With economic growth having slowed, Budget 2009 provides an historic opportunity to invest in initiatives that will stimulate the Canadian economy in the short term while also strengthening it in the long term. With the federal government now considering several areas for potential fiscal stimulus, the Canadian Medical Association (CMA) views infrastructure spending as the government's best option. In order to provide much-needed immediate economic stimulus and a responsible, long-term strategy to achieve economic stability, the CMA recommends the federal government invest $2.4 billion in health infrastructure upgrade initiatives to be carried out over the next two years. These initiatives fall into three priority areas:
1) Accelerating existing or "construction-ready" capital projects in health care facilities.
The CMA recommends a federal investment of $1.5 billion over two years to accelerate existing hospital and health facility construction projects. While investments in physical infrastructure are required across the continuum of care, a focus on hospital construction - specifically on construction-ready projects already approved at the provincial level - will allow funds to flow more quickly and thus provide a more immediate economic stimulus. Federal investment in hospital and health facility construction will create 16,500 jobs over two years and 11,000 jobs in 2009 alone. These projects may be financed through existing public-private partnerships (P3s). With targeted and strategic federal investment, health facility capital projects would also stimulate further investment in the form of private-sector financing of these capital projects.
2) Accelerating implementation of electronic medical records.
Health system information technology is an area where infrastructure investments are needed and would provide significant return on investment through immediate economic stimulus and improved health system efficiency in the medium and long term. CMA recommends that the federal government make a strategic "strings attached" $225-million investment in an Electronic Medical Record Patient Transition Fund that could be managed by the Canada Health Infoway.
3) Modernizing information systems in small- and medium-sized health care facilities.
A federal investment of $700 million over two years to upgrade information system hardware and software in small- and medium-sized hospitals could be implemented within the next eight quarters and begin to create 7,700 jobs and rapidly improve health care efficiency.
These health infrastructure investments would create 27,000 new jobs over the next two years:
1. 16,500 jobs for existing hospital building projects that are "construction ready";
2. 4,950 jobs for electronic medical records (EMR) implementation for community-based health care offices;
3. 7,700 jobs for hospital information systems in small- and medium-sized hospitals.
In these challenging economic times, the federal government is to be commended for casting a wide net in search of effective and immediate measures to stimulate Canada's economy. Of course, Canadians must also be assured that we will not be mortgaging our future by doing so.
In order to both provide much-needed immediate economic stimulus and a responsible, long-term strategy to achieve economic stability, the CMA recommends that the federal government invest $2.4 billion in health infrastructure upgrade initiatives to be carried out over the next two years. These investments would stimulate further provincial/territorial and private-sector investment. To be clear: these recommendations are in the context of a fiscal stimulus plan and do not encompass CMA's entire long-term vision for high-quality and patient-focused health care.
The CMA initiatives fall into three priority areas:
1) Accelerating existing or "construction-ready" capital projects in health care facilities;
2) Accelerating implementation of electronic medical records;
3) Modernizing information systems in small- and medium-sized health care facilities.
A critical factor in these recommendations is the fact that the federal government already has in place funding mechanisms to deliver stimulus funds rapidly in all three areas. Canada Health Infoway is such an established vehicle for the EMR initiative and the upgrading of hospital information systems. The Canada Foundation for Innovation or an expanded "Building Canada" program are initiatives that have organizations in place to administer the investments in hospital construction projects. Additionally, these initiatives are flexible in both size and duration.
Most economists agree that increasing infrastructure spending generally will boost the economy by creating jobs. In no sector is this more true than health care. Infrastructure investments, will lead to higher employment and more spending on products and services, and generate higher overall demand.i (See Appendix A for investment and job creation quarterly forecasts 2009/2010ii). The Business Register of Statistics Canada reports there were 75,615 establishments in the health service delivery (HSD) industry in 2003, employing 1.3 million people. That year, they accounted for 3.3% of all Canadian business establishments and 7.6% of total employment. In 2003, the GDP of the HSD industry was larger than wholesale trade, retail trade, and the upstream oil and gas mining industry, and almost as large as the construction sector. Physicians' offices (30,120 establishments) accounted for almost 39% of all HSD establishments and employed 142,000 people, or almost 11% of all HSD employees. By targeting investment in the three areas outlined above, the government will respond to Canadians' desire for a strengthened health care system, support Canada's competitive advantage and create 27,000 jobs in the next two years (Figure 1).
1. Accelerating Health Facility Construction Projects
The CMA recommends that the federal government invest $1.5 billion over two years to accelerate hospital and/or health facility projects that are "construction ready".
In 2001 the CMA identified inadequate investment in buildings, machinery and equipment and in scientific, professional and medical devices as major hurdles to timely access to health care services. While spending has increased in health care since then, governments have placed a lower priority on capital investment when allocating financial resources for health care.
The CMA recommends a federal investment of $1.5 billion over two years to accelerate existing hospital and health facility construction projects. This does not capture all the capital requirements in the health system in the medium- and long-term. While investments in physical infrastructure are required across the continuum of care, a focus on hospital construction - specifically on construction-ready projects - will allow funds to flow more quickly and thus provide a more immediate stimulus to the economy. Federal investment in hospital and health facility construction will create 16,500 jobs over a two-year period and 11,000 jobs in 2009 alone. These projects may be financed through existing public-private partnerships (P3s).
With targeted and strategic federal investment, health facility capital projects can also stimulate further investment in the form of private-sector financing of capital projects. Across Canada hospitals are seeking to develop innovative approaches to financing capital infrastructure. The CMA agrees with other organizations such as the Canadian Healthcare Association about the need to explore the concept of entering into public-private partnerships to address capital infrastructure needs as an alternative to relying on government funding. Joint ventures and hospital bonds are but two examples of P3 financing.
As these types of partnerships are pursued, the CMA recommends that governments establish uniform requirements and regulations to ensure the transparency of the tendering process and adequate measuring of quality of care and cost-effectiveness in both public and private settings.iii
The federal government has long showed great leadership in partnering to build Canada's health care system - the Hospital Construction Grants Program of 1948 and the Health Resources Fund Act of 1966. Today our country and our health care system need a new vision for replacing aging physical infrastructure.
2. Electronic Medical Records - Accelerating Coverage for 26 Million Patients
CMA recommends that the federal government invest $225 million over two years to accelerate the implementation of an interoperable electronic medical record across Canada.
International studies confirm that Canada lags behind nearly every major industrial country
when it comes to the adoption of health information technology (Figure 8). The Conference Board of Canadaiv, the Organization for Economic
Co-operation and Development (OECD)v, the World Health Organizationvi, the Commonwealth Fundvii, and the Frontier Centre for Public Policy all rate Canada's health care system poorly in terms of value for money and efficiency. The impact of this underinvestment is longer wait times, poorer quality, greater health system costs and a severe lack of financial accountability - especially when it comes to federal dollars.
Health system information technology is an area where infrastructure investments are needed and would provide significant return on investment through immediate economic stimulus and improved health system efficiency in the medium- and long-term. CMA recommends that the federal government make a strategic, "strings attached,"1 $225-million investment in an Electronic Medical Record Patient Transition Fund that could be managed by the Canada Health Infoway.2 The fund would finance EMR capital equipment acquisition and EMR change management and transition support, specifically the conversion of 26 million patient records in 30,000 physician offices.
This federal investment would be matched by provincial-territorial funds and would thus provide a total of $450 million in economic stimulus and create 5000 new jobs over two years. While public funds would kick-start this initiative, they would stimulate considerable private sector activity in the provision of EMR capabilities across Canada. Assuming the current trend prevails, the ongoing management of the data holdings would be outsourced to private sector companies based on application service provider arrangements.
Moreover, these investments are consistent with the Building Canada plan's focus on broadband and connectivity, and with Advantage Canada's goals of creating a knowledge advantage and an infrastructure advantage.
Beyond providing immediate stimulus to the Canadian economy, a fully realized EMR system will improve patient outcomes, system efficiency and accountability and save billions of dollars annually. Technology consulting firm Booz Allen Hamilton found that the benefits of an interconnected Electronic Health Record (EHR) in Canada could provide annual system-wide savings of $6.1 billion.viii These savings would come from reduced duplicate testing, transcription savings, fewer chart pulls and less filing time, reductions in office supplies and reduced expenditures due to fewer adverse drug reactions. The study also found that the benefits to health care outcomes would equal or surpass these annual savings, thus providing a possible combined annual savings of $12.2 billion.
By reducing wait times, an interoperable EMR will contribute to saving the Canadian economy billions of dollars each year. A study commissioned by the CMA conservatively calculated that excessive wait times involving just four procedures (joint replacements, cataract surgery, coronary artery bypass grafts and MRIs) cost the economy over $14 billion in 2007 due to lost output and government revenues.ix
The Electronic Medical Record Patient Transition Fund focuses on community care and the physician offices where most patient visits occur. Most of the emphasis on connectivity in Canadian health care to date has not focused on the point of care, even though the number of patient interactions with hospitals is greatly exceeded by the number of visits to physicians' offices.x Thus, patient-physician office interactions outnumber patient-hospital interactions by a ratio of 18 to 1. In Ontario (Figure 2), just 3,000 of an average of 247,000 patient visits per day, or 1.2%, are made in hospitals.
Figure 2 Patient visits per day in Ontario (Canada Health Infoway)
3. Modernizing Hospital Information Systems
The federal government should invest $700 million over two years to modernize information systems in small- and medium-sized hospitals.
Aging information systems in small hospitals (fewer than 100 beds) and medium-sized hospitals (100 to 300 beds) create considerable inefficiency in patient care and administration. While larger hospitals have upgraded their information systems, hundreds of smaller facilities have information systems that are at least 10 years old.
This means that patients are often forced to provide their personal and health information many times: when checking in to the emergency department, then when having a diagnostic test performed, and again when being admitted to hospital. Each step creates room for error and needlessly wastes the time of health care staff and patients. In addition, these discrete systems may not be networked, a situation that risks compromising patient care.
A federal investment of $700 million over two years to upgrade information system hardware and software in small- and medium-sized hospitals could be implemented within the next eight quarters and begin to create 7,700 jobs and rapidly improve health care efficiency. The $700 million investment is based on a recent conservative estimate for outfitting hospitals across the country (see Appendix B).
There are at least 70 medium-sized Canadian hospitals requiring major system upgrades immediately at a cost of $15 million per hospital. The distribution of these hospitals would help spread out the fiscal stimulus regionally and mitigate against potential labour shortages.
The $700-million recommendation assumes that the majority of hospital information system investments (64%) would need to be focused on the hardware and professional services related to implementing the new systems, with the rest focused on system software. It is important to note that these investments would help support related Canadian software, hardware and professional services firms over the next 24 months and beyond. More importantly, the hospital information system sector is a multibillion dollar global industry.
A fiscal stimulus investment in this sector now would help Canadian firms to capitalize on a golden opportunity to export these goods and services, which are increasingly in high demand.xi It is also important that patients be involved in evaluating these systems in order to improve care and system efficiencies. As Roger Martin, Dean of the Rotman School of Business noted: "We can dramatically improve the production of globally competitive health care product and services firms, but only if we work to significantly improve the demand side (patients) of our innovation equation."xii This is in line with the CMA's call for patient-focused funding.
That these are extraordinary economic times is beyond question, but the CMA contends that it is precisely during such times that opportunities often present themselves. We think the federal government must continue to examine and leverage all available policy levers at its disposal, including studying how the tax system could be used to support renewal within the health care sector.
The tax system's level of support for people facing high out-of-pocket expenses remains a particularly pressing question. Currently, the medical expenses tax credit provides limited relief to those whose expenses exceed $1,637, or 3% of net income. The 3% threshold was established before medicare was introduced. Does it still make sense in 2009? Are there ways to enhance this provision to reduce financial disincentives facing many Canadians when they have to pay for health services?
The CMA encourages the federal government to undertake a comprehensive review of these and other tax questions pertaining to health. By itself, tax policy will not solve all the challenges facing Canada's health care system, but the CMA believes that the tax system can play a key role in helping the system adapt to changing circumstances, thereby complementing the other two components of our renewal strategy.
Similarly, the government must remember that almost five million Canadians do not have a family physician and that Canada needs 26,000 more doctors to meet the OECD average of physicians per population. The federal government wisely recognized the urgency of this situation when it committed to several targeted and affordable measures to begin to address the doctor shortage. It should follow through on its election commitment to take first steps towards addressing the shortage, including contributing $10 million per year over four years to provinces to allow them to fund 50 new residencies per year in Canada's major teaching hospitals, and $5 million per year over four years to help Canadian physicians living abroad who wish to relocate to Canada. These initiatives would begin to increase the supply and retention of physicians in areas of priority need, and could bring back as many as 300 Canadian physicians over four years.
Today, the federal government is focused on instituting specific, strategic and immediate economic stimulus measures, and rightfully so. However, we must not let the urgent crowd out the important in terms of building a sustainable health care system that provides timely access to quality health care services for all Canadians.
Appendix A. Investment and job creation profile estimates 2009-10
B. Projected Costs to Implement / Upgrade Hospital Information Systems3
1. Total number of hospitals in Canada = 734
a. % small hospitals (< 100 beds) = 69%
b. % medium hospitals (< 300 beds) = 18%
2. Components in hospital information systems
a. Finance & Administration
b. Admission, Discharge, Transfer (ADT) System
c. Patient Information System
d. Radiology Information System
e. Laboratory Information System
f. Pharmacy Information System
g. Coding & Abstracting System
3. Cost to implement complete HIS for medium size hospital = $15 million
a. Ratio of software to hardware and professional services - 1:1.8
b. Software = $5,357,143
c. Hardware & Professional Services = $9,642,857
4. Small hospitals (i.e. < 25 beds) would not have the resources to manage a full HIS
a. Cluster implementations among 8 hospitals
b. Number of clusters = 33 (total # of hospitals = 270)
5. Small hospitals would have greater requirement for full implementation of HIS
a. % of hospitals requiring full implementations = 50%
b. Number of hospitals (exclusive of clusters in #4) = 117
c. Total number including clusters in # 4 requiring full implementation = 91
d. Cost to implement full HIS - 60% of medium hospital implementation = $9 million
6. Medium sized hospitals with systems > 10 years old would require full implementation
a. % of hospitals requiring full HIS implementation = 30%
b. Number of hospitals= 40
7. Major system upgrades are estimated at 40% of cost of a full HIS
a. Cost to complete system upgrade = $6 million
b. % small hospitals (# of beds between 25 - 99) requiring upgrade = 30%
c. Number of hospitals = 70
d. % of medium hospitals requiring upgrade = 30%
e. Number of hospitals = 40
1. Investment required for small hospitals - full implementation
$ 9,000,000 x 91 = $ 819,000,000
2. Investment required for small hospitals - system upgrade
$ 6,000,000 x 70 = $ 420,000,000
3. Investment required for medium hospitals - full implementation
$ 15,000,000 x 40 = $ 600,000,000
4. Investment required for medium hospitals - system upgrades
$ 6,000,000 x 40 = $ 240,000,000
5. Total investment for HIS for small and medium size hospitals
1 The conditions of this health information investment should include:
* Fifty-fifty FPT cost sharing;
* Involvement of the clinical community in the input and oversight of the program;
* Use of consistent standards.
2 See Table l in Appendix A for full investment horizon details.
3 Prepared for the Canadian Medical Association by Branham Group December 2008
i Will Stimulus Help Employment in a 21st Century Economy? Wall Street Journal, Dec. 5, 2008.
ii These estimates were derived using the principle of an employment multiplier and adapted using the methodology applied by Informetrica for an infrastructure study they prepared for the Federation of Canadian Municipalities (05/08).
iii Improving performance measurement, quality assurance and accountability in the public-private interface - CMA Policy Statement, It's still about access! Medicare Plus, July 2007
iv A Report Card on Canada see: http://sso.conferenceboard.ca/HCP/overview/health-overview.aspx
v Organization for Economic Co-operation and Development [OECD] (2007). OECD Health
Data 2007. Version 07/18/2007. CD-ROM. Paris: OECD.
vi World Health Organization [WHO] (2007). World Health Statistics 2007. see: http://www.who.int.
vii Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care May 15, 2007 (updated May 16, 2007)
Authors: Karen Davis, Ph.D., Cathy Schoen, M.S., Stephen C. Schoenbaum, M.D., M.P.H., Michelle M. Doty, Ph.D., M.P.H., Alyssa L. Holmgren, M.P.A., Jennifer L. Kriss, and Katherine K. Shea
Editor(s):Deborah Lorber see: www.commonwealthfund.org/publications/publications_show.htm?doc_id=482678
viii Booz, Allan, Hamilton. Canada Health Infoway's 10-Year Investment Strategy: pan-Canadian electronic health record, March 2005-09-06.
ix The economic cost of wait times in Canada, January 2008. This study was commissioned by the Canadian Medical Association to analyze the economic costs of wait times in Canada's medical system. The CMA's membership includes more than 67,000 physicians, medical residents and medical students. It plays a key role by representing the interests of these members and their patients on the national stage. Located in Ottawa, the CMA has roots across the country through its close ties to its 12 provincial and territorial divisions.
x Sources: Physician visits - CIHI - Physicians in Canada: Fee-for-Service Utilization 2005-2006. Table 1-21. Hospital contacts - CIHI - Trends in Acute Inpatient Hospitalizations and Day surgery Visits in Canada 1995-1996 to 2005-2006 and CIHI -National Ambulatory Care Reporting System - Visit Disposition by Triage Level for All Emergency Visits - 2005-2006.
xi Canada boasts a sophisticated network of providers, many globally-recognized hospitals, and a number of major centres for health research. We spend aggressively in global terms on health research, which is supported nationally by the Canadian Institutes of Health Research (CIHR). But against this backdrop lies a mystery: why do so few Canadian health care firms sell their products and services in the international market? Only nine sell as much as $100 million of any product or service to customers outside the country, with total sector sales outside Canada of less than $5 billion. This sector total compares unfavourably with the foreign sales of individual firms such as Bombardier at $22 billion, and Magna International at $14 billion; overseas health-care sales are even dominated by the export of sawn logs, at $9 billion. see: http://www.rotman.utoronto.ca/rogermartin/Canadianhealthcaremystery.pdf (accessed January 7, 2009)
From: Roger, Martin, The Canadian Health Care Mystery: Where Are the Exports? Rotman magazine (Winter 2006).
The Canadian Medical Association (CMA) brief submitted to the House of Commons Standing Committee on Health makes 12 practical recommendations within the jurisdiction of the federal government for investing in the capacity needed to expand and retain our practising physician population. These recommendations are a clarion call for pan-Canadian planning and innovative thinking to meet an ever-increasing demand for physician services from the Canadian public. CMA's research on Health Care Transformation has shown that a commitment to ensuring an adequate supply of health human resources (HHR) is a common trait shared by high-performing European health systems. The last federal election campaign saw most political parties pledge to urgently address HHR shortages. Now is the time to keep those election commitments.
Cuts to medical school enrolment in the 1990s contributed to Canada's significant shortage of physicians. Growing demand for physician services, the aging of the physician population and changing practice styles among younger physicians are further compounding the problem. Seriously addressing HHR shortages is crucial to transforming Canada's health care system into one that is truly patient focused.
Canada should strive for self-sufficiency in physician supply and do more to repatriate Canadians studying and practising medicine abroad. The CMA supports bringing into practice qualified international medical graduates (IMGs) already in Canada. IMGs should be assessed according to the same evaluation standards as Canadian graduates and more should be done to reduce the backlog in assessing IMGs. With recent increases to medical school enrolment, more support must also be given for the capital infrastructure and faculty required to ensure the highest standard of medical education.
Competition for physicians is an issue with both international and inter-provincial/territorial facets. The revised Agreement on Internal Trade (AIT) and bilateral agreements will ease the movement of health professionals across jurisdictions, but may exacerbate retention difficulties in underserviced areas. Canada should be active in retaining and repatriating our health care professionals, particularly since the predicted physician shortage in the United States may result in a return to the physician out-migration seen in the 1990s.
Canada must do more to encourage innovation within our health care system. Collaborative care - including care delivered with the assistance of Physician Assistants (PAs) - and advances in information technology hold the promise of helping create a more efficient health care system that provides higher quality care.
Canada has suffered from a significant physician shortage since the mid-1990s. Nationally, we rank 26th of 30 Organisation for Economic Co-operation and Development (OECD) member countries in physician-to-population ratio. We would need 20,000 new physicians just to meet the OECD average.
Figure 1: Physicians per 1000 population (including residents)
Source: OECD 2008 Health Data; CMA Physician Resources Evaluation Template
During the 2008 federal election campaign, four of the five parties represented in the House of Commons recognized the urgency of this situation and promised measures that would address HHR shortages. Following through on these promises is critical if we are to transform Canada's health care system into one that truly puts the needs of patients first. Research conducted for CMA's Health Care Transformation initiative demonstrates that European countries whose health care systems outperform our own all share a strong commitment to HHR, as demonstrated by their higher physician-to-population rankings.
First-year medical school enrolment was already in decline when health ministers imposed a further 10% cut resulting in a low of 1,577 places in 1997. While there have been substantial increases since then, it took a decade to rebound. In 2007, first-year enrolment stood at 2,569 - 63% higher than a decade earlier. If we had left our domestic production unchanged, we would have almost 1,300 more physicians than we have today.
Canada remains well behind other industrialized countries in the education and training of physicians. In 2005, Canada graduated 5.8 physicians per 100,000 population, 40% below the 9.6 average for the OECD.
Currently, between 4 and 5 million Canadians do not have a family physician. Over one-third of all Canadian physicians are over the age of 55. Many will either retire soon or reduce their practice workload. Most are not accepting new patients.
Ironically, advances in medicine and lifestyle that are helping Canadians live better and longer also mean increased demand for health care professionals. An aging population with high expectations of the health care system is increasing pressure on health care providers to ensure they maintain a high quality of life through their elder years. A growing culture of 'health consumerism,' facilitated by the Internet has resulted in a very knowledgeable patient population that expects top quality care delivered in a timely manner by the appropriate health professional.
Advances in medical diagnostics and technology, new and evolving diseases and increasingly complex protocols and guidelines for medical care all increase the demand for physician services. Declining mortality rates for patients with diseases such as cancer have increased treatment of what have become 'chronic' diseases. In a collaborative care setting, physicians often take responsibility for the most complex patients.
There is evidence of a cultural change among physicians to place greater importance on their home life by working less. This trend may have a positive effect on the health of the profession but it means Canada will need more physicians to provide the same volume of services.
Greater coordination among jurisdictions is needed to facilitate HHR planning on a national scale. Canada's doctors and other health professions are ready to assist policy-makers in their planning and coordination to better meet the health care needs of Canadians.
During the 2008 federal election campaign, most political parties recognized the urgency of addressing HHR shortages. The Conservative Party, specifically, promised to fund 50 new residency positions to increase supply of physicians in areas of priority need.
Recommendation 1: The federal government should fulfill its promise to fund 50 new residency positions at a cost of $10 million per year for four years.
Support for IMGs
The CMA fully supports bringing into practice qualified IMGs already in Canada. Canada has historically benefited from a steady flow of IMGs to our country. In fact, close to one quarter of all physicians in Canada and over 50% of doctors in Saskatchewan are IMGs. Many areas in Canada would have no physicians if not for the contribution of these practitioners.
While IMGs are a boon to Canada, actively recruiting from developing countries is not an acceptable solution to our physician shortage. Canada must strive for greater self-sufficiency in the education and training of physicians. In fact, self-sufficiency is a key principle of the government's Advisory Committee on Health Delivery and Human Resources' Framework for Collaborative Pan-Canadian Health Human Resources Planning.
CMA supports online assessment tools and websites that provide information to foreign-trained physicians so they know what standards they must meet once they arrive in Canada. In 2006, over 1700 people used the online assessment tool established by the Medical Council of Canada (MCC). CMA also supports applying the same evaluation standards to international graduates as it does to graduates of Canadian medical schools.
Despite a four-fold increase in the number of IMGs in ministry-funded postgraduate training programs over the last decade, there is still a backlog of IMGs awaiting entry into these programs. About 1300 IMGs applied for a postgraduate training position last year but only 350 (27%) were successful. CMA recommends that funding be made available to provinces for use in mentoring IMGs towards licensure. This could lower costs for the IMGs, pay the community preceptors, cover operational costs and defray other expenses.
It is estimated that up to 1500 Canadians are studying medicine abroad. Two-thirds of these IMGs want to come home to complete their postgraduate training. Canada turns away four good applicants for every student accepted into medical school. Increased training opportunities for all groups of IMGs will ensure that Canada fully utilizes the skills and knowledge of its citizens who have studied medicine.
Recommendation 2: The federal government should make $5 million (over five years), available to provinces/territories to address the backlog of IMGs through community preceptorship programs that mentor and assess IMGs for integration into the physician community.
Recommendation 3: The federal government should take concrete steps to ensure Canada becomes self-sufficient when it comes to the supply of health care professionals.
Recommendation 4: The federal government should continue to fund information tools such as the IMG-Canada website to better inform offshore physicians.
Infrastructure and faculty
Canada's teaching centres have had to absorb increases in operational and infrastructure costs to accommodate increased enrolment. This includes instructors, space, overhead and supplies. While it appears that the number of faculty members has kept pace with the increased number of medical students, part-time faculty now make up a much larger proportion of the total than 10 years ago. i
In addition to the traditional academic centres, much of the training of doctors now occurs in a community environment. Mentoring is provided by physicians who may have less experience or resources than do those in the larger centres. Those who teach often experience lost productivity in their practice and receive little or no remuneration. This deficiency must be addressed to achieve a sustainable educational workforce.
Recommendation 5: The federal government should implement a Health Human Resources Infrastructure Fund in the amount of $1 billion over 5 years to expand health professional education and training capacity by providing funding to support the:
* Direct costs of training providers;
* Indirect or infrastructure costs associated with the educational enterprise; and
* Resources that improve Canada's data collection and management capacity in the area of health human resources.
B. Retention of Canadian Physicians
Competition for physicians is both an international and an inter-jurisdictional challenge. The new Agreement on Internal Trade within Canada and numerous bilateral agreements will no doubt ease the movement of health professionals. This may exacerbate the already difficult task of retaining physicians in underserviced areas. On the positive side, it is hoped this will facilitate the movement of physicians who provide short-term relief for physicians needing time off for continued professional development and vacation (i.e., locum tenens).
As the political situation and health care plans evolve south of our border, Canada should remain active in the quest to retain the health professionals we have educated and trained and make it easier for those who have emigrated to return to practice in Canada. The Conservative Party committed in the 2008 election campaign to create a repatriation fund for Canadian physicians practising abroad. The federal government should keep this important commitment.
Migration to the United States peaked in the late 1990s when Canada lost between 600 and 700 physicians per year. While some physicians returned to Canada each year, our net losses for this period were over 400 per year. Today we are enjoying small net gains each year but this may not last given the predicted shortages in the U.S. of between 80,000 and 100,000 physicians in the years ahead. We can expect U.S. recruiters to ramp up activities in Canada in the near future.
Recommendation 6: The federal government should fulfill its election promise to establish a fund of $5 million per year over four years to help Canadian physicians living abroad who wish to relocate to Canada. It is thought this initiative could bring back as many as 300 Canadian physicians over four years.
Recommendation 7: The federal government should establish a Health Professional Repatriation Program in the amount of $30 million over 3 years that would include the following:
* A secretariat within Health Canada that would include a clearinghouse function on issues associated with health care workers returning to practise in Canada.
* An ad campaign in the United States.
* A program of one-time relocation grants for returning health professionals.
Physician Health and Well Being
Ultimately, we hope that healthier physicians will create a more vibrant profession. Hopefully these healthier physicians will in turn create a more healthful professional environment that will support their ability to provide patient care of the highest quality.
Through programs and conferences, the CMA has contributed to growing efforts to reduce the stigma surrounding physician ill-health and to support a new, healthier culture for the profession. Given the myriad other issues that contribute to our doctor shortage, it is clear that Canada cannot afford to lose a single physician to ill health.
Our research shows that the most stressful aspect of the medical profession is being on call after hours. Physicians average 50 hours a week in the usual settings of office, hospital or clinic but then 70% are on call for another 30 hours per week. In small communities, physicians are often on call all the time. A quarter of all physicians face some form of mental health challenge that makes their work difficult. This is higher than the 1 in 5 Canadians that will face a mental illness over their lifetime.ii
The ongoing pressures experienced by overworked physicians can result in stress related disorders and burn-out and are frequently a precursor to more significant physical and mental health problems. If not addressed early, these conditions can lead to physicians taking prolonged periods of time off work, changing their practice patterns or leaving the practice of medicine altogether.
Prevention programs are the key to assisting physicians before they are at significant risk. The CMA visited such a program in Norway which has been shown to significantly reduce burn-out and reduce the subsequent time-off work related to stressiii. A program to enhance physician resiliency and prevent stress related disorders, based on the Norway model, could be expanded to include services for all health professionals. The potential impact would be improved provider health and morale, reduced sick days and fewer long-term leaves.
Recommendation 8: The federal government should invest in research directed at assessing the quality of work life among health workers through an interprofessional survey at a cost of $1.5 million.
Recommendation 9: The federal government should explore the feasibility of developing a 'made in Canada' Resiliency Program for Health Professionals that would include the development of a feasibility study, including a business case, and a pilot curriculum, at a cost of $500,000.
While Canada must do more to increase both our supply and retention of HHR, we must also encourage innovation within our health care system to make better use of our existing health resources. Collaborative models of interprofessional care and advances in information technology hold the promise of helping create a more efficient health care system that provides higher quality care.
Increasingly physicians are working in interprofessional teams that may include professions that are relatively new to Canada's health workforce such as physician assistants (PAs). The CMA accredits PA curricula and has held two conferences to promote the use of PAs in all levels of care.
Recommendation 10: The federal government should fund a study to evaluate the impact of physician assistants on access to health care and to determine their cost effectiveness relative to other providers at cost of $150,000.
Technology to Support Health Care Delivery
Information technology will continue to create a more efficient and effective health care system. It will lead to more patient safety, more Canadians finding a physician, better care, cost avoidance such as eliminating duplicate tests and the establishment of collaborative interprofessional health care teams.
Canada's adoption of electronic medical records lags behind other OECD countries. We only spend a third of the OECD average on information technology in our hospitals. The adoption of EMRs in community settings (primary care, home care and long-term care facilities) also trails most other countries (Figure 2iv). This is not due to any general resistance by providers, but rather a combination of: a lack of evidence on how best to use electronic records to improve care delivery; a need to improve the return on investment for physicians by providing value-added solutions such as greater connectivity to lab results, drug data and colleagues; the time it takes to implement a new electronic record capability and a lack of funds to acquire new technology.
Recent investments in Canada Health Infoway (CHI) will help address some of these issues but it is estimated that for Canada to have a fully automated health care delivery system we need to invest $ 10 to $12 billionv. An overall investment of $2 billion is required to fully IT enable the community-based health care delivery sector. While Budget 2009 provided $500 million to CHI for EMRs, more is still required.
Recommendation 11: The federal government should provide a further investment of $500 million for new technology to fully enable all points of care in the community settings and an enhanced change management program to speed up EMR adoption.
Recommendation 12: The federal government should create a $10-million fund to establish an applied research program for the next five years that will provide evidence on how best to integrate information technology into the health care delivery system.
Canada's doctors believe that we can build a health care system where all Canadians can get timely access to quality health care services regardless of their ability to pay. Developing a comprehensive HHR strategy that assures an adequate supply of all health care providers, including physicians, is a pillar of achieving timely access to high quality care. Building such a system requires that we shift our attitude and move to implement new strategies, new ideas and new thinking. That new thinking must begin with a commitment to act now to address Canada's physician shortage. A promise made must be a promise fulfilled.
i Canada's Health Care Providers 2007, Ottawa: CIHI, 2007
ii Frank E. Canadian physicians healthy - national survey finds. A report from the 2008 International Conference on Physician Health. London, UK Nov 2008.
iii Isaksson Ro, K et al. Counselling for burnout in Norwegian doctors : One year cohort study. BMJ. November 2008. Vol 337, 1146-9.
iv * Count of 14: EMR, EMR access other doctors, outside office, patient; routine use electronic ordering tests, prescriptions, access test results, access hospital records; computer for reminders, Rx alerts, prompt test results; easy to list diagnosis; medications, patients due for care.
v Vision 2015 - Advancing Canada's Next Generation of Healthcare, Canada Health Infoway, 2008
As signs of economic recovery begin to emerge, both in Canada and globally, the Canadian Medical Association is pleased to put forward three recommendations that will initiate a needed transformation of our health care system so that it is truly patient focused and sustainable. Additionally, these measures will create 17,000 jobs and solidify Canada's health care competitive advantage. Although related to the health care sector, these recommendations are within the context of ensuring a prosperous, and sustainable economic, social and environmental future for Canada in the short, medium and long-term. Each of these three recommendations also takes into account the finance committee's questions:
1. What federal tax and program spending measures are needed to ensure prosperity and a sustainable future for Canadians from an economic, social and/or environmental perspective?
2. What federal stimulus measures have been effective and how might relatively ineffective measures be changed to ensure that they have the intended effects?
CMA research demonstrates that it is possible to maintain a universally accessible health care system without long waits for care. In 2007 alone, waiting for care in just four clinical areas cost the Canadian economy $14.8 billion. In particular, two areas require federal attention:
1. ENHANCING PATIENT ACCESS ACROSS THE CONTINUUM OF CARE
Continuing care (ie. long-term care and home care) and prescription drug coverage need urgent attention. Many Canadians do not have access to as wide a range of insured care as citizens in other highly industrialized countries.
Recommendation 1: The federal government should expand the Building Canada Plan to include 'shovel-ready' health facility construction projects including ambulatory, acute and continuing care facilities. Cost: $1.5 billion over 2 years
2. HELPING PROVIDERS HELP PATIENTS
a. Accelerating physician EMR adoption: Both national and international studies confirm that
Canada lags behind nearly every major industrialized country when it comes to health information technology. Accelerating physician EMR adoption will reduce wait times, improve quality, and improve financial accountability especially of federal dollars. Budget 2009 proposed $500 million in additional funding to Canada Health Infoway and a temporary, accelerated capital cost allowance for computer hardware. Transfer of these funds to Infoway is imperative. Together, transferring the funding to Infoway and further improving of the capital cost allowance will ensure these initiatives have the intended effects of improving EMR adoption and stimulating the economy.
b. Boosting Health Human Resources: Canada does not have enough physicians, nurses, technicians or other health care professionals to provide the care patients need. Addressing HHR shortages is critical to ensuring sustainable, accessible, responsive and high-quality health care.
Recommendation 2: The federal government should expand the 2-year time-limited accelerated Capital Cost Allowance for hardware costs related to health information technologies by extending it to five years; removing the 50% half-year rule on related software; and including electronic tools involved in connecting patient records from physician offices to laboratories and hospitals. Cost: $50 million over four years.
Recommendation 3: The federal government should fulfill its 2008 election promise, beginning in 2010, of investing $65 million in health human resources over four years to fund 50 new residencies per year; repatriate Canadian physicians living abroad; and launch pilot projects with nursing organizations to promote recruitment and retention.
1. INTRODUCTION - HEALTHY ECONOMICS: THE FOUNDATION OF FUTURE PROSPERITY
The CMA believes that by being innovative in its actions Canada can sustain a publicly funded, universal health care system. In fact, doing so provides Canadian industry with a significant competitive advantage in the global marketplace. Despite having one of the richest health care programs in the industrialized world (eighth among 28 Organization for Economic Co-operation and Development [OECD] countries), international benchmarking studies consistently report that the Canadian program is not performing as well as it should. The Euro-Canada Health Consumer Index ranked Canada 30th out of 30 countries in terms of value for money spent on health care in both 2008 and 2009.The CMA's recent review of several European health systems illustrates that a sustainable, patient-centred approach to health care is possible on a system-wide level without compromising founding principles such as universality, and without causing financial difficulty for the country or its citizens. However, getting there will require transformational change to refocus our system.
The Canadian Medical Association's 2010 pre-budget submission puts forward three recommendations in the areas of health care infrastructure, health human resources (HHR) and electronic medical records (EMRs).1 These three affordable, strategic initiatives fall within the jurisdiction of the federal government and recognize both the ongoing and promising economic recovery and the current fiscal capacity of the federal government. CMA's recommendations help to chart a course toward a prosperous, and sustainable economic, social and environmental future for Canada in the short, medium and long terms. These proposals will kickstart a transformation of the health care system and create over 17,000 jobs that will ensure a competitive economic foundation for the future.
Based on CMA's research, transforming Canada's health care system to better meet the needs of Canadians hinges on five directions for a reorientation of the system:
1. Building a culture of patient-centred care;
2. Incentives for enhancing access and improving quality of care;
3. Enhancing patient access across the continuum of care;
4. Helping providers help patients;
5. Building accountability/responsibility at all levels.
While each of the five directions is important to reorienting the system, points 3 and 4 are directly relevant to the Finance Committee's deliberations.
2. ENHANCING PATIENT ACCESS ACROSS THE CONTINUUM OF CARE
While all elements of the continuum of care are important, the CMA believes that continuing care (long-term care and home care) and prescription drug coverage need urgent attention. Many Canadians do not have access to as wide a range of insured care as citizens in other highly industrialized countries. In fact, many of these other industrialized countries count access to prescription drugs and home care/long-term care among their basic insured services.
a. Continuing care: Augmenting the Building Canada Plan to include health care infrastructure
Recommendation 1: The federal government should expand the Building Canadai Plan to include 'shovel-ready' health facility construction projects including ambulatory, acute and continuing care facilities. Cost: $1.5 billion over two years
Continuing care in Canada faces three key challenges: capacity and access; informal caregiver support and long-term care funding. At 91%, Canada has the highest hospital occupancy rate in the OECD.ii Roughly 25-30% of hospital acute care beds are occupied by patients who do not require hospital or medical care but rather need 24-hour supervised care. Scarce long-term care facilities and home-care services dictate that patients remain in hospital, delaying hospitals from performing elective surgeries and restricting the movement of other patients from the emergency room to acute care wards. Much of the burden of continuing care falls on informal (unpaid) caregivers who need to be better supported. Statistics Canada reported that in 2007 about 2.7 million Canadians aged 45 and over, or approximately one-fifth of the total in this age group, provided some form of unpaid care to seniors (people 65 years of age or older) who had long-term health problems iiiIt seems unlikely that future requirements for long-term care can be funded on the same "pay-as-you-go" basis as other health expenditures.
The seven-year, $33-billion Building Canada Plan announced in Budget 2007 and augmented in Budget 2009, could better support a smart economic recovery and the health needs of Canadians if it were to be expanded to include health facility construction.iv Federal investment in hospital and health facility construction will create 16,500 jobs over a two-year period and 11,000 jobs in 2010 alone. (Appendix: Table 1).
Although CMA's $1.5 billion recommendation does not eliminate the entire health-facility infrastructure gap in Canada, estimated at over $20 billionv, it does provide additional stimulus aimed at shovel-ready projects. It also better prepares our health system to deal with the needs of an aging population. Federal government investment in health infrastructure has two important precedents - the first in 1948 (Hospital Construction Grants Program) and the second in 1966 (Health Resources Fund Act). Infrastructure funding should be directed toward projects that deliver long-term value and enhance Canadians' lives.
b. Prescription drugs: 3.5 million Canadians underinsured
Prescription drugs represent the fastest growing item in the health budget, and the second largest category of health expenditure. More than 3.5 million Canadians have no prescription drug coverage or are underinsured against high prescription drug costs. In 2006 almost one in 10 (8%) of Canadian households spent more than 3% of their after-tax income on prescription drugs; and almost one in 25 (3.8%) spent more than 5%. It is estimated that less than one-half of prescription drug costs were publicly paid for in 2008. Canada must strive for a program of comprehensive pharmaceutical coverage that is universal and effectively pools risks across individuals and public and private plans throughout Canada.
3. HELPING PROVIDERS HELP PATIENTS
Canada's health care workforce needs more people and more tools to care for Canadians.
a. Accelerating physician EMR adoption
Recommendation 2: The federal government should expand the 2-year, time-limited accelerated Capital Cost Allowance for hardware costs related to health information technologies by extending it to 5-years; removing the 50% half-year rule on related software; and including electronic tools involved in connecting patient records from physician offices to laboratories and hospitals. Cost: $50 million over four years.
Both national and international studies confirm that Canada lags behind nearly every major industrialized country when it comes to health information technology (see Figure 1 and Figure 22). The impact of this underinvestment is longer wait times, reduced quality, and a severe lack of financial accountability, especially of federal dollars.
The Conference Board of Canadavi, the Organization for Economic Co-operation and Development (OECD) vii, the World Health Organizationviii, the Commonwealth Fundix, and the Frontier Centre for Public Policyx all rate Canada's health care system poorly in terms of "value for money" as well as efficiency.
The CMA applauds the temporary 100% Capital Cost Allowance (CCA) rate for computer hardware and systems software acquired after January 27, 2009 and before February 1, 2011 that was proposed in Budget 2009. The measure will provide stimulus by helping businesses to increase or accelerate investment in computers. It will also help boost Canada's productivity through the faster adoption of newer technology. However, for this initiative to provide the greatest benefit, the 100% CCA rate should be extended to five years and expanded to include related EMR software. The benefits of EMR investments are clear. International strategy and technology consulting firm Booz Allen Hamilton found the benefits of an interconnected Electronic Health Record (EHR) in Canada could save the health system $6.1 billionxi a year.
The CMA's recommendation of delivering incentives through the tax system to adopt EMRs is a bottom-up approach that has gained widespread support. John Halamka, the chief information officer at Harvard Medical School, thinks that reformers need to take a bottom-up approach and listen to both doctors and patients. Studies showxiithat most of the benefits of EMRs flow to the payer. Incentives for hardware, software and as importantly the time that it takes to implement these e-systems must be taken into account and incented. The urgency for e-health is being recognized in the United States and needs to be in Canada.
Beyond tax incentives, Budget 2009 also provided Canada Health Infoway (Infoway) with $500 million to support the goal of having 50 % of Canadians with an electronic health record by 2010. As of March 31, 2009, Infoway and its partners had put in place an electronic health record for 17% of the population. Budget 2009 funding will allow Infoway to extend EHRs to 38% of the population by March 31, 2010. xiii This investment will not only enhance the safety, quality and efficiency of the health care system, but will also result in a significant positive contribution to Canada's economy, including the creation of thousands of sustainable, knowledge-based jobs throughout Canadaxiv. Infoway has not yet received this funding and the CMA strongly encourages the federal government to transfer the funds promised in Budget 2009 as soon as possible.
b. Boosting Health Human Resources
Recommendation 3: The federal government should fulfill its 2008 election promisexv, beginning in 2010, of investing $65 million in health human resources over four years to fund 50 new residencies per year; repatriate Canadian physicians living abroad; and launch pilot projects with nursing organizations to promote recruitment and retention.
Canada does not have enough physicians, nurses, technicians or other health care professionals to provide the care patients need. Addressing health workforce shortages is critical to ensuring sustainable, accessible, responsive and high-quality health care across the nation. Canada has suffered from a significant physician shortage since the mid-1990s. Nationally, we rank 26th of 30 OECD member countries in physician-to-population ratio (see Figure 3). The lack of physicians in Canada puts the system under pressure and the impact of this is being felt by patients across the country. Currently, approximately five million Canadians do not have a family physician. In 2008, a study commissioned by the CMA found that the Canadian economy lost $14.8 billion as a result of excessive wait times for just four procedures: joint replacements, MRIs, coronary artery bypass surgery and cataract surgery.
As health care reform plans evolve south of our border, Canada should be proactive in order to retain the health professionals we have educated and trained and make it easier for those who have emigrated to return to practice in Canada. In the 2008 federal election, most parties recognized the urgency of HHR shortages and committed to address the situation. The Conservative Party committed to fund additional medical residency positions, create a repatriation fund for Canadian physicians practising abroad and fund nursing recruitment and retention pilot projects. It is thought this repatriation program could bring back as many as 300 Canadian physicians over four years. The federal government should keep this important commitment. Migration to the United States peaked in the late 1990s when Canada lost between 600 and 700 physicians per year. While some physicians returned to Canada each year, our net losses for this period were over 400 per year. Today we are enjoying small net annual gains but this may not last. With predicted shortages in the U.S. of between 80,000 and 100,000 physicians in the years ahead, we can expect U.S. recruiters to ramp up activities in Canada soon.
The emerging economic recovery offers an excellent opportunity for the federal government to create a more patient-focused and sustainable health care system. Enhancing patient access across the continuum of care by bolstering the Building Canada infrastructure plan and helping providers help patients by enhancing EMR tax incentives and addressing health workforce shortages are important first steps in transforming our health care system. Looking ahead, it will be important to continue to honour the financial transfers of the 2004 Health Care Accord, including the annual 6% escalator, through to 2014. Past cuts to health care funding at all levels have had significant negative effects that continue to be felt to this day. Now is the time to begin thinking ahead to the fiscal needs of the health care system in the post-2014 era.
Appendix Table 1
[For correct dispaly of table information, see PDF]
1 A full schedule of the recommended federal investments as well as their job creation potential is included at the end of the document in the Appendix, Table 1.
2 14 functions are: EMR, EMR access, access other doctors, outside office, patient: routine use, electronic ordering tests, prescriptions, access test results, access hospital records, computer for reminders, Rx alerts, prompt test results; easy to list diagnosis, medications, patients due for care.
i Building Canada Plan., Announced in Budget 2007, the seven-year, $33-billion Building Canada plan consists of a suite of programs to meet the varying needs of infrastructure projects across Canada.
See page 142 of the 2009 Federal Budget. www.budget.gc.ca/2009/pdf/budget-planbugetaire-eng.pdf
ii Hospital Occupancy Rates. Organization for Economic Co-operation and Development [OECD] (2008). OECD Health.
Data 2007. Version 07/18/2007. CD-ROM. Paris: OECD.
iii.Cranswick, Kelly, Donna Dosman. "Eldercare: What we Know Today" Canadian Social Trends.No. 86. Statistics Canada
iv Building Canada Plan, Federal Budget 2009 page 142. .
v This estimate is based on survey work in a forthcoming publication commissioned by the Association of Canadian Academic Healthcare Organizations.
vi How Canada Performs 2008: A Report Card on Canada, The Conference Board of Canada
vii Organization for Economic Co-operation and Development [OECD] (2007). OECD Health
Data 2007. Version 07/18/2007. CD-ROM. Paris: OECD.
viii World Health Organization [WHO] (2007). World Health Statistics 2007. see: http://www.who.
ix Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care May 15, 2007 (updated May 16, 2007)
Authors: Karen Davis, Ph.D., Cathy Schoen, M.S., Stephen C. Schoenbaum, M.D., M.P.H., Michelle M. Doty, Ph.D., M.P.H., Alyssa L. Holmgren, M.P.A., Jennifer L. Kriss, and Katherine K. Shea
Editor(s):Deborah Lorber see: www.commonwealthfund.org/publications/publications_show.htm?doc_id=482678
x Euro-Canada Health Consumer Index 2008, Health Consumer Powerhouse, Frontier Centre for Public Policy, FC Policy Series No. 38 see:www.fcpp.org/pdf/ECHCI2008finalJanuary202008.pdf
xi Booz, Allan, Hamilton Study, Pan-Canadian Electronic Health Record, Canada's Health Infoway's 10-Year Investment Strategy, March 2005-09-06.
xii Although the savings would accrue to different stakeholders, in the long run they should accrue to payers. If we allocate the savings using the current level of spending from the National Health Accounts (kept by the Centers for Medicare and Medicaid Services), Medicare would receive about $23 billion of the potential savings per year, and private payers would receive $31 billion per year. Thus, both have a strong incentive to encourage the adoption of EMR systems. Providers face limited incentives to purchase EMRs because their investment typically translates into revenue losses for them and health care spending savings for payers. From: Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, And Costs, by Richard Hillestad, James Bigelow, Anthony Bower, Federico Girosi, Robin Meili, Richard Scoville and Roger Taylor, Health Affairs, 24, no. 5 (2005): 1103-1117
xiii Corporate Business Plan 2009/2010, Canada Health Infoway, "Anticipated Progress to March 31, 2010" page 7 see:www2.infoway-inforoute.ca/Documents/bp/Business_Plan_2009-2010_en.pdf
xiv Federal Budget 2009 page 152. see: www.budget.gc.ca/2009/pdf/budget-planbugetaire-eng.pdf
xv Health Care Certainty for Canadian Families, the Conservative Party of Canada, backgrounder 10/08/08.
It is my pleasure to address the committee as part of its monitoring of the situation related to the supply of medical isotopes. While I am not an expert in nuclear medicine, I do refer patients for diagnostic and treatment services that require the use of medical isotopes.
First and foremost, I want to note that the CMA is proud of the efforts and dedication of health care providers from across the country who have stepped up to help meet patients' needs during this ongoing, stressful and demanding time.
Through their concerted efforts, and those of the industry and governments, the system appears to be "coping." Patients are receiving needed diagnostic and treatment services, either through radiopharmaceutical models or their alternatives.
However, there are reports of sporadic adverse events, as has been the case since the beginning of this situation. These include delays of 48-72 hours and suboptimal imaging due to the extensive use of thallium-201 rather than technetium-99m, which is in short supply.
The CMA and representatives from the nuclear medical community continue to work with Health Canada to mitigate the impact of the shortage of medical isotopes.
Scheduling appropriate care commensurate with the expected supply of isotopes has been aided by the efforts of Lantheus and Covidien, suppliers of generators and radiopharmaceuticals, who regularly share vital production information with the nuclear medical community. This has improved communications and allowed for the better predictability of supply than had been the case last May and June.
Lest you interpret my comments to mean "all is well", let me be clear: Much is being done, but the current situation is neither optimal nor sustainable and there appears to be no long term plan.
Canada's physicians are concerned about the toll the current shortage of isotopes is taking on the health care system as a whole. In particular, the resulting increased demand on resources - both human and financial - and especially now in the midst of a pandemic, is not sustainable.
Therefore, we have called upon governments to invest in a five-year action plan, that includes an emergency fund, to increase the use of positron emission technology and the production of associated radiopharmaceuticals across Canada.
At our annual meeting this August, Canada's physicians expressed their concerns by passing a series of motions calling for government action. This action included demands that the federal government:
* retain Canada's leadership and ability to produce and export medical isotopes, and reconsider its decision to withdraw from their production;
* appoint an international independent expert panel to assess thoroughly the decision to abandon the MAPLE I & II nuclear reactors at Chalk River: and
* release promptly the conclusions and recommendations of the panel to the public.
Our delegates also demanded that the federal government conduct open, meaningful and ongoing consultations with nuclear medicine physicians and their respective national associations on any and all federal decisions directly affecting the supply of medical isotopes. Concern was expressed that decisions have been, and will continue to be, made for political and financial expediency without taking into account medical ramifications of those decisions.
We appreciated having the opportunity to participate in discussions with the Expert Review Panel on Medical Isotope appointed by the Minister of Natural Resources. While it is anticipated the panel will report to the Minister by the end of this month, we do not know when that report will be made public and how long it will take to move recommendations to action.
Canadian physicians also urge the federal government to invest immediately in research in basic and clinical science to find viable alternative solutions to the production and use of technetium-99m. The announcement of $6 million for research into alternatives to medical isotopes through a partnership between the Canadian Institutes of Health Research (CIHR) and the Natural Sciences and Engineering Research Council of Canada (NSERC) is a good start. We must emphasize that bench to bedside research is critical - there must be a clinical translation of new technology to the provision of care.
To conclude, the CMA remains concerned about health care providers' and the health care system's ability to sustain the current shortage; Canada's ability to ensure a long-term stable and predictable supply of medically necessary isotopes and our lack of contingency planning for the next shortage.
The CMA will continue to work with all involved to ensure Canadians have access to the best possible care and treatment.
Canadians are deeply concerned about their health care system. They worry about situations such as whether they will have access to diagnostic testing when they need it or whether they can get a family physician if they move to a new community. This is not what was envisioned when Canada embarked upon a universal public health care system in 1966. Over the past two years an unprecedented number of reports and commissions have been examining what can and must be done to ensure the long-term sustainability of the system. But Canadians are growing inpatient. The time for studying the issues is quickly passing. They are counting on governments, to listen to the reports and then act upon them quickly – turning the corner from debate to action.
This year’s submission from the CMA to the Standing Committee on Finance focuses on the need for action in the short and longer terms by identifying strategic investments that will ensure a strong health care system that is securely supported by a dependable and comprehensive public health infrastructure as its foundation. Hand in hand with new financing, the CMA firmly believes that additional financing must be accompanied by updated governance structures, including a Canadian Health Charter and a Canadian Health Commission that can inject real accountability into the system.
The CMA believes that the federal government has responsibility, alongside the provinces and territories, to increase its financial support of Canada’s health care system. Only by increasing funding and identifying clearly the amount allocated to health will the federal government be able to regain its position as an equal player with the provinces.
In our submission to the Commission on the Future of Health Care in Canada, the CMA recommended that the federal contribution to the public health care system be locked in for a 5-year period. We indicated that the longer-term goal would be for the federal contribution to rise to 50% of total spending for core services over time as new and improved services and technologies products became available. We also said that it should be tied to a built-in GDP-growth escalator once that target is reached. To be specific, in order to raise funding to the 50% target level the CMA recommends that funding for new services and technologies be introduced on a 50/50 cost-sharing basis. This would encourage provinces and territories to become early adopters of new technology and help to update the basket of core services available to Canadians.
For illustration purposes the CMA recommends an initial investment of $16 billion over the first five years starting in 2003/04 with the majority of that funding weighted towards the back-end of the five-year period. This investment would take us partway (45 federal/55 provincial cost sharing) towards reaching our goal of 50/50 cost sharing.
To further support funding for health care across the country, a buffer is needed to protect provincial and territorial health care budgets from the ebbs and flows of the economic cycle. This could be done, for example, by renewing the Fiscal Stabilisation Program or removing the cap on the current Equalisation program.
In conjunction with the longer-term financing needs of Canada’s health care system, there are some urgent objectives that cannot wait for governments to finalise and implement their plan.
The pressing nature of these issues warrants the use of one-time, targeted, special-purpose transfers in the areas of health human resources supply and training; capital infrastructure; and health information technology.
Finally, last year, our submission reflected Canadians’ concerns following the September 11, 2001 events in the United States. It highlighted people’s anxiety about security in our country, the safety of our airlines and the vulnerability of our public health infrastructure and health care systems to potential threats. We believe that this work has not been completed and there is ongoing need to support public health as a priority for Canada’s health care system particularly in the areas of emergency preparedness, childhood immunisation and a national drug strategy.
Reform of Canada’s health care system is a formidable task. It involves the participation and agreement of all levels of government as well as providers, other stakeholders and ultimately the acceptance of the end-users, Canadians. The CMA looks forward eagerly to the Romanow Commission’s recommendations and those of the Senate Committee. We will be watching carefully over the coming months on behalf of Canadian physicians, and our patients, to ensure that these discussions result in a timely, action-oriented response and that involvement of the community of providers is early, ongoing and meaningful. Canadian physicians are ready to do our part, all we ask is for the opportunity.
The Canadian Medical Association (CMA) values participating once again in the Standing Committee on Finance’s Pre-Budget Consultations process. We see these consultations as an essential part of Canada’s democratic process, allowing non-government organisations and individuals the opportunity to provide input into the government’s fiscal agenda.
We know Canadians value their health care system and the high-quality treatment they receive. What concerns them is whether they’ll be able to access the care they need when and where they need it. The past two years have seen the most significant public concern over Canada’s health care system in a generation. Governments have responded by examining the system through an unprecedented number of reports and commissions. In addition to the Commission on the Future of Health Care in Canada (the Romanow Commission) and the Standing Senate Committee on Social Affairs, Science and Technology’s work on the state of the health care system (the Kirby Commission), since 2000 there have been four other major provincial reviews of health care systems in Canada.i
Canadians are now looking to governments to turn the corner from studying what needs to be done to acting upon this work. This year’s submission from the CMA to the Standing Committee on Finance focuses on this need for action in the short and longer terms by identifying strategic investments that will ensure a strong health care system that is securely supported by a dependable and comprehensive public health infrastructure as its foundation. In this way, it is the belief of the CMA that health and health care go hand in hand.
The CMA believes that to achieve real reform, more than “tweaking” of our current system is required. We see change as requiring a fundamental rethinking of the system including its governance and accountability structures in order to move forward and turn the corner towards a sustainable health care system. The momentum created with the release of the Romanow Commission’s report provides a unique opportunity for the federal government, in partnership with the provinces and territories, to capitalise on that energy by responding in a substantive way to the report within 100 days of its release with an implementation plan.
We were very encouraged by the commitment made in the September 30, 2002 Speech from the Throne to hold a First Ministers’ Meeting early in 2003 to put in place a comprehensive plan for reform. We were also encouraged by the commitment to an action plan in the areas of health policy under direct federal jurisdiction such as addressing emerging health risks and the adoption of modern technology.
We will be watching carefully over the coming months on behalf of Canadian physicians, and our patients, to ensure that these discussions result in a timely, action-oriented response and that involvement of the community of providers is early, ongoing and meaningful.
On June 6, 2002, the CMA released its final submission to the Romanow Commission, A Prescription for Sustainability. In this submission, we outlined what the Commissioner called “bold and intriguing” changes to reaffirm and realign our health care system. Specifically, the CMA report laid out an approach for the renewal of Canada’s health care system comprised of three essential interrelated components: a Canadian Health Charter; a Canadian Health Commission; and renewal of the federal legislative framework (including federal-provincial fiscal transfers).
Canada’s health care system does not have the governance structures in place to provide for real accountability or transparency. Often governments meet behind closed doors and make decisions with little or no input from those who ultimately have to implement change and use the system. Rather, full accountability requires the involvement of all key players – federal and provincial/territorial governments, health care providers and patients.
Fundamentally, the current lack of accountability in Canada’s health care system comes down to an inherent conflict of interest between public accountability, which Canadians are demanding, and governments’ desire to retain maximum fiscal control and flexibility. Even with increased cash transfers identified in the September 2000 First Ministers Accord, the federal government has fallen well short of providing the necessary funding to ensure compliance with national principles today and for the future. Clearly, the financial means must be equal to the desired health outcomes. The CMA believes that with appropriate financial reinvestment and updated governance structures the federal government will be on the path towards putting national back into national heath care insurance system.
Canadian Health Charter
Currently, neither the Canada Health Act nor the Charter of Rights and Freedoms offers Canadians an explicit right of access to quality health care delivered within an acceptable time frame.ii Increasingly, this has resulted in an unacceptable degree of uncertainty not only for patients but also for health care providers and ultimately for those (both private and public) who contribute to the financing of the health care system.
A Canadian Health Charter would underline governments’ shared commitment to ensuring that Canadians have access to quality health care within an acceptable time frame. It would clearly articulate a national health policy that sets out our collective understanding of Medicare and the rights and mutual obligations of individual Canadians, health care providers, and governments.
Canadian Health Commission
Creating a permanent, independent Canadian Health Commission, would help address the lack of transparency and accountability at the national level. It would create an institution, the very purpose of which would be to report annually to Canadians on the performance of the health care system and the health status of the population. It would put health on the same level as other national priorities such as the environment, transportation and research. Its legitimacy would be strengthened by not having to report to any one government or governments. Rather it would forge a direct reporting relationship with Canadians and not leave Canadians hostage to ongoing inter-governmental disputes.
A Canadian Health Commission would also be uniquely situated to provide ongoing advice and guidance on other key national health care issues. Issues such as: defining the basket of core services that would be publicly financed; establishing national benchmarks for timeliness; accessibility and quality of health care; planning and coordinating health system resources at the national level; and developing national goals and targets to improve the health of Canadians.
* Implement a Canadian Health Charter and provide federal funding for a permanent Canadian Health Commission to reaffirm Medicare’s social contract and to promote accountability and transparency within the health care system.
Improved accountability is an essential, but not complete, answer with respect to reforming Canada’s health care system. The CMA believes that the federal government has a responsibility, alongside the provinces and territories, to increase its financial support of Canada’s health care system. At the same time, the CMA also believes that governments must provide financing in an accountable and transparent manner that links the funding sources with the use of those funds.
The way we see it, much of the current tension between the two levels of government on health care issues can be traced back to unilateral federal changes to the funding formula. It started with the first changes to the Established Programs Financing (EPF) in 1982, and culminated with the introduction of the Canada Health and Social Transfer (CHST – 1995) when the federal government unilaterally announced substantially reduced funding for health, social services and post-secondary education. By claiming to spend the same taxpayers dollar three times – once for health, again for post secondary education and again for social services – the federal government’s moral authority to uphold national principles for health is undermined.
Together, these initiatives weaken the federal government’s legitimacy in health care and encumber its ability to stand-up for Canadians, as was highlighted in the most recent Auditor General’s report.
In order to regain this authority the federal government must be willing to clearly identify a discrete contribution to health care that is large enough so as to be relevant in all jurisdictions. In our submission to the Commission on the Future of Health Care in Canada, we recommended that the federal contribution to the public health care system be locked in for a 5-year period. We indicated that the longer-term goal would be for the federal contribution to rise to 50% of total spending for core services over time as new and improved services and technologies became available. We also said that it should be tied to a built-in GDP-growth escalator once that target is reached.
This submission provides more detailed financial projections and recommendations on the federal contribution to the health care system. To be specific, in order to raise funding to the 50% target level the CMA recommends that financing of new services and technologies be introduced on a 50/50 cost-sharing basis. This would encourage provinces and territories to become early adopters of new technology and help to update the basket of core services available to Canadians. How quickly 50% cost-sharing of all core services were realised would depend on the rate of uptake of new technologies. However, for illustration purposes the CMA recommends an initial investment of $16 billion over the first five years starting in 2003/04 with the majority of that funding weighted towards the back-end of the five-year period. This investment would take us partway (45 federal/55 provincial cost sharing) towards reaching our goal of 50/50 cost sharing. The expectation would also be that expansion beyond the current basket of services would be funded on a 50/50 cost-sharing basis.
The key message is that the federal government must be an equal partner with the provinces and territories in providing funding for new pressures. This includes taking measures to meet the needs of Canadians living in rural and remote areas where there are unique considerations with respect to ensuring access to, and support of, physicians and other health care services.
To further support funding for health care across the country, a buffer is needed to protect provincial and territorial health care budgets from the ebbs and flows of the economic cycle. As well, varying fiscal capacities of individual provinces and territories has made it increasingly difficult to ensure the provision of reasonably comparable health services across Canada.
Currently, the federal Fiscal Stabilisation Program compensates provinces if their revenues fall substantially from one year to the next due to changes in economic circumstances. However, this program is not health-specific and only takes effect when provincial revenues drop by over 5%. The federal Equalisation program also provides some protection for have-not provinces. However, its effectiveness is limited by virtue of the “ceiling provision” that places a cap on increases in payments to the rate of national GDP growth. This provision was temporarily lifted for fiscal year 1999/2000 in conjunction with the September 2000 health accord, generating an additional $700 million in Equalisation payments to the have-not provinces.
It is the CMA’s belief that this ceiling is one of the contributing factors to the disparity that exists between provinces in their capacity to provide funding for health care services and as such, should be permanently removed.
Making improvements to either or both of these programs would help address the concern raised in the CMA’s submission to the Romanow Commission on the need to provide provinces with ways to curb the impact on the health care system from the ebbs and flows of the business cycle.
LONG-TERM FINANCING REQUIREMENTS ($16 Billion over 5 years)
* Provide funding for new core services and technologies on a 50/50 cost-shared basis with the ultimate goal of reaching 50% of provincial/territorial spending on core services over time.
* Provide greater protection against provincial/territorial revenue shortfalls for example by removing the ceiling on the federal Equalisation program or enhancing the federal Fiscal Stabilisation Program.
Short-Term Bridge Financing of Health Infrastructure
In conjunction with the longer-term financing needs of Canada’s health care system, there are some urgent objectives that cannot wait for governments to finalise and implement their plan. We think of these shorter-term objectives as requiring “bridge financing” in areas of health infrastructure that are necessary to support health care innovation.
As roads and highways are the backbone to the production and delivery of products, so too is Canada’s health infrastructure the foundation on which the health care system delivers care to Canadians. We applaud the Canadian Foundation for Innovation and other similar programs for their important contributions in this area. Increasingly, however, “infrastructure” incorporates more than bricks and mortar – it can also mean providing improving health information capacity in hospitals; providing human resource infrastructure or the latest diagnostic equipment. Experience has taught us that investments of this type lead to increased innovation, productivity and efficiency.
The pressing nature of these issues warrants the use of one-time, targeted, special-purpose transfersiii specifically in the areas of:
* Health human resources supply and training;
* Capital infrastructure; and
* Health information technology.
Health Human Resources Supply and Training
Consistently, Canadians point to the shortage of physicians as a key health care system concern. Factors underlying this shortage include physician demographics (e.g., age and gender distribution), changing lifestyle choices and productivity levels (expectations of younger physicians and women differ from those of older generations), and insufficient numbers entering certain medical fields. According to 2001 data from the Organisation for Economic Co-operation and Development (OECD), Canada ranked 21st out of 26 countries in terms of the ratio of practising physicians to population.iv
The need is particularly great in rural and remote areas where 30% of Canadians live but where only approximately 10% of Canadian physicians practice.v This is complicated by the fact that accessing services for patients in rural and remote areas can be difficult. In a survey done by the CMA in 1999, physicians living in rural communities indicated that their level of professional satisfaction – i.e., how they are able to meet the health care needs of their patients – fell significantly since the early 1990s. In a striking example, only 17% reported being very satisfied with the availability of hospital services in 1999 compared to 40% in 1991.
The necessary increases in undergraduate enrolment in medicine needed to address this situation require funding not only for the positions themselves, but also for the infrastructure (human and physical resources) needed to ensure high-quality training that meets North American accreditation standards. In addition, capacity must be sufficient to provide training to international medical graduates and allow currently practising physicians the opportunity to return to school to obtain postgraduate training in new skill areas.vi
As well, the CMA remains very concerned about high and rapidly escalating increases in medical school tuition fees across Canada. According to data from the Association of Canadian Medical Colleges (ACMC), between 1996 and 2001 average first-year medical school tuition fees increased 100%. In Ontario, they went up by 223% over the same period. Student financial support through loans and scholarships has simply not kept pace with this rapid escalation in tuition fees.
Findings from recent research show that high tuition fees and fear of high debt loads create barriers that discourage people to apply to medical school and potentially threaten the socio-economic diversity of future physicians serving the public. They may also exacerbate the “brain drain” of physicians to the United States where newly graduated physicians can pay down their large student debts much more quickly. In addition, high debt loads may influence physicians’ choice of specialty and practice location.
Medical Equipment and other Capital Infrastructure
The crisis in health human resources is exacerbated by an underdeveloped capital infrastructure - brick, mortar and tools. This is seriously jeopardising timely access to quality care within the health care system.
In September 2000, the federal government announced a series of new investments to support agreements by First Ministers on Health Renewal and Early Childhood Development. One of these investments was a two-year $1 billion fund for the provinces and territories, the Medical Equipment Fund (MEF), to purchase new health technologies and diagnostic equipment. However, analysis done by the CMA suggests that of the $1 billion allocated through the Medical Equipment Fund, only approximately 60% was used to pay for new (incremental) expenditures on medical equipment. It appears the remaining 40% replaced what provinces and territories would have already spent in this area from their own funding sources.
Additional analysis suggests that there continues to be a significant gap between access in Canada to medical equipment and availability of medical equipment in other OECD countries. Cost estimates suggest that an additional investment of some $1.15 billion in health technology is still needed to bring Canada up to the level of the 7-country OECD comparator country average. Of that amount $650 million is required for capital expenditures and $500 million is required to provide the provinces/territories with 3 years of operating funds.
All governments have the responsibility to be transparent and accountable to taxpayers for health care spending. The conditions of the Medical Equipment Fund did not live up to this responsibility. Provinces and territories provided widely variable and often incomplete information that is largely inaccessible to the public, and at the very least difficult to trace. To this end, one of the responsibilities envisioned for a Canadian Health Commission would be to report on the health of health care in Canada and keep Canadians informed as to how their taxpayer dollars are being spent.
Health Information Technology
While the health sector is as information intensive as other industries, it has lagged behind other sectors in investing in information and communication technologies (ICTs). The benefits that ICT promises to deliver the health care system include better quality care, enhanced access to health services (particularly for those 30% of Canadians living in rural and remote locations), and better utilisation of scarce human health resources.
As part of the September 2000 Health Accord, the federal government invested $500 million to create Canada Health Infoway Inc. with a mandate to accelerate the development and adoption of modern systems of information technology, such as electronic patient records. The CMA applauds this investment, but notes that the $500-million needs to be seen as a “down-payment”. It provides only a fraction of the $4.1 billion the CMA estimates it would cost to fully connect the Canadian health care system with all the health benefits that would flow from this in terms of improved national safety and a reduced number of duplicate tests.
Studies point to two key ingredients for successful uptake of information and communication technology: creating mechanisms to help people adapt to the new environment and testing out solutions in real work situations before moving to full-scale implementation. To date, very little investment has been directed towards helping providers prepare for new investments in infrastructure being made by the provinces, territories and the federal government.
The CMA is prepared to play a pivotal partnership role in achieving the buy-in and cooperation of physicians and other health care providers through a multi-stakeholder process.
As well, currently the majority of ICT investments have targeted acute care and primary care settings. Changing demographics in the Canadian population suggest that new pressures are likely to emerge in home care settings – an area that has hitherto been largely neglected with respect to ICT and is currently ill equipped to cope with growing demand. A potential safety valve that could be made available, however, is the application of remote healthcare solutions amenable to care provided in the home.
SHORT-TERM BRIDGE FINANCING ($2.5B over five years)
* Establish a $1-billion, five-year Health Resources Education and Training Fund.
* Increase targeted funding to post-secondary institutions to alleviate some of the pressures driving the rise in tuition fees. Provide enhanced direct financial support to students, in particular, through bursaries and scholarships.
* Establish a one-time catch-up fund of $1.15 billion to restore medical equipment to an acceptable level.
* Assist providers to improve and/or gain skill sets to work to become more ICT enabled and provide for aggressive piloting of remote ICT solutions.
The proposals as outlined above for the overall financing of the health care system recommend an incremental approach to increased federal support for health care with the more significant investments not beginning until after 2005/06. We feel that this approach would allow for the majority of funds to come from within existing (or anticipated) fiscal frameworks.
Within the context of broader discussion, the CMA brought together key experts on September 25, 2002 to discuss issues related to the interface between tax and health. One of the issues discussed was the potential for using earmarked taxes as a mechanism for raising revenue, particularly for short-term capital-type investments. With respect to any new funding mechanism, there was agreement on the need to take into account the principles of fairness, progressivity and horizontal and vertical equity in determining any new source of funding for health care services.
While some suggest that efficiencies remain in the system, that if eliminated could provide funding for future health care needs, this is not the view of CMA members working on the front-line of the health care system. CMA’s challenge to governments is to not allow the lack of a revenue source to provide an excuse for not proceeding with health care reform in Canada. The CMA is looking forward to the recommendations in the Kirby and Romanow reports to further inform work in this area.
INVESTMENTS IN PUBLIC HEALTH
In essence, public health is the organised response by society to protect and promote health and to prevent illness, injury and disability. These efforts require co-ordination and co-operation between individuals, federal, provincial, territorial, and municipal governments, community organisations and the private sector. A major component of public health is focused on the promotion of healthy living to improve the health status of the population and reduce the burden and impact of chronic and infectious diseases. A recent commitment of $4.3 billion in the U.S. for the Centers for Disease Control and Prevention challenges us to equally support activities that further strengthen Canada’s public health system.vii
The September 30, 2002 Speech from the Throne noted the importance of a strong public health system and promised to “move ahead with an action plan in health policy areas under its direct responsibility” including addressing emerging risks, adapting to modern technology and emphasizing health prevention activities. We see this as an important commitment and will be watching closely as the plan is developed. In the meantime, we have identified three areas of public health that require more immediate federal assistance.
Last year our submission to the Standing Committee addressed the urgent health security and health care issues arising out of the tragic events of September 11, 2001 in the United States. The CMA raised serious concerns with the ability of Canada’s public health care system to respond to disasters and made a number of recommendations to address national preparedness in terms of security, health and capacity of the system. While there has been some movement towards meeting these needs, the CMA firmly believes that there remain significant shortcomings in our capacity to respond to health care emergencies.
At the time of an emergency, among the first points of contact with the health system for Canadians are doctors’ offices and hospital emergency rooms. As noted in past CMA submissions to the Standing Committee, we have witnessed in recent years the enormous strain these facilities can face when even something quite routine like influenza strikes a community.
Regardless of how well prepared any municipality is, under certain circumstances public health officials will need to turn to the province, territory and/or the federal government for help. The success of such a multi-jurisdictional approach is contingent upon good planning beforehand between the federal, provincial/territorial and local-level governments. There is an important role for the federal government to urgently improve the co-ordination amongst authorities and reduce the variability between various response plans in co-operation with provincial authorities (including assisting in the preparation of plans where none exist).
At the beginning of the last century, infectious diseases were the leading cause of death worldwide. In Canada, they are now responsible for less than 5% of all deaths thanks to immunisation programs. Immunisation protects an entire population by preventing the spread of disease from one individual to another: the more people immunised, the less chance of disease. To minimise the spread of vaccine-preventable diseases the maintenance of very high levels of immunisation is required. The National Advisory Committee on Immunisation (NACI) has provided general Canadian recommendations on the use of vaccines, drawing upon the expertise of specialists in public health, infectious diseases and paediatrics from across the country.
Canadian children in all provinces are routinely immunised against nine diseases. For approximately $150 worth of vaccines, a Canadian child can be vaccinated against these diseases from infancy to adolescence, the impact of which can last a lifetime. Unfortunately, the level of immunisation varies across Canada. This is unacceptable. All children in Canada should and must have the protection that current science has made available against vaccine-preventable diseases according to the recommendations of public health experts.
The CMA recommends a two-step strategy. First we encourage the federal government to work with the provinces and territories to jointly develop goals in the area of vaccination, such as linking record-keeping systems, implementing vaccine safety guidelines and seeking purchasing partnerships. Second, we urge the federal government to work within this framework to ensure that three new vaccines be introduced across the country to prevent children from contracting varicella (chicken pox); meningitis and pneumococcus (the leading cause of invasive bacterial infections, bacterial pneumonia and middle ear infection in children).
National Drug Strategy
The development of a national strategy for addressing issues related to illicit drug use should be a priority for federal leadership and investment. Illicit drug use has adverse effects on the personal health of Canadians and the well-being of society. The CMA believes that the government must take a broad public-health policy approach to address illicit drug use.
A single-handed criminal justice approach to dealing with illicit drug use is inappropriate particularly when there is increasing consensus that it is ineffective and exacerbates harm. Addiction should be regarded as a disease and therefore, individuals suffering with drug dependency should be diverted, whenever possible, from the criminal justice system to treatment and rehabilitation.
We applaud the recent commitment in the September 30, 2002 Speech from the Throne to implement a national drug strategy to address addiction while promoting public safety. In keeping with this, the CMA urges the government to fully implement and evaluate a national drug strategy prior to proceeding with any movement toward changes in the legal status of marijuana.
INVESTMENTS IN PUBLIC HEALTH ($700 million over three years)
* Create an assistance fund for municipal and provincial authorities to support public health infrastructure renewal at a local level, improve the co-ordination among public health officials, police, fire and ambulance services, hospitals and other services and to support the infrastructure for public health emergency response.
* Continue to invest in the resources and infrastructure (i.e., medical supplies, equipment, laboratory facilities, and training for health care professionals) needed to anticipate and respond to disasters.
* Implement a National Immunisation Strategy to achieve the optimal level of immunisation for all Canadians and ensure coverage of all children with routinely recommended childhood vaccines.
* Develop a comprehensive national drug strategy on the non-medical use of drugs that re-balances the distribution of resources so that a greater proportion is allocated to drug treatment, prevention, cessation and harm reduction.
Reform of Canada’s health care system is a formidable task. It involves the participation and agreement of all levels of government. It also requires that providers, other stakeholders and ultimately the acceptance of the end-user, Canadians are at the planning table. The Commission on the Future of Health Care in Canada, over the past year and a half, has undertaken a vast review of the issues impacting Canada’s health care system including Canadians’ values. As providers of care at the front-line of the health care system, Canadian physicians see themselves as key partners in this reform.
The CMA will be looking eagerly at the Romanow Commission’s recommendations and those of the Senate Committee. We will be holding the federal, provincial and territorial governments accountable for implementing, in a timely fashion, a response with clear deliverables. Clearly, we see the report’s release as offering a short window of opportunity to turn the corner on health care system reform. We need to act now and not just wait for the system to fix itself. Canadian physicians are ready to do our part, all we ask is for the opportunity.
i Since 2000 there have been four major provincial reviews of their health care systems (Caring for Medicare: Sustaining a Quality System (the Fyke Commission), April 2001; la commission d’étude sur les services de santé et les services sociaux (the Clair Commission); Patients First: Renewal and Reform of British Columbia’s Health Care System, December 2001; A Framework for Reform: Report of the Premier’s Advisory Council on Health (the Mazankowski Report), January, 2002.
ii A recent article by Patrick Monahan and Stanley Hartt published by the C.D. Howe Institute argues that Canadians have a constitutional right to access privately-funded health care if the publicly funded system does not provide access to care in a timely way.
iii Precedents for these types of transfers include the National Health Grants Program created in 1948 to develop hospital infrastructure across the country. More recently, several funds were created to support early child development, medical equipment, the health infoway and primary care renewal at the time of the First Ministers’ Agreement on Health in September 2000.
iv Organisation for Economic Cooperation and Development. Health at a Glance. Paris, France: OECD; 2001.
v The CMA has developed a policy on Rural and Remove Practice Issues which was released on October 17, 2000 (CMAJ, October 17, 2000, Vol. 163 (8)).
vi Canadian Medical Forum membership includes: CMA, Association of Canadian Medical Colleges, College of Family Physicians of Canada, Royal College of Physicians and Surgeons of Canada, Canadian Federation of Medical Students, Canadian Association of Interns and Residents, Federation of Medical Licensing Authorities of Canada, Medical Council of Canada, and Association of Canadian Academic Healthcare Organizations.
vii As announced on December 20, 2001 by the United States Department of Health and Human Services. Copy available at: http://www.hhs.gov/news
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.
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.
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.
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.
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.
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.
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
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APPENDIX 2: ESTIMATED COST OF IMPLEMENTING THE RECOMMENDATIONS
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Estimated cost over 5 years
Legislative and institutional reform
1. Canada Emergency Health Measures Act
2. Canadian Office for Disease Surveillance and Control (CODSC)
3. Chief Public Health Officer of Canada
4. Canadian Centre of Excellence for Public Health
5. Canadian Public Health Emergency Response Service
6. Canadian Institute for Health Information and Statistics Canada
7. Surge capacity
Research, surveillance and communications
8. Canadian Institutes of Health Research
9. Mandatory reporting
Included under 2 and 3 above
10. Enhanced reporting
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 3: CHRONOLOGY OF THE CMA’S RESPONSE TO SARS
* First known case of atypical pneumonia (SARS) occurs in Guangdong province, China
* World Health Organization (WHO) receives reports from the Chinese Ministry of Health about SARS; 305 persons affected and 5 deaths
* Canadian index case arrives in Hong Kong for a family visit
* Canadian index case is a guest at the Metropole hotel in Kowloon
* 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
* Canadian index case returns home to Toronto
* Canadian index patient dies in Toronto, 9 days after the onset of her illness
* WHO issues global alert about SARS
* 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
* First reports from Toronto about deaths from SARS
* 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
* 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
* CMA alerts all its divisions and affiliates to the Health Canada and CMA SARS web pages
* eCMAJ includes SARS updates on its website
* 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
* 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
* 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
* CMA holds teleconference with divisional communication directors re: SARS
* 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
* 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
* CMA hosts second teleconference among national health care organizations to discuss SARS developments
* Electronic grand rounds on SARS updated and promoted through cma.ca
* CMA sends email to membership requesting volunteers for the CMA Volunteer Emergency SARS Relief Network
* CMA consults with the American Medical Association regarding the possibility of US physicians volunteering for the relief network
* 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
* Health Canada announces the National Advisory Group on SARS and Public Health, headed by Dr. David Naylor
* Opinion editorial by Dr. Dana Hanson, CMA president, on SARS and public health surge capacity published in The Ottawa Citizen;
* CMA organizes a meeting of national health care organizations to discuss lessons learned from SARS
* CMA receives an invitation to submit a brief to the National Advisory Group on SARS and Public Health
* 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
* 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
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Health alert may be declared in:
* 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
Chief public health officer takes the lead in coordinating the response
Regulation or prohibition of travel
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
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
Lead response team
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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.
It has been over three years since the Social Union Framework Agreement (SUFA) was signed by the federal and provincial/territorial governments, with the exception of Quebec. At the time, it was heralded as an important breakthrough in federal-provincial relations that would clear the way for greater intergovernmental cooperation on pressing social policy issues such as health care renewal.
Functional federalism is essential to achieving social policy objectives that will be of benefit to Canadians from coast to coast. While SUFA may not be perfect, it is better than the alternative of federal-provincial paralysis and dysfunction. And as SUFA acknowledges, Canada’s social union is about more that how governments relate to each other: it is about how governments can and should work with external stakeholders and individual Canadians to improve the social policies and programs.
The health sector is an important test case for SUFA. It is the most cherished of Canada’s social programs. Canadians want and expect their governments to work together to improve the health care system and ensure its future sustainability. Ironically, it is also the area where government intergovernmental discord has been the greatest. On the eve of the final report of the Commission on the Future of Health Care in Canada, it is timely to reflect on SUFA and its role in the renewal of Canada’s health system.
SUFA and the Health Sector – Strengths and Weaknesses
The attached table provides a summary of the key elements of SUFA and the CMA’s assessment of how well SUFA provisions have been applied in the health sector.
On the positive side, the health sector has fared relatively well in the area of mobility within Canada. Physicians and other regulated health care providers generally enjoy a high degree of mobility. Portability of hospital and medical benefits is largely ensured through interprovincial eligibility and portability agreements. There are, however, two areas of concern. First, there is the longstanding failure to resolve the non-portability of medical benefits for Quebec residents. Second, there is growing disparity in coverage for services that are currently not subject to national standards under the Canada Health Act, particularly prescription drugs and home care.
In the area of dispute avoidance and resolution, governments have agreed to a formal process to address concerns with the Canada Health Act. This is a positive step, though few details have been made public. The real test will be whether this new process accelerates the resolution of non-compliance issues (most of which, as the Auditor-General recently pointed out, have remained unresolved for five years or longer), and whether the federal government will have the political will to levy discretionary penalties for non-compliance.
There has also been progress on public accountability and transparency as governments have begun reporting results in 14 health indicator areas pursuant to the September 2000 health accord. The CMA is disappointed, however, that governments did not fulfil their pledge to involve stakeholders at all levels in the development of these indicators. Moreover, governments have short-changed Canadians by not providing them with a national roll-up of indicators that would facilitate comparisons across jurisdictions. Looking to the future, it will be critical to put in place a process that moves from benchmarks (indicators) to the bedside (best practices, better outcomes). This must be done in collaboration with health care researchers, providers and health managers—those individuals who understand the importance of taking research and importing it into practice. Clinical researchers across the country are doing this work and must to be supported.
Overshadowing these relative successes in the first three years of the Social Union Framework Agreement are three key challenges that must be addressed:
* inadequate institutional mechanisms to improve accountability across the system
* failure to reduce uncertainty about what the health system will deliver, now and into the future
* resistance on the part of governments to engage stakeholders in a true partnership for health system renewal
The CMA is concerned that if these fundamental weaknesses are not addressed, they will undermine future attempts to renew Canada’s health system.
With the adoption of SUFA, governments have significantly increased emphasis on performance measurement and public reporting. While this is a positive development, it also has the potential to lead towards information overload and paralysis, unless two critical elements are addressed. First, there is a need for a clear accountability framework that sets out the roles, rights and responsibilities of all key players in Canada’s health system: patients, health care providers and governments. This, in turn, requires the creation of a credible arm’s length institution to monitor compliance with this framework and rise above the fray to give Canadians the straight goods on health care. One has to look no further that the recent rekindling of the so-called “shares debate” between the federal and provincial governments as an example of why these changes are necessary.
Over the past decade, Canada’s health system has been plagued by an escalating crisis of uncertainty. Patients have faced increasing uncertainty about the accessibility and timeliness of essential health care services. Health care providers have seen working conditions deteriorate. Employers and private insurers have seen their contribution to funding health services increase unpredictably as governments have scaled back their funding commitments. Furthermore, provincial and territorial governments have had to contend with an unstable federal funding partner.
Canadians deserve better. They need more certainty that their public health system will care for them when they need it most. They need more transparency from governments about “what’s in” and “what’s out” in terms of public or private coverage. They need their governments to act on their SUFA undertaking to make service commitments for social programs publicly available such as establishing standards for acceptable waiting times for health care. And they need governments to follow through with their SUFA commitment to ensure stable and adequate funding for the health system and other social programs.
Fostering real partnerships
In the health care field, deliberations and agreements have taken place behind closed doors and governments have discounted the role that non-governmental organizations and citizens should play in decision-making. It is these very providers and patients who are expected to implement and live with the results of such cloistered decision-making. The consequences of this systematic exclusion are all too evident in the current critical and growing shortages of physicians, nurses and other health professionals. If we are to achieve the vision of a sustainable Medicare program, it is critical that governments come clean on their SUFA commitment to work in partnership with stakeholders and ensure opportunities for meaningful input into social policies and programs.
CMA’s Prescription for Sustainability – Building on SUFA
The Social Union Framework Agreement has created the necessary, but not sufficient, conditions for health system renewal. It has codified the emerging consensus on federal-provincial relations and has clarified the "rules of the game". However, it is an enabling framework that is of limited value in the health sector unless it is given life through institutional mechanisms that establish enduring partnerships not just between governments, but between governments health care providers, and patients.
In its final submission to the Commission on the Future of Health Care in Canada entitled “Prescription for Sustainability”, the CMA proposes the implementation of three integrated “pillars of sustainability” that together would improve accountability and transparency in the system: a Canadian Health Charter, a Canadian Health Commission, and federal legislative renewal.
Canadian Health Charter
A Canadian Health Charter would clearly articulate a national health policy that sets out our collective understanding of Medicare and the rights and mutual obligations of individual Canadians, health care providers, and governments. It would also underline governments’ shared commitment to ensuring that Canadians will have access to quality health care within an acceptable time frame. The existence of such a Charter would ensure that a rational, evidence-based, and collaborative approach to managing and modernizing Canada’s health system is being followed.
Canadian Health Commission
In conjunction with the Canadian Health Charter, a permanent, independent Canadian Health Commission would be created to promote accountability and transparency within the system. It would have a mandate to monitor compliance with and measure progress towards Charter provisions, report to Canadians on the performance of the health care system, and provide ongoing advice and guidance to the Conference on Federal-Provincial-Territorial ministers on key national health care issues. Recognizing the shared federal and provincial/territorial obligations to the health care system, one of the main purposes of the Canadian Health Charter is to reinforce the national character of the health system.
Federal legislative renewal
Finally, the CMA’s prescription calls for the federal government to make significant commitments in three areas: 1) a review of the Canada Health Act, 2) changes to the federal transfers to provinces and territories to provide increased and more targeted support for health care, and 3) a review of federal tax legislation to realign tax instruments with health policy goals.
While these three “pillars” will address the broader structural and procedural problems facing Canada’s health care system, there is many other changes required to meet specific needs within the system in the short to medium term. The CMA’s Prescription for Sustainability provides specific recommendations in the following key areas:
* Defining the publicly-funded health system (e.g. a more rational and transparent approach to defining core services, a “safety valve” if the public system fails to deliver, and increased attention to public health and Aboriginal health)
* Investing in the health care system (e.g. human resources, capital infrastructure, surge capacity to deal with emergencies, information technology, and research and innovation)
* Organization and delivery of services (e.g. consideration of the full continuum of care, physician compensation, rural health, and the role of the private sector, the voluntary sector and informal caregivers)
On balance, the Social Union Framework Agreement has been a positive step forward for social policy in Canada, though its potential is far from being fully realized.
The CMA’s proposal for a Canadian Health Charter, a Canadian Health Commission and federal legislative review entail significant changes to the governance of Canada’s health system. These changes would be consistent with the Social Union Framework Agreement and would help “turn the corner” from debate to action on health system renewal.
The early, ongoing and meaningful engagement of health care providers is the sine qua non of securing the long-term sustainability of Canada’s health system. Canada’s health professionals, who have the most to contribute, and next to patients – who have the most at stake – must be at the table when the future of health and health care is being discussed.
The CMA’s Assessment of the Social Union Framework Agreement ANNEX
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1. All Canadians to be treated with fairness and equity
2. Promote equality of opportunity for all Canadians
3. Respect for the equality, rights and dignity of all Canadian women and men and their diverse needs
4. Ensure access for all Canadians to essential social programs and services of reasonably comparable quality
5. Provide appropriate assistance to those in need
6. Respect the principles of Medicare: comprehensiveness, universality, portability, public administration and accessibility
7. Promote the full and active participation of all Canadians in Canada’s economic and social life
8. Work in partnership with stakeholders and ensure opportunities for meaningful input into social policies and programs
9. Ensure adequate, affordable, stable and sustainable funding for social programs
10. Respect Aboriginal treaties and rights
[#4] Progress towards the objective of ensuring access to essential health services of reasonably comparable quality is difficult to assess. First, there is no agreed-upon definition of essential health services. Second there the development of indicators and benchmarks of health care quality is still in its infancy. However, the CMA is very concerned that the system is not headed in the right direction, with growing shortages of physicians, nurses and other health care providers. According to Statistics Canada’s recently released survey on access to health care services, an estimated 4.3 million Canadians reported difficulties accessing first contact services and approximately 1.4 million Canadians reported difficulties accessing specialized services.
[#6]Although there is broad support for the five principles of Medicare, there continue to be a number of longstanding violations of Canada Health Act that are not being addressed, including the portability of medical benefits for Quebec residents. The emergence of privately-owned clinics that charge patients for medically-necessary MRI scans is also cause for concern.
[#8] There is no formal, ongoing mechanism for input from stakeholders and the individual Canadians in debates about national health policy issues. (See also #17 below).
[#9] Ensuring adequate, affordable, and stable funding for Canada’s health system is essential to its long-term sustainability. During the 1990s, billions of dollars were siphoned out of the system to eliminate government deficits. To put Medicare back on a sustainable path, governments must make long-term funding commitments to meet the health care needs of Canadians. The CMA has recommended that the federal government should significantly increase its financial contribution to restore the federal-provincial partnership in health care, and increase accountability and transparency through a new earmarked health transfer.
Mobility within Canada
11. Removal of residency-based policies governing access to social services
12. Compliance with the mobility provisions of the Agreement on Internal Trade
[#11] Residency-based policies are generally not an issue for physician and hospital services, where inter-provincial portability is guaranteed through reciprocal billing arrangements. As noted above, however, the portability of medical benefits for many Quebec residents is limited because the province only reimburses out-of-province services at home-province (as opposed to host-province) rates.
[#12] Regulatory authorities initiated work towards meeting the obligations of the Labour Mobility Chapter of the Agreement on Internal Trade in fall 1999. A Mutual Recognition Agreement has been developed and endorsed by all physician licensing authorities.
Public accountability & transparency
13. Performance measurement and public reporting
14. Development of comparable indicators to measure progress
15. Public recognition of roles and contributions of governments
16. Use funds transferred from another order of government for purposes agreed and pass on increases to residents
17. Ensure effective mechanisms for Canadians to participate in developing social priorities and reviewing outcomes
18. Make eligibility criteria and service commitments for social programs publicly available
19. Have mechanisms in place to appeal unfair administrative practices
20. Report publicly on appeals and complaints
[#13-14] Pursuant to the September 2000 Health Accord, the federal government and provinces have developed common health indicators in 14 areas and have released a first slate of reports. However, the usefulness of these reports is hampered by missing data elements on quality of care (access and waiting times in particular) and the absence of a national roll-up to facilitate inter-provincial comparisons.
[#15] Continuing federal-provincial bickering about shares of health funding makes it clear that this provision is not being met.
[#16] The CMA’s analysis of the Medical Equipment Fund found that incremental spending by provinces on medical technology accounted for only 60% of the $500 million transferred by the federal government for this purpose.
[#17] There is no mechanism in place to ensure ongoing input from Canadians and health care providers in national health policy development. The CMA has recommended the creation of a Canadian Health Commission, with representation from the public and stakeholders to provide advice and input to governments on key national health policy issues.
[#18] Although there have been proposals to this effect in a couple of provinces, governments currently do not make explicit commitments about the quality and accessibility of health services. In order to reduce the uncertainty Canadians are feeling with respect to Medicare, the CMA has recommended the creation of a Canadian Health Charter that would set out the rights and responsibilities of patients, health care providers and governments. In particular, the health charter would require all governments to set out care guarantees for timely access to health services based on the best available evidence.
[#19-20] The Auditor-General recently reported that Health Canada provides inadequate reporting on the extent of compliance with the Canada Health Act.
Governments working in partnership
21. Governments to undertake joint planning and information sharing, and work together to identify priorities for collaborative action
22. Governments to collaborate on implementation of joint priorities when this would result in more effective and efficient service to Canadians.
23. Advance notice prior to implementation of a major policy or program change that will substantially affect another government
24. Offer to consult prior to implementing new social policies and programs that are likely to substantially affect other governments.
25. For any new Canada-wide social initiative, arrangements made with one province/territory will be made available to all provinces/territories.
26. Governments will work with the Aboriginal peoples of Canada to find practical solutions to address their pressing needs
The requirement for governments to work together collaboratively is perhaps the most important part of SUFA, yet there it is impossible for organizations and individuals outside of government to assess the degree to which these provisions have been met. This so-called “black box of executive federalism” is not serving Canadians well. In the health sector, there are too many examples of governments developing policy and making decisions with little or no input from those who will ultimately have to implement change.
To achieve a true social union, the tenets of good collaborative working relationships – joint planning, advance notice and consultation prior to implementation – must be extended beyond the ambit of federal-provincial decision-making. The CMA’s proposal for a Canadian Health Commission would go some distance in addressing these concerns. A key part of its mandate would be to bring the perspective of health providers and patients into national health policy deliberations and decision-making.
Federal spending power
27. Federal government to consult with P/T governments at least one year prior to renewal or significant funding changes in social transfers
28. New Canada-wide initiatives supported by transfers to provinces subject to:
a) collaborative approach to identify Canada wide objectives and priorities
b) Agreement of a majority of provincial governments
c) Provincial discretion to determine detailed design to meet agreed objectives
d) Provincial freedom to reinvest funding in related area if objectives are already met
e) Jointly developed accountability framework
29. For new Canada-wide initiatives funded through direct transfers to individuals or organizations, federal government to provide 3-months notice and offer to consult
There have been three new Canada-wide health initiatives supported by the federal spending power: the $500M Medical Equipment Fund, the $800 Primary Health Care Transition Fund and the $500M fund for health information technology.
The Medical Equipment Fund was created to respond to a genuine need for more modern diagnostic and treatment equipment. However, objectives were vague, money was transferred with no strings attached, and there was no accountability framework. The result, as the CMA’s analysis has shown, is that a significant portion of the funding did not reach its destination.
The jury is still out in the case of the Primary Care Transition Fund. Delivery of this program through normal government machinery will entail a higher degree of accountability than in the case of the Medical Equipment Fund. However, objectives of this initiative may be too broad to have a significant steering effect on the system as a whole.
Canada Infoway Inc. is an arm’s length body created by the federal government to disburse the $500M in health information technology funding. While this model has the advantage of being less politicized than government-run programs; accountability to Parliament and to Canadians is weaker.
Dispute avoidance & resolution
30. Governments committed to working together and avoiding disputes
31. Sector negotiations to resolve disputes based on joint fact-finding, including the use of a third party
32. Any government can require a decision to be reviewed one year after it enters into effect
33. Governments will report publicly on an annual basis on the nature of intergovernmental disputes and their resolution
Federal and provincial governments have agreed to a formal dispute avoidance and resolution process under the Canada Health Act. The Canadian Health Commission recommended by the CMA could play a useful role as an independent fact-finder.
Review of SUFA
34. By the end of the 3rd year, governments will jointly undertake a full review of the Agreement and its implementation. This review will ensure significant opportunities for input and feedback from Canadians and all interested parties, including social policy experts, the private sector and voluntary organizations.
[#34] Governments have taken a minimalist approach to the SUFA review by opting for an internet-based consultation and closed meetings with invited external representatives.
This approach is not sufficient. Future reviews should be more inclusive of all stakeholders.
This year’s submission from the Canadian Medical Association (CMA) to the Standing Committee on Finance focused on the need for action in the short and longer terms by identifying strategic investments that will ensure a strong health care system supported by a dependable and comprehensive public health infrastructure as its foundation. Specifically, the CMA recommended an initial investment of $16 billion over five years starting in 2003/04 and an additional $3.2 billion for shorter-term and public health initiatives.
Following our October 22, 2002 presentation to the Standing Committee on Finance, the CMA has developed four supplementary specific proposals for one-time funding in areas of urgent national need. They represent highly visible initiatives that, taken together, would substantially enhance Canada’s capacity in the health care sector in areas of federal jurisdiction. They are:
ACCESS HOME (Accelerating Community Care through Electronic Services)
Funding of specific sites across Canada to undertake aggressive, large scale project implementation of remote information and communication technology (ICT) solutions to facilitate care in home and community based settings.
PRO-MISe (Pro Medical Immigrant Selection)
Establishment of an international off-shore assessment program to pre-screen potential medical graduates who wish to immigrate to and practice medicine in Canada.
RREAL HEALTH Communication and Coordination Initiative (Rapid, Reliable, Effective, Accessible and Linked)
Increased capacity in areas of public health system to ensure communication in real time, both between multiple agencies and with health care providers, especially in times of national emergency or to meet national health needs.
PAN-CANADIAN NETWORKS OF CLINICAL EXCELLENCE
Improved national planning for specialty care across Canada by implementing needs-based planning tools; building synergies around areas of expertise; maximizing the efficiency in the delivery of care; and creating mechanisms for ensuring timely access to highly specialized quaternary care throughout Canada.
This initial facet of a comprehensive federal reinvestment strategy corresponds with priorities identified in the Speech from the Throne and with the strategic priorities identified in our submission to the Standing Committee on Finance. Together, they constitute an important next step toward implementing the government’s Speech from the Throne commitments. However, given the particular urgency of these initiatives, and their ability to stand as independent projects, we feel they would be excellent candidates for modest but meaningful allocations from the federal surplus that may become available towards the end of this fiscal year.
Each of these proposals incorporates a highly visible, targeted approach that not only builds the necessary evidence for transition to a renewed health care system but is also amenable to one-time funding. They reflect priorities that, due to their inter-jurisdictional nature, are highly unlikely to be undertaken by the provinces and territories without federal assistance. They would substantially reduce the uncertainties that Canadians feel and experience in dealing with the health system. Indeed, these initiatives provide an opportunity for the federal government to show immediate leadership in areas that fall clearly under its jurisdiction in ways that are certain to be complementary to the recommendations from the Commission on the Future of Canada (the Romanow Commission).
The Canadian Medical Association believes that the time for targeted action is now as part of a comprehensive strategy for a sustainable health care system. Canadians are counting on governments to turn the corner from debating what needs to be done to implementing necessary changes. We see time-limited, targeted reinvestments as an essential part of this renewal.
Accelerating Community Care through Electronic Services
In the September 2000 Health Accord, health information and communications technology (ICT) was highlighted as an area where First Ministers agreed to work together to strengthen a Canada-wide health infostructure to improve quality, access and timeliness of health care for Canadians. As part of the funding initiatives announced at that time, Canada Health Infoway Inc. (CHII), received $500 million in funding to accelerate the adoption of modern ICTs to provide better health care.
Given that implementation of a full health ICT strategy will require significantly more funding, CHII has given priority to the development of the electronic health record. Further, with the sunsetting of the two-year $80 million Canada Health Infostructure Partnerships Program (CHIPP) there are no other federal programs that provide funding for ITC pilot projects.
Changing demographics in the Canadian population point to emerging pressures to meet increased non-institutional care needs of our aging population. To date, the home care sector has been largely neglected with respect to ICT – the majority of current ICT investments target acute and, to a lessor extent, primary care settings – and is currently ill equipped to cope with growing demand.
Remote healthcare solutions show considerable potential to improve the care provided in home and community settings. Current projects in this area have demonstrated the benefits of using ICTs to facilitate care in non-traditional settings. Larger scale testing of remote ICT solutions should be undertaken to determine how best they can be applied to facilitate the provision of care in home and community based settings, and the implications for provider practice.
Through funding of specific sites across Canada (mini centres of excellence), engage in aggressive, large scale project implementations of remote ICT solutions to facilitate care in home and community based settings. This would involve working through how best to apply ICTs in these settings, determining what works best and developing practice procedures for the provider community.
The ACCESS-HOME proposal is based on the underlying principle of a collaborative model and the following potential key partners have been identified: provinces and territories, regional health authorities, and the private sector (e.g., March Networks).
Undertake, over a three year period, a variety of home and community care projects to learn how best to apply remote ICT solutions to facilitate provision of care in these settings. These could include projects to link primary care physicians to elderly frail patients in their home; to link patients with severe chronic conditions to specialists for remote monitoring of their conditions; to link home care nurses to patients to carry out preventive and promotion related activities on line; and to link physicians with recently discharged patients to monitor their rate of recovery.
Part of the project funding proposal would include an evaluation component to build a knowledge base of what works and why. The assessments then would be placed on the Health Canada web site to promote knowledge transfer.
FUNDING & ACCOUNTABILITY MECHANISMS
A one-time, lump sum endowment of $50 million in this fiscal year to Canada Health Infoway Inc. (CHII) to manage the program and funds.
Over a three-year period, CHII would operate under a very clear mandate set out by Health Canada to fund projects ($1-2 million each) across the country, in urban, rural and isolated settings, to more aggressively apply ICTs to facilitate provision of care in home and community based settings and to explore the implications for practice management. Accountability for the funds and the program implementation would be set out in a Memorandum of Understanding between Health Canada and CHII.
Funds would be allocated on a cost-shared basis with a threshold of 70% federal funding. The remaining 30% would come from partnership contributions (in-kind costs, human resources, etc.). It is anticipated that it would take one year to get the projects operational and a second year to implement their mandates. The third year would be dedicated to completing the projects and undertaking evaluations in a format that would contribute to the overall knowledge base in this area.
Pro Medical Immigrant Selection
The establishment of an assessment program to pre-screen international medical graduates wanting to immigrate to Canada and practice medicine in this country.
International medical graduates have always been, and continue to be, a valuable addition to the Canadian medical workforce. Recently, the federal government passed new immigration legislation, changing the focus of immigration requirements away from an occupation basis toward a concentration on skills, training, and potential for successful integration into the Canadian workforce and society.
In light of the implementation of these provisions, the Canadian Medical Association (CMA) and the Medical Council of Canada (MCC) propose the establishment of a Pro Medical Immigrant Selection (PRO-MISe) program for foreign-trained physicians seeking to immigrate to Canada. The purpose of this program would be to ensure that the anticipated increased numbers of foreign-trained medical graduates applying to immigrate to Canada receive fair treatment.
The CMA and MCC have already had a preliminary meeting with a senior advisor to the Honourable Minister Denis Coderre, Minister of Citizenship and Immigration in follow-up to a meeting with his predecessor, the Honourable Elinor Caplan in May 2001.
The goal of the project is to expedite the remote processing of applications by highly qualified international medical graduates who wish to immigrate to, and practice medicine in, Canada. This could be facilitated by creating an off-shore electronic assessment system for pre-screening in their country of origin.
In these times of physician workforce shortages, Canadian jurisdictions must be cautioned against “poaching” physicians from under-serviced parts of the world to meet their own health care needs (particularly in under-serviced areas or disciplines). Ethical recruitment practices must be established and maintained.
In the longer term, the Canadian medical community strongly believes that Canada must strive for reasonable self-sufficiency in the production of physicians, while continuing to offer opportunities to qualified international medical graduates.
Even in times of physician shortages, it remains imperative that foreign applicants who wish to practise medicine in Canada undergo a comprehensive assessment of knowledge and skills, on par with the assessment of graduates of Canadian medical schools.
The process for assessing international medical graduates must be, and be seen to be, fair, transparent, and accountable to all stakeholders, expedient and cost-effective (for both the applicant and the government).
The project would be comprised of a three-phased approach. Phase I would set up five pilots sites over 4-6 months in varied geo-political areas (e.g., London, Paris, Tokyo, Hong Kong and Port-of-Spain) that would test an Internet-based assessment system providing:
1. Updated and comprehensive information on the Canadian health care system and the Canadian medical education system, with a view to managing expectations regarding opportunities to practise medicine in Canada;
2. Electronic self-assessment tools for international medical graduates, containing questions comparable to those in the official Medical Council of Canada Evaluating Exam (MCCEE);
3. An electronic assessment system for the official MCCEE; and
4. Electronic forms, including the waiver currently used by CIC (Citizenship and Immigration Canada) indicating that the applicant understands there is no guarantee of an opportunity to practise medicine in Canada.
Phase II would evaluate the project’s success. Phase III, full implementation on a global scale, would follow.
FUNDING & ACCOUNTABILITY MECHANISMS
$5 million for Physician Assessment
A one-time, lump sum endowment of a $5 million sequestered fund in this fiscal year to be made to the Medical Council of Canada, to be managed and administered in keeping with the goals and objectives of the project (disbursement criteria would be set in collaboration with Health Canada and Human Resources Development Canada, as required).
$15 million for Assessment of Other Health Care Providers
There is a shortage of many health care providers. The CMA has had preliminary discussions with the Canadian Nurses Association (CNA) and the Canadian Pharmacists Association (CPhA). The Federal Government should consider funding the development of similar programs for other professions, in partnership with CNA, CPhA and others.
RREAL HEALTH COMMUNICATION & COORDINATION INITIATIVE
Rapid, Reliable, Effective, Accessible and Linked
Through its public health initiatives society protects and promotes health and works to prevent illness, injury and disability. In today’s world these public health functions require an increasingly specialized and well-trained workforce; sophisticated surveillance, monitoring and information systems; and adequate and continuously available laboratory support. Its ultimate effectiveness, however, is dependent on the ability of the system to communicate crucial information and health advice to the right professional in real time when they need it.
The devastating impact of the failure to effectively communicate essential information is evident in examples as diverse, as the water tragedy in Walkerton, and the untimely death of Vanessa Young who died as the result of a fatal adverse drug reaction 1. In both cases, the information health professionals needed to make optimum treatment decisions was not accessible in a reliable and timely manner.
The public health infrastructure is put to the test whenever there is a disaster, large or small, in Canada and, not withstanding the best efforts of dedicated public health professionals, it does not always receive a passing grade. The public health system is further challenged by the potential for a disconnect in communications between differing jurisdictions that may be found when, for example, First Nations communities under federal jurisdiction overlap areas of provincial jurisdiction. In the aftermath of 9/11 and the anthrax scare in the United States, Canadians must be assured of a rapid, knowledgeable, expert response to emergency public health challenges.
It is essential that the federal government take a leadership role to ensure that the communication tools and information technology necessary to allow for a more rapid and informed response to situations such as natural disasters, disease out-breaks, newly-discovered adverse drug reactions, man-made disasters, or bio-terrorism is accessible in real time in all regions of the country.
A one time infusion of $30 million for the creation of a RREAL Health Communication and Co-ordination Initiative would strengthen Canada’s public health infrastructure and enhance co-ordination and communication among all levels of government, public health officials, health care providers and multiple agencies such as police, fire, ambulance and hospitals.
The RREAL Health Communication and Co-ordination Initiative would address current deficiencies, and increase the capacity of the public health system to communicate in real time, both between multiple agencies and with health care providers in order to:
* Provide a focal point for inter-jurisdictional communication and co-ordination in order to be better prepared in times of emergency; and
* Disseminate emergency information, health alerts and current best practices in public health to health professionals and targeted public health officials in real time and in an effective and accessible fashion.
The RREAL Health Communication and Co-ordination Initiative would involve such key players in public health service and delivery as the Canadian Public Health Association, the Canadian Paediatrics Society, the Chief Medical Officers of Health, the Canadian Federation of Municipalities, the Canadian Red Cross and Health Canada in a collaborative model to ensure integrated co-ordination and communication.
The initiative would undertake a planned program of demonstration projects over a five-year period.
1. To enable the widespread accessibility of information such as newly discovered adverse drug reactions to physicians and other health providers by rapid, reliable, and effective dissemination.
2. To ensure that rural and remote areas of the country and First Nations, Metis and Inuit communities under federal health jurisdiction are linked to public health information systems.
3. To enhance clinical practice guidelines to make them more user friendly and accessible to health care providers.
4. To improve the interoperability of communication technology between multiple agencies such as public health, police and fire services, disaster relief agencies and hospitals in times of emergency.
FUNDING & ACCOUNTABILITY MECHANISMS
A one-time, lump sum endowment of $30 million in this fiscal year to a designated organization positioned to manage the administration of these funds over a five-year project duration. One option would be to establish a new Canadian Foundation for Public Health as an arms-length agency associated with the Office for Public Health at the Canadian Medical Association.
PAN-CANADIAN NETWORKS OF CLINICAL EXCELLENCE
Canada’s health care system commits to providing Canadians with reasonably comparable access to medically necessary care. This commitment must be met across the spectrum, from primary care to highly specialized care. However, low volumes associated with highly specialized care often does not warrant the ongoing maintenance of the physical and human resources necessary in all regions of the country to be able to respond to patients’ needs.
Recent evidence has found that a critical volume of patients is required to ensure a high quality standard of care. In the Canadian Institute for Health Information’s 2002 Health Care in Canada report, they state that “for many types of care and for many different surgeries, research shows that patients treated in hospitals with higher numbers of cases are often less likely to have complications or to die after surgery”. 2
Although clinical centres of excellence (hospitals/clinics that house the human and physical resources necessary to deliver care that meets or exceeds accepted professional standards) currently exist, in Canada they are generally focussed on serving the patient needs of a single province and, in some cases, the city in which they reside. There are no formal mechanisms at the national level to facilitate needs-based planning and sharing of best practices and pooling of resources for highly specialized care. The resulting capacity “deficit” manifests itself in difficulties in accessing care – an issue that has become central to the debate on the renewal of Canada’s health care system.
This proposal is about networking existing centres to achieve improved economies of scale and to accelerate quality improvement. It would build the infrastructure necessary to support and link these centres across the country. It would not aim to further consolidate or centralize the delivery of highly specialized services.
Implement a Pan-Canadian Networks of Clinical Excellence program as a means to improve the quality and accessibility of highly specialized care in Canada.
This proposal is premised on:
* A collaborative/partnership model between health organizations such as the Canadian Stroke Network, the Association of Canadian Academic Health Organizations (ACAHO); and the Canadian Medical Association (CMA);
* Support the Provincial/Territorial Premiers’ commitment to develop Sites of Excellence in various fields such as paediatric cardiac surgery and gamma knife neurosurgery 3 ;
* Consensus building and consultation;
* Build on, and learn from, existing provincial models (e.g., Cardiac Care Network of Ontario, Ontario Stroke System);
* Reliance on evidence-based practices;
* Improved quality of care;
* Rapid diffusion and adoption of new and emerging technologies;
* Pilots and on-going evaluation leading to additional networks; and
* Adoption of an evidence-based approach to network development.
Building on the experience of earlier network models, activities envisioned for a Pan-Canadian Networks of Clinical Excellence program would be to:
* Develop electronic registries to track and connect patients and physicians across the country;
* Support collaborative research extending from the bench to bedside 4 ;
* Establish and implement clinical best practices;
* Develop and implement knowledge translation plans; and
* Promote the sharing of human capital and expertise across jurisdictions.
Beyond striving to reach optimum efficiency in the delivery of sub-acute care specialties, a Pan-Canadian Networks of Clinical Excellence program would support the development of internationally competitive centres of excellence that would offer attractive employment opportunities for the best and brightest in health human resources thereby helping to attract and retain health human resources in Canada.
FUNDING & ACCOUNTABILITY MECHANISMS
A five year phased approach to the development of the networks is envisaged.
The first phase (two years) would involve piloting and evaluating a small number of networks. Based on detailed evaluation of the pilots, the second phase (year 2) could involve additional networks to be determined through consultation with partners. It is anticipated that by year 5, there would be five networks fully operational. The funding would be ideally delivered through a single year endowment of $25 million to existing foundations such as the Canadian Stroke Network. The new consortium would allocate funding over a 5-year period based on established criteria with regular reporting to the funding consortium partnership and ultimate accountability to report back to Parliament. A steering committee would be struck with representatives from each of the participating partners to provide direction and guidance on the project’s implementation.
1 Canadian Medical Association Journal, May 1, 2001, 164(9), page 1269.
2 Dudley RA, Johansen KL, Brand R, Rennie DJ, Milstein A. (2000). Selective referral to high-volume hospitals: Estimating potentially avoidable deaths. Journal of the American Medical Association, 283(9), 1159-1166 as cited in Health Care in Canada, 2002, Canadian Institute for Health Information, Ottawa: May 2002, p. 52.
3 As agreed to at the January 24-25, 2002 Provincial-Territorial Premiers’ Meeting in Vancouver. Information available at: www.scics.gc.ca/cinfo02/850085004_e.html
4As discussed in a presentation to the House of Commons Standing Committee on Health regarding Bill C-13: An Act to Establish the Canadian Institutes of Health Research. Dr. Peter Vaughan, Secretary General and CEO, Canadian Medical Association, December 6, 1999, Ottawa, Ontario.
Thank you Madame Chair and Committee members for the opportunity to speak to you today.
As mentioned, I am Briane Scharfstein, Associate Secretary General at the Canadian Medical Association (CMA). I am a family physician by training and a member of the Ad Hoc Working Group on Medical Isotopes.
The working group was created to advise the Minister of Health in 2008 when the first major sustained shutdown of the Chalk River occurred. When I agreed to join the group, I certainly didn't expect it to still be going over two years later. And, while I am a member of the working group, I want to be clear, that today I am speaking on behalf of the CMA and our more than 72,000 physician members across the country.
My comments are a reflection of the Working Group's June 2008 Lessons Learned report and I regret to say that a good portion of our observations are still true today.
I congratulate the Senate for looking specifically at the AECL proposals and for looking at implications for patients. While the CMA is not taking a specific position on the proposal in
Bill C-9 for Atomic Energy Canada Ltd (AECL), in whole or in part, to be sold off to the private sector, we do believe that it is in the best interests of our patients that Canada remains a leader in the sector.
As well, Canada's doctors strongly believe that the impact on individual patient care must be considered and factored into any decisions that might result in disruptions of the supply of medical isotopes.
The CMA acknowledges that the federal budget did include $48 million over two years for research, development and application of medical isotopes and alternatives. Further, there was another allocation of $300 million on a cash basis for AECL's operations in 2010/11 to cover anticipated commercial losses and support the corporation's operations to ensuring a secure supply of medical isotopes and maintaining safe and reliable operations at the Chalk River Laboratory.
However, the CMA remains preoccupied with Canada's ability to ensure a long-term, stable and predictable supply of medically necessary isotopes. That is why we are uneasy about the federal government's exit strategy from the isotope production sector.
The report of the federal government's Expert Panel on the Production of Medical Isotopes, (December 2009) and the federal government's response to that report, (March 2010) appears to focus on the viability of this specific sector of the nuclear industry and has not alleviated our concerns. The government's response to the Panel Report was disappointing to the medical community. The government's decision to abandon Canada's long-standing international leadership in this sector is disheartening.
Of particular concern is the absence of both immediate and medium-term solutions to address the current and impending challenges facing nuclear medicine. This is simply unacceptable.
The CMA, along with our colleagues in the medical community, continues to assert that ensuring access to safe and reliable medical procedures and the provision of high-quality patient care must be the fundamental consideration of government decisions. While the production cost of isotopes cannot be ignored, particularly in times of global fiscal challenges, the medical application and benefits received are of paramount importance and must be neither discounted nor dismissed.
Early diagnosis and treatment are key factors in successful outcomes in cardiac and cancer cases. Without early diagnosis and treatment, patients have an increased risk of needing greater medical intervention later on. With more intensive treatment comes a corresponding increase in costs to the health care system and, most importantly, poorer outcomes for patients.
Specific concerns identified by the CMA and the medical community include, but are not limited to the following:
* Canada's current dependence on international reactors, without a practical back-up plan should these reactors experience difficulties, or shutdown for routine maintenance.
This is especially worrisome as the international agency, the Association of Imaging Producers & Equipment Suppliers (AIPES) warns of the unprecedented level of shortages, in a large part due to the Canada's Chalk River nuclear reactor remaining off line until August 2010 or beyond. In a recent Supply Crisis Update, AIPES points out that with a number of international reactors off-line for scheduled maintenance, the remaining reactors -the OPAL (Australia), Maria (Poland) and REZ (Czech Republic) reactors-are producing Mo99, but their combined output is limited to 15 - 20 % of the world requirements.
* The abandonment of Canada's international responsibilities and world leadership in this sector is counter to the government's own innovation and productivity agenda.
* A growing reliance on emerging technology, cyclotrons and liner accelerators that have yet to be proven as a suitable secure alternative source of radiopharmaceutical.
* A projected future supply chain that is reliant on external sources, rather than domestic production, in times of domestic supply shortages. As well, we are concerned that the federal government is leaving it to the marketplace, solely relying on current distributors to identify external sources supply, rather than searching to identify alternative safe sources of supply.
* Basing Canada's supply strategy on relicensing of the Chalk River reactor five years past its current license with no current guarantees that the plant will return and remain in production, let alone meet relicensing standards.
* The apparent lack of a federal contingency plan if, in 2016, alternative sources of supply and alternative emerging technology does not meet clinical needs.
* An analysis of the overall costs to the health care system as a result of the increased costs incurred during the prolonged period of shortages of isotopes supply and the rising costs as the demand for the alternative diagnostic and treatment models is not apparent.
* Initiatives to help mitigate increased costs for governments and particularly for nuclear medicine facilities do not exist.
The just released survey by the Canadian Institute for Health Information found that two-thirds of nuclear medicine facilities reported that they experienced an increase in the cost of isotopes and that they were managing but exceeding their budget due to vendor surcharges. Only 2% reported that the isotope supply disruptions had no economic impact.
Canada's medical community therefore strongly urges that consideration be given to:
* investing in a mixed-use reactor for research and isotope production, as per the recommendation of the Expert Panel on Isotopes Production report of December, 2009;
* putting in place appropriate strategies and contingency plans to meet the health needs of Canadians; in particular consider a national deployment of PET technology for cancer detection and follow up.
* enhancing transparency by the government that provides more information on the short and medium-tern detailed plans to address isotope shortages;
* increasing the direct consultation with the official representatives of the nuclear medicine and medical community;
* making a public commitment to keep the Chalk River NRU reactor operational beyond the arbitrary date of 2016, as long as necessary and until secure alternative supplies of isotopes or alternative radiopharmaceuticals are proven and are in place; and,
* ensuring that the CNSC resurrects the external medical advisory council to facilitate communication between the medical community and the commission. Prior to 2001, members of the council provided CNSC staff with insight into how operational and policy decisions would affect patient care across the country.
Canada's doctors believe that the federal government must maintain a leadership role in this sector and must not compromise the medical needs of Canadians.
The Canadian Medical Association's (CMA) pre-budget submission is based on the premise that healthier Canadians are more productive Canadians. It also recognizes that the delivery of quality health care, in a timely manner, is paramount and is not mutually exclusive of any productivity agenda. With the recent release of its Health Care Transformation in Canada: Change That Works. Care That Lasts. policy document, the CMA declared its readiness to take a leadership position in confronting the hard choices required to make health care work better for Canadians. Physicians are reaching out to the Canadian public, opinion and business leaders, governments, interested parties and stakeholders to find ways to improve our health care system and to make sure that the upcoming reforms will focus on better serving patients.
Canada's health care system cannot continue on its current path, especially as pressure grows from an aging population. The system needs to be massively transformed, a task that demands political courage and leadership, flexibility from within the health care professions and far-sightedness on the part of the public. It is a lot to demand, but one of Canada's most cherished national institutions is at stake. We must work together toward a common vision of what we aspire for our health care system.
The CMA commends the federal government for publicly stating it will honour its previous commitment of a 6% annual increase to the Canada Health Transfer through to 2014. This sustained predictable funding has brought some long-term stability to the publicly financed health care sector. However, the CMA believes that the health care system must be capable of withstanding or accommodating demand surges and fiscal pressure. Capacity and innovation strategies need to be developed and implemented to meet emerging health necessities.
In this brief, the CMA identifies a number of key issues related to health human resources and infrastructure that require immediate attention if the Canadian economy is to retain its competitive position in the global economy. Pressure is mounting on the system and there is a need to move beyond data collection to interdisciplinary collaboration. Including health care providers in the decision-making process would lead to better health public policy decisions, and result in much needed pan-Canadian health human resource planning. By making strategic direct investments in health human resources, public health and retirement savings, the federal government would retain its leadership role and contribute to the sustainability of a patient-centred health care system.
Health care's contribution: A more productive and innovative economy
The health care system in Canada employs over a million people, or 7.5% of the labour force. In 2009, Canada invested $183 billion in health care, representing 11.9% of our GDP. The benefits of health care investments not only contribute to a higher quality of life for all Canadians, but the economic multiplier effect of the initial investment is estimated to create an additional $92 billion in economic activity, such as in the high technology sector, financial services and R&D jobs.i Further federal investments in the health care system contribute to ensuring a more productive and innovative economy.
Better Health, Improved Productivity
The Conference Board of Canadaii, the Organization for Economic Co-operation and Development (OECD) iii, the World Health Organizationiv, the Commonwealth Fundv, and the Frontier Centre for Public Policyvi all rate Canada's health care system poorly in terms of "value for money" as well as efficiency. In both 2008 and 2009, the Euro-Canada Health Consumer Index ranked Canada 30th of 30 countries (the U.S. was not included in the sample) in terms of value for money spent on health care. Canadians deserve better. We know that investments in quality today will pay off in improved health that will reduce health care demand and expenditures down the road. The resultant improved productivity from the reduction of illness in the population will generate economic dividends for the country.
Our proposals are informed by regular consultations with our 72,000 physician members and reflect what they believe are the most pressing gaps that exist in our health care system today. These recommendations will also start the process of fostering transformation of the health care system that not only serves the health needs of Canadians, but makes our health care system more effective, accountable and sustainable now and for generations to come.
* Please note that the sum of the following recommendations would add less than 0.5% to the current $25 billion Canada Health Transfer that is committed to the provinces.
Recommendations for the 2011 Federal Budget:
A. Investing in Health Human Resources: $53.1 million over 4 years
1. The federal government should fulfill the balance of its 2008 election promisevii of investing $33.1 million over 4 years to fund 35 new residencies per year; and invest $20 million over 4 years in the repatriation of Canadian physicians working abroad.
B. Investing in pandemic preparedness (post H1N1): $500 million over 5 years
2. The federal government should increase funding ($200 million over 5 years) to enhance disease surveillance by linking public health databases with real-time clinical information through patient Electronic Medical Records in order to facilitate data collection and analysis between local public health authorities and primary care practices.
3. The federal government should increase funding ($200 million over 5 years) for local health emergency preparedness planning to improve collaboration and coordination of clinical care and public health structures at the local level during public health crises and reduce the variation of capacity across the country.
4. The federal government should invest in the creation of a pan-Canadian strategy ($100 million over 5 years) to build a process for a harmonized national clinical response, including vaccine programs in times of potential health crises.
C. Improving retirement savings options for the self-employed: federal taxes to be deferred over time
5. The federal government should increase RRSP limits and explore opportunities to provide pension vehicles for self-employed Canadians.
D. Encourage Canadians to save for long-term care needs: federal taxes to be deferred over time
6. The federal government should study options for pre-funding long-term care, including private insurance, tax-deferred and tax-prepaid savings approaches, and contribution-based social insurance.
E. Support for informal caregivers
7. The federal government should undertake pilot studies that explore tax credit and/or direct compensation for informal caregivers for their work and expand relief programs for informal caregivers that provide guaranteed access to respite services for people dealing with emergency situations.
A. Investing in Health Human Resources: $53.1 million over 4 years
Every high-performing health system begins with a strong primary care system. Yet roughly 5 million Canadians do not have a regular family physician, and once Canadians do access primary care, they often face long waits to see consulting specialists and further waits for advanced diagnostics and treatment. Part of the reason for these delays is the shortage of health care professionals in Canada and the lack of long-term pan-Canadian planning to ensure needs are met.
Canada ranks 26th of 30 OECD member countries in physician-to-population ratio. The lack of physicians in Canada puts the system under pressure and the impact of this is being felt by patients across the country. A Centre for Spatial Economics studyviiicommissioned by the CMA, found that the Canadian economy is expected to lose $4.7 billion in 2010, as a result of excessive wait times for just four procedures: joint replacements, MRIs, coronary artery bypass surgery and cataract surgery. When people wait too long for care businesses face increased human resource costs to replace lost or affected employees. There is a loss in output and especially productivity. The reduction in output would lower federal and provincial government revenues in 2010 by $1.8 billion. The econometric model in the report used to calculate these costs also estimates that to cut wait times to government recommended benchmarks would require a $586 million investment or just 2% of the current Canada Health Transfer. This investment would boost GDP by $6.2 billion.
The global shortage of health professionals compounds the problem - while Canadian training programs still lack sufficient seats to produce enough new providers to meet current and future demands, Canadian-educated physicians, nurses, technicians, and other health professionals are being lured away by ample opportunities to train and work outside Canada.
The CMA commends the federal government for recently announcing the Northern and Remote Family Medicine Residency Program in Manitoba, which constitutes an investment of just over $6.9 million. The program will provide extensive medical training for 15 additional family medicine residents over the next four years. We urge the government to build on this announcement and honour its full commitment. Thousands of health care professionals are currently working abroad, including approximately 9,000 Canadian-trained physicians. We know that many of the physicians who do come back to Canada are of relatively young age, meaning that they have significant practice life left. While a minority of these physicians return on their own, many more can be repatriated in the short term through a relatively small but focussed effort by the federal government, led by a secretariat within Health Canada.
Recommendation 1: The federal government should fulfill its 2008 election promiseix of investing $33.1 million over 4 years to fund 35 new residencies per year; and invest $20 million over 4 years in the repatriation of Canadian physicians working abroad.
B. Investing in pandemic preparedness (post H1N1): $500 million over 5 years
The absence of a national communicable disease/immunization monitoring system is an ongoing problem. In 2003, the report of the National Advisory Committee on SARS and Public Health recommended that "the Public Health Agency of Canada should facilitate the long term development of a comprehensive and national public health surveillance system that will collect, analyze, and disseminate laboratory and health care facility data on infectious diseases... to relevant stakeholders." Seven years later, Canada still does not have a comprehensive national surveillance and epidemiological system.
Clinicians' practices are highly influenced by illness patterns that develop regionally and locally within their practice populations; thus, surveillance data are useful in determining appropriate treatment. During the H1N1 outbreak, real-time data were not available to most physicians and when data did become available, they were already several weeks old. Greater adoption of electronic medical records (EMRs) in primary care and better public health electronic health records (EHRs), with the ability to link systems, will augment existing surveillance capacity and are essential to a pan-Canadian system. International strategy and technology consulting firm Booz Allen Hamilton found that the benefits of an interconnected Electronic Health Record (EHR) in Canada could provide annual system-wide savings of $6.1 billion. A pan-Canadian electronic health information system is urgently needed and must become a priority during the inter-pandemic phase, with adequate federal funding and provincial/territorial collaboration.
Recommendation 2: The federal government should increase funding ($200 million over 5 years) to enhance disease surveillance by linking public health databases with real-time clinical information through patient Electronic Medical Records in order to facilitate data collection and analysis between local public health authorities and primary care practices.
Recommendation 3: The federal government should increase funding ($200 million over 5 years) for local health emergency preparedness planning to improve collaboration and coordination of clinical care and public health structures at the local level during public health crises and reduce the variation of capacity across the country.
A key measure to combat pandemic influenza is mass vaccination. On the whole, Canada mounted an effective campaign: 45% of Canadians were vaccinated, and the proportion was even higher in First Nations communities - a first in Canadian history. The outcome was positive, but many public health units were stretched as expectations exceeded their pre-existing constrained resources. Nationally promulgated clinical practice guidelines had great potential to create consistent clinical responses across the country. Instead, the variation and lack of coordination in providing important clinical information during this crises eroded the public's confidence in the federal, provincial and territorial response.
Recommendation 4: The federal government should invest in the creation of a pan-Canadian strategy ($100 million over 5 years) to build a process for a harmonized national clinical response, including vaccine programs in times of potential health crisis.
C. Improved retirement savings options for self-employed: federal taxes to be deferred over time
With the aging Canadian population and the decline in the number of Canadians participating in employer-sponsored pension plans, now is the time to explore strengthening the third pillar of Canada's government-supported retirement income system: tax-assisted savings opportunities and vehicles available to help Canadians save to meet future continuing care needs.
Of keen interest to the medical profession are measures to help self-employed Canadians save for their retirement. Physicians represent an aging demographic - 38% of Canada's physicians are 55 or older. Self-employed physicians, like many other self-employed professionals, are unable to participate in workplace registered pension plans (RPPs). This makes them more reliant on Registered Retirement Savings Plans (RRSPs) relative to other retirement savings vehiclesx. The recent economic downturn has shown that volatility of global financial markets can have an enormous impact on the value of RRSPs over the short-and medium-term. This variability is felt most acutely when RRSPs reach maturity during a time of declining market returns and RRSP holders are forced to sell at a low price.
The possibility that higher-earning Canadians, such as physicians, may not be saving enough for retirement was raised by Jack Mintz, Research Director for the Research Working Group on Retirement Income Adequacy of Federal-Provincial-Territorial Ministers of Finance. In his Summary Report, Mr. Mintz wrote that income replacement rates in retirement fall below 60% of after-tax income for about 35% of Canadians in the top income quintile. This is due to the effect of the maximum RPP/RRSP dollar limits and the government should consider raising these limits.
Recommendation 5: The federal government should increase RRSP limits and explore opportunities to provide pension vehicles for self-employed Canadians.
D. Encourage Canadians to save for long-term care needs: federal taxes to be deferred over time
According to Statistics Canada's most recent population projections, the proportion of seniors in the population (65+) is expected to almost double from its present level of 13% to between 23% and 25% by 2031xi. With Canadians living longer and continuing care falling outside the boundaries of Canada Health Act (CHA) first-dollar coverage, there is a growing need to help Canadians save for their home care and long-term care needs. These needs are an important part of the retirement picture as the federal government considers options for ensuring the ongoing strength of Canada's retirement income system.
Additional information is contained in CMA's submission to the House of Commons Standing Committee on Finance during its study on Retirement Income Security of Canadians (May 13, 2010).
Recommendation 6: The federal government should study options for pre-funding long-term care, including private insurance, tax-deferred and tax-prepaid savings approaches, and contribution-based social insurance.
E. Support for informal caregivers
Much of the burden of continuing care falls on informal (unpaid) caregivers. More than a million employed people aged 45-64 provide informal care to seniors with long-term conditions or disabilities, and 80% of home care to seniors is provided by unpaid informal caregivers. Canada lags behind several countries, including the U.K., Australia, Germany, Japan, the Netherlands and the U.S. in terms of supporting informal caregivers.
Recommendation 7: The federal government should undertake pilot studies that explore tax credit and/or direct compensation for informal caregivers for their work and expand relief programs for informal caregivers that provide guaranteed access to respite services for people dealing with emergency situations.
The CMA encourages the federal government to consider the recommendation found in the report entitled; Raising the Bar:A Roadmap for the Future of Palliative Care in Canada supported by the Canadian Hospice Palliative Care Association.
The recommendations contained in the CMA's pre-budget submission represent our priority recommendations for federal investments that will contribute to a healthy, more productive and innovative economy. These recommendations will also start the process of fostering transformation of the health care system that not only serves the health needs of Canadians but makes our health care system more effective, accountable and sustainable now and for generations to come. As the federal government's commitment to the provinces through the 2004 Health Care Accord expires in 2014, it is imperative that investments are made that not only provide better care but are also sustainable for our country's economy.
Appendix Table 1
i The additional economic activity generated by the health care sector is based on a conservative 1.5 multiplier. The CMA is pursuing precise estimates of the benefits of health care investments in Canada. Please see:
Economic Footprint of Health Care Services in Canada Prepared for: Canadian Medical Association by Carl Sonnen
with Natalie Rylska Informetrica limited January 2007 In economics, the multiplier effect or spending multiplier is the idea that an initial amount of spending (usually by the government) leads to increased consumption spending and so results in an increase in national income greater than the initial amount of spending. The existence of a multiplier effect was initially proposed by Richard Kahn in 1930 and published in 1931. http://en.wikipedia.org/wiki/Fiscal_multiplier Snowdon, Brian and Howard R. Vane. Modern macroeconomics: its origins, development and current state. Edward Elgar Publishing, 2005. ISBNS 1845422082, 9781845422080. p. 61.
ii How Canada Performs 2008: A Report Card on Canada, The Conference Board of Canada
iii Organization for Economic Co-operation and Development [OECD] (2007). OECD Health
Data 2007. Version 07/18/2007. CD-ROM. Paris: OECD.
iv World Health Organization [WHO] (2007). World Health Statistics 2007. see: http://www.who.
v Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care May 15, 2007 (updated May 16, 2007)
Authors: Davis, Schoen, Schoenbaum, Doty, Holmgren, Kriss, Shea
vi Euro-Canada Health Consumer Index 2008, Health Consumer Powerhouse, Frontier Centre for Public Policy, FC Policy Series No. 38 see:www.fcpp.org/pdf/ECHCI2008finalJanuary202008.pdf
vii Health Care Certainty for Canadian Families, the Conservative Party of Canada, backgrounder 10/08/08.
viii The economic cost of wait times in Canada, the Centre for Spatial Economics, July 2010.
ix Health Care Certainty for Canadian Families, the Conservative Party of Canada, backgrounder 10/08/08.
x A more detailed outline of the issues surrounding pension reform can e found in CMA's Submission on Pension Reform Backgrounder for the Standing Committee on Finance, May 13, 2010. www.cma/submissions-to-government
xi Statistics Canada. Populations projections. The Daily, Thursday, December 15, 2005.