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Acting on today's and tomorrow's health care needs: Prebudget submission to the House of Commons Standing Committee on Finance

https://policybase.cma.ca/en/permalink/policy14123
Date
2019-08-02
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2019-08-02
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Text
The Canadian Medical Association (CMA) is pleased to provide the House of Commons Standing Committee on Finance this pre-budget submission. It provides recommendations to address major pan-Canadian challenges to the health of Canadians: improve how we provide care to our growing elderly population; improve access to primary care across the country; increase digital health literacy to take advantage of the benefits of new health information technologies; and better prepare for and mitigate the health impacts of a changing climate on Canadians. Seniors Care Health systems across the country are currently struggling to meet the needs of our aging population. People aged 85 years and over—many of whom are frail—make up the fastest growing age group in Canadai. Provincial and territorial health care systems (as well as care systems for populations falling under federal jurisdiction) are facing many challenges to meet the needs of an aging population. Canadians support a strong role for the federal government in leading a national seniors strategy and working with the provinces to ensure that all Canadians have the same level of access and quality of services, no matter where they live. The 2017 federal/provincial/territorial funding agreement involving $6 billion over 10 years to improve access to home care services is a welcomed building block. But without greater investment in seniors care, health systems will not keep up. To be truly relevant and effectively respond to Canadians’ present and future needs, our health care system must provide integrated, continuing care able to meet the chronic and complex care needs of our growing and aging population. This includes recognizing the increased role for patients and their caregivers in the care process. The federal government must ensure transfers are able to keep up with the real cost of health care. Current funding levels clearly fail to do so. Health transfers are estimated to rise by 3.6% while health care costs are expected to rise by 5.1% annually over the next decade.ii Recommendation: The federal government ensure provincial and territorial health care systems meet the care needs of their aging populations by means of a demographic top-up to the Canada Health Transfer.iii Providing care often comes with a financial cost such as lost income due to the caregiver’s withdrawal from the workforce to provide care. There are also increasing out-of-pocket costs for both caregivers and care receivers for health care-related expenses—privately covered expenditures on home and long-term care for seniors are projected to grow by an average of 5.8 per cent annually—nearly 1.5 times the pace of household disposable income growth. While the federal government offers tax credits that can be claimed by care receivers/caregivers, they are significantly under-utilized. While representing a significant proportion of caregivers, those with low or no income receive little to no federal government support through these programs. Middle-income earners also receive less than those earning high incomes. 4 Recommendation: The federal government create a Seniors Care Benefit that would be an easier, fairer and more effective way to support caregivers and care receivers alike.iv Access to Care Since the mid-1990s, the federal and provincial/territorial governments (FPT) have provided sustained leadership in promoting and supporting the transformation of primary care in Canada. In 2000, the First Ministers concluded the first of three Health Accords in which they agreed to promote the establishment of primary health care teamsv supported by a $800 million Primary Health Care Transition Fund (PHCTF) funded by the federal government, but jointly governed. The PHCTF resulted in large-scale sustained change in primary care delivery models in Ontario, Quebec and Alberta with interest in other jurisdictions as well. However, the job is far from finished. Across Canada, access to primary care is challenging for many Canadians with a persistent shortage of family physicians. In 2017, 4.7 million Canadians aged 12+ reported they did not have a regular health care provider.vi Even those who have a regular provider experience wait time issues. There has been widespread interest in primary care models since the development of the College of Family Physicians of Canada’s (CFPC) vision document Family Practice: The Patient’s Medical Home (PMH), initially launched in 2011vii and recently re-launched.viii The model is founded on 10 pillars depicted in Figure 1. Figure 1. The Patient’s Medical Home, 2019 The updated model places increased emphasis on team-based care and introduces the concept of the patient’s medical neighborhood that sets out connections between the primacy care practice and all delivery points in the surrounding community. While comprehensive baseline data are lacking, it seems 5 safe to conjecture that most Canadians are not enrolled in a primary care model that would measure up to the model’s 10 pillars. Recommendation: The federal government, in concert with provinces and territories, establish a targeted fund in the amount of $1.2 billion to support a new time-limited Primary Health Care Transition Fund that would build on the success of the fund launched in 2000 with the goal of widely introducing a sustainable medical home model across jurisdictions. This would include the following key elements:
Age-sex-weighted per capita allocation across the provinces and territories;
Joint governance of the FPT governments with meaningful stakeholder engagement;
Respect for the Canada Health Act principles;
Common objectives (e.g., modeled on the CFPC Patient’s Medical Home framework);
Operating Principles specifying eligible/ineligible activities;
Reporting provisions and agreed-upon metrics; and
Sustainability plans. Digital/Virtual Care Canada and most industrialized countries will experience a digital health revolution over the next decade with great potential to improve patient and population health. Digital health can be described as the integration of the electronic collection and compilation of health data, decision support tools and analytics with the use of audio, video and other technologies to deliver preventive, diagnostic and treatment services that promote patient and population health. While most Canadian physicians’ offices and health care facilities are now using some form of electronic record keeping and most households have internet access, there remains a large deficit in using virtual care, both within jurisdictions and across provincial/territorial boundaries. Recently the CMA, the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada established a Virtual Care Task Force to identify opportunities for digital health to improve health care delivery, including what regulatory changes are required for physicians to deliver care to patients within and across provincial/territorial boundaries. To take full advantage of digital health capabilities it will be essential for the population to have a functional level of digital health literacy: the ability to seek, find, understand and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem.ix This also includes the capability of communicating about one’s health to health care professionals (e.g., e-consults), self-monitoring health (e.g., patient portals) and receiving treatment online (e.g., Web-based cognitive behavioral therapy).x There are no current data available on health literacy in Canada, let alone digital health literacy. One basic barrier to achieving digital health literacy is access to, and usage of the Internet, which has been termed the “digital divide” (e.g., older Canadians and low income households are less likely to have Internet access).Error! Bookmark not defined. 6 In 2001 the federal government established the Financial Consumer Agency of Canada (FCAC). Its mandate includes informing consumers about their rights and responsibilities in dealing with financial institutions and providing information and tools to help consumers understand and shop for financial products and services.xi In 2014 the FCAC appointed a Financial Literacy Leader who has focused on financial literacy, including activities such as conducting financial capability surveys and the development of a National Strategy for Financial Literacy.xii Considering the anticipated growth of digital/virtual care it would be desirable to understand and promote digital health literacy across Canada. What the federal government has done for financial literacy could serve as a template for digital health literacy. Recommendation: The federal government establish a Digital Health Literacy Secretariat to:
Develop indicators and conducting surveys to measure and track the digital health literacy of Canadians;
Develop tools that can be used both by Canadians and their health care providers to enhance their digital health literacy; and
Assess and make recommendations on the “digital divide” that may exist among some population sub-groups due to a lack of access to information technology and lower digital health literacy. Climate Change and Health Climate change is the public health imperative of our time. There is a high level of concern among Canadians about their changing climate. A 2017 poll commissioned by Health Canada demonstrates a high level of concern among Canadians about their changing climate: 79% were convinced that climate change is happening, and of these, 53% accepted that it is a current health risk, with 40% believing it will be a health risk in the future. The World Health Organization (WHO) has identified air pollution and climate change as one of the biggest threats to global health. Health care professionals see first-hand the devastating health impacts of our changing climate including increased deaths from fine particulate matter air pollution and increased heat-related conditions. Impacts are most common in vulnerable populations such as adults over 65 years, the homeless, urban dwellers and people with a pre-existing disease. Canada’s health care system is already treating the health effects of climate change. A lack of progress in reducing emissions and building adaptive capacity threatens both human lives and the viability of Canada’s health system, with the potential to disrupt core public health infrastructure and overwhelm health services, not to mention the economic and social costs. The federal government must provide leadership to deal with the impact already being felt in Canada and around the world. Recommendation: 7 The federal government make strong commitments to minimize the impact of climate change on the health of Canadians by:
Ensuring pan-Canadian and inter-jurisdictional coordination to standardize surveillance and reporting of climate-related health impacts such as heat-related deaths, develop knowledge translation strategies to inform the public, and generate clinical and public health response plans that minimize the health impacts;
Increasing funding for research on the mental health impacts of climate change and psychosocial adaptation opportunities; and
Ensuring funding is provided to the health sector to prepare for climate change impacts through efforts to increase resiliency (i.e., risk assessments, readiness to manage disease outbreaks, sustainable practice). 8 i Statistics Canada. The Chief Public Health Officer's Report on the State of Public Health in Canada, 2014: Public Health in the Future. Ottawa: Statistics Canada; 2015. Available: http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2014/chang-eng.php; (accessed 2016 Sep 19). ii The Conference Board of Canada. Meeting the care needs of Canada’s aging population. Ottawa: The Conference Board; 2018. iii Canadian Medical Association. Meeting the demographic challenge: Investments in seniors care. Pre-budget submission to the House of Commons Standing Committee on Finance. August 3, 2018. https://policybase.cma.ca/documents/Briefpdf/BR2018-16.pdf iv The Conference Board of Canada. Measures to Better Support Seniors and Their Caregivers. March 2019. https://www.cma.ca/sites/default/files/pdf/health-advocacy/Measures-to-better-support-seniors-and-their-caregivers-e.pdf v Canadian Intergovernmental Conference Secretariat. News release – First Ministers’ meeting communiqué on health. September 11, 2000. http://www.scics.ca/en/product-produit/news-release-first-ministers-meeting-communique-on-health/. Accessed 04/22/19. vi Statistics Canada. Primary health care providers, 2017. https://www150.statcan.gc.ca/n1/en/pub/82-625-x/2019001/article/00001-eng.pdf?st=NGPiUkM5. Accessed 04/21/19. vii College of Family Physicians of Canada. A vision for Canada. Family Practice: the patient’s medical home. http://www.cfpc.ca/uploadedFiles/Resources/Resource_Items/PMH_A_Vision_for_Canada.pdf. Accessed 04/22/19. viii College of Family Physicians of Canada. The patient’s medical home 2019. https://patientsmedicalhome.ca/files/uploads/PMH_VISION2019_ENG_WEB_2.pdf. Accessed 04/21/19. ix Norman C, Skinner H. eHealth literacy: essential skills for consumer health in a networked world. J Med Internet Res 2006;8(2):e9. Doi:10.2196/jmir.8.2.e9. x Van der Vaart R, Drossaert C. Development of the digital health literacy instrument: measuring a broad spectrum of health 1.0 and health 2.0 skills. J Med Internet Res. 2017;19(1):e27. Doi:10.2196/jmir.6709. xi Financial Consumer Agency of Canada. About FCAC. xii Financial Consumer Agency of Canada. National Strategy for Financial Literacy. Phase 1: strengthening seniors’ financial literacy. https://www.canada.ca/content/dam/canada/financial-consumer-agency/migration/eng/financialliteracy/financialliteracycanada/documents/seniorsstrategyen.pdf. Accessed 06/24/19. https://www.canada.ca/en/financial-consumer-agency/corporate/about.html. Accessed 07/01/19.
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Answering the Wake-up Call: CMA’s Public Health Action Plan : CMA submission to the National Advisory Committee on SARS and Public Health

https://policybase.cma.ca/en/permalink/policy1960
Last Reviewed
2010-02-27
Date
2003-06-25
Topics
Health systems, system funding and performance
Health care and patient safety
Population health/ health equity/ public health
  2 documents  
Policy Type
Parliamentary submission
Last Reviewed
2010-02-27
Date
2003-06-25
Topics
Health systems, system funding and performance
Health care and patient safety
Population health/ health equity/ public health
Text
The public health system in Canada lies at the heart of our community values. It is the quintessential “public good” and is central to the continued good health of our population. When the public health system is working well, few are even aware that it is at work! Only when something goes terribly wrong — like the Walkerton tragedy or when we are faced with a new threat like SARS — is the integral, ongoing role of public health really recognized. The Canadian Medical Association (CMA) has been warning that our public health system is stretched to capacity in dealing with everyday demands, let alone responding to the latest crises. Canada’s physicians have repeatedly called for governments to enhance public health capacity and strengthen the public health infrastructure throughout Canada. Our public health system is the first — and often the only — line of defence against emerging and ongoing infectious and noninfectious threats to the health of Canadians. But we are only as strong as the weakest link in the emergency response chain of survival. As most health threats know no boundaries, our public health armaments must be in a constant state of “battle readiness.” In today’s climate of SARS, West Nile Virus, mad cow disease and monkey pox, even the thought that the public health system may be stretched beyond capacity strikes fear into the hearts of Canadians. Physicians have always been an integral part of the public health system serving as medical officers of health, community health specialists and other related roles. Indeed public health cannot successfully fulfill its mandate without the cooperation and commitment of front-line clinicians. In this submission, we reflect on the lessons to be learned from our recent experience with SARS and reflect on the longer-term needs of the public health system as a whole. The objectives of the pan-Canadian Public Health Action Plan proposed by the CMA are, first to realize a clearer alignment of authority and accountability in times of extraordinary health emergencies; and, second, to enhance the system’s capacity to respond to public health threats across the country (see recommendations, below, and Appendix 1). To achieve these twin objectives, three broad strategies are presented for immediate attention. They are legislative reform; capacity enhancement; and research, surveillance and communications. Legislative reform (see recommendations 1–3) The country’s response to SARS has brought into stark relief the urgent need for national leadership and coordination of public health activity across the country, especially during a health crisis. The apparent reluctance to act quickly to institute screening at airports, the delay in unifying the practice community for a concerted response and the appalling communications confusion worked against optimum handling of the outbreak — despite the best efforts of health care professionals. This is a wake-up call that highlights the need for comprehensive legislative reform to clarify the roles of governments with respect to the management of public health threats. A renewed and enhanced national commitment to public health should be anchored in new federal legislation to be negotiated with the provinces and territories. Specifically, the CMA recommends an Emergency Health Measures Act, to deal with emergent situations in tandem with the creation of a Canadian public health agency headed by a Chief Public Health Officer of Canada. Capacity enhancement (see recommendations 4–7) The SARS crisis has demonstrated the diminished capacity within the public health system. The Greater Toronto Area (GTA), with one of Canada’s most sophisticated public and acute health systems, has not been able to manage the SARS crisis adequately and carry on other health programs. The acute care system virtually ground to a halt in dealing with SARS. There was little or no surge capacity in Canada’s largest city. We should be grateful that SARS did not first strike a smaller centre in a far less-advantaged region of Canada. A critical element of the public health system is its workforce and the health professionals within the acute care system, such as hospital-based infectious disease specialists and emergency physicians who are the front-line interface. Let there be no doubt that the ongoing efforts of the GTA front-line providers are nothing short of heroic. However, the lack of coordinated contingency planning of hospital and community-based disease control efforts was striking. The overall shortage of critical care professionals and the inability of governments to quickly deploy the required professionals to areas of need contributed to the enormous strain on the public and health care system. Considering the importance of the public health system and its clearly limited capacity to protect and promote the health of Canadians, it is incomprehensible that we do not know how much is actually spent on the system. It is imperative that public health expenditures and capacity, in terms of both physical and human resources, be tracked and reported publicly. The CMA recommends a $1-billion, 5-year capacity-enhancement program to be coordinated with and through the new Canadian public health agency. Research, surveillance and communications (see recommendations 8–10) Canada’s ability to respond to public health threats and acute events, such as SARS, and to maintain its effective public health planning and program development depends on sound research, surveillance and rapid, real-time communications. A concerted pan-Canadian effort is required to take full advantage of our capacity for interdisciplinary research on public health, including infectious disease prevention and control measures. New-millennium challenges require moving beyond old-millennium responses. Enhanced surveillance is an overdue and integral part of public health, performing an essential function in early detection and response to threats of infectious diseases. Mandatory national reporting of identified diseases by all provinces and territories is critical for national and international surveillance. During times of crisis, rapid communication to the public, public health staff and front-line clinicians is of critical importance, but in many jurisdictions impossible. We tested our systems during the SARS outbreak and they came up short. The CMA recommends a one-time federal investment to enhance technical capacity to allow for real-time communication. Conclusion The CMA believes that its proposed three-pronged strategy, as set out in the attached recommendations, will go a long way toward addressing shortfalls of the Canadian public health system. Action now will help to ensure that Canadians can once again be confident that they are protected from any future threat of new infectious diseases. Action now will help Canada regain its position as a leader in public health. We wish the advisory committee well in its deliberations and offer the CMA’s assistance at any time in clarifying the strategies set out in our submission. Recommendations to the National Advisory Committee on SARS and Public Health Legislative reform ($20 million / 5 years*) 1. The enactment of a Canada Emergency Health Measures Act that would consolidate and enhance existing legislation, allowing for a more rapid national response, in cooperation with the provinces and territories, based on a graduated, systematic approach, to health emergencies that pose an acute and imminent threat to human health and safety across Canada. 2. The creation of a Canadian Office for Disease Surveillance and Control (CODSC) as the lead Canadian agency in public health, operating at arm’s length from government. 3. The appointment of a Chief Public Health Officer of Canada to act as the lead scientific voice for public health in Canada; to head the Canadian Office for Disease Surveillance and Control; and to work with provinces and territories to develop and implement a pan-Canadian public health action plan. Capacity enhancement ( $1.2 billion / 5 years*) 4. The creation of a Canadian Centre of Excellence for Public Health, under the auspices of the CODSC, to invest in multidisciplinary training programs in public health, establish and disseminate best practices among public health professionals. 5. The establishment of a Canadian Public Health Emergency Response Service, under the auspices of the CODSC, to provide for the rapid deployment of human resources (e.g., emergency pan-Canadian locum programs) during health emergencies. 6. Tracking and public reporting of public health expenditures and capacity (both physical and human resources) by the Canadian Institute for Health Information and Statistics Canada, on behalf of the proposed Canadian Office for Disease Surveillance and Control. 7. Federal government funding in the amount of $1 Billion over 5 years to build adequate and consistent surge capacity across Canada and improve coordination among federal, provincial/territorial and municipal authorities to fulfill essential public health functions. Research, surveillance and communications ($310 million / 5 years*) 8. An immediate, sequestered grant of $200 million over 5 years to the Canadian Institutes of Health Research to initiate an enhanced conjoint program of research with the Institute of Population and Public Health and the Institute of Infection and Immunity that will expand capacity for interdisciplinary research on public health, including infectious disease prevention and control measures. 9. The mandatory reporting by provinces and territories of identified infectious diseases to the newly established Chief Public Health Officer of Canada to enable appropriate communications, analyses and intervention. 10. The one-time infusion of $100 million, with an additional $2 million a year, for a “REAL” (rapid, effective, accessible and linked) Health Communication and Coordination Initiative to improve technical capacity to communicate with front line public health providers in real time during health emergencies. *See Appendix 2: Estimated cost of implementing recommendations. PURPOSE The CMA prepared this submission in response to an invitation from Dr. Naylor to provide input to the National Advisory Committee on SARS and Public Health. We applaud this initiative and welcome the opportunity to present the views of Canada’s medical community to the committee. The CMA’s basic message is that our health protection laws are woefully outdated and the public health system is stretched beyond capacity. This submission draws on our long history of engagement in public health in Canada and our experience both post-September 11, 2001 and with SARS. It builds on the knowledge and experience of our members, national specialist affiliated societies and provincial and territorial divisions. (We acknowledge, in particular, the outstanding efforts of the Ontario Medical Association and the Canadian Association of Emergency Physicians in battling SARS.) In this submission, we examine the lessons to be learned from our experience with the SARS outbreak and reflect on both the immediate and longer-term needs of the public health system as a whole. The objectives of the public health action plan proposed by the CMA are, first, to realize a clearer alignment of authority and accountability in times of extraordinary health emergencies and, second, to enhance the system’s capacity to respond to public health threats across the country, including those posed by preventable chronic disease. INTRODUCTION The public health system in Canada lies at the heart of our community values. It is the quintessential “public good” and is central to the continued good health of the population. When the public health system is working well, few are even aware that it is at work! Only when something goes terribly wrong — like the contamination of the blood supply in the 1980s, the Walkerton tragedy or SARS — is the integral, ongoing role of public health recognized. Our public health system is the first — and often the only — line of defence against emerging and ongoing infectious and noninfectious threats to the health of Canadians. But we are only as strong as the weakest link in the emergency response chain of survival. As most health threats know no boundaries, our public health system must be in a constant state of “battle readiness.” We can ill afford any weakness in our public health preparedness. In today’s climate of SARS, West Nile Virus, mad cow disease and monkey pox, the mere thought that the public health system may be stretched beyond capacity strikes fear into the hearts of Canadians. Physicians have always been an integral part of the public health system serving as medical officers of health, specialists in infectious disease and community medicine (who will not remember the stalwart efforts of Dr. Donald Low on SARS?) and in other related roles. Indeed, public health cannot successfully fulfill its mandate without the cooperation and commitment of front-line clinicians. The CMA has been warning for some time that our system is stretched to capacity in dealing with everyday demands, let alone responding to crises. Canada’s physicians have repeatedly called for governments to enhance public health capacity and strengthen the public health infrastructure throughout Canada. For example, the CMA’s submission to the House of Commons Standing Committee on Finance’s prebudget consultations on October 22, 2001 called for substantial investments in public health and emergency response as a first step to improve the public health system infrastructure and its surge capacity. This submission not only reiterates our previous recommendations, but also outlines specific actions that the CMA believes must be taken to ensure a strong public health system in Canada. The Enduring Impact of Severe Acute Respiratory Syndrome SARS (Severe Acute Respiratory Syndrome): in February 2003, these four letters sent massive shock waves around the world, causing widespread fear and confusion among health care officials and citizens of many countries. The “fear factor” extended across Canada as people realized the full threat of SARS. Since SARS was first identified in a patient in Toronto in March 2003, 438 probable or suspected cases have been reported to Health Canada and 38 people have died (as of June 23, 2003). However, these numbers do not reflect the full impact of the outbreak. The number of indirect deaths due to system shutdown will never be known. Local public health authorities across the country went on high alert. Those in the Greater Toronto Area (GTA) as well as their provincial counterparts diverted almost all of their resources to respond to the crisis. Acute care services were adversely affected as stringent infection-control and screening measures were put into place to control the spread of SARS. In the GTA, the health system — acute and public — was brought to its knees. Over half of the reported SARS cases involved front-line providers as the outbreak largely affected health care settings. Approximately 20 physicians in Ontario contracted SARS and close to 1000 were quarantined. Thousands of nurses and other health care workers also faced quarantine, some more than once. Institutions closed their doors, limiting access to emergency departments, clinics and physicians’ offices. Intensive care units were full and surgeries were cancelled. Front-line health care professionals involved in critical care were stretched to their physical and mental limits. Others found themselves underutilized due to the impact of the infection-control measures on their practice settings. Feast and famine co-existed. Although the outbreak was mainly confined to health care settings, the entire GTA felt the effects. Upwards of 20,000 people entered voluntary quarantine. Businesses were affected. The tourism industry is still reeling. The disruption that SARS caused continues to reverberate through health care systems and economies. In response to urgent requests from both the Ontario Medical Association and Health Canada, the CMA mobilized its membership and assisted in the country’s response to SARS. Everything that could be done was done to facilitate bringing in qualified personnel to relieve those on the front line and make appropriate information available in real time. The CMA has learned its own lessons, both positive and negative. A full chronology of CMA activity is attached as Appendix 3. It has become abundantly clear that Canada’s public health system was ill prepared to deal with the SARS outbreak. If not for the heroic efforts of public health officials, health care providers and research scientists, Canada’s experience would have been much worse. Public health in Canada Public health is the science and art of protecting and promoting health, preventing disease and injury, and prolonging life. It complements the health care system, which focuses primarily on treatment and rehabilitation, sharing the same goal of maximizing the health of Canadians. However, the public health system is distinct from other parts of the health system in two key respects: its primary emphasis is on preventing disease and disability and its focus is on the health needs of populations rather than those of specific individuals. Public health is the systematic response to infectious diseases. It also ensures access to clean drinking water, good sanitation and the control of pests and other disease vectors. Further, it is immunization clinics and programs promoting healthy lifestyles. But it is also there to protect Canadians when they face a public health crisis like SARS. If the public health system is fully prepared to carry out essential services, then communities across the country will be better protected from acute health events. The reality in Canada today is that a strong, consistently and equitably resourced and integrated public health system does not exist. Public health systems across Canada are fragmented — a patchwork of programs, services and resources across the county. In reality, it is a group of multiple systems with varying roles, strengths and linkages. Each province has its own public health legislation. Most legislation focuses on the control of communicable diseases. Public health services are funded through a variable mix of provincial and municipal funding formulae, with inconsistent overall strategies and results, and with virtually no meaningful role for input from health professionals via organizations such as the CMA, or the federal level, in terms of strategic direction or resources. Federal legislation is limited to the blunt instrument of the Quarantine Act and a variety of health protection-related acts. (e.g., Food and Drugs Act, Hazardous Products Act, Controlled Drugs and Substances Act, Radiation Emitting Devices Act) Some of the laws, such as the Quarantine Act, date back to the late 19th century. Taken as a whole, the legislation does not clearly identify the public health mandate, roles and responsibilities of the different levels of government. In many cases, the assignment of authorities and accountabilities is anachronistic. Moreover, there is little information available on the functioning and financing of Canada’s public health system. There is no “one-stop shopping” for authoritative information on public health issues. In 2001, a working group of the Federal, Provincial and Territorial Advisory Committee on Population Health assessed the capacity of the public health system through a series of key informant interviews and literature reviews. The consistent finding was that public health had experienced a loss of resources and there was concern for the resiliency of the system infrastructure to respond consistently and proactively to the demands placed on it. Significant disparities were observed between “have” and “have-not” provinces and regions in their capacity to address public health issues. The report’s findings are consistent with previous assessments by the Krever Commission and the Auditor General of Canada. In 1999, the Auditor General said that Health Canada was unprepared to fulfill its responsibilities in public health; communication between multiple agencies was poor; and weaknesses in the key surveillance system impeded the effective monitoring of injuries and communicable and non-communicable diseases. In 1997, Justice Horace Krever reported that the “public health departments in many parts of Canada do not have sufficient resources to carry out their duties.” The Challenges Ahead The 21st century brings with it an awesome array of new public health risks and ancient foes. Not all of them can be identified at the present time. New diseases (e.g., SARS, West Nile Virus) will likely continue to emerge. Dr. Alan Bernstein, President of the Canadian Institutes of Health Research, recently noted that SARS is here to stay. Old threats, such as contamination of a community water supply (e.g., Walkerton), can strike quickly if vigilance is relaxed or delegated to third parties. This century will likely bring greater focus on threats from the physical environment. Our social environment is also a source of illness as shown by the recent epidemic trends in obesity and type 2 diabetes mellitus. A substantial minority of Canadians continue to smoke. In short, there is no lack of public health threats to Canadians. Although for each of these issues, there is a clear role for clinical care, it is the public health system that will identify and monitor health threats and provide interventions to prevent disease and injury and improve health. The system will also be at the front lines in any response to a biological, chemical or nuclear event. The public health system must have the infrastructure to respond to a range of threats to health, including emergencies. The experience with SARS has reaffirmed that we do not have the system flexibility to respond to these events after they have occurred. It is vital that we take steps now “to embrace not just the essential elements of disease protection and surveillance but also new strategies and tactics capable of addressing global challenges.”<1> CMA’S PROPOSED PUBLIC HEALTH ACTION PLAN No one policy instrument can possibly address the multiple factors involved in meeting the public health challenge head on. Similarly, no one level of government or constituency (e.g., community medicine) can or should shoulder all of the responsibilities. Although we need to restore public confidence quickly, we must also do what it takes to get it right. Accordingly, the CMA is proffering a three-pronged approach to meet the challenge: * A legislative reform strategy * A capacity enhancement strategy * A research, surveillance and communication strategy. These three broad strategies make up the CMA’s proposed 10-point Public Health Action Plan. Taken together, the CMA believes the Plan, if adopted, will serve us very well in the future. Legislative Reform Our experience with SARS — and the seeming lack of coordination between international, federal, provincial and local system levels — should be a massive wake-up call. It highlights the need for legislative reform to clarify the roles of governments with respect to the management of public health issues and threats. Four years ago, national consultations on renewing federal health protection legislation<2> resulted in a recommendation that * “The federal government must be given, either through legislation or through memoranda of understanding among provincial and territorial governments, the authority it needs to effectively address any outbreak of a communicable disease, where the health risk extends beyond provincial borders. * “Federal health protection legislation should be amended to give Health Canada authority to act quickly and decisively in the event of a national health emergency... if it poses a serious threat to public health; affects particularly vulnerable segments of the population; exceeds the capacity of local authorities to deal with the risk; and involves pathogens that could be rapidly transmitted across national and international borders.” Such legislative reform is consistent with the federal government’s well-recognized responsibility to act to protect public health and safety. It fits well with Health Minister McLellan’s recently announced plans to act now to review and update health protection legislation. The SARS outbreak has provided further experience to support these, and in our view, even stronger recommendations. There is ample historical evidence to support the federal government’s role in the management of communicable disease, a role that dates back to the time of confederation. The quarantine power was the initial manifestation of this authority in 1867 under Section 91 of the British North America Act and it gave the federal government the responsibility for ensuring the containment of infectious diseases. The outbreak of the Spanish Flu epidemic in 1918 further highlighted the need for coordinated national efforts and (at the urging of the CMA and others) resulted in the creation of the federal Department of Health in 1919. It would be reasonable to assume that legislators at the time had an expansive view of the need for centralized authority to deal with pan-Canadian health threats. One hundred and thirty-five years after confederation, we have a highly mobile global community. This mobility and the attendant devastating speed with which diseases can spread demand a national response. Currently, there is tremendous variation in public health system capacity among the various provinces and territories and, more particularly, among municipalities and local authorities. Inconsistencies in provincial approaches to public health matters have resulted in significant disparities between and within the provinces.<3> Health Canada’s mandate as set out in its enabling legislation states that “[t]he powers, duties and functions of the Minister extend to and include all matters over which Parliament has jurisdiction relating to the promotion and preservation of the health of the people of Canada.” The CMA believes that it is time for the federal government to take responsibility for public health matters that touch the lives of all Canadians. The legal staffs at CMA, in consultation with external experts, have conducted a detailed review of existing legislation. We have concluded, as Health Minister McLellan recently announced, that there is a long overdue need to consolidate and rationalize current related laws. We also believe there is now public support and a demonstrable need to enhance the powers afforded the federal government. We recognize that the government has put forward Bill C-17, the Public Safety Act and a review of health protection legislation is underway. We believe that amending and updating existing legislation is necessary but not sufficient to address today’s public health challenges. The CMA is calling for the enhancement of the federal government’s “command and control” powers in times of national health emergencies. Specifically we are recommending a three-pronged legislative approach. 1. The CMA recommends The enactment of a Canada Emergency Health Measures Act that would consolidate and enhance existing legislation, allowing for a more rapid national response, in cooperation with the provinces and territories, based on a graduated, systematic approach, to health emergencies that pose an acute and imminent threat to human health and safety across Canada. The existing Emergencies Act gives the federal government the authority to become involved in public welfare emergencies when regions of the country are faced with “an emergency that is caused by a real or imminent... disease in human beings... that results or may result in a danger to life or property... so serious as to be a national emergency.” However, to use this power, the federal government must declare a “national emergency,” which itself has political and economic ramifications, particularly from an international perspective, and mitigates against its use. The CMA believes that this all-or-nothing approach is not in the public’s best interest. The concept of emergency in the context of public health requires a different response from governments in the future. Although we recognize that provincial and municipal governments currently have preplanned sets of responses to health threats, the CMA is proposing new legislation to allow for a rapid federal response to public health emergencies. The proposed Emergency Health Measures Act clarifies the roles and authority of governments and ensures a consistent and appropriate response with sufficient human and financial resources to protect Canadians faced with a public health emergency. Of utmost importance, all Canadians, regardless of their location, can be assured that the response to a health emergency will be delivered systematically by experts who can sustain the effort as needed. The proposed legislation would be founded on a graduated approach that would give the federal government the powers necessary to deal with a crisis, in an appropriately measured way, as it escalates. As the emergency grows, the government could implement stronger measures as required to meet the challenge — in principle, akin to the Unites States’ homeland security levels, which increase as the level of threat increases (see Appendix 4 for a description of the Canadian Emergency Health Alert System). The CMA strongly believes that the federal government must have jurisdiction to act when the ability of the provinces to respond to public health emergencies is so disparate. The inability of one province to stop the spread of virulent disease would have serious implications for the health of residents in the rest of the country. The federal government and the provinces must work together to ensure the safety of all our citizens. 2. The CMA recommends The creation of a Canadian Office for Disease Surveillance and Control (CODSC) as the lead Canadian agency in public health, operating at arm’s length from government. Although some provinces have established centres of public health expertise, considering the breadth of public health issues, the relative population sizes and differences in wealth, it will never be feasible to have comprehensive centres of public health expertise for each province and territory. Even if one achieved this, there would increasingly be issues of economies of scale and unnecessary duplication among centres. This issue is not unique to Canada.1 The CMA is proposing the development of a Canadian Office for Disease Surveillance and Control (CODSC) operating at arm’s length from any level of government. CODSC would have overall responsibility for protecting the health of Canadians. The Office would provide credible information to enhance health decisions and promote health by developing and applying disease prevention and control, environmental health and health promotion and education activities. CODSC would enable a consistent and coordinated approach to public health emergencies as well as play a key role in the prevention and control of chronic diseases and injuries. It would provide national health surveillance, apolitical scientific expertise, system development including standards and guideline development, development and dissemination of an evidence base for public health interventions, skills training and transfer of expertise (i.e., through secondment of staff) and resources, including funding for core programs, to other levels of the system (e.g., provincial and local). 3. The CMA recommends The appointment of a Chief Public Health Officer of Canada to act as the lead scientific voice for public health in Canada; to head the Canadian Office for Disease Surveillance and Control; and to work with provinces and territories to develop and implement a pan-Canadian public health action plan. Many national or federal–provincial–territorial committees play an important role in recommending public health strategies or actions. The National Advisory Committee on Immunization and the Federal, Provincial and Territorial Advisory Committee on Population Health are two excellent examples. But there is currently no single credible public health authority in whom is vested, through legislation or federal–provincial–territorial agreement, the overall responsibility for pan-Canadian public health issues. Therefore, the CMA is recommending the appointment of a Chief Public Health Officer of Canada. Potential roles for this officer may include: * Serve as the head of the Canadian Office for Disease Surveillance and Control * Serve as the national spokesperson for public health with the independence to comment on critical public health issues * Report annually on the health of the population * Develop, implement and report independently to parliament on public health system performance measures * Lead processes to identify and address gaps in the nation’s public health system. Capacity enhancement The public health system infrastructure is the foundation that supports the planning, delivery and evaluation of public health activities. In March 2001, the Federal, Provincial and Territorial Advisory Committee on Public Health<3> reported, In the view of respondents the system ‘is lacking in depth.’ This means that a sustained crisis would seriously compromise other programming. While the research does not indicate that the public health system in Canada is strained beyond capacity, there does appear to be agreement that there is a capacity to manage just one crisis at a time. However, just 2 years later, the GTA, an area with one of Canada’s most sophisticated public and acute care health systems, was not able to manage the SARS crisis and carry on any other programs. The Ontario government recognized this state of affairs when, on 12 June, Ontario’s Health Minister Tony Clement said, “I was concerned that if we had one additional large-scale crisis, that the system would crash.” Important public health issues ranging from immunization to suicide prevention went virtually unaddressed, as the public health capacity in Toronto was overwhelmed. In the absence of a mechanism to share resources within the system and a general lack of overall system surge capacity, the city of Toronto and the province competed with each other to recruit trained staff from other health departments. The SARS outbreak has shown there is no surge capacity in Canada’s largest city. The acute care system in Toronto virtually ground to a halt in dealing with SARS. We must ask ourselves what would have happened if SARS had struck first in a smaller centre in a far less-advantaged region of Canada. Clearly Canada is not fully prepared. We should not have needed a crisis to tell us this. The CMA sees several components to rebuilding the capacity of the public health system. Public health human resources For the essential functions of the public health system to be realized, public health agencies need a workforce with appropriate and constantly updated skills. Canada’s public health workforce is extremely thin. There appear to be too few graduate-level public health professionals (i.e., those holding a master’s degree and physicians who are certified specialists in community medicine); those who do exist are not distributed equitably across jurisdictions. The scarcity of hospital-based infection control practitioners and emergency physicians within the acute care system and the lack of integration of hospital and community-based disease control efforts have been particularly striking during the SARS outbreak. The knowledge and skills required for effective public health practice are not static. They continually evolve as new evidence is identified. However, continuing education programming for public health practitioners is woefully underdeveloped in Canada. Health Canada has made some limited progress in this area, but the issue needs to be addressed much more substantively. 4. The CMA recommends The creation of a Canadian Centre of Excellence for Public Health, under the auspices of the CODSC, to invest in multidisciplinary training programs in public health, establish and disseminate best practices among public health professionals. Canada has world-class expertise in public health. However, it does not have the depth of other countries, partly because we do not have a national multidisciplinary school of public health of the calibre of Harvard in Boston, Johns Hopkins in Baltimore and the School of Hygiene and Tropical Medicine in London. A national school of public health, which might be based on a virtual network of centres nationwide, could * Develop a plan to assess and address the substantial educational needs of new and existing public health staff * Address the coordination of the various academic training programs to meet the needs of the field * Ensure self-sufficiency of our public health workforce. 5. The CMA recommends The establishment of a Canadian Public Health Emergency Response Service, under the auspices of the CODSC, to provide for the rapid deployment of human resources (e.g., emergency pan-Canadian locum programs) during health emergencies. The SARS outbreak clearly demonstrated the need for a pre-planned approach to supporting and augmenting the public health and acute care workforce during a crisis. When health professionals in the GTA were overwhelmed, we were ill prepared to move health professionals in from other jurisdictions to help. Health professional associations like the CMA took the first steps in investigating and overcoming obstacles regarding licensure and insurance. We were taken aback when we found that the Ontario government had unilaterally awarded an exclusive contract to a for-profit company to arrange for emergency relief. The further delay caused by concerns about privacy, confidentiality and harmonizing fees hampered relief efforts. The deployment of health professionals during health emergencies is too important to be left in the hands of for-profit organizations as it was during the SARS experience. An established Canadian Public Health Emergency Response Service, operating on a non-profit basis, would * Maintain a “reserve” of public health professionals who are fully trained and could be deployed to areas of need during times of crisis * Co-ordinate the logistics of issues such as portable licensing, malpractice and disability insurance * Identify funding for staff training and a more equitable distribution of numbers and skills among jurisdictions. Investment in public health Considering the importance of the public health system and its capacity to protect and promote the health of Canadians, it is amazing that we have no reliable or comprehensive information about how much money is actually spent on the system or what public health human resources are available across Canada. This is partially due to the lack of uniform definitions, service delivery mechanisms and accounting practices. Even in the absence of reliable data on public health expenditures, there is ample evidence that the public health system continues to operate under serious resource constraints across Canada. 6. The CMA recommends Tracking and public reporting of public health expenditures and capacity (both physical and human resources) by the Canadian Institute for Health Information and Statistics Canada, on behalf of the Canadian Office for Disease Surveillance and Control. In its latest report on health system expenditures, the CIHI states that 6% of total expenditures in 2000 were spent on “public health and administration.”<4> The inclusion of administrative costs in this figure means that public health funding is substantially less than 6% of health system expenditures.2 Federal Government Estimates report that Health Canada allocated $433 million in 2003–2004 for health promotion and prevention activities with spending scheduled to decrease to $308 million by 2005–2006 or by almost 30%. This decrease in spending exemplifies a decade that has seen tremendous fluctuations in spending on public health activities. The situation is alarming when looked at from a current-dollar basis; there was an 8.8% decrease in funding of public health activities between 1994–1995 and 1997–1998. In fact, federal spending on public health on a constant dollar basis did not regain its 1994–1995 level until 2000–2001. Although the late 1990s saw some reinvestment in public health initiatives, the most recent 2003–2004 estimates suggest that, once again, federal investment in public health will decrease dramatically over the next few years. Indeed, public health continues to represent only a small fraction of total federal direct spending on health (9.7% in 2002–2003). At the provincial level, although we cannot distance public health from administration, we know that it fell victim to the brutal climate of fiscal retrenchment of the 1990s, when in real terms provincial–territorial per capita health spending declined for 5 consecutive years after 1991–1992. During this period, public health was further destabilized by regionalization. According to the Survey of Public Health Capacity in Canada most provincial and territorial officials reported reductions in programming as a result of the transfer of funding and responsibility to regional structures. Although Ontario did not regionalize, in 1997 public health funding was downloaded to municipalities, which left public health departments scrambling to find funds to meet existing programs as well as new services that were mandated by the provincial Health Protection and Promotion Act. Whether talking about federal or provincial–territorial jurisdictions, we can no longer afford to have funding for health and safety subject to the vagaries of financial cycles. However, what perhaps is most alarming is the potentially large economic impact of underinvestment in this area. Although the net cost of the SARS outbreak in Ontario is not yet known, recent estimates suggest that it could be as high as $2.1 billion.3 Given this, the proverbial ounce of prevention that is worth a pound of cure comes to mind suggesting that a relatively modest increase in funding for public health could potentially result in substantial savings in the longer term. 7. The CMA recommends Federal government funding in the amount of $1 billion over 5 years to build adequate and consistent surge capacity across Canada and improve coordination among federal, provincial/territorial and municipal authorities to fulfill essential public health functions. The best way to ensure that the public health system is capable of addressing the range of public health threats, including emergencies, is to significantly increase investment in its capacity. This investment must assist all levels of the system to fulfill essential public health functions, with particular attention to local and regional agencies. The strategic national leadership that we are calling for includes the development of new mechanisms for federal cost sharing of basic public health services and the guarantee of a basic core set of local programs serving everyone in Canada, regardless of where they live. The system also needs to receive targeted funds so that it can do its work smarter and more effectively. Priority areas for this targeted funding should include development of an integrated information system and staff training. Research, surveillance and communications Canada’s ability to respond to emerging public health threats and acute events, such as the SARS outbreak, and to maintain its effective public health planning and program development depends on sound research, surveillance and rapid, real-time communications. 8. The CMA recommends An immediate sequestered grant of $200 million over 5 years to the Canadian Institutes of Health Research to initiate an enhanced conjoint program of research with the Institute of Population and Public Health and the Institute of Infection and Immunity that will expand capacity for interdisciplinary research on public health, including infectious disease prevention and control measures. Similar to the efforts in clinical care to support the use of evidence-based practices, interventions in public health must be based on research, evidence and best practices. A national effort should be undertaken to develop and make widely available, on an ongoing basis, a comprehensive and up-to-date review of the evidence base for public health programs. This information would support effective practice, enhance public health research capacity and support other infrastructure elements (e.g., minimum programs and services, performance measurement, system funding). It could also reduce unnecessary duplication of efforts by different public health agencies. We applaud the tremendous work of the unique trans-Canada partnership of 4 CIHR-funded research teams who, in just 11 weeks, discovered the complete DNA sequence of the coronavirus associated with SARS. This is a perfect example of what can be accomplished when our talented research teams work together. The recent announcement by the CIHR of an integrated national strategy for research on SARS reflects the intent of this recommendation for other public health challenges. 9. The CMA recommends The mandatory reporting by provinces and territories of identified infectious diseases to the newly established Chief Public Health Officer of Canada to enable appropriate communications, analyses and interventions. Public health surveillance is defined as the ongoing, systematic collection, analysis and interpretation of health data necessary for designing implementing and evaluating public health programs. It is an integral part of the public health system and performs an essential function in early detection and response to threats to human health. Current surveillance systems for communicable and noncommunicable diseases are inadequate to allow public health professionals to detect and react to major health issues. For effective public health management, surveillance must be a continuous process covering a range of integrated data sources to provide useful and timely information. 10. The CMA recommends The one-time infusion of $100 million, with an additional $2 million a year, for a “REAL” (rapid, effective, accessible and linked) Health Communication and Coordination Initiative to improve technical capacity to communicate with front line public health providers in real time during health emergencies. In today’s world, international travel, business and migration can move infectious diseases around the world at jet speed. But during the SARS experience, governments and public health authorities were unable to communicate in real time with health professionals on the front lines. Gaps in the basic communication infrastructure prevent public health agencies from talking with each other in real time, and also hinder exchanges between public health staff, private clinicians and other sources of information about emerging new diseases. In response to requests from both the Ontario Medical Association and Health Canada, the CMA mobilized its communication networks to provide physicians with critical information about public health management of SARS. In less than 48 hours, via email and fax, we reached over 45,000 physicians with authoritative information. Through the good offices of the Canadian Council of Health Services Accreditation, this information was also made available to over 1500 accredited health facilities across Canada. Although necessity caused the limits of the system to be tested, SARS highlighted the fact that we do not have information systems in place to facilitate real-time communication with health professionals. Information is the key to effective response during times of emergency. Information in real time is also essential for effective day-to-day health care to provide, for example, information on adverse drug reactions. CONCLUSION SARS brought out the best in Canada and Canadians’ commitment to one another. It also turned a bright, sometimes uncomfortable spotlight on the ability of this country’s health care system to respond to a crisis, be it an emerging disease, a terrorist attack, a natural disaster or a large-scale accident. We must learn from the SARS experience and quickly move to rebuild the infrastructure of a strong public health system. The CMA believes that this 10-point Public Health Action Plan will go a long way toward addressing shortfalls in the Canadian public health system. Action now will help to ensure that Canadians can be confident once again that their governments are doing all they can to protect them from the threat of new infectious diseases. We wish the advisory committee well in its deliberations and offer the CMA’s assistance at any time in clarifying the strategies set out in our submission. APPENDIX 1: THE CMA’S PUBLIC HEALTH ACTION PLAN [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [TABLE END] APPENDIX 2: ESTIMATED COST OF IMPLEMENTING THE RECOMMENDATIONS [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Recommendation Estimated cost over 5 years Legislative and institutional reform 1. Canada Emergency Health Measures Act N/A 2. Canadian Office for Disease Surveillance and Control (CODSC) ? $20 million 3. Chief Public Health Officer of Canada Capacity enhancement 4. Canadian Centre of Excellence for Public Health $100 million 5. Canadian Public Health Emergency Response Service $35 million 6. Canadian Institute for Health Information and Statistics Canada $35 milliona 7. Surge capacity $1 billionb Research, surveillance and communications 8. Canadian Institutes of Health Research $200 millionc 9. Mandatory reporting Included under 2 and 3 above 10. Enhanced reporting $110 million TOTAL $1.5 billion a. Work is currently underway to break-out public health from the current category of “public health and administration.” b. This is an incremental investment in addition to funding currently available under Health Canada’s Health Promotion and Prevention Strategic Outcome area. c. Funding must be sequestered specifically for new initiatives related to public health. Additional money could also be acquired through funding from the Canadian Foundation for Innovation, which received an additional $500 million in 2002–2003 (announced in the 2003 federal budget) to enhance the Foundation’s support of public health infrastructure. [TABLE END] APPENDIX 3: CHRONOLOGY OF THE CMA’S RESPONSE TO SARS 2002 November 16 * First known case of atypical pneumonia (SARS) occurs in Guangdong province, China 2003 February 11 * World Health Organization (WHO) receives reports from the Chinese Ministry of Health about SARS; 305 persons affected and 5 deaths February 13 * Canadian index case arrives in Hong Kong for a family visit February 18-21 * Canadian index case is a guest at the Metropole hotel in Kowloon February 21 * A medical doctor from Guangdong checks into Metropole hotel in Kowloon. The physician, who became ill a week before staying at the hotel, is considered to be the original source of the infection * This leads subsequently to outbreaks in Vietnam, Hong Kong, Singapore and Canada after guests leave the hotel and return home February 23 * Canadian index case returns home to Toronto March 5 * Canadian index patient dies in Toronto, 9 days after the onset of her illness March 12 * WHO issues global alert about SARS March 13 * National and international media reports begin appearing about SARS * The Canadian index patient’s son, Canada’s second SARS victim, dies 15 days after the onset of his illness March 14 * First reports from Toronto about deaths from SARS March 16 * Health Canada receives notice of SARS patients in Ontario and British Columbia; begins regular updates on SARS on its website * Health Canada initiates its pan-Canadian communication infrastructure, based on its pandemic influenza contingency plans March 17 * CMA calls Health Canada to offer assistance and request “real time information.” CMA immediately placed on list of participants in daily pan-Canadian teleconferences. * CMA adds a SARS page to its website home page (cma.ca) with CMA Shortcuts to expert information and daily updates March 19 * CMA alerts all its divisions and affiliates to the Health Canada and CMA SARS web pages * eCMAJ includes SARS updates on its website March 20 * CMA divisions add a link to SARS information for health professionals to their websites * Health Canada requests CMA’s assistance to inform physicians of the public health management guidelines for SARS March 28 * CMA sends an email to 33,000 members (copied to divisions and affiliated societies) to alert them to Health Canada’s SARS public health management documents and SARS web page April 1 * CMA CEO initiates cross-directorate task force and deploys dedicated staff resources. Some other CMA programs deferred/delayed. Task force begins daily staff SARS Working Group meetings * CMA communicates with the Ontario Medical Association on a daily basis April 2 * CMA holds teleconference with divisional communication directors re: SARS April 3 * CMA contacts the British Medical Association to establish whether we can secure a supply of masks from European sources * CMA organizes a teleconference among national health care organizations to discuss SARS developments April 7 * CMA posts electronic grand rounds on SARS for clinicians on cma.ca; * CMA sends email and fax communication to physicians to raise awareness of SARS e-grand rounds on cma.ca * Working with the Mental Health Support Network of Canada, CMA prepares and posts on cma.ca, fact sheets for health professionals and the public on coping with the stress caused by SARS April 9 * CMA hosts second teleconference among national health care organizations to discuss SARS developments April 17 * Electronic grand rounds on SARS updated and promoted through cma.ca April 23 * CMA sends email to membership requesting volunteers for the CMA Volunteer Emergency SARS Relief Network April 24 * CMA consults with the American Medical Association regarding the possibility of US physicians volunteering for the relief network April 25 * CMA CEO sends letter to deputy minister of health about the urgent need to create a national ministerial SARS task force April 30-May 1 * CMA participates in Health Canada-sponsored international SARS conference in Toronto May 6 * Health Canada announces the National Advisory Group on SARS and Public Health, headed by Dr. David Naylor May 12 * Opinion editorial by Dr. Dana Hanson, CMA president, on SARS and public health surge capacity published in The Ottawa Citizen; May 28 * CMA organizes a meeting of national health care organizations to discuss lessons learned from SARS June 3 * CMA receives an invitation to submit a brief to the National Advisory Group on SARS and Public Health June 6 * CMA sends e-mail to targeted segment of its membership (community medicine, public health, infectious disease and medical microbiology) requesting volunteers for the CMA Volunteer Emergency SARS Relief Network June 25 * CMA president outlines the CMA’s Public Health Action Plan during a speech at the Canadian Club in Toronto * CMA submission to the National Advisory Committee on SARS and public health APPENDIX 4: CMA’S PROPOSED HEALTH EMERGENCY ALERT SYSTEM [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Health alert may be declared in: Level 1 Level 2 Level 3 Level 4 Level 5 * Any area under federal jurisdiction * Any community or province/territory with a risk of transmission to other provinces/territories or countries * Any community or province/territory with insufficient resources to manage the public health emergency within the capacity of the local public health authorities Definition of the area of concern Voluntary quarantine for individuals or property Increasing surveillance Chief public health officer takes the lead in coordinating the response Regulation or prohibition of travel Facilitating communication Reviewing and updating health emergency procedures Determination of local capacity to lead and respond Coordinating necessary response efforts with national disaster relief agencies, armed forces or law enforcement agencies at the federal–provinical–territorial level Medium to significant limitations of civil rights and freedoms Mandatory surveillance Assessing future resource requirements Deployment of a national response team Medium to significant limitations of civil rights and freedoms Evacuation of persons and the removal of personal property Providing the public with necessary information. Discretionary deployment of the national response team or on request of local authorities Quarantine of individuals and/or property with enforcement by law Implementing interventions, as appropriate, and emergency response actions Regulation of the distribution and availability of essential goods, services and resources Assessing further refinement of actions Restricting access to the area of concern Requisition, use or disposition of property Required consent of governor in council No No Yes Yes Yes Lead response team Municipal or provincial Provincial or national Provincial or national National or international International [TABLE END] REFERENCES 1. Garrett, L. Betrayal of trust: the collapse of global public health. New York: Hyperion; 2000. 2. Health Canada. National consultations, summary report: renewal of the federal health protection legislation. Ottawa: Health Canada; 1999. 3. Federal, Provincial and Territorial Advisory Committee on Population Health. Survey of public health capacity in Canada: highlights. Ottawa: The Committee; 2001. 4. Canadian Institutes for Health Information. National health expenditure trends: 1975–2002. Ottawa: CIHI; 2002. 5. Lévesque M. The economic impact of SARS. TD Economics Topic Paper. TD Bank Financial Group; 6 May 2003. Available: http://www.td.com/economics/topic/ml0503_sars.html (viewed: 20 June 2003). 1 Many countries (e.g., United States, United Kingdom, Norway and the Netherlands) have developed critical masses of public health expertise at the national level. The Centers for Disease Control and Prevention in the United States, which has a critical mass, great depth of scientific expertise and the tools and fiscal resources to fund public health programs at both state and local levels through demonstration projects, is a sterling example of the effectiveness of such a central agency. 2 A review by the Canadian Institute for Health Information recognizes the problem with current expenditure tracking systems and has recommended separating public health from government administrative costs and prepayment administration in future health system cost estimates. 3 On 6 May, the TD Bank released a paper<5> suggesting that the cost of SARS to the Canadian economy may be between $1.5 and $2.1 billion.
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Canada Pension Plan Disability Program : CMA Presentation to the Sub-Committee on the Status of Persons with Disabilities

https://policybase.cma.ca/en/permalink/policy1965
Last Reviewed
2010-02-27
Date
2003-03-18
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2010-02-27
Date
2003-03-18
Topics
Population health/ health equity/ public health
Text
The Canadian Medical Association appreciates the opportunity to once again participate in the deliberations of the Sub-Committee on the Status of Persons with Disabilities. I am accompanied today by Mr. William Tholl, Secretary General and Chief Executive Officer of the Canadian Medical Association. Before I begin my remarks, I want to congratulate this Committee, and particularly the Chair of the Committee, for your efforts in regard to another federal program, the Disability Tax Credit. Your 2002 report on this program, Getting it Right for Canadians, no doubt led to some of the important measures in regard to disabilities undertaken by the government in the recent federal budget. The appointment of the Technical Advisory Committee on eligibility criteria and the $105 million allocated over the next two years to improve assistance for persons with disabilities is, in our view, significant progress. The CMA appreciates this opportunity to discuss issues relating to the Canada Pension Plan (CPP) specifically as the program relates to the disability benefit. I will focus my remarks today in three areas: * Physician experience with federal health programs and forms * The need for common criteria * Recommendations for action While the subject matter before the Subcommittee today is the CPP disability program, we believe a broader focus on the issue of “disability” and federal health programs in general is needed. Issues related to the CPP disability program are issues common to other federal disability assistance programs. THE PHYSICIAN EXPERIENCE I don’t think I need to tell this Committee about the alarming shortages of physicians and other health care providers in Canada. Canada’s physicians have been stretched to the limit and beyond. Therefore, it’s more important than ever that physician’s time be managed in such a way as to maximize our interaction with patients. Unfortunately however, this is not the case. Increasingly physicians are spending more and more of their time filling out forms. Forms for federal health programs such as the CPP or for-private insurance claims, pension benefits, tax credit eligibility, pharmaceutical plans and workers compensation claims to name just a few. To figure out all the various forms and determine eligibility you almost need to be a physician, a lawyer and a tax expert. The result of the proliferation in the number of forms and their increasing complexity has resulted in less time for what physicians are trained to do; treating illness and providing care to patients. If you were to ask the average physician his or her greatest frustration with the health system, the response would be too much time spent administrating the system and not enough time in providing care to patients. In regard to the CPP specifically, we have had in the past a good working relationship with the officials who manage this program. We have worked together well in the past in regard to improving the forms and bring great integrity to the program which has resulted in a reduction of appeals under the program. The CMA believes that in terms of a federal health program, the CPP set the template both in terms of administrative processes and cooperation that should be adopted across all federal programs in this area. That said, there is still considerable room for improvement. I urge the Committee to take into consideration the cumulative impact these various health programs, such as the CPP, have on our health provider workforce. We must look at ways in which to relieve the heavy administrative burden so that physicians can concentrate their efforts on what they do best, patient care. COMMON CRITERIA As with our presentation on the Disability Tax Credit program, the CMA recommends that a standard of fairness and equity be applied across all federal disability benefit programs. Currently, there is virtually a different definition and a different assessment process for each and every program. A common frustration of physicians is that while a patient qualifies as “disabled” under one disability program, that same patient does not under another. When you look at some of the common criteria used to determine the level of a disability, the problem is readily apparent. The CPP criteria define “severe” as preventing an applicant from working regularly at any job and “prolonged” as long term or that which may result in death. However, the DTC program notes that “severe” is to be interpreted to mean markedly restricting any of the basic activities of daily living and that a disability must be “prolonged” over a period of at least 12 months. While daily living includes working regularly at any job it encompasses so much more. Under the CPP criteria the physician is responsible for determining how to define long term; six months or twelve months. Other programs, such as the Veterans benefits that have entirely different criteria, are added to this mixture. This is confusing for physicians, patients and others involved in the application process. If the terms, criteria and the information about the programs are not as clear as possible then we have no doubt that faulty interpretation on the part of physicians when completing the forms can occur. This could then inadvertently disadvantage those who, in fact, qualify for benefits. There needs to be some consistency in definitions across the various government programs. This does not mean that eligibility criteria must be identical. However, there must be a way for a more standardized approach. Inconsistency in the application and administration of the program is likely without a more standardized definition of the program. The reality is that certain individuals with conditions or disabilities may qualify for the CPP disability benefit in one region of the country, while in other regions, an individual with the same condition will be deemed ineligible. There are a number of conditions that society would today view as a “disability,” yet may not fit under the current program. Severe and prolonged is a rigid standard, especially as it is applied to some medical conditions. The reality is that such a standard cannot be applied fairly in all situations. There needs to be greater flexibility and more realistic criteria that takes into account the special nature of some medical conditions that may not meet yesterday’s standards. RECOMMENDATIONS Canada’s physicians offer four specific actions for the Committee to consider: 1. That an emphasis be placed on reducing the administrative burden placed on health care providers under all federal health programs. The CPP program, both in terms of the consultative and administration process, should serve as the template for change. Unlike other federal health programs, the cost of having the eligibility form completed by a physician is subsumed under the program itself. The CMA believes this should be the case for all federal health programs. 2. The establishment of a joint governmental and stakeholder advisory group, similar to the recently announced DTC Advisory Committee, to monitor and appraise the performance of the CPP disability program to ensure it meets its stated purpose and objectives. Representation on this advisory group would include senior program officials; health care providers; various disability organizations; and patient advocacy groups. 3. That there be some consistency in definitions across the various government programs. This would not circumvent the purposes or mandates of the programs. 4. That a comprehensive information package be developed for health care providers and the public that provides a description of each program, its eligibility criteria, the full range of benefits available, copies of sample forms, physical assessment and form completion payment information, etc. CONCLUSION To conclude, the CMA believes that the CPP is a deserving benefit to those Canadians living with a disability. We again congratulate the Committee for the progress it has achieved on behalf of people with disabilities in regard to the recent initiatives announced in the federal budget. The CMA looks forward to working with all concerned to improve the CPP program and all other federal disability health programs. Thank You.
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CMA presentation to the House of Commons Standing Committee on Finance on Bill C-38

https://policybase.cma.ca/en/permalink/policy10441
Date
2012-05-31
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2012-05-31
Topics
Health systems, system funding and performance
Text
Thank you for this opportunity to appear before this committee on behalf of the CMA and its 76,000 members. Canadians believe that transforming our health care system to meet the needs of 21st century Canada must be among the highest priorities for all levels of government, including the federal government. I would like to begin by commenting on the health transfer framework announced by the Minister of Finance in December. This announcement provided some predictability for the years ahead. However, with the federal government reducing its involvement in several areas affecting health or health care, added costs will end up in the laps of the provinces and territories. So while this budget may enhance the federal government's fiscal prospects, it will do so to the detriment of the provinces and territories. But there's more to this debate than funding. We believe that Canadians would be better served if federal health care transfers came with specific guidelines ensuring that the system provides care of comparable access and quality to Canadians across the country, regardless of their circumstances. We are encouraged that the Minister of Health has indicated she wants to collaborate with the provinces and territories on developing accountability measures to ensure value for money and better patient care. We look forward to the minister's plan for accountability. This budget is notable for other missed opportunities. For many years, groups across the political spectrum have called for a pharmaceutical strategy to reduce national disparities. In fact, such a strategy was committed to by governments under the 2004 Health Accord. Minister Kenney referred to this issue indirectly when he said the recent cancellation of supplemental health benefits for refugee claimants is justified because refugees should not have access to drug coverage that Canadians do not have. Rather than cutting off those desperately vulnerable people, Canada's physicians urge the federal government to work with the provinces and territories to develop a plan that ensures all Canadians have a basic level of drug coverage. Indeed, we now appear to be in a race to the bottom in the way we treat vulnerable groups - by, for example, deferring Old Age Security for two years; and changing service delivery to veterans, mental health programs for our military and the Employment Insurance program. Significant policy changes have been announced since the budget, with little opportunity for debate and little evidence provided. We note, as well, the lack of open consultation with Canadians on matters of great import to their lives. Successful policy requires buy-in, which is best achieved when those interested are able to participate in the policy-making process. This brings me to a wider concern shared by our members - that policy-makers are not paying adequate attention to the social determinants of health, factors such as income and housing that have a major impact on health outcomes. We remind the government that every action that has a negative effect on health will lead to more costs to society down the road. The federal government is the key to change that benefits all Canadians. While there are costs and jurisdictions to consider, the CMA believes the best way to address this is to make the impact on health a key consideration in every policy decision that's made. The federal government has used this approach in the past, in considering rural Canadians, for example. We therefore call for a new requirement for a health impact assessment to be carried out prior to any decision made by cabinet. This would require that, based on evidence, all cabinet decisions take into account possible impacts on health and health care, and whether they contribute to our country's overall health objectives. A similar model is in use in New Zealand and some European countries. For instance, what health impact will cuts in funding to the tobacco strategy have? Such an assessment would in particular have a dramatic impact with regard to poverty. Poverty hinders both human potential and our country's economic growth - and needlessly so as there are many ways to address it effectively. The National Council on Welfare - which will disappear as a result of this budget - reported last fall that the amount it would have taken in 2007 for every Canadian to have an income over the poverty line was $12.6 billion, whereas the consequences of poverty that year added up to almost double that figure. Close to 10 per cent of Canadians were living in poverty in 2009, many of them children, as UNICEF underlined yesterday. This is a huge challenge for our country. In closing, as this budget cycle ends and as you begin to prepare for the next, please bear in mind that as prosperous as our country is, if we do nothing for the most vulnerable in our society - children, the elderly, the mentally ill, Aboriginal peoples - we will have failed. Thank you.
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CMA Presentation to the Senate Standing Committee on Social Affairs, Science and Technology - Prescription Drugs: Clinical Trials and Approval

https://policybase.cma.ca/en/permalink/policy10437
Date
2012-05-09
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Parliamentary submission
Date
2012-05-09
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
Good afternoon. My name is Dr. Maura Ricketts and I am the Director of Public Health for the Canadian Medical Association. The CMA appreciates the opportunity to appear before this Committee today as part of your study of clinical trials and drug approvals. The CMA represents more than 76,000 physicians in Canada. Its mission is to serve and unite the physicians of Canada and to be the national advocate, in partnership with all Canadians, for the highest standards of health and health care. Because prescription drugs are an essential component of health care, the CMA has developed a considerable body of policy on pharmaceutical issues. This work can be distilled into one fundamental principle: The CMA believes that our country requires a National Pharmaceutical Strategy to ensure every individual has timely access to safe, effective and affordable prescription drugs. Despite the commitment in the 2004 Health Accord to the creation of such a strategy, Canadians continue to wait for government leadership on this issue. Drugs replace more costly and invasive medical interventions. They are an essential tool in the physician's tool box. To ensure safety and effectiveness, the CMA also believes in the need for a strong, unbiased, evidence-based system for research and approval. This is at the heart of our commitment to patient-centred care. In evaluating whether to prescribe a new drug to a patient, a physician will weigh several factors: Does this product offer any benefits over what I am prescribing now? Will it be more effective? Will this new drug be safer? Will it solve any tricky clinical problems, such as drug interactions, or reduce side effects that prevent a medication from being used properly? The physician may also ask: What is the evidence that this new drug is an improvement? Can I trust the evidence? Where can I get access to accurate, reliable information and data on this drug? Pre-approval drug research must provide answers to these fundamental questions. Clinical Trials I will now focus on two particular issues of concern to practising physicians with regard to clinical trials: * First, what is being compared to what? Clinical trials may be sufficient for Health Canada's regulatory purposes, but may provide only part of the information a physician needs. For example, is a new cholesterol drug effective on all patients, or only on some of them? Would other patients derive equal benefit from an already existing drug, or from a lifestyle change such as diet or exercise? The CMA recommends that researchers compare a new product to other drugs on the market - and to other interventions, as well. * Second, is timely, reliable and objective information available on all clinical trial results, not just the positive ones? Canadians need to be informed when a drug has performed disappointingly in trials if they are to make informed decisions about their health care. The CMA, therefore, recommends the results of all clinical trials, not just those with positive results, be made available to health professionals and the public. I would like to add that the current documentation is not very user-friendly. We recommend that Health Canada prepare summaries of the most essential data, not only for physicians, but for all Canadians to be able to access this information. The Drug Approval Process Turning now to the drug approval process, the CMA believes the following principles should apply: * The primary criteria for approval should be whether the drug improves health outcomes and offers an improvement over products currently on the market. * The review process should be as timely as is consistent with ensuring optimal health outcomes and the safety of the drug supply. * The review process should be impartial and founded on the best available scientific evidence. * The review process should be open and transparent. * Finally, approval of a drug is not an endpoint, but rather one step in that drug's life cycle. It is not uncommon to identify serious safety hazards after a drug has been approved, because that's when it first goes into wide use. It is important that the approval process be complemented by a rigorous and vigilant post-market surveillance process. We look forward to presenting our recommendations on this subject to your Committee at a future session. Before closing, I would like to briefly address two other matters: First, the issue of drugs for rare disorders. We are aware that the current clinical trial and approval processes, which place a high value on studies with large population samples, may be unable to adequately capture the value of drugs that are prescribed to only a handful of people. Some patient groups active in the area of rare disorders, such as the Canadian MPS Society and Alpha-1 Canada, have shared their concerns about this with us. These groups, along with the Canadian Organization for Rare Disorders, have been advocating for years for a fair process for evaluating drugs for rare diseases. Because Canada doesn't have a rare disorders strategy, Canadian patients have access to fewer therapies than patients in other developed countries. The issue of how to approve drugs for rare disorders merits closer consideration. The CMA recommends that the federal government develop a policy on drugs for rare disorders that encourages their development, call for ongoing evaluation of their effectiveness, and ensures fairness so that all patients who might benefit have reasonable access to them. The second matter is that Health Canada's review process provides little guidance on another question which physicians are increasingly asking: Can my patient afford this drug? It is not sufficient that the Common Drug Review conducts reviews of the cost effectiveness of drugs and that provincial/territorial formularies undertake similar studies, as the fact remains that cost is one of the factors physicians need to consider when deciding whether to prescribe a new drug. This is especially true in the case of new biologics, which are very expensive. Canadian doctors believe that the difficulty of making effective prescribing decisions without information about cost needs to be overcome. This only underscores the necessity of a National Pharmaceutical Strategy. Thank you. We would be happy to answer your questions.
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CMA’s Annual Check-up of Canada’s Health Care System: Presentation to the House of Commons Standing Committee on Finance Pre-Budget Consultations

https://policybase.cma.ca/en/permalink/policy1953
Last Reviewed
2011-03-05
Date
2003-09-25
Topics
Health systems, system funding and performance
  2 documents  
Policy Type
Parliamentary submission
Last Reviewed
2011-03-05
Date
2003-09-25
Topics
Health systems, system funding and performance
Text
The past year has been an historic one for health and health care in Canada. We applaud the federal government for the reinvestments that were made at the time of the February 2003 Health Accord. However, what we as physicians continue to hear in our offices, clinics and hospitals right across the country is continuing concern from our patients that Canada’s health care system won’t be there for them when they need it. And so while we can understand government’s desire to “turn the page” on health care issues, the temptation must be resisted. It is appropriate and prudent that at least once a year, the federal government take the pulse of the health care system – an annual check-up – to take stock of where we’ve been and identify priorities for the coming year. This year, the Canadian Medical Association’s (CMA’s) submission to the Standing Committee on Finance moves largely away from macro funding issues to focus in on strategic initiatives that are national in scope and promise high returns in terms of value for money. Specifically, we identify three areas that require immediate new investments while reminding committee members of work that remains unfinished from years past. Unfinished Business While the CMA applauds the federal government for its leadership in achieving the 2003 Health Accord, it is now time to follow through on some outstanding promises that were made. In particular, there are two areas that require special mention. At the time of the First Ministers’ Health Accord in February 2003, the federal government agreed to provide up to an additional $2 billion into Canada’s health care system at the end of this fiscal year (2003/04) if a sufficient surplus above the normal Contingency Reserve were available. The federal government must honour their commitment. Health cannot be treated as a residual after other contingencies are addressed. Equally important is moving forward with establishing the Canada Health Council. Suggestions to water down the mandate of the health council to make it more palatable to some jurisdictions are not the answer. Canada needs a robust mechanism that will provide for enhanced evidence and accountability on how Canada’s health care dollars are spent. Canada needs a Health Council that will create a meaningful place at the table for Canadians, health care providers and other stakeholders to provide input on how the system operates and monitor its performance. Protecting Public Health The public health system in Canada lies at the very heart of our community values. It is the quintessential “public good” and is central to the continued good health of our population. It is the view of the CMA that our public health system is stretched to capacity in dealing with everyday demands, let alone responding to emerging crises. On June 25, 2003, the CMA submitted a brief to the National Advisory Committee on SARS and Public Health headed by Dr. David Naylor. In it the CMA called upon the federal government to make a minimum investment of $1.5 billion over five years to achieve legislative reform; capacity enhancement; and enhanced research, surveillance and communications capacities. In particular, the CMA calls for immediate funding of two specific priorities. The first is the same proposal that the CMA brought to the Standing Committee on Finance last year – the REAL (rapid, effective, accessible and linked) Health Communication and Co-ordination Initiative. The purpose of this initiative is to increase the capacity of the public health system to communicate in real time, between multiple agencies and with health care providers. Had CMA’s earlier recommendations been acted upon, perhaps we would have been better prepared to communicate with health care providers when SARS first appeared in Toronto. Improved communications must be a priority this time around – we cannot afford to let this recommendation languish another year. The second short-term priority for public health is to invest in an emergency supply chain for use in times of crisis. SARS showed us that the Greater Toronto Area, an area with one of Canada’s most sophisticated public and acute care health systems, was not able to manage the SARS crisis and maintain its capacity to meet other acute care requirements or important public health services such as suicide prevention programs. The federal government must assure Canadians that plans are in place when the health care system is again tested with another public health emergency. Ensuring Adequate Supply, Distribution and Mix of Canada’s Health Human Resources Health is primarily a people business. Of all of the critical issues facing Canada’s health care system, none is more urgent than the shortages of health providers. Simply put, if people are not available to provide care and treatment to patients everything else is irrelevant. While we were encouraged with the $90 million provided in the 2003-04 to “improve national health human resources planning and co-ordination, including better forecasting of health human resources needs”, details of how these funds will be allocated and for what purposes remain unclear. The CMA has proposals on how this money could be used to support much needed health human resource planning that are ready to be pulled off the shelf and implemented. For example, the CMA believes that an arm’s length Health Institute for Human Resources (HIHuR) should be established to address the human side of health, just as existing institutes address the technological (CCOHTA) and information aspects of health (CIHI). Addressing the Health Status of Canada’s Aboriginal Peoples Particularly alarming is the health status of Canada’s Aboriginal peoples where, despite some improvements over the past few decades, Canada has been largely unable to adequately address the health issues facing this community. At CMA’s annual general meeting in August 2003, Health Minister Anne McLellan noted that despite significant investment Canada’s aboriginal people continue to have poor health outcomes. The CMA recommends that the federal government adopt a comprehensive review to look at how the money being spent on health, health care and related areas of investment for Aboriginal people can result in better health outcomes. The current results are not good enough. We must do better. Conclusion For those involved in the health care community, and indeed for all Canadians, this has truly been a remarkable year for Canada in terms of health and health policy. In many ways, the events of February marked a turn toward significant reinvestment in the health care system. However, with the outbreak of SARS in Ontario and the emergence of other significant public health concerns such as West Nile virus, health continued to be a top-of-mind concern for many Canadians. We also know that despite investments made in the 2003 federal budget, there continue to be areas for targeted, strategic initiatives that promise high payoff in terms of value for money. Public health, health human resources and the health status of Canada’s aboriginal people are the three areas that we have highlighted where additional attention and funding can make a real impact at the national level. When considering these investments, however, we must remember that we cannot afford to rob Peter to pay Paul. Both the public health and the acute care systems must simultaneously benefit from increased investment in order not to download one problem onto the other. To return to the analogy of an annual health check-up, let us conclude with this prognosis. Many actions taken in the past year should help over time address the acute symptoms of the patient. However, we must not be complacent. Long term health requires follow-through on last year’s initiatives, targeted new investments and ongoing vigilance. We look forward to the year ahead. INTRODUCTION When historians look back on 2003, they may very well call it the year of health. Since the Canadian Medical Association’s (CMA’s) presentation to the Standing Committee on Finance on October 22, 2002, several key events have highlighted health and health care issues in the minds of Canadians. Senator Michael Kirby and the Standing Committee on Social Affairs, Science and Technology kicked off the year by releasing its final report of the review of the federal health care system in October 2002. This report was followed closely by the release of the final report of the Commission on the Future of Health Care in Canada (the Romanow Commission) in November. In February 2003, Canada’s First Ministers agreed to their second Health Accord in just over two years. February also brought the federal government’s 2003 federal budget, which featured health as a key element. Emerging threats to the health of Canadians such as SARS and West Nile virus, coupled with ongoing concern that the health care system is not meeting patient needs in a timely way, clearly illustrate the prominence health care has played as an issue over the past year. Indeed, Canadians continue to show unwavering interest in health and the health care system. According to an EKOS Poll, Private Voices, Public Choices, health care was consistently identified as Canadians’ highest priority for the federal government as compared to other significant public policy issues (debt, level of taxation and unemployment) between August 1995 and January 2002.i Despite ongoing consensus on the need to make progress in the area of health, polling done for the CMA by Ipsos Reid found that the public remains unsatisfied with the federal government’s response to the health issue. In the CMA’s recently released Third Annual National Report Card on Health Care, 64% of respondents gave the federal government either a “C” or “F” rating in their performance in dealing with health care in Canada.ii Notwithstanding, the CMA acknowledges that the flurry of activity and the amount of public attention that health and health care has garnered over the past year can lead to policy fatigue. However, practitioners working in the health care system continue to see the concern of Canadians about being able to access health care services when and where they need them. Add to that their heightened sense of vulnerability in the face of new infectious diseases and ongoing reports about the poor state of our public heath care infrastructure, and anxiety regarding health and the health care system over the past year has become almost palpable. Health care is also a huge sector of our economy. At over $112 billion dollars,iii Canada’s health care system represents 9.7% of our Gross Domestic Productiv. At the federal level, major transfers to other levels of government (a large proportion of which goes to support health care in the provinces and territories) represents almost a quarter (22%) of total program spending by the federal government.v And so, while the physicians of Canada can understand the desire to “turn the page” on health care issues, the temptation must be resisted. It is appropriate and prudent that at least once a year, the federal government take the pulse of the health care system – an annual check-up if you like – to take stock of where we’ve been and identify priorities for the coming year. The CMA recognizes that great strides were made last year in terms of reinvestment in Canada’s health care system. As such, this submission to the Standing Committee on Finance will move largely away from macro funding issues to focus in on targeted, initiatives that are national in scope and promise high returns in terms of value for money. Specifically, we have identified three areas that require immediate new investment. 1. Protecting public health; 2. Ensuring adequate supply, distribution and mix of Canada’s health human resources; and 3. Addressing the health status of Canada’s Aboriginal peoples. Will any of these initiatives alone improve the overall health of Canadians and increase their access to health care? The answer is no. But by improving the public health infrastructure; ensuring better supply of health human resources; and addressing the particularly urgent health care needs of Canada’s Aboriginal peoples, the proposed initiatives represent significant steps that can be taken toward eliminating many of the access issues that are top of mind concerns for so many Canadians. However, before discussing these priorities for new investment, there are a couple of areas of unfinished business that need to be brought to the attention of members of the Standing Committee. Unfinished Business – delivering on the health accord promise Federal Reinvestments in Health Care Financing In February 2003, the federal government announced new funding of $24.9 billion over 5 years1 for the provinces and territories. This was a significant investment and we applaud the federal government for making health a priority, while noting that a gap persists between the reinvestments made and the CMA’s recommendations for new funding to shore up Canada’s core health care system. (Appendix A provides further details of this gap in funding). At the time of the First Ministers’ Health Accord in February 2003, the federal government agreed to provide up to an additional $2 billion into Canada’s health care system at the end of this fiscal year (2003/04) if a sufficient surplus above the normal Contingency Reserve were available.vi Over the past summer however reports in the media have suggested that this money may not be forthcoming, a concern that has impacted negatively on the federal/provincial/territorial (F/P/T) relationship and created a barrier for advancing the business of health care reform. It is exactly this unpredictability that fosters provincial/territorial distrust of the federal government’s role in health care. While the CMA firmly believes that the federal government has a critical role to play in supporting health care across the country, it must fulfil this role in a manner that reassures provinces and territories that promises made are promises kept. This must be the modus operandi of federal health investments. Let us state in the strongest words possible that the CMA and Canada’s physicians expect the Government of Canada to ensure its fiscal house is in order so that this commitment can be fulfilled. Canada’s health care system must not be treated as a residual after other contingencies are addressed. Canada Health Transfer The CMA was pleased to see the 2003 budget announce the creation of a separate Canada Health Transfer effective April 1, 2004. It is the CMA’s view that this measure is a significant step toward greater accountability and transparency of funds and we applaud the federal government for this bold initiative. However, in creating the Canada Health Transfer the government has neglected to build-in the key feature of how to ensure the ongoing sustainability of federal support for health care in the provinces and the territories. Without a built-in escalator, claims by the federal government that its investments have introduced sustainability into the system ring hollow. As it stands now, the Canada Health Transfer does not provide for increases in funding to grow in step with increases in health care expenditures or our ability to pay as a country. In the longer term this will result in a return to the imbalance between federal funding of provincial and territorial health expenditures. The CMA reiterates its recommendation made last year to the Standing Committee on Finance and to the Commission on the Future of Health Care in Canada, that a built-in escalator tied to increases in GDP is a fundamental component of the Canada Health Transfer. Canada Health Council One of the biggest piece of unfinished business arising from the February 2003 Health Accord is the continued lack of progress in the area of the Canada Health Council. Canadians are demanding greater accountability for their health care system. Canadians are also fed-up with inter-jurisdictional bickering on health care financing. A Council would provide a forum to allow for non-political assessment of health care issues divorced from the political wrangling that has defined health care in Canada for more than a decade. It would also enhance F/P/T accountability on how health care dollars in Canada are being spent in order to ensure that Canada’s health care dollars are being used wisely. In February, governments promised Canadians that the Health Council would be set up in May. Throughout the summer of 2003, federal government officials indicated that it would be just a matter of time. Most recently, at their Annual Conference on September 4, 2003, F/P/T Ministers of Health agreed to take another seven weeks to “expedite work on the Health Council”.vii Prior to that meeting, the CMA challenged Health Ministers to ratify an implementation plan for a Canada Health Council that would have a council in place no later than November 28, 2003, one year after the release of the final report of the Romanow Commission.viii Suggestions to water down the mandate of the Health Council to make it more palatable to some jurisdictions are not the answer. Canada needs a robust mechanism that will provide for enhanced evidence and accountability on how Canada’s health care dollars are spent. Canadians need an independent, empowered Council. Senator Kirby said it when he called for a National Health Care Council.ix Commissioner Romanow said it when he recommended a Health Council of Canada.x Canadians are demanding greater accountability. Enough is enough. Get on with it. Health Research Another area for continued reinvestment is health research. In our submission to the Romanow Commission, the CMA called for federal government support of health research equal to at least 1% of national health expenditures. For 2002 this would equal approximately $1.1 billion. Actual budgeted expenditure by the federal government for the Canadian Institutes of Health Research for 2002/03 was only $727.2 million.xi Canada must move beyond viewing health care expenditures as a drain on government budgets and start treating them the same as in any other sector – investments. Today’s research provides tomorrow’s treatments. For example, the benefits of increased investment in research extend far beyond the scientist’s lab. Rather, the return on investment is potentially many times the initial investment through increased trade potential, increased innovation and increased productivity. For this reason, the CMA supports, in principle, that idea proposed by Dr. Henry Friesen for the creation of a Health Innovation Council to encourage greater innovation and investment in Canada’s health care system. Key Recommendations Keep your word. Direct the Minister of Finance to honour his promise to put $2 billion back into Canada’s health care system in this fiscal year. Introduce a built-in escalator into the Canada Health Transfer to ensure the federal contribution to the health system keeps pace and remains sustainable. Enough is enough! Establish the Canada Health Council. Identify support for health research equal to at least 1% of national health expenditures. Protecting public health The public health system in Canada lies at the very heart of our community values. It is the quintessential “public good” and is central to the continued good health of our population. It includes the systematic response to infectious disease, but also much more. It ensures access to clean drinking water, good sanitation and the control of pests and other disease vectors. It provides immunization clinics, and programs promoting healthy lifestyles as well as being there to protect Canadians when they face a public health crisis like SARS. Our public health system is the first — and often only — line of defence against emerging and ongoing infectious and noninfectious threats to the health of Canadians. But we are only as strong as the weakest link in the emergency response chain of survival. Most health threats know no boundaries, so our public health armaments must be in a constant state of “battle readiness.” It is the view of the CMA that our public health system is stretched to capacity in dealing with everyday demands, let alone responding to emerging crises. At no time was this more apparent than following the tragic events of September 2001. As a result, the CMA dedicated our 2001 submission to the Standing Committee on Finance to issues related to emergency preparedness in terms of security, health and capacity. In light of SARS and other public health threats those recommendations continue to ring true today.xii It is our contention that had these actions been taken, Canada would have been better prepared to face the recent public health challenges. Unfortunately, the opposite road was taken. Rather than making reinvestments in public health, the federal government has scheduled declines in departmental spending in this area. In fact, according to Government of Canada estimates, by 2005/06 public health expenditures are planned to decrease in current dollars to their lowest level in over a decade (Chart 1). And while we were encouraged by recent investments made in the health care system, we question the lack of investment and forecast reductions in funding for public health. We cannot continue to rob Peter to pay Paul. Both the public health and acute care systems require ongoing investments and attention. On June 25, 2003, the CMA submitted a brief to the National Advisory Committee on SARS and Public Health headed by Dr. David Naylor. In it we identified the need to establish a clearer alignment of authority and accountability in times of extraordinary health emergencies. We also highlighted the need to enhance the system’s capacity to respond to public health threats across the country. To achieve this, we call on the federal government to make a minimum investment of $1.5 billion over five years to achieve legislative reform; capacity enhancement; and enhanced research, surveillance and communications capacities. (For additional detail, please refer to CMA’s submission to the National Advisory Committee on SARS and Public Health, June 2003.xiii A copy of our recommendations and associated costs are attached as Appendix B.) While significant, this level of funding represents only a small investment relative to the massive potential cost of, for example, another SARS crisis. $1.5 billion over five years should be treated as the minimum that could be allocated to these initiatives in order to operationalize each of the recommendations. Estimates do not include existing expenditures on public health that would be reallocated within the public health system. While all of our recommendations for the public health care system are important, there are two components that the CMA believes need immediate action by the federal government. The first refers to the particular urgency to improve communications between health professionals and address immediate shortages in supplies and equipment. Last year we came to the Standing Committee on Finance with a proposal for the REAL (rapid, effective, accessible and linked) Health Communication and Co-ordination Initiative. The purpose of this plan was to increase the capacity of the public health system to communicate in real time, between multiple agencies and with health care providers. (A copy of the REAL proposal is attached as Appendix C.) This followed the call in our 2001 submission for increased communications between public health officials, police, fire and ambulance services, hospitals and other services.xiv The effectiveness of the public health system depends, largely, on its capacity to disseminate authoritative information in a timely way. Information is key to be able to respond to patient needs effectively during times of emergency. Information in real time is also essential for effective day-to-day health care to provide, for example, information on adverse drug reactions. Had the CMA’s 2001 and 2002 recommendations been acted upon, perhaps we would have been better prepared to communicate with health care providers when SARS first appeared in Toronto. As it was, the CMA mobilized its own communication networks to provide physicians with the critical information that they needed to manage SARS. And while this worked to get the word out in a pinch – it also underlined the fact that Canada does not have information systems in place to facilitate real-time communication with health professionals. How many SARS-type events must we have? This must be a priority. With a one-time infusion of $100 million, and an additional $2 million a year, the REAL proposal would provide the technical capacity to communicate with front-line public health providers in real time during health emergencies. We cannot afford to let this recommendation languish another year. The second short-term priority for public health is to invest in emergency supply chain for use in times of crisis. SARS showed us that the Greater Toronto Area, an area with one of Canada’s most sophisticated public and acute care health systems, was not able to manage the SARS crisis and maintain its capacity to meet other acute care requirements or important public health services such as suicide prevention programs. Most hospitals work on a just-in-time inventory basis for the purchase of drugs. Without some sort of plan to quickly re-supply their pharmacies and expand their capacity, patient care suffers. Emergency bed space is also lacking. The federal government must assure Canadians that plans are in place when the health care system is again tested with another public health emergency. That is where the federal government can ensure the health system’s readiness and reassure Canadians that help will be there when they need it. (Additional information is provided in Appendix D.) Key Recommendation Immediately allocate $1.5 billion over 5 years to reinforce Canada’s public health care system in order to respond to public health threats and acute events, such as SARS starting with a Rapid Effective Accessible Linked (REAL) Health Communications and Co-ordination Initiative; and an emergency medical supplies and equipment supply chain. Health human resources Health is primarily a people business. Of all of the critical issues facing Canada’s health care system, none is more urgent than the shortages of health providers. Bluntly put, if the people are not available to provide care and treatment to patients everything else is irrelevant. The CMA has been encouraged by significant movement toward the implementation of the 1999 Canadian Medical Forum recommendations calling for an increase in undergraduate medical training positions and the subsequent 30% increase in the number of first-year, first-time medical students. Despite these efforts, there continues to be growing concern over the shortage of physicians. Statistics Canada figures suggest that the number of Canadians who do not have a family physician is greater than three million. Indeed, in order for Canada to meet the OECD average with respect to physician numbers, Canada must increase the number of physicians by an alarming 38%. Given that Canada continues to average a net loss of approximately 200 physicians per year due to emigration, action must come without delay to address this growing concern. Similarly, research published last year by CNA predicts that Canada will have a shortage of 78,000 registered nurses by 2011 and up to 113,000 by 2016.xv While we were encouraged with the $90 million provided in the 2003-04 to “improve national health human resources planning and co-ordination, including better forecasting of health human resources needs”xvi, details of how these funds will be allocated and for what purposes remain unclear. Indeed, it appears to be somewhat of a shell game with various federal departments vying for funding but no one department coming forward to provide leadership with clear proposals. The CMA has proposals on how this money could be used to support much needed health human resource planning that are ready to be pulled off the shelf and implemented. For example, the CMA believes that an arm’s length Health Institute for Human Resources (HIHuR) should be established to address the human side of health, just as existing institutes address the technological (CCOHTA) and information aspects of health (CIHI). It would be a virtual institute, in the same sense as the Canadian Institutes for Health Research (CIHR). The Institute should promote collaboration and the sharing of research among the well-known university-based centres of excellence (e.g., MCHP and CHSPR) as well as research communities within professional associations and governments. It would enable and focus on needs-based long-term planning. HIHuR would have the ability to embark upon large scale research studies such as needs-based planning that is beyond the purview or financial ability of any single jurisdiction. Standard methodologies could be established for data collection and analysis to estimate health human resource requirements based on the disease-specific health needs and demands of the population (e.g., Aboriginal peoples, the elderly, etc.). The institute would work in close collaboration with primary data providers such as Statistics Canada and CIHI. It would complement the work of the new Canada Health Council. Possible deliverables of the model could include such cross-disciplinary issues as measuring effective supply, functional specialization, regulatory restrictions, and assessing new and existing models of delivery. The institute could build on and maintain the initiatives of the various health sector studies. The institute would advise on medium and long-term research agendas that could be adopted and implemented by such funding bodies as CHSRF and CIHR. The CMA recommends that base funding be provided by the federal government (with other members also financially supporting the HIHuR) and that the annual budget for the institute be $2.5 million with an initial institute development grant from the federal government of $1 million. (Further details of the HIHuR funding proposal are attached in Appendix E). High tuition fees also have the potential to have a serious, negative impact on the supply, mix and distribution of health human resources. The CMA is very concerned that high tuition fees in undergraduate programs in medicine are creating barriers to access to a medical education and threatening the diversity of future physicians who later serve the needs of Canadians. High tuition fees have made a medical education unaffordable to many Canadians and may create an imbalance in admissions to medical school by favouring those who represent the affluent segment of society and not the variety of groups reflected in the Canadian population. High student debt loads, as a consequence of high tuition fees and insufficient financial support, can also influence students’ decisions about practice specialty and practice location. Ultimately, these factors could threaten the availability of services provided to Canadians, particularly in rural and remote communities. For these reasons, the CMA is an active participant on the National Professional Association Coalition on Tuition (NPACT) and supports its recommendations concerning professional tuition and access to post-secondary education. Key Recommendation Instruct federal departments to work together on key health human resource initiatives and fund a new Health Institute for Human Resources (HIHuR). Health status of Aboriginal peoples Throughout the 1980s, Canada either just maintained or lost ground in the international rankings on key health indicators with other leading industrialized countries. In 1990, Canada ranked fifth on the United Nations Human Development Index measuring average achievement on three basic dimensions of human development – a long and healthy life; knowledge; and a decent standard of living. In 1991, Canada moved to second place behind Japan and in 1992 Canada topped the list. In 2001, however, Canada dropped back to third place as a result of new figures for life expectancy and educational enrolment.xvii Since the 1980s, Canada has continued to improve in key indicators such as infant mortality and life expectancy. However, other industrialized countries have also made improvements either equalling and in many cases, quite dramatically surpassing gains made in Canada. As a result, Canada’s ranking has either stayed the same or dropped. For example, although Canada’s infant mortality rate dropped by 22% between 1990 and 1999, its rank dropped from 5th to 17th among the 31 industrialized countries included in the Organization for Economic Cooperation and Development (OECD). Similarly, Canada’s ranking for life expectancy at birth decreased over the same period from 3rd to 5th. (Additional information on how Canada compares to other countries in terms of health status indicators is attached as Appendix F.) Particularly alarming is the health status of Canada’s Aboriginal peoples where, despite some improvements over the past few decades, Canada has been largely unable to adequately address the health issues facing this community. The facts speak for themselves: * The incidence and prevalence of chronic and degenerative diseases (diabetes, cardiovascular disease, cancer and arthritis) is higher among Aboriginal Canadians than for the rest of the population (e.g., the rate of Type II diabetes among First Nations is three to five times that of Canadians in general and is considered a growing problem); * Certain infectious diseases are more prevalent among Aboriginal Canadians (e.g., the incidence of hepatitis and tuberculosis are five and ten times higher, respectively, than for other Canadians); and * Manifestations of mental health problems such as violence, suicide and sexual abuse are widespread (e.g., the rate of death from suicide is four times higher among the Inuit than Canadians in general.) These problems are compounded by the remoteness of many Aboriginal communities, which makes access to health services and infrastructure costly and difficult. Other issues include the distinct health needs of different Aboriginal communities (First Nations, Metis, Inuit and urban Natives) and jurisdictional problems such as the separation of health and social services and conflicting or overlapping F/P/T areas of responsibility. As well, it is broadly accepted that the health status of Canada’s Aboriginal peoples is a result of a broad range of factors and is unlikely to be improved significantly by merely increasing the quantity of health services. Instead, inequities within a wide range of social and economic factors must also be addressed, for example: income and education; environmental hazards, water quality, housing quality and infrastructure; and maintenance of cultural identity. At CMA’s annual general meeting in August 2003, Health Minister Anne McLellan noted that despite significant investment Canada’s aboriginal people continue to have poor health outcomes. Simply put, these results are unacceptable. The CMA recommends that the federal government adopt a comprehensive review to look at how the money being spent on health, health care and related areas of investment for Aboriginal people can result in better health outcomes. The current results are not good enough. We must do better. Key Recommendation The federal government should adopt a comprehensive review to look at how the money being spent on health, health care and related areas of investment can result in better health outcomes. CONCLUSION For those involved in the health care community, and indeed for all Canadians, this has truly been a remarkable year for Canada in terms of health and health policy. In many ways, the events of February marked a turn toward significant reinvestment in the health care system. However, with the outbreak of SARS in Ontario and the emergence of other significant public health concerns such as West Nile virus, health continued to be a top-of-mind concern for many Canadians. We also know that despite investments made in the 2003 federal budget, there continue to be areas for targeted, strategic initiatives that promise high payoff in terms of value for money. Public health, health human resources and the health status of Canada’s aboriginal people are the three areas that we have highlighted where additional attention and funding can make a real impact at the national level. When considering these investments, however, we must remember that we cannot afford to rob Peter to pay Paul. Both the public health and the acute care systems must simultaneously benefit from increased investment in order not to download one problem onto the other. Finally, promises made must be promises kept. The federal government must ensure that the fiscal environment is such so that it can fulfill its commitment to provide an additional $2 billion in this fiscal year. As well, the CMA intends to hold the federal government and the provinces and territories to their promise to implement a Canada Health Council. Governments must open the political black box of health decision making and let others in. To exclude physicians and other health stakeholders would seriously undermine the Health Council and deprive it of the benefits of first-hand insight into how care is actually delivered. Governments must take advantage of this opportunity to introduce a mechanism that will provide evidence to Canadians that they are getting a good return on their investment in health care. To return to the analogy of an annual health check-up, let us conclude with this prognosis. Many actions taken in the past year should help over time address the acute symptoms of the patient. However, we must not be complacent. Long term health requires follow through on last year’s initiatives, targeted new investments and ongoing vigilance. We look forward to the year ahead. Appendix A: Federal Reinvestments in Health Care Financing In the January 2003 document, From Debate to Actionxviii, the Canadian Medical Association challenged Canada’s First Ministers to put the health of Canadians first. With respect to health care financing, we underlined the need for a financial commitment to health care that is adequate, stable, predictable, transparent and sustainable. In February 2003, the federal government announced new funding to the provinces and territories of $24.9 billion over 5 years.2 The CMA and others suggested that these reinvestments were good but insufficient to address the challenges facing Canada’s health care system.xix Specifically, we had called for a minimum commitment by the federal government to “fund 50% of the core health care system with at least half of the federal government’s contribution in cash”.xx. (Core defined to include non-targeted and targeted investments in infrastructure such as health human resources, information technology, capital infrastructure, and rural and remote access.) Altogether, we called for a minimum cash investment of $31.5 billion over 5 years to renew the health care system. [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Gap Between 2003 Health Accord and CMA Recommended Re-Investments in Canada’s Health Care System ($ billions) 2003?2004 2004?2005 2005?2006 2006?07 2007?2008 Total Core Funding 3.5 3.9 4.4 4.6 4.9 $21.3 Targeted Core 0.5 0.5 0.5 0.5 0.5 $2.5 Targeted New Programs 1.1 2.1 2.2 2.3 $7.7 Total 4.0 5.5 7.0 7.3 7.7 $31.5 Federal Reinvestments 4.8 3.3 4.9 5.2 6.7 $24.9 Remaining Gap in Funding (0.8) 2.2 2.1 2.1 1.0 $ 6.7 [TABLE END] There remains a significant gap of almost $ 7 billion over 5 years between our estimate of the minimum requirement needed for the renewal of the health care system and the new resources dedicated by the federal government. In light of this, the CMA calls upon the federal government to finish its unfinished business and allocate an additional $7 billion over 5 years in its next budget for the Canada Health Transfer to shore up Canada’s health care system. Appendix B: Recommendations to the National Advisory Committee on SARS and Public Health Legislative reform ($20 million / 5 years*) 1. The enactment of a Canada Emergency Health Measures Act that would consolidate and enhance existing legislation, allowing for a more rapid national response, in cooperation with the provinces and territories, based on a graduated, systematic approach, to health emergencies that pose an acute and imminent threat to human health and safety across Canada. 2. The creation of a Canadian Office for Disease Surveillance and Control (CODSC) as the lead Canadian agency in public health, operating at arm’s length from government. 3. The appointment of a Chief Public Health Officer of Canada to act as the lead scientific voice for public health in Canada; to head the Canadian Office for Disease Surveillance and Control; and to work with provinces and territories to develop and implement a pan-Canadian public health action plan. Capacity enhancement ( $1.2 billion / 5 years*) 4. The creation of a Canadian Centre of Excellence for Public Health, under the auspices of the CODSC, to invest in multidisciplinary training programs in public health, establish and disseminate best practices among public health professionals. 5. The establishment of a Canadian Public Health Emergency Response Service, under the auspices of the CODSC, to provide for the rapid deployment of human resources (e.g., emergency pan-Canadian locum programs) during health emergencies. 6. Tracking and public reporting of public health expenditures and capacity (both physical and human resources) by the Canadian Institute for Health Information and Statistics Canada, on behalf of the proposed Canadian Office for Disease Surveillance and Control. 7. Federal government funding in the amount of $1 Billion over 5 years to build adequate and consistent surge capacity across Canada and improve co-ordination among federal, provincial/territorial and municipal authorities to fulfill essential public health functions. Research, surveillance and communications ($310 million / 5 years*) 8. An immediate, sequestered grant of $200 million over 5 years to the Canadian Institutes of Health Research to initiate an enhanced conjoint program of research with the Institute of Population and Public Health and the Institute of Infection and Immunity that will expand capacity for interdisciplinary research on public health, including infectious disease prevention and control measures. 9. The mandatory reporting by provinces and territories of identified infectious diseases to the newly established Chief Public Health Officer of Canada to enable appropriate communications, analyses and intervention. 10. The one-time infusion of $100 million, with an additional $2 million a year, for a “REAL” (rapid, effective, accessible and linked) Health Communication and Co-ordination Initiative to improve technical capacity to communicate with front line public health providers in real time during health emergencies. Appendix B: Estimated Cost of Implementing the Recommendations [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] RECOMMENDATION ESTIMATED COST OVER 5 YEARS Legislative and Institutional Reform 1. Canada Emergency Health Measures Act N/A 2. Canadian Office for Disease Surveillance and Control (CODSC) ? $20 million 3. Chief Public Health Officer of Canada Capacity Enhancement 4. Canadian Centre of Excellence for Public Health $100 million 5. Canadian Public Health Emergency Response Service $35 million 6. Canadian Institute for Health Information and Statistics Canada $35 milliona 7. Surge capacity $1 billionb Research, surveillance and communications 8. Canadian Institutes of Health Research $200 millionc 9. Mandatory reporting Included under 2 and 3 above 10. Enhanced communications $110 million TOTAL $1.5 billion [TABLE END] a. Work is currently underway to break out public health from the current category of “public health and administration.” b. This is an incremental investment in addition to funding currently available under Health Canada’s Health Promotion and Prevention Strategic Outcome area. c. Funding must be sequestered specifically for new initiatives related to public health. Additional money could also be acquired through funding from the Canadian Foundation for Innovation, which received an additional $500 million in 2002–2003 (announced in the 2003 federal budget) to enhance the Foundation’s support of public health infrastructure. Appendix C: REAL (Rapid, Effective, Accessible , Linked) Health Communication and Co-ordination Initiative The effectiveness of the public health system is dependent, in large part, on its capacity to communicate authoritative information in a timely way. A two-way flow of information between experts and the practising community is necessary at all times. It becomes essential during emergency situations. Information, including health advice and alerts, needs to move out to front line health care providers from public health bodies. Information, such as data for surveillance and analysis purposes, needs to move in from these front line providers to the public health authorities. To detect new emerging diseases or health threats and effectively care for their patients, front-line health professionals must have accurate and timely information. Conversely public health specialists depend on information coming in from the front lines to track disease and institute appropriate public health interventions. Despite the tremendous developments in information management, there has been scant attention paid to this issue within public health. The SARS outbreak highlighted various weaknesses in our current communication capacity. Gaps in the basic IT infrastructure prevented public health agencies and acute care institutions from communicating with each other in real-time. There are a number of anecdotal reports of public health units stationing personnel inside hospitals to retrieve information and then telephone it into their units. Case investigators used paper-based files to manage the hundreds of cases reported to public health units, and to investigate and follow up of thousands of contacts. Identification of clusters and links between cases literally depended upon pencil and paper and brainpower. Toronto Public Health did create a database for its SARS cases and could send it electronically to the province. However the province had a different database which raised concerns about the transfer of data files from one system to another. The deficiency in IT capacity hindered exchanges between public health staff, private clinicians and other sources of information. The potential for a disconnect in communications between different jurisdictions (international, national, provincial/territorial, municipal) and sectors (environment, health, transportation) that are affected by a health emergency is a further challenge to the public health system. The importance of communicating essential health advice and public health management protocols to front line practitioners and institutions cannot be overstated. During the SARS experience it became evident that government did not have information systems in place to communicate rapidly with physicians across the country. In response to requests from Health Canada the CMA was able to mobilize its communication networks to get information to physicians in real-time. It is interesting to note that in local areas the problem often was not one of not enough information, but of too much information, which was often confusing, conflicting or impractical for a practice setting. Consistent messaging disseminated in a coordinated fashion is essential for a consistent and coordinated response to a health crisis. The CMA believes that the federal government must take a leadership role to ensure that the communication tools and information technology necessary for a modern efficient public health system, with the capacity to mount a rapid and informed response to public health emergencies, are in place in all regions of the country. The CMA brought this to the attention of the House of Commons Standing Committee on Finance in October 2001, and again in October 2002 with our recommendation for a REAL (rapid, effective, accessible, linked) Health Communication and Co-ordination Initiative. We called for a one-time infusion of $100 million, and an additional $2 million a year, to improve technical capacity to communicate with front-line public health providers in real-time during health emergencies. This initiative would facilitate seamless communication between local, provincial and federal levels of the public health system and rapid, real-time communication between the public health sector and other components of the health care system. It must also ensure a two-way flow of information between front-line health care providers and public health professionals at the local public health unit, the provincial public health department and the proposed Canadian Office for Disease Surveillance and Control. The REAL Health Communication and Co-ordination Initiative would improve the ability of the public health system to communicate in a rapid fashion by: * Providing a focal point for inter-jurisdictional communication and co-ordination in order to improve preparedness in times of emergency; * Developing a seamless communication system leveraging formal and informal networks and * Researching the best way to disseminate emergency information and health alerts to targeted health professionals and public health officials in a rapid, effective and accessible fashion. As well as funding research and demonstration projects, funding should also be allocated to provinces/territories and municipalities to build their connectivity infrastructure. The initiative should build on communication systems currently in place, filling gaps and enhancing capacity. Communicating with Health Professionals. One of the key lessons the CMA has drawn from the experience of SARS is that physicians take up information in different ways. Some want it by e-mail, others by fax and still others by mail. Even those with e-mail have expressed a desire to get emergency information in a different format. Other health care associations have also employed various ways to communicate with their membership. During the SARS crisis, the existing communication networks between health professionals were an important, if informal, avenue to disseminate and in some cases explain public health interventions and information. In fact ten national health care associations3 met via teleconference and in person during the crisis to share information and ensure a consistency of message to health professionals. This sector can play a critical role in bridging the gap between clinicians and the public, as well as in the delivery of credible public education and training to both professionals and the public. The importance of communicating timely and relevant information directly to those in leadership positions (Chief of Staff, Hospital CEO) should not be overlooked. These individuals can make the information relevant for their particular setting, and ensure that it is widely disseminated within their community. The uptake of new information is influenced by many qualitative factors and research is needed to determine how best to communicate with individual physicians and other health care providers in emergency situations. Any new communication processes should be based on sound research and build on existing communication networks. The REAL Health Communication and Co-ordination Initiative would be led by the Canadian Office for Disease Surveillance and Control and would undertake work in three phases. 1. Research Phase For example: * Evaluation of communications during the SARS crisis * Quantitative research on how health professionals want to receive information * Catalogue of existing communication networks 2. Pilot projects in areas such as risk communications and information management in public health. 3. Evaluation and dissemination of best practices in communications and information management. Appendix D: Emergency Medical Supplies and Equipment Supply Chain In the aftermath of the September 11, 2001 terrorist attacks in the United States, the CMA, in its October 2001 pre-budget submission to the Standing Committee on Finance, stressed the fact that in the event of a significant attack on our population among the first points of contact with the health system will be doctors’ offices and the emergency rooms of our hospitals. The SARS outbreak has proven that this point is just as valid when faced with a public health emergency. SARS showed us that the Greater Toronto Area, an area with one of Canada’s most sophisticated public and acute care health systems, was not able to manage the SARS crisis and maintain its capacity to meet other acute care requirements or important public heath services such as suicide prevention programs. Most hospitals work on a just-in-time inventory basis for the purchase of drugs. Without some sort of plan to quickly re-supply their pharmacies and expand their capacity, patient care suffers. Emergency bed space is also lacking. The federal government must assure Canadians that plans are in place when the health care system is again tested with another public health emergency. That is where the federal government can ensure the health system’s readiness and reassure Canadians that help will be there when they need it. We have also witnessed in recent years the enormous strain these facilities can be placed under when even something quite routine like influenza strikes a community hard. The acute care occupancy rates of Ontario public hospitals across the Ontario Hospital Association regions in 1999-00 illustrate this point. In three of the five regions (Eastern Ontario, Central and South West) the occupancy rate ranged from 94% to 97%.xxi The highest rate was found in the very heavily populated Central region. A British Medical Journal study suggests that an occupancy rate over 90% indicates that the hospital system is in a regular bed crisis.xxii This problem is not unique to Ontario: “the decrease in the number of acute care beds across Canada over the past decade, coupled with an aging population and our extraordinary success in extending the survival of patients with significant chronic illness, has eliminated any cushion in bed occupancy in the hospital system.”xxiii With this in mind, picture the impact of another public health crisis such as an influenza pandemic when hundreds of thousands of individuals could be affected. The public health system and medical diagnostic and treatment systems in the community and hospitals would become overwhelmed very quickly without the ability to absorb the extra caseload. We need no further demonstration of the need to enable hospitals to open beds, purchase more supplies, and bring in the health care professionals it requires to meet the need. Currently the National Emergency Stockpile System can supply up to 40,000 cots, as well as medical supplies and relatively rudimentary hospital equipment. Reports indicate, however, that much of the equipment is decades old, and that protocols for logistical management (e.g., transport and rapid deployment) are outdated. There is an urgent need to reassess and reaffirm capacity in this context. The SARS experience also brought to our attention the critical lack of equipment. The Canadian Association of Emergency Physicians (CAEP) has noted that many emergency departments across the country are not adequately equipped for 21st century infection control challenges. They do not have negative pressure rooms with contained toilets, often have only one resuscitation suite for critically ill patients and do not have a safe place to segregate accompanying persons. Nor do they have protective hoods like the PARR device that is needed to safely intubate SARS patients. CAEP concluded that most emergency departments are not physically designed to cope with infection control problems. The federal government must assure Canadians that municipal and provincial plans are in place with an overarching national plan to support these jurisdictions if their service capacities are overwhelmed. But the government should help further by making available an emergency fund that would enable hospitals to plan and organize their surge capacity. The purpose of having such elaborate response plans and stockpiles of supplies and equipment is to be ready for the possibility that, in spite of all efforts to prevent a catastrophe from occurring, it nevertheless happens. That is where the federal government can facilitate the health system’s readiness and reassure Canadians that help will be there when they need it. Appendix E: Health Institute for Human Resources (HIHuR) While the need for more health human resources is apparent, resource planning is difficult and fraught with complexity. Answers must balance affordability, reflect population health needs and consider issues pertaining to the supply, mix and distribution of physicians. Over the last decade, a number of stakeholders including government, associations, and researchers have invested significant resources in health human resource planning.xxiv However, these groups do not systematically communicate with each other and do not always buy into each other’s products. The result is silo-based planning, lack of progress on key areas of database development, and an overall failure to address important issues such as professional burnout. The CMA seeks to build consensus within the medical profession on major program and policy initiatives concerning the supply, mix and distribution of physicians and to work with major stakeholders in identifying and assessing issues of mutual importance. At the same time, the CMA remains sensitive to Canada’s provincial and territorial realities with respect to the fact that health human resource planning requires assessment and implementation at the local or regional level. However, there is a need for a national body to develop and coordinate health human resources planning initiatives that take into account the mobility of health care providers nationally and internationally. Identification of the need for more coordinated research in the area of health human resources has come from many sources. In the Listening for Directions report of 2001xxv, the partner organizations indicated health human resources as the number one priority theme for research funding over the next two to five years. A joint report in 1995 by national organizations representing occupational therapists, physiotherapists, dieticians and nurses established an integrated health human resources development framework with three main components of planning, education and training, and management.xxvi Similarly, the Canadian Policy Research Networks Inc. (CPRN) commissioned by Mr. Romanow to investigate and summarize health human resource issues, recommended the creation of a national health human resources coordinating agency to provide focus and expertise for health human resource planning. Senator Kirby also identified the need for such a planning body in his final report. He recommended that the federal government work with other concerned parties to create a permanent National Coordinating Committee for Health Human Resources, to be composed of representatives of key stakeholder groups and of the different levels of government.xxvii Finally, the final report of the Commission of the Future of Health Care in Canada called for a substantial improvement in the base of information on Canada’s health workforce and the need to establish a comprehensive plan for addressing supply, distribution, and education issues.xxviii The CMA believes that an arm’s length Health Institute for Human Resources (HIHuR) should be established to address the human side of health, just as existing institutes address the technology (CCOHTA) and information aspects of health (CIHI). It would be a virtual institute, in the same sense as the Canadian Institute for Health Research. The Institute should promote collaboration and the sharing of research among the well-known university based centres of excellence (e.g., MCHP and CHSPR) as well as research communities within professional associations and governments. It would enable/focus on needs-based long term planning. HIHuR should have the ability to embark upon large scale research studies such as needs-based planning that is beyond the purview or financial ability of any single jurisdiction. Standard methodologies could be established for data collection and analysis to estimate health human resource requirements based on the disease-specific health needs and/or demands of the population (e.g., Aboriginal peoples, the elderly, etc.). The institute would work in close collaboration with primary data providers such as Statistics Canada and CIHI. It would complement the work of the new Canada Health Council. Possible deliverables of the model could include such cross-disciplinary issues as measuring effective supply, functional specialization, regulatory restrictions, and assessing new and existing models of delivery. The institute could build on, and maintain, the initiatives of the various health sector studies. The institute would advise on medium and long-term research agendas that could be adopted and implemented by such funding bodies as CHSRF and CIHR. It is recommended that base funding be provided by the federal government (with other members also financially supporting the HIHuR). It is proposed that the annual budget for the institute would be $2.5 million with an initial institute development grant from the federal government of $1 million. Appendix F : Straight facts about health…Is Canada getting left behind? Straight facts about health... Is Canada getting left behind? Through the 1980s, Canada has either remained the same or lost ground in the international rankings on key health indicators with other leading industrialized countries surpassing our progress. This worrisome turn of events, the Canadian Medical Association believes, needs attention. United Nations Human Development Index In 1990, the United Nations Development Programme (UNDP) began publishing an annual Human Development Report (www.undp.org/hdr). The Human Development Index (HDI) is one of the key indicators in this report. It is a composite index that measures average achievement in three basic dimensions of human development: a long and healthy life; knowledge and a decent standard of living. How has Canada fared? In 1990, Canada ranked fifth. Canada moved to 2nd place behind Japan in 1991 and into 1st place in 1992. It again dropped behind first-place Japan in 1993. Canada then led the world on the HDI between 1994 and 2000. In 2001, Canada dropped back to 3rd place. As the UNDP reported in 2001, “Norway is now ranked first in the world and Australia second. Both moved narrowly ahead of Canada, the leader for the previous six years, as a result of new figures for life expectancy and educational enrolment. Canada fell in the rankings even though its per capita income rose by 3.75 percent.” Canada remained in 3rd place in 2002. World Health Organization health system performance indicators The World Health Organization (WHO) (www.who.int/whr) ranked the health system performance of 191 member countries for the first time in its 2000 World Health Report. The ranks are based on the measurement of population health in relation to what might be expected given the level of input to the production of health. WHO presented two rankings. The first, performance on health level, considers health status in disability-adjusted life expectancy relative to a country’s resource use and human capital. Canada ranked 35th among 191 countries with respect to this indicator in 2000. The second indicator is a measurement of overall performance. This assesses health system attainment relative to what might be expected for five goals of the health system, including health status, health inequality, level and distribution of responsiveness and fairness in financing. In 2000, Canada ranked 30th on the index of overall performance. France led the world on this indicator in 2000. International health indicators Since the 1980s, Canada has continued to record improvements on key health indicators such as infant mortality and life expectancy. However, other industrialized countries have also recorded improvements that have either equaled or, in some cases, quite dramatically surpassed the gains made in Canada. As a result, Canada’s ranking has either stayed the same or dropped. Infant Mortality — Although Canada’s infant mortality rate dropped by 22% between 1990 and 1999, its rank dropped from 5th to 17th among the 31 industrialized coun-tries included in the Organization for Economic Cooperation and Development (OECD). Other countries have recorded even greater gains; for example, Sweden and Austria both recorded a drop of 43% in infant mortality over the same time period. Among others, Spain, Italy and the Czech Republic now rank ahead of Canada. However, the United Kingdom, United States and Australia rank behind Canada. Perinatal Mortality — Between 1990 and 1999, Canada’s perinatal mortality rate declined by 18% while its international ranking remained essentially the same — moving from 10th in 1990 to 11th in 1999. In comparison, the perinatal mortality rate for 1st-ranked Japan dropped by 31% during the same period. Life Expectancy — In 1999, Canada ranked 5th in life expectancy at birth, down from 3rd in 1990. During the 1990–1999 period, total life expectancy increased by 1.8% in Canada, compared to 2.0% in 1st-ranked Japan. Healthy Life Expectancy (HALE) — Healthy life expectancy is based on life expectancy but includes an adjustment for time spent in poor health. In its 2002 World Health Report, WHO presented HALE esti-mates for 191 countries during 2001. Among these countries, Canada ranked 20th in 2001, tying with the Netherlands at 69.9 years at birth. Japan and Switzerland headed the list at 73.6 and 72.8 years respectively in 2001. Health human resources per capita Canada continues to lag behind other industrialized countries with respect to physicians per 1000 population. The OECD average of 2.8 per 1000 population is one-third higher than Canada’s rate of 2.1 (including post-graduate residents), placing us 23rd out of 27th for this indicator. In a comparison of G-8 countries (excluding Russia) between 1990 and 1999, Canada was the only country that did not show any improvement in the physician-to-population ratio. The situation for nurses is equally distressing. Canada placed only 12th in 1999 and experienced a 7% drop in the ratio between 1990 and 1999 from 8.1 per 1000 population to 7.5. This puts Canada in the middle of the G-8 group. Public sector as percent of total health spending Among the industrialized (OECD) countries, Canada has consistently reported one of the lower public shares of total health spending since the 1980s. In 1985, Canada’s public spending on health represented 75.6% of total health spending — placing Canada at 14th among the 22 countries reporting. In 2000, with public spending rep-resenting 72% of total health spending, Canada ranked 16th among 26 countries reporting. Canada’s 2000 level of public spending was down almost four percentage points from 1985. Note: The UNDP contains 173 countries, WHO contains 191 countries and the OECD contains 31 countries. Life expectancy figures represent years at birth. Infant mortality represents the number of deaths of babies less than one year of age that occurred during a year per 1000 live births during the same year expressed as a rate. Perinatal mortality represents the number of deaths under 7 days (early neonatal deaths) plus fetal deaths of 28 weeks of gesta-tion or more per 1000 total live births (live and stillbirths). Health indicators data are from OECD Health Data, 2002, 4th ed. www.oecd.org/healthdata. WHO performance indicators for 2002 are based as estimates for 1997. ENDNOTES 1 $24.9 billion includes all new federal transfers to the provinces and territories (targeted and non-targeted) announced at the time of the First Ministers’ meeting on February 4/5, 2003 and confirmed in the February 18, 2003 Federal Budget. It includes the $2 billion in funding to be made available at the end of fiscal year 2002/03. It does not include previously announced CHST funding, nor investments in federal health programs. 2 $24.9 billion includes all new federal transfers to the provinces and territories (targeted and non-targeted) announced at the time of the First Ministers’ meeting on February 4/5, 2003 and confirmed in the February 18, 2003 Federal Budget. It includes the $2 billion in funding to be made available at the end of fiscal year 2002/03. It does not include previously announced CHST funding, nor investments in federal health programs. 3 Canadian Association of Emergency Physicians, Canadian Council on Health Services Accreditation, Canadian Dental Association, Canadian Healthcare Association, Canadian Medical Association, Canadian Infectious Disease Society, Canadian Nurses Association, Canadian Pharmacists Association, Canadian Public Health Association, Association of Canadian Academic Healthcare Organizations i Ekos Research Associates. Presentation to the Charles E. Frosst Foundation for Health Care. Private Voices, Public Choices. November 7, 2002. ii Canadian Medical Association. Third Annual National Report Card on Health Care. August, 2003. (Conducted by Ipsos Reid). p. 17. iii Canadian Institute of Health Information. National Health Exenditure Trends, 1975-2002. December 2002. iv Organization for Economic Cooperation and Development (OECD), Health Data 2003. v Government of Canada. The Budget Plan, 2003. February 18, 2003. p. 211. vi Government of Canada. The Budget Plan, 2003. February 18, 2003. p. 69. vii News Release, Annual Conference of Federal-Provincial-Territorial Ministers of Health, Halifax, Nova Scotia, September 4, 2003. viii Canadian Medical Association. Press Release, “CMA Calls for Council by November 28 – Further Delay Unacceptable”. September 3, 2003. ix Standing Senate Committee on Social Affairs, Science and Technology. Final Report on the State of the Health Care System in Canada: The Health of Canadians – The Federal Role Volume Six: Recommendations for Reform. October 2002. p. 17 - 20. x Commission on the Future of Health Care in Canada. Building on Values: The Future of Health Care in Canada – Final Report. November 2002. p. 52. xi Canadian Institutes of Health Research. Report on Plans and Priorities for the Fiscal Year, 2003-2004. p. 29. xii For more information, please refer to CMA’s 2001 report to the Standing Committee on Finance, Security Our Future … Balancing Urgent Health Care Needs of Today with the Important Challenges of Tomorrow. November 1, 2001. xiii Canadian Medical Association. Submission to the National Advisory Committee on SARS and Public Health. Answering the Wake-up Call: CMA’s Public Health Action Plan. June 2003. xiv Canadian Medical Association. Presentation to the Standing Committee on Finance Pre-Budget Consultations. Securing our Future … Balancing Urgent Health Care Needs of Today With the Important Challenges of Tomorrow. November 1, 2001. xv Canadian Nurses Association. Canada’s Nurses See Latest Data as a Warning: Action Needed to Address Nursing Shortage. Press Release, September 17, 2003. xvi Government of Canada. The Budget Plan, 2003. February 18, 2003. p. 78. xvii United Nations Human Development Project. Human Development Report 2001. Press Release, July 10, 2001, Mexico City (www.undp.org/hdro). xviii Canadian Medical Association. From debate to action. Message to First Ministers … It’s time to put the health of Canadians first. January 2003. xix Other organizations that reiterated the need for additional investment in health care included the Canadian Healthcare Association (Press Release, February 18, 2003 (www.cha.ca) and the Association of Canadian Academic Healthcare Organizations (Press Release, February 19, 2003 (www.ACAHO.org). xx Canadian Medical Association. From debate to action. Message to First Ministers … It’s time to put the health of Canadians first. January 2003. p. 8. xxi Ontario Hospital Reporting System, 2001. Acute Care Occupancy Rates, Ontario Public Hospitals by OHA region, 1999/00. Ontario Ministry of Health and Long Term Care. xxii Bagust A, Place M, Posnett J. Dynamics of bed use in accommodating emergency admissions: stochastic simulation model. BMJ; 319: 155-158 July 17, 1999. xxiii Nicolle L. Viruses without borders. Can J Infect Dis Vol. 11, Issue 3, May/June 2000 (Downloaded from Web: October 23, 2001: www.pulsus.com/Infdis/11_03/nico_ed.htm) xxiv At the national level there are a number of bodies that, in some cases, have been involved in health human resource planning issues for literally decades. The long standing Advisory Committee on Health Human Resources reported to the Conference of Deputy Ministers on health human resource issues but it functioned without outside expertise from the provider community and found it difficult to implement an integrated approach to planning. The National Coordinating Committee on Postgraduate Medical Training did include membership from both the medical profession and the government but its mandate was narrow (postgraduate training of physicians) and the committee was de facto sunsetted a couple of years ago. xxv Canadian Health Services Research Foundation. Listening for Direction: A National Consultation on Health Services and Policy Issues. June 2001. xxvi Canadian Association of Occupational Therapists, Canadian Dietetic Association, Canadian Nurses Association, Canadian Physiotherapy Association, Integrated Health Human Resources Development – Pragmatism or Pie in the Sky, August 1995. xxvii Standing Senate Committee on Social Affairs, Science and Technology, The Health of Canadians – The Federal Role, Final Report, October 2002. xxviii Commission on the Future of Health Care in Canada. Building on Values: The Future of Health Care in Canada – Final Report. November 2002. p. 108.
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CMA's Response to Questionnaire From the House of Commons Standing Committee on Finance: 2012-2013 Pre-Budget Consultation

https://policybase.cma.ca/en/permalink/policy10445
Date
2012-08-03
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2012-08-03
Topics
Health systems, system funding and performance
Text
Question 1: Economic recovery and growth (What federal measures are required for sustained economic recovery and growth?) The health sector has an important role in sustaining Canada's economic recovery and enhancing economic growth beginning with supporting a healthy and productive workforce and providing over one million high value jobs, representing about 10 per cent of the labour force. Despite the importance of the sector, there is general agreement that Canada's health care system is no longer a strong performer when compared to similar nations. While the OECD's 2011 Health Data ranks Canada 7th highest of 34 member states in per capita health care spending, the performance of Canada's health care system continues to rank below most of our comparator countries. Health spending accounts for an increasing proportion of provincial and territorial budgets, and many warn of increasing future demands on the overall system. In his Economic and Fiscal Outlook Report of May 17, 2012, the Parliamentary Budget Officer stated that "the provincial-territorial long-term fiscal situation has deteriorated." Taken together, these issues highlight significant potential for the health sector, through efficiency improved gained by health care transformation, to support long-term economic recovery and growth in Canada. While the provinces and territories have initiated positive steps to collaborate on sharing best practices, there are key responsibilities under federal leadership that would contribute to these efforts by addressing the overall performance of the health care system in Canada. The CMA recommends that: - The federal government recognize the relationship of the social determinants of health on the demands of the health care system and that it implement a requirement for all cabinet decision-making to include a Health Impact Assessment (see Question 5 for more detail). - Further to the comments by the Health Minister following the new fiscal arrangement announcement, the federal government should prioritize federal-provincial-territorial engagement focused on accountability and undertake a consultative process with the aim of identifying pan-Canadian metrics and measurement that will link health expenditures and comparable health outcomes. Question 2: Job creation (What federal actions should be taken to promote job creation in a context of enhanced internal and international trade?) A high performing health care system across the country will help support labour mobility and job creation. An effective, comprehensive public health care system provides an important international competitive advantage. The contribution of Canada's health care system to the international competitiveness of our economy has been repeatedly demonstrated in KPMG's Competitive Alternatives report. However, there are several signs that indicate health care services and coverage are not keeping up with Canadians' needs and vary depending on where one lives in Canada. For instance, long wait times for medical care can be found in smaller provinces, while drug coverage and services for seniors are particularly poor in Atlantic Canada. Wide variation in access to pharmaceutical treatments remains the most glaring example of inequity in our health care system-all Canadians should have a basic level of drug coverage. These variations are growing and will hinder job creation in some regions, serving as barriers to labour mobility for Canadians wishing to seek work elsewhere in the country. We believe that Canadians would be better served if federal health care transfers came with specific guidelines ensuring that the system provides care of comparable access and quality to Canadians across the country, regardless of their circumstances. Recognizing the contribution of the health care system to Canada's international competitive advantage, improvements in Canada's health care system would further support job creation. The federal government should focus its efforts towards supporting the transformation of our health care system to better meet the objectives of better care, better health and better value. The CMA recommends that: - The federal government, in consultation with provincial, territorial and other stakeholders, establish a program of comprehensive prescription drug coverage to be administered through reimbursement of provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drugs. - The federal government, together with the provinces and territories, develop and implement a pan-Canadian strategy for continuing care which would integrate home care and facility- based long-term, respite and palliative care services fully within health care systems. Question 3: Demographic change (What federal measures should be implemented to help address the aging population and skills shortages?) The CMA remains concerned about the status of Canada's retirement income system and the ability of Canada's seniors to adequately fund their long-term and supportive care needs. Steps need to be taken to ensure that Canada is prepared to handle the long-term care needs of its citizens, including the funding of necessary infrastructure and additional support for both health care providers and informal caregivers. The availability of long-term care facilities has an important role in the efficiency of the overall health care system. For example, in its most recent report, the Wait Time Alliance noted that dementia is a key diagnosis related to the rise in alternate-levels-of-care (ALC) patient stays in hospitals. This is yet another issue facing all provinces and territories for which the federal government is well positioned to coordinate a pan-Canadian strategy. In addition, as part of the next long-term infrastructure program, the federal government should include a targeted health sector infrastructure fund for long-term care facilities as part of a pan-Canadian strategy to redirect care from the hospitals to homes, communities and long-term care facilities, where better care is provided at a lower cost. The CMA recommends that: - The federal government establish programs to encourage Canadians to save for their long- term care needs by pre-funding long-term care, including private insurance, tax-deferred and tax-prepaid savings approaches, and contribution-based social insurance, such as an RESP- type savings vehicle. - That a targeted health infrastructure fund be established as part of the government's long- term plan for public infrastructure. The purpose of this fund would be to address infrastructure shortages in the health sector that prevent the optimization of health human resources and exacerbate wait times. The CMA has supported the federal government's efforts to expand retirement savings options by establishing the Pooled Retirement Pension Plans. However, as highlighted by federal, provincial and territorial finance ministers, this is only one component of a larger pension reform framework to address the retirement income adequacy needs of Canadians. The CMA encourages the federal government to continue working with the provinces, territories and stakeholders to implement all elements of this framework. Question 4: Productivity (What federal initiatives are needed to increase productivity in light of labour market challenges such as the aging of Canada's population?) An effective and comprehensive health care system supports the productivity of the Canadian workforce. Failure of our health care system to respond to workers' health needs, on the other hand, leads to loss of productivity and high costs both in terms of lost income for Canadian families as well as foregone tax revenues for governments. Numerous studies have pointed out the enormous cost of waiting (in the billions of dollars per year) affecting both individuals and the economy. Another related issue that has the potential to increasingly affect productivity is the burden of providing care to family members. Without adequate provision of long-term care resources and support for home care, Canada's labour force may experience a productivity drag through increased leaves and absenteeism to care for elderly relatives. The 2011 federal budget took a first step at providing tax relief for informal caregivers through the Family Caregiver Tax Credit. However, this credit of a maximum of $300 per year by no means provides sufficient support for informal caregivers. A 2004 Canadian study estimated that the annual cost of a caregiver's time at market rates for moderately to severely disabled home care clients ranged from $5,221 to $13,374 depending on the community in which they reside. An increase to the Family Caregiver Tax Credit is positive for the development of one aspect of the necessary support informal caregivers require but the CMA believes other enhancements will also be needed in the coming years. In order to meet the needs of our country's aging population, the CMA recommends that: - The federal government expand the relief programs for informal caregivers to provide guaranteed access to respite services for people dealing with emergency situations, as well as increase the Family Caregiver Tax Credit to better reflect the annual cost of family caregivers' time at market rates. - That a targeted health infrastructure fund be established as part of the government's long-term plan for public infrastructure. The purpose of this fund would be to address infrastructure shortages in the health sector that prevent the optimization of health human resources and exacerbate wait times. Question 5: Other challenges (Who is facing most challenges, what are they and what federal action is required?) Despite significant investments in health and improvements in medical treatment and technologies, health outcomes in Canada have not been moving in the right direction. Chronic diseases such as diabetes and the corresponding risk factors, among them obesity, continue to rise. These negative outcomes can have a significant impact on the prosperity of the country as health is necessary for individuals to lead a prosperous and autonomous life. Research suggests that 50 per cent of population health is determined by our social and economic environment. While a strong health care system is vital, changes to medicare alone will not improve health outcomes or reduce the disparities that currently exist in disease burden and health risks. What is needed is a process to address the social determinants of health that can be barriers or enablers to health, a process to ensure healthy public policy for all Canadians. A Health Impact Assessment (HIA) is a systematic process for making evidence-based judgments on the health impacts of a policy and to identify and recommend strategies to protect and promote health. HIA is used in several countries, including Australia, New Zealand, Norway, the Netherlands and the United States. HIA is also used in Canada, most extensively for policy appraisals in Quebec. HIA is necessary for ensuring that all government departments are able to consider the health impacts of their work. Such a tool would have been very beneficial in assessing cuts to program spending to ensure the impact on health would not be counterproductive (i.e., lead to higher overall costs to society once the health impact is taken into account). The adoption of an evidence-based HIA is one way in which the federal government can play a leadership role in health care. The CMA recommends that: - The federal government include a Health Impact Assessment as part of its policy development process to ensure that the health of Canadians is a key factor in every policy decision it makes. - The federal government recognize the relationship of the social determinants of health on the demands of the health care system.
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CMA's Submission to Finance Canada regarding proposed amendments to the Income Tax Act

https://policybase.cma.ca/en/permalink/policy10353
Date
2012-02-14
Topics
Physician practice/ compensation/ forms
  1 document  
Policy Type
Parliamentary submission
Date
2012-02-14
Topics
Physician practice/ compensation/ forms
Text
As previously indicated in the Retirement Income Improvement Coalition's (RIIC) letter to the Minister of Finance on August 10, 2011, the CMA supports the federal government's proposal to expand access to pensions, specifically by establishing a legislative and regulatory framework to permit pooled registered retirement plans (PRPPs). The CMA is concerned that as currently proposed, the PRPP framework, including Bill C-25 and the proposed legislative amendments to the Income Tax Act, would limit the potential for PRPPs to contribute to expanding access to, and investment in, pensions for self-employed individuals. With respect to the pension framework, a critical issue, two principles are central to the CMA's membership of over 76,000 physicians. These are, to encourage the federal government to: 1) ensure that self-employed Canadians can retire with an appropriate level of retirement income (e.g., a 70% of pre-retirement income target); and, 2) expand the retirement savings options that are available to self-employed Canadians. The CMA's comments herein on the proposed amendments to the Income Tax Act are in support of these two principles. As elaborated below, the CMA encourages the federal government to: 1. Increase the retirement savings capacity of self-employed individuals by raising the combined limit for RRSPs; 2. Expand the PRPP framework to include defined benefit and targeted benefit pension plans; and, 3. Clarify the eligibility criteria of "PRPP administrators" to include professional associations. 1. Increase the combined contribution limit for PRPPs and RRSPs As proposed, it is our understanding that the core benefit of the PRPP framework is in providing smaller businesses access to low-cost pension plans, thereby providing a vehicle to encourage employers to establish, and contribute to, pensions for their employees. While the CMA recognizes the value of, and supports, this objective, this proposal in effect maintains the status quo for self-employed individuals. Under Clause 10 of the proposed amendments to the Income Tax Act, the contribution limit to PRPPs would be calculated as an additional component of the current registered retirement savings plan (RRSP) contribution limit. As outlined in the Explanatory Notes, "an employer's contributions to an individual's PRPP account [and...] an individual's PRPP contributions in a taxation year will immediately reduce the individual's ability to make deductible RRSP contributions in that same year." While individuals with employer contributions stand to benefit from increased retirement savings via employer contributions, self-employed individuals are merely provided with access to an alternate retirement savings vehicle. As explained in the Summary Report on Retirement Income Adequacy Researchi, "[h]igher income groups tend to exhibit a greater tendency to substitute one form of saving for another since they tend to be bound by limits...[I]f newly introduced plans are included in limitations imposed on the degree to which contributions may be deductible for tax purposes, saving may not increase for individuals who are constrained (i.e. saving up to their limit), since they would more likely substitute one type of saving for another (e.g., RRSP for a private pension plan)." Therefore, the CMA encourages the federal government to consider increasing the retirement savings capacity of self-employed individuals by raising the combined limit for RRSPs and PRPPs. 2. Include defined benefit and targeted benefit pension plans As noted under Clause 12, the registration criteria for PRPPs will be established by the PRPP Act, Bill C-25. Of concern, Bill C-25 limits PRPPs to defined contribution pension plans by specifically excluding from eligibility of registration: (a) a pension plan as defined by 2(1) of the Pension Benefits Standards Act; (b) an employees' or a deferred profit sharing plan; (c) an RRSP or a retirement compensation arrangement defined by 248(1) of the Income Tax Act; and, (d) any other prescribed plan or arrangement. As highlighted by the Summary Report on Retirement Income Adequacy Research, "defined benefit pension funds and annuities enable investors to share longevity risks as well as pool risky investments to diversify risk." By pooling risk, defined benefit and targeted benefit pension plans provide more secure savings vehicles than defined contributions plans. The CMA encourages the federal government to expand the PRPP framework to include defined benefit and targeted benefit pension plans. While the CMA will advance this recommendation to the House of Commons Finance Committee during its consultation on Bill C-25, we include it as part of this submission as modifications to the proposed amendments to the Income Tax Act would be required. 3. Clarify the eligibility criteria of "PRPP administrators" to include professional associations Further clarification is required on the type of organization that may qualify as a PRPP administrator. As noted under Clause 12, an administrator of a PRPP is authorized under the PRPP Act. As Bill C-25, the PRPP Act, is still in the legislative process, the CMA will elaborate on this issue during the formal Parliamentary consultation. However, as it stands, further clarification is required on the eligibility criteria proposed by Bill C-25. While Bill C-25 can be interpreted to extend administrator eligibility to organizations that are able to fulfill the criteria established by the PRPP Act, Finance Canada's Framework for PRPPs states that eligibility of administrators would be limited to "regulated financial institutions that are capable of taking on a fiduciary role". Well-governed professional organizations that represent a particular membership should be able to sponsor and administer RPPs and PRPPs for their own members, including self-employed members. Conclusion While the CMA supports the proposed PRPP framework in principle, the proposed limitations to PRPPs should be addressed to ensure that they also provide value to self-employed Canadians, including physicians. The CMA appreciates the opportunity to comment on the proposed amendments to the Income Tax Act and to once again advance recommendations to Finance Canada on the PRPP framework. i Prepared for the Research Working Group on Retirement Income Adequacy of Federal-Provincial-Territorial Ministers of Finance.
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CMA's Submission to Finance Canada's 2012 Pre-budget Consultations

https://policybase.cma.ca/en/permalink/policy10350
Date
2012-01-12
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2012-01-12
Topics
Health systems, system funding and performance
Text
The Canadian Medical Association (CMA) appreciates the opportunity to provide additional comments and recommendations as part of Finance Canada's 2012 pre-budget consultations. The health sector provides essential services and high value jobs supporting communities across Canada. Statistics Canada reports that employment in the health sector accounts for 10% of the Canadian labour force.i In considering possible additional economic stimulus measures that build on the success of Canada's Economic Action Plan, the CMA encourages the federal government to consider investments that target efficiency improvements in the health sector. Efficiency improvements in the health sector yield benefits to all orders of government and Canadians. The following recommendations are advanced for Finance Canada's consideration: * In order to improve the delivery of better care, better health, and better value, the CMA recommends that the federal government work with the provinces, territories and health sector stakeholders to develop a model for accountability and patient-centred care. The CMA encourages the federal government to adopt the Principles to Guide Health Care Transformation, developed by the CMA together with the Canadian Nurses Association and since endorsed by over 60 organizations, as the basis of a pan-Canadian model for accountability and patient-centred care. * Recognizing the significance of nationally comparable metrics on health outcomes and the health care system together with the effectiveness of national public reporting in demonstrating accountability, the CMA recommends that the federal government undertake efforts towards identifying pan-Canadian metrics and measurement that will link health care expenditures to comparable health outcomes. * As the federal government prepares to engage with the provinces and territories to further map out improvements to Canada's health system, the CMA strongly encourages consideration be given to the federal role in coordinating the development of pan-Canadian clinical practice guidelines (CPGs). * While, as previously indicated, the CMA supports the federal government's proposal to expand access to pensions, specifically by developing pooled registered retirement plans (PRPPs), the limitations to PRPPs should be addressed to ensure that they provide value to self-employed Canadians, including physicians. Specifically, addressing the limitations would include: (1) expanding the PRPP framework to include defined benefit and targeted benefit pension plans; (2) increasing the retirement savings capacity of self-employed individuals by either raising the RRSP limit or providing a distinct limit for PRPPs; and, (3) ensuring the PRPP framework expands the eligibility of administrators beyond financial institutions. Introduction The Canadian Medical Association (CMA) appreciates the opportunity to provide additional recommendations to the Government of Canada as part of its 2012 Pre-Budget consultation. Building upon the CMA's recommendations to the House of Commons' Finance Committee, this submission focuses on three issues: (1) improving accountability and patient-centred care in the delivery of new federal health care funding; (2) coordinating the development of pan-Canadian clinical practice guidelines; and (3) addressing limitations in the federal framework for pension reform. 1. Accountability and patient-centred care "Raising sufficient money for health is imperative, but just having the money will not ensure universal coverage. Nor will removing financial barriers to access through prepayment and pooling. The final requirement is to ensure resources are used efficiently." World Health Organization (2010) As the federal government finalizes the Strategic and Operating Review and considers other measures to eliminate the deficit, including scaling down the Economic Action Plan, it must be recognized that improved health systems and the resultant improved productivity pay economic dividends for the country; and, further, that "health" by today's standards is not just the assessment and treatment of illness, but also the prevention of illness, and the creation and support of social factors that contribute to health should also be considered. With the recent announcement by Minister Flaherty with respect to the Canada Health Transfer (CHT) and Canada Social Transfer (CST), the financial parameters for future health care funding have been established. Consistent with previous public opinion research, recent polling by Ekos Research Associates shows that 76% of Canadians identify improving health care as the leading priority for the federal government, ahead of reducing the national debt and deficit.ii However, as we have learned with the 2004 Health Accord, funding alone is not sufficient to ensure Canadian taxpayers benefit from improvements in health care, health outcomes, and value for money. Despite laying out laudable objectives, progress to improve our health care system has been slow following the 2003 and 2004 agreements. There is a general agreement that Canada's health care system is no longer a strong performer when compared to similar nations. The OECD's Health Data, 2011 ranks Canada eighth highest of 34 member states in per capita health care spending, the second highest in hospital spending per discharge, and the seventh lowest in the number of physicians per capita. While Canada outperforms the U.S. on most measures, we fall below the median performance of the OECD on common health quality and system measures. With the new health care funding commitment to 2024, it is now time to plan how to transform the health care system. Principles-based approach is required The CMA is advocating built-in accountability mechanisms to ensure Canada's health care system is focused on delivering improved patient outcomes. Developing a system that is accountable and patient-centred depends on continuously striving to achieve the Institute for Healthcare Improvement's (IHI) Triple Aim objectives of better care, better health and better value. Launched in 2007, the IHI Triple Aim initiative was designed to direct the improvement of the patients' experience of care (including quality, access, and reliability) while lowering the per capita cost of care. It was with the Triple Aim objectives in mind that the CMA jointly developed Principles to Guide Health Care Transformation in Canada with the Canadian Nurses Association (CNA). It is our strong belief that discussions about the future of health care in Canada must be guided by these principles. The CMA-CNA principles are summarized as follows: * Patient-centred: Patients must be at the centre of health care, with seamless access to the continuum of care based on their needs. * Quality: Canadians deserve quality services that are appropriate for patient needs, respect individual choice and are delivered in a manner that is timely, safe, effective and according to the most currently available scientific knowledge. * Health promotion and illness prevention: The health system must support Canadians in the prevention of illness and the enhancement of their well-being, with attention paid to broader social determinants of health. * Equitable: The health care system has a duty to Canadians to provide and advocate for equitable access to quality care and commonly adopted policies to address the social determinants of health. * Sustainable: Sustainable health care requires universal access to quality health services that are adequately resourced and delivered across the board in a timely and cost-effective manner. * Accountable: The public, patients, families, providers and funders all have a responsibility for ensuring the system is effective and accountable. In order to ensure that future federal funding delivers on the Triple Aim objectives of better care, better health and better value, a model for accountability and patient-centred care is required. Such a model would expand upon the CMA-CNA Principles through the development of a set of measurable indicators related to each principle that can be used for setting national standards, monitoring progress and demonstrating accountability to Canadians. The CMA therefore urges the federal government to facilitate discussions with the provinces and territories to identify how resources will be used to improve patient care and health outcomes across the country. To this end, the CMA has urged the Minister of Health to move quickly to engage the provincial and territorial health ministers on transforming the health care system. The CMA recommends that the federal government work with provinces and territories, in consultation with national health sector stakeholders, to develop a model for accountability and patient-centred care. The CMA encourages the federal government to adopt the CMA-CNA Principles to Guide Health Care Transformation as the basis of a pan-Canadian model for accountability and patient-centred care. Improving public reporting: The cornerstone of accountability The federal government has a significant stake in national public reporting on the health of Canadians and on the performance of the health care system. As required by the Canada Health Act, the Minister of Health must publicly report administration, operation and adherence to the Act each year. Further, as the largest contributor to the single-payer system, the federal government has a unique role in demonstrating value for money and reporting on strategies to improve the quality, effectiveness and sustainability of the health care system. To facilitate public reporting, in addition to Statistics Canada, the federal government is supported by the Health Council of Canada and the Canadian Institute for Health Information, both established as government-funded non-profits, however, with distinct mandates. Despite pan-Canadian efforts such as provincial health quality councils and federal and non-governmental reporting, there remains significant room for improvement in the area of monitoring and reporting, both on health outcomes and system performance. As noted in the Commonwealth Fund's report on international health care systems, "reporting on health system performance [in Canada] varies widely across the provinces and territories...there is so far little connection between financial rewards and public reporting of performance." Not surprising, this issue was also identified by the Health Council of Canada in its Progress Report 2011. It highlights the challenges in reporting progress and explains the difficulties inherent to the current patchwork, "[w]here provinces and territories had set and publicized targets, it was easier for us to track progress. Where we could not find targets, assessing progress was more difficult." The CMA has long supported improved pan-Canadian public reporting on health and health care. Most recently, the CMA hosted a symposium with health reporting stakeholders to discuss the current status of national reporting and the need for the development of a pan-Canadian reporting framework. As recognized by the symposium's participants, there is a great deal of excellent data collection work occurring across the country. However, these efforts are largely uncoordinated and do not tell the full story of the health of Canadians or adequately assess the performance of the health care system. Indeed, despite an abundance of metrics and measurement, in many cases, data is not necessarily usable by the public or decision-makers and, unfortunately, is not necessarily comparable between jurisdictions. The CMA recommends that the federal government recognize the significance of nationally comparable metrics on health and the health care system and national public reporting in demonstrating accountability (i.e. better health, better care, and better value). In achieving these objectives, the CMA recommends that the federal government mandate an appropriate national organization, such as the Health Council of Canada, to undertake a consultative process with the aim of identifying pan-Canadian metrics and measurement that will link health expenditures and comparable health outcomes. 2. Coordinate the development of pan-Canadian Clinical Practice Guidelines As the federal government prepares to engage with the provinces and territories to further map out improvements to Canada's health system, the CMA strongly encourages consideration be given to the federal role in coordinating the development of pan-Canadian clinical practice guidelines (CPGs). Such a role would build upon the commitment made by the provinces and territories under the auspices of the Council of the Federation to collaborate on the development of three to five CPGs over the coming year. CPGs are systematically developed, evidence- or consensus-based statements to assist health care providers in making decisions about the most appropriate health care to be provided in specific clinical circumstances. There is compelling evidence in the literature, supported by the experience of other countries, that well-designed and disseminated CPGs can enhance the clinical behaviour of providers and provide a positive impact on patient outcomes. The principle argument in support of CPGs is their ability to enhance quality of care and patient outcomes. In addition, CPGs have been found to: * Provide publicly accessible descriptions of appropriate care by which to gauge health care performance; * Help to reduce inappropriate variations in care across diverse geographical and clinical settings; * Offer the potential of empowering patients as to appropriate care expectations; and, * Contribute to public policy goals, such as cost containment, through encouraging more appropriate provider use of resources. However, in the absence of a pan-Canadian approach, CPGs across Canada are of uneven quality and even excellent guidelines may not be effectively disseminated or implemented. In contrast to Canada, peer-nations such as the United Kingdom, the United States and Australia have committed at a national level to support the development and dissemination of CPGs. In November 2011, the CMA, together with leading national medical and health sector stakeholders, convened a Canadian Clinical Practice Guidelines Summit, attended by representatives of the federal and most provincial and territorial governments, to explore key components of a pan-Canadian strategy on CPGs. Emerging from this summit was a clear consensus that it was the federal role to provide the infrastructure support necessary to facilitate the development and dissemination of high-quality CPGs, customizable to the needs of all jurisdictions in Canada. Guideline development and implementation is a complex, lengthy and resource-intensive process. In the absence of federal coordination in Canada, guidelines are produced by disparate, disease-specific groups, often funded by the pharmaceutical industry. This creates an obvious potential for conflict of interest where the guideline development process is far from transparent. Many guidelines are published without disclosure on conflict of interest or methodology applied. Concern over the quality of guidelines presents one the most persistent barriers to adoption by physicians of the recommended practice. The resulting underutilization of CPGs in Canada is widely documented. Clearly, the development and dissemination of pan-Canadian CGPs present a unique and significant opportunity for improvement in Canada's health care system. The CMA recommends that as part of further discussions with the provinces and territories, the federal government commit to working with the provinces, territories and health sector stakeholders towards the development of a pan-Canadian clinical practice guideline initiative. In particular, the CMA recommends that the federal government commit support for the infrastructure necessary for the development, maintenance, and active dissemination of relevant, high-quality clinical practice guidelines. 3. Address the limitations proposed under the pension reform framework As previously indicated in the August 2011 submission to Finance Canada by the Retirement Income Improvement Coalition (RIIC), the CMA supports the federal government's proposal to expand access to pensions, specifically by developing pooled registered retirement plans (PRPPs). While we are currently assessing the package of proposed Income Tax Act amendments and will provide more detailed comments as part of the legislative process, the CMA is concerned that the framework, as proposed, limits the potential for PRPPs to expand physician access to, and investment in, pensions. Based on preliminary analysis, it is our understanding that the core benefit of the PRPP framework is in providing small businesses access to low-cost pension plans, thereby providing a vehicle to encourage employers to establish, and contribute to, pensions for their employees. Given that a significant proportion of physicians are self-employed, they would not benefit from employer contributions to a PRPP. Further, as proposed, the contribution limit to PRPPs would be calculated as an element of the current RRSP and pension contribution limit. Finally, further clarification is required on the type of organization that may qualify as a PRPP administrator. Well-governed organizations that represent a particular membership should be able to sponsor and administer RPPs and PRPPs for their own members, including self-employed members. While the CMA supports the proposed PRPP framework in principle, the limitations to PRPPs should be addressed to ensure that they provide value to self-employed Canadians, including physicians. The CMA recommends that Finance Canada consider amendments to the proposed Income Tax Act amendments to address limitations to PRPPs, specifically: (1) expanding the PRPP framework to include defined benefit and targeted benefit pension plans; (2) increasing the retirement savings capacity of self-employed individuals by either raising the RRSP limit or providing a distinct limit for PRPPs; and, (3) ensuring the PRPP framework expands the eligibility of administrators beyond financial institutions. Conclusion The comments and recommendations provided herein represent the CMA's priority recommendations for targeted federal funding towards the achievement of efficiency improvements in Canada's health sector. It is the CMA's position that these measures will contribute to a healthy, more productive and innovative economy by contributing to better care, better health and better value in the health care system. Once again, the CMA appreciates the opportunity to provide these additional comments and recommendations. i 2006 Census data ii http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Media_Release/2011/Dec-Poll_en.pdf
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CMA's Submission to the House of Commons Standing Committee on Finance: Amending Bill C-25 to expand the PRPP framework to provide value to self-employed Canadians

https://policybase.cma.ca/en/permalink/policy10355
Date
2012-02-24
Topics
Physician practice/ compensation/ forms
  1 document  
Policy Type
Parliamentary submission
Date
2012-02-24
Topics
Physician practice/ compensation/ forms
Text
The Canadian Medical Association (CMA) supports the Government of Canada's efforts to improve Canada's retirement income system, specifically by establishing a legislative framework to permit pooled registered pension plans (PRPPs) as proposed in Bill C-25, the PRPP Act. The CMA has long supported the Government of Canada's efforts to expand access to pensions, including by permitting PRPPs. However, the CMA is concerned that as currently proposed, Bill C-25 limits the potential for PRPPs to expand the access to, and investment in, pensions of self-employed individuals. The CMA has participated in, and made recommendations to, Finance Canada over the course of the department's multi-year consultative process, including responding to the 2010 consultative paper Ensuring the Ongoing Strength of Canada's Retirement Income System. The CMA has also made recommendations to Finance Canada as a member of the Retirement Income Improvement Coalition (RIIC), which consists of 11 national professional associations representing over 1 million self-employed professionals. The following discussion and recommendations align with those previously made by the CMA and the RIIC. The pension framework is a critical issue to CMA's membership of over 76,000 physicians. In addressing the pension framework, including permitting PRPPs, two principles are central to the CMA's membership: to ensure that self-employed Canadians can retire with an appropriate level of retirement income (e.g., a target of 70% of pre-retirement income); and, to expand the retirement savings options that are available to self-employed Canadians. The CMA's comments herein, and recommendations to the Finance Committee to amend Bill C-25, are in support of these two principles. As elaborated below, the CMA encourages the Finance Committee to: 1. Amend Bill C-25 to raise the combined limit for RRSPs and PRPPs in order to increase the retirement savings capacity of self-employed individuals. 2. Amend Section 12(1) of Bill C-25 to expand the PRPP framework so it includes defined benefit and targeted benefit pension plans, which provide more secure savings vehicles than defined contributions plans. 3. Ensure the eligibility clauses of Bill C-25 (Sections 14-26) would allow well-governed professional organizations that represent a particular membership to be able to sponsor and administer RPPs and PRPPs for their own members, including self-employed members. 1. Increase the combined contribution limit It is our understanding that the core benefit of the proposed PRPP framework is in providing smaller businesses access to low-cost pension plans, thereby providing a vehicle to encourage employers to establish, and contribute to, pensions for their employees. However, as explained by the Explanatory Notes accompanying the proposed Income Tax Act amendments, "an employer's contributions to an individual's PRPP account [and...] an individual's PRPP contributions in a taxation year will immediately reduce the individual's ability to make deductible RRSP contributions in that same year." While the CMA recognizes the value of, and supports, this objective, this proposal in effect maintains the status quo for self-employed individuals. Like the Canadian population at large, physicians represent an aging demographic - 38% of Canada's physicians are 55 or older - for whom retirement planning is an important concern. In addition, the vast majority of CMA members are self-employed physicians and, as such, they are unable to participate in workplace registered pension plans (RPPs). At present, physicians are more reliant on registered retirement savings plans (RRSPs) relative to other retirement savings vehicles. While individuals with employer contributions stand to benefit from increased retirement savings via employer contributions, self-employed individuals are merely provided with access to an alternate retirement savings vehicle. As explained in the Summary Report on Retirement Income Adequacy Researchi, "[h]igher income groups tend to exhibit a greater tendency to substitute one form of saving for another since they tend to be bound by limits...[I]f newly introduced plans are included in limitations imposed on the degree to which contributions may be deductible for tax purposes, saving may not increase for individuals who are constrained (i.e. saving up to their limit), since they would more likely substitute one type of saving for another (e.g., RRSP for a private pension plan)." Therefore, the CMA encourages the Finance Committee to consider amending Bill C-25 to increase the retirement savings capacity of self-employed individuals by raising the combined limit for RRSPs and PRPPs. 2. Include Defined Benefit and Targeted Benefit Pension Plans As currently proposed, Section 12(1) of Bill C-25 limits PRPPs to defined contribution pension plans by specifically excluding from eligibility of registration: (a) a pension plan as defined by 2(1) of the Pension Benefits Standards Act; (b) an employees' or a deferred profit-sharing plan; (c) an RRSP or a retirement compensation arrangement defined by 248(1) of the Income Tax Act; and, (d) any other prescribed plan or arrangement. As highlighted in the Summary Report on Retirement Income Adequacy Research, "defined benefit pension funds and annuities enable investors to share longevity risks as well as pool risky investments to diversify risk." By pooling risk, defined benefit and targeted benefit pension plans provide more secure savings vehicles than defined contribution plans. The CMA encourages the Finance Committee to amend Bill C-25 to expand the PRPP framework to include defined benefit and targeted benefit pension plans. 3. Clarify the eligibility criteria of "PRPP administrators" to include professional associations Further clarification is required on the type of organization that may qualify as a PRPP administrator under Bill C-25. While Sections 14-26 of Bill C-25 can be interpreted to extend administrator eligibility to organizations that are able to fulfill the criteria it establishes, Finance Canada's Framework for Pooled Registered Retirement Plans states that eligibility of administrators would be limited to "regulated financial institutions that are capable of taking on a fiduciary role." The CMA encourages the Finance Committee to ensure that the eligibility clauses of Bill C-25 would allow well-governed professional organizations that represent a particular membership to be able to sponsor and administer RPPs and PRPPs for their own members, including self-employed members. Conclusion While the CMA supports the proposed PRPP framework in principle, the limitations currently proposed by Bill C-25 should be addressed to ensure that PRPPs also provide value to self-employed Canadians, including physicians. The CMA appreciates the opportunity to comment to the Finance Committee as part of its study of Bill C-25. Summary of Recommendations Recommendation 1 Amend Bill C-25 to raise the combined limit for RRSPs and PRPPs in order to increase the retirement savings capacity of self-employed individuals. Recommendation 2 Amend Section 12(1) of Bill C-25 to expand the PRPP framework so it includes defined benefit and targeted benefit pension plans, which provide more secure savings vehicles than defined contributions plans. Recommendation 3 Ensure the eligibility clauses of Bill C-25 (Sections 14-26) would allow well-governed professional organizations that represent a particular membership to be able to sponsor and administer RPPs and PRPPs for their own members, including self-employed members. i Prepared for the Research Working Group on Retirement Income Adequacy of Federal-Provincial-Territorial Ministers of Finance.
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