recommends:
That the federal government through Health Canada work with organizations such as the Canadian Patient Safety Institute to promote the development of health-quality council concepts.
That the Canadian Institute for Health Information work with provincial and territorial governments and relevant stakeholders to develop a pan-Canadian patient-centred comparable-health-indicator framework to measure the quality and performance of health-care systems in Canada.
11. Dispute Avoidance and Resolution
The 10-Year Plan also included a provision that formalized a dispute avoidance and resolution process related to the interpretation and enforcement of the principles of the Canada Health Act, which was agreed to through a series of letters between the Premier of Alberta and then Prime Minister Jean Chrétien in April 2002.24 During the course of its review, the committee heard from witnesses that the dispute avoidance activities undertaken by Health Canada had been successful in preventing the need for using the formal dispute resolution process agreed to by governments. The committee also heard that the process had allowed for transparency in the enforcement of the Canada Health Act through its reporting requirements. However, the committee also received written submissions outlining instances of violations of the Canada Health Act by private for-profit health delivery clinics in Canada. They therefore called for the federal, provincial and territorial governments to take a more proactive role investigating these violations and enforcing the principles of the Act. The committee therefore recommends:
That all governments put measures in place to ensure compliance with the Canada Health Act and more accountability to Canadians with respect to implementation of the Act.
Implementing the Communiqué on Improving Aboriginal Health
On 13 September, 2004 First Ministers and the Leaders of the National Aboriginal Organizations agreed to the Communiqué on Improving Aboriginal Health, in which they committed to developing a blueprint to improve the health status of Aboriginal peoples through initiatives that would focus on:25
- Improving delivery and access to health services to meet the needs of all Aboriginal peoples through better integration and adaptation of all health systems;
- Measures that will ensure that Aboriginal peoples benefit fully from improvements to Canadian Health systems; and
- A forward looking agenda of prevention, health promotion and other upstream investments.
The Communiqué also announced $700 million in federal funding for initiatives developed in support of these objectives.26
During the course of its review, the committee heard from witnesses that the Communiqué had led to the development of the Blueprint on Aboriginal Health: A 10-Year Transformative Plan, which outlined a plan to close the gap in health outcomes between the general Canadian population and Aboriginal peoples, including First Nations, Inuit and Métis, within 10 years.27 The committee also heard that the federal funding under the Communiqué had created many programs that were seen by witnesses as important. However, they outlined several ways in which they could be improved, including: ensuring that all Aboriginal organizations had equitable access to funding; providing stable multi-year funding arrangements; and ensuring that these initiatives reflected the unique needs and cultures of different Aboriginal peoples. Furthermore, they explained that the gap in health outcomes between Aboriginal and non-Aboriginal Canadians remained despite these initiatives. Consequently, they saw that there was a need to address ongoing challenges such as jurisdictional issues related to health care financing and delivery and the social determinants of health. The committee heard that the way forward in this area was the establishment of new health governance models, such as the historic tripartite health agreement in British Columbia, as well as ensuring that Aboriginal organizations had a voice in the design and delivery of the programs affecting them. The committee therefore recommends:
That Health Canada work with provincial and territorial partners to ensure equitable access to programs and initiatives related to improving Aboriginal health.
That Health Canada work with provinces and territories to ensure that the design and delivery of its programs and initiatives meet the unique needs and culture of Inuit people.
That Health Canada work closely with provincial and territorial governments to ensure improvements in Aboriginal health through the federal, provincial and territorial multi-year funding agreements.
That the federal government work with Aboriginal communities to improve the delivery of health-care services in Canada, and deal specifically with removing jurisdictional barriers.
That Health Canada establish a working group with provincial and territorial partners and all national Aboriginal organizations to identify ways in which the role of Aboriginal organizations could be strengthened in the policy-making and development process.
That the federal government work with the provinces and territories to address the social determinants of health, with a priority focus on potable water, decent housing and educational needs.
The committee believes that it is important for governments to keep in mind that two years remain before the expiry of the 10-Year Plan in 2014. The committee’s review found that more progress needs to be made towards its objectives, in particular in the areas of primary care reform, establishing electronic health records, health human resources planning, and catastrophic drug coverage. However, the committee’s review revealed that real systematic transformation of health care systems across the country had not yet to occurred, despite more than a decade of government commitments and increasing investments. For witnesses appearing before the committee, the way forward was clear: long lasting transformative change could only occur through the breaking down silos between sectors within health care systems; facilitating collaboration among different health care professionals; adopting compatible health information systems; and establishing health governance and funding arrangements to support these developments. In addition, health care systems need to be reoriented towards the prevention of disease and injury; the needs of patients; and a holistic view of health which sees physical and mental wellbeing as inextricably linked, while not forgetting that many of the factors that affect the health and wellbeing of Canadians remain outside of health care systems. Our witnesses spoke with conviction and experience. It is now time for us to act.
1 These included the Assembly of First Nations (AFN), the Inuit Tapiriit Kanatami (ITK), the Métis National Council (MNC), the Congress of Aboriginal Peoples (CAP) and the Native Women’s Association of Canada (NWAC).
2 Canadian Intergovernmental Conference Secretariat, “Improving Aboriginal Health: First Ministers’ and Aboriginal Leaders’ Meeting,” Special Meeting of First Ministers and Aboriginal Leaders, Ottawa ON, 13 September 2004, http://www.scics.gc.ca/english/conferences.asp?x=1&a=viewdocument&id=1167
3 Further details regarding these ten components of the 10-Year Plan and its associated communiqués are outlined in subsequent sections of this report. Health Canada, “A 10-year plan to strengthen health care,” Health Care System: First Minister’s Meeting on the Future of Health Care 2004,http://www.hc-sc.gc.ca/hcs-sss/delivery-prestation/fptcollab/2004-fmm-rpm/index-eng.php.
4 Finance Canada, “The Canada Health Transfer,” brief submitted to the Senate Standing Committee on Social Affairs, Science and Technology, March 2011.
5 The Canada Health Transfer consists of cash levels that are set in Federal-Provincial Fiscal Arrangements Act and an equalized tax point transfer to the provinces and territories that grows in line with economy and is based upon a province or territory’s resource revenue and its participation in Canada’s equalization program. For further details, please see: James Gaulthier, “Background Paper: The Canada Health Transfer: Changes to Provincial Allocations,” Publication No. 2011-02E, 25 February 2011, http://lpintrabp.parl.gc.ca/lopimages2/prbpubs/pdf/bp1000/2011-02-e.pdf
7 The Canadian Health Services Research Foundation is an independent not-for-profit corporation established through endowed funds from the federal government and its agencies that is dedicated to accelerating health-care improvement and transformation, by converting innovative practices and research evidence into practice. It commissions research that focuses on the following areas: health-care financing and transformation, primary care, and Canada’s aging population. http://www.chsrf.ca/AboutUs.aspx
8 Health Canada, “A 10-year plan to strengthen health care,” Health Care System: First Minister’s Meeting on the Future of Health Care 2004,http://www.hc-sc.gc.ca/hcs-sss/delivery-prestation/fptcollab/2004-fmm-rpm/index-eng.php
10 Health Canada, “A 10-year plan to strengthen health care,” Health Care System: First Minister’s Meeting on the Future of Health Care 2004,http://www.hc-sc.gc.ca/hcs-sss/delivery-prestation/fptcollab/2004-fmm-rpm/index-eng.php
11 First dollar coverage refers to an insurance policy that provides full dollar coverage of the service without the payment of a deductible by the client.
12 Health Canada, “A 10-year plan to strengthen health care,” Health Care System: First Minister’s Meeting on the Future of Health Care 2004,http://www.hc-sc.gc.ca/hcs-sss/delivery-prestation/fptcollab/2004-fmm-rpm/index-eng.php
13 Health Canada, “First Minister’s Meeting on the Future of Health Care 2004: A 10-year plan to strengthen health care,” 16 September, 2004,” http://www.hc-sc.gc.ca/hcs-sss/delivery-prestation/fptcollab/2004-fmm-rpm/index-eng.php
14 An electronic health record (EHR) refers to a secure and private record that provides, in a digital or computerized format, lifetime information on a person’s history within the health care system.
15 Health Canada, Health care system: A 10-year plan to strengthen health care, 2004, http://www.hc-sc.gc.ca/hcs-sss/delivery-prestation/fptcollab/2004-fmm-rpm/index-eng.php.
16 Canada Health Infoway Inc. is the private not-for-profit cooperation, which was established with the mandate of building the foundations of an interoperable EHR in Canada.
19 The nine elements included the following: develop, assess and cost options for catastrophic pharmaceutical coverage; Establish a common National Drug Formulary for participating jurisdictions based on safety and cost effectiveness; Accelerate access to breakthrough drugs for unmet health needs through improvements to the drug approval process; Strengthen evaluation of real-world drug safety and effectiveness; Pursue purchasing strategies to obtain best prices for Canadians for drugs and vaccines; Enhance action to influence the prescribing behaviour of health care professionals so that drugs are used only when needed and the right drug is used for the right problem; Broaden the practice of e-prescribing through accelerated development and deployment of the Electronic Health Record; Accelerate access to non-patented drugs and achieve international parity on prices of non-patented drugs; and Enhance analysis of cost drivers and cost-effectiveness, including best practices in drug plan policies. Health Canada, First Minister’s Meeting on the Future of Health Care 2004: A 10-year plan to strengthen health care, 16 September 2004, http://www.hc-sc.gc.ca/hcs-sss/delivery-prestation/fptcollab/2004-fmm-rpm/index-eng.php.
20 Standing Senate Committee on Social Affairs, Science and Technology, “Proceedings of the Standing Senate Committee on Social Affairs, Science and Technology,” Issue 5, Evidence, 27 October, 2011, /en/Content/SEN/Committee/411/soci/05cv-e.htm?Language=E&Parl=41&Ses=1&comm_id=47
22 Health Canada, First Minister’s Meeting on the Future of Health Care 2004: A 10-year plan to strengthen health care, 16 September 2004, http://www.hc-sc.gc.ca/hcs-sss/delivery-prestation/fptcollab/2004-fmm-rpm/index-eng.php.
24 Health Canada, First Minister’s Meeting on the Future of Health Care 2004: A 10-year plan to strengthen health care, 16 September 2004, http://www.hc-sc.gc.ca/hcs-sss/delivery-prestation/fptcollab/2004-fmm-rpm/index-eng.php.
25 Canadian Intergovernmental Conference Secretariat, “Improving Aboriginal Health: First Ministers’ and Aboriginal Leaders’ Meeting,” Special Meeting of First Ministers and Aboriginal Leaders, Ottawa ON, 13 September 2004, http://www.scics.gc.ca/english/conferences.asp?x=1&a=viewdocument&id=1167
26 Health Canada, “Commitments to Aboriginal Health,” Health Care System: Information, September 2004, http://www.hc-sc.gc.ca/hcs-sss/delivery-prestation/fptcollab/2004-fmm-rpm/fs-if_abor-auto-eng.php.
27 Health Canada, “Blueprint on Aboriginal Health: A 10-Year Transformative Plan,” Prepared for the Meeting of First Ministers and Leaders of National Aboriginal Organizations, 24-25 November, 2005, http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/2005-blueprint-plan-abor-auto/plan-eng.pdf.