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Access to quality health care

https://policybase.cma.ca/en/permalink/policy323
Last Reviewed
2019-03-03
Date
1998-09-09
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC98-23
That access to quality health care must be available to all Canadians, in a manner consistent with provincial/territorial human rights legislation and the Canadian Charter of Rights and Freedoms.
Policy Type
Policy resolution
Last Reviewed
2019-03-03
Date
1998-09-09
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC98-23
That access to quality health care must be available to all Canadians, in a manner consistent with provincial/territorial human rights legislation and the Canadian Charter of Rights and Freedoms.
Text
That access to quality health care must be available to all Canadians, in a manner consistent with provincial/territorial human rights legislation and the Canadian Charter of Rights and Freedoms.
Less detail

Answering the Wake-up Call: CMA’s Public Health Action Plan : CMA submission to the National Advisory Committee on SARS and Public Health

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

https://policybase.cma.ca/en/permalink/policy1987
Last Reviewed
2019-03-03
Date
1998-08-31
Topics
Health human resources
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
1998-08-31
Topics
Health human resources
Health systems, system funding and performance
Text
I. INTRODUCTION The Canadian Medical Association (CMA) commends the federal government, in its second mandate, for continuing the public pre-budget consultation process. This visible and accountable process encourages public dialogue in the development of finance and economic policies of the country. As part of the 1999 pre-budget consultation process, the CMA welcomes the opportunity to submit its views to the House of Commons Standing Committee on Finance, and looks forward to meeting with the Committee at a later date to discuss our recommendations and their rationale in greater detail. II. POLICY CONTEXT While the current and future status of our health care system is a top priority for all Canadians, it is evident that their faith in the system’s ability to ensure access to quality care is eroding. In May 1991, 61% of Canadians rated the system as excellent/very good. By February 1998 that rating had slipped to 29% - a dramatic decrease in the confidence level of Canadians in the health care system. 1 Unfortunately, their outlook on the future of the health care system is not much better. Some 51% of Canadians believe that their health care will be in worse condition in 10 years than it is today. 2 It is not surprising that Canadians are losing confidence in the future sustainability of the health care system. They have experienced firsthand the decline in access to a range of health care services (see Table 1): * 73% reported that waiting times hospital emergency departments had worsened, up from 65% in 1997, and 54% in 1996 * 72% reported that waiting times for surgery had lengthened, up from 63% in 1997, and 53% in 1996 * 70% reported that availability of nurses in hospitals had worsened, up from 64% in 1997, and 58% in 1996 * 61% reported that waiting times for tests had increased, up from 50% in 1997, and 43% in 1996 * 60% reported that access to specialist physicians has worsened, up from 49% in 1997, and 40% in 1996 [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table 1 (a) [TABLE END] [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table 1 (b) [TABLE END] Clearly, these findings are significant, and demonstrate the public’s increasing concerns regarding current access to quality health care, as well as the future sustainability of our health care system. Canadians have made it clear that it is not, nor can it be, “business as usual” in attempting to meet their health care needs as we move into the next millennium. Medicare, Canada’s crowning social policy achievement, is in crisis. It is time for the federal government to re-establish its leadership role in this strategic priority area. The CMA has repeatedly placed its concerns about access to quality health care on the public record. Physicians, as patient advocates, have consistently expressed their frustration with the difficulties faced in accessing medically necessary services - only to fall on the deaf ears of the federal government. In surveying Canadian physicians on the front lines, they know the degree of difficulty in accessing services that their patients need: 3 * only 27% of physicians surveyed rated as excellent/very good/good their access to advanced diagnostic services (e.g., MRI) * only 30% of physicians surveyed rated as excellent/very good/good their access to long-term institutional care * only 45% of physicians surveyed rated as excellent/very good/good their access to psychosocial support services * only 46% of physicians surveyed rated as excellent/very good/good their access to acute institutional care for elective procedures These findings are cause for concern. Particularly troublesome is that only 63% of physicians surveyed rated as excellent/very good/good their access to acute institutional on an urgent basis. The cause for this crisis of confidence is clear - the federal government's unilateral and repeated decreases in the rate of increase in transfer payments beginning with Established Financing Programs (EPF), established in 1977, and continuing for the next decade-and-a-half. It culminated, in April, 1996, with the severe and successive cuts in cash transfers for health, post-secondary education (PSE) and social assistance via the Canada Health and Social Transfer (CHST). The CMA is not alone in its view. In addition to the public, other health groups and the Provincial and Territorial Premiers have expressed serious concern about the sustainability of the health care system and the urgent need for Federal leadership and reinvestment. Following their meeting in August, 1998, the Premiers "re-affirmed their commitment to maintaining and enhancing a high quality universal health care system for all Canadians and observed that every government in Canada but one - the federal government - has increased its funding to health care - the people's priority". 4 Underscoring the Premiers' view was a detailed proposal submitted to the federal government calling for an immediate increase in CHST cash transfers. From Federal Government Acknowledgement to Action At the 1997 Annual General Meeting of the CMA in Victoria, the federal minister of health, Allan Rock, stood before delegates and acknowledged "the very real anxiety that's being felt by Canadians" over the future of the health care system. 5 The minister also conceded that cuts to transfer payments have not been insignificant and have had an impact on the system, a point on which the CMA wholeheartedly agrees. The CMA recognizes that the federal government has made a series of difficult decisions when it comes to its funding priorities in order to restore our country’s fiscal health. However, the time has come to consider the fundamental issue of reinvesting in the health of Canadians. The federal government must move beyond the rhetoric in terms of acknowledging the pain and suffering that the cuts have caused, and move to an agenda of action by showing leadership and making the necessary and overdue re-investments in our health care. At a time when the federal government is beginning to reap the benefits of a fiscal dividend, it must recognize that health care is not simply a consumption good that, once spent, provides no additional benefits. Investments in the health care system provide a substantial and lasting social rate of return in terms of restoring, maintaining and enhancing Canadians health. Furthermore, in an increasingly interdependent and global marketplace, a sustainable health care system must be viewed as a necessary precondition for Canadians to excel, thus strengthening the link between good economic policy and good health care policy in Canada. They should not be viewed as competing against each other or that one must be sacrificed at the expense of the other. The 1998 federal budget ignored Canadians' number one concern and did nothing to bolster their confidence that the system will be there when they or their family need it. In responding to the massive reductions in cash transfers to the provinces and territories, in his February 24, 1998, budget speech, federal finance minister Paul Martin announced that he had increased the floor under cash transfers to the provinces in support of health and other programs from the $11.0 billion to $12.5 billion annually and further that it "will provide provinces with nearly $7 billion more in cash over the 1997/98 to 2002/03 period”. 6 While this was announced as an "increase" these statements are misleading. It must be remembered that this is not “new” money; the $12.5 billion represents nothing more than a partial restoration, which falls $6.0 billion (or 32%) short of the cash floor of $18.5 billion prior to the introduction of the CHST in 1996/97. To date, the cumulative impact of cuts to the Canada Health and Social Transfer (CHST) in 1996 and 1997 amounts to a $15.5 billion withdrawal in federal cash from health and social transfers. Their impact is still working its way through the system and being felt in patients' pain and suffering and unfortunately, even death. The CMA has consistently stated publicly that the integrity of the health care system is being jeopardized by reductions to federal cash transfer payments for health. The federal government, however, has failed to respond to these concerns. Unless the federal government reinvests in health care, it will only deepen the crisis of confidence Canadians share about the future sustainability of the health care system. III. HEALTH CARE FUNDING AND THE FEDERAL ROLE The Federal Role When it comes to the health care system, the federal government’s role is aimed at ensuring that Canadians have access to health care services under “uniform terms and conditions”. This derives from the government’s right to exercise its spending power and has been manifested over the past 40 years through a number of cash-transfer mechanisms to the provinces and territories, framed more precisely by the principles of the Canada Health Act (i.e., public administration, comprehensiveness, universality, portability and accessibility). Since the inception of national health insurance in Canada, the federal government has played a central role in the funding of health care. Until 1977, the government reimbursed each province 50 cents on each dollar spent in the areas of hospital and medical care insurance. Following a renegotiated formula, government moved from a “cost-sharing” to a “block funding” formula from 1977/78 to 1995/96. Federal-provincial transfers were distributed through a funding mechanism known as Established Programs Financing (EPF). Under EPF, a combination of (basic) cash and tax points were transferred to the provinces for health care and post-secondary education (PSE). While both the tax points and cash components are important in funding health care, there are those who argue that the level of federal cash should be viewed as a true reflection of the government’s commitment to health care. This is significant for two reasons. First, it demonstrates the priority the government places on our health care system, and secondly, the cash component (which can be withheld under the Canada Health Act) can play an important role in preserving and enhancing national standards. 7 The Origins of Federal Cash Withdrawal The genesis for the crisis in confidence about the future of Canada’s health care system can be traced to 1982, when the federal government introduced a series of unilateral decisions which reduced its cash contributions to the provinces and territories for health and other social programs. Figure 1 highlights the changes made to the EPF formula used to fund health and post-secondary education between 1977 and 1995. These unilateral changes, resulted in the withholding of approximately $30 billion in federal cash that would have otherwise been transferred to provincial and territorial health insurance plans (and an additional $12.1 billion for post-secondary education - for a total of $42.1 billion). 8 This dollar amount is of no small consequence when it comes to ensuring that all Canadians have access to quality health care. [FIGURE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Figure 1 [FIGURE END] Into the Mist... Prior to April 1, 1996 the federal government's commitment to insured health services, post-secondary education and social assistance programs could be readily determined since the federal government made separate notional cash contributions to the provinces and territories in each of these areas. 9 Announced in the 1995 federal budget, the creation of the Canada Health and Social Transfer (CHST), on April 1, 1996, saw EPF merge with the Canada Assistance Plan (CAP). In effect, health, post-secondary education, and social assistance were collapsed into one large cash transfer. At the time, the government claimed that the CHST was “a new approach to federal-provincial fiscal relations marked by greater flexibility and accountability for provincial governments, and more sustainable financing arrangements for the federal government.” 10 In reality, the increased “flexibility and accountability” was accompanied by a $7.0 billion reduction in the cash portion of the new transfer, and introduced a lower level of transparency with respect to where and what proportion the federal government notionally allocated its dollars for health, PSE and the social programs previously funded under CAP. In its 1998 budget, the federal government moved to partially restore CHST funding by establishing a new cash floor of $12.5 billion (see Table 2) - however, this is still $6.0 billion short of the pre-CHST cash floor. To date, the cumulative impact of previous CHST cash reductions in 1996 and 1997 amounts to a $15.5 billion withdrawal of cash from health and social transfers to 1998/99. By 2002/03, it is estimated that $39.5 billion will have been removed from the CHST. This is in addition to the $30 billion withheld from fiscal transfers that would otherwise have gone to the provinces and territories for health between 1982 and 1995. 11 [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [TABLE END] Furthermore, in addition to the current cash floor, the cash entitlement will stagnate at $12.5 billion, as adequate provision has not been made to maintain the value of the cash portion of the transfer. 12 This means the spending power of the cash entitlement will continue to erode as the health care system is forced to meet the changing needs of Canadians based on population growth, aging, epidemiology, new technologies and inflation. With the introduction of the CHST, the disappearance of health, post-secondary education and social assistance into the shadowy mist makes it impossible to hold the federal government accountable with respect to its relative commitment to each of these important policy areas. Using the pre-CHST percentage distribution, the federal government’s current cash allocation to health care stands at roughly $5.0 billion, or 7% of total health care expenditures. This is not surprising considering that the “H” in CHST was added later, only after health organizations protested its absence. Based on the reduced federal cash contribution to health care, it would appear that the government has made a conscious decision to abdicate its responsibility and leadership role in funding health care. While claiming to uphold the integrity of our national health care system, the reality of reduced cash transfers has forced all provinces and territories to make do with significantly fewer federal dollars for health. Federal “offloading” at its best has allowed the federal government to meet (and exceed) its own financial projections; at its worst it has forced the provinces and territories to consider a series of unattractive options: re-allocate program spending from within current budgets; deficit-financed program spending; or reduced program spending. To be clear, from a national perspective, the CMA believes that the single most important reason for the deterioration of the health care system is the significant decline in federal financial support for health care. It is critical that the federal government immediately signal its commitment to Canadians that the health care system is a high priority, and to immediately reinvest in a program that will restore the confidence of Canadians' that the system will be there for them when they need it. Now is the time for the federal government to demonstrate leadership and address the number one concern of Canadians by turning the "vicious cycle" of deficit reduction into a "virtuous cycle" of reinvesting in the health care system. This is not business as usual, and the status quo is not sustainable. IV. A TIME TO RE-ESTABLISH FEDERAL LEADERSHIP IN HEALTH CARE Stabilize the System Canadians, who strongly support a publicly-funded health care system - a conviction shared by the CMA - need to see some leadership from their federal government about how it perceives the future of the health care system unfolding. The failure to re-invest in health care in the last federal budget leaves them confused by the contradiction of seeing the government withdraw funding while at the same time talking about introducing new programs such as home care and pharmacare. Before the federal government can even contemplate future program expansion, it must move quickly to stabilize our current health care system. Canadians have made it very clear where they believe the federal government's spending priorities lie. Seventy-one percent (Angus Reid, November, 1997) want federal cash transfer restored and 81% (Ottawa Sun/Roper, June 1998) of Canadians want the federal government to dedicate more resources to Medicare. The CMA believes strongly that there is an immediate need for a measured, deliberate and responsible approach to re-invest in our health care system. Canadians need to be reassured that the system will be there for them and their families when they need it. To restore access to quality health care for all Canadians, the CMA respectfully recommends: 1. That in order to ensure greater public accountability and visibility, the federal government introduce a health-specific portion of the cash transfers to the provinces and territories. 2. That in addition to the current level of federal cash transferred to the provinces and territories for health care, the federal government restore at a minimum $2.5 billion in cash on an annual basis to be earmarked for health care, effective April 1, 1999. 3. That beginning April 1, 2000, the federal government fully index the total cash entitlement allocated to health care through the use of a combination of factors that would take into account the changing needs of Canadians based on population growth, aging, epidemiology, current knowledge and new technologies, and economic growth. The principles outlined in the above recommendations are fundamental and underscore the importance of establishing an accountable (i.e., linking sources with their intended uses) and visible transfer for federal cash that is targeted for reinvestment into health care. While there is ongoing discussion about the mechanism(s) to reinvest in health care, the minimum federal cash restoration of $2.5 billion on an annual basis into the health care system recognizes the high priority of placing health care on a more sustainable financial footing for the future. This figure is separate from the $5 billion notionally allocated to health care via the current CHST, and is calculated on the basis of the recent historical federal cash allocation (approximately 41%) under EPF and CAP (now the CHST) to health care as a proportion of the $6.0 billion dollars required to restore the CHST cash floor to $18.5 billion (1995/96 level). The recommendations also speak to the necessity of having in place a fully indexed escalator to ensure that the federal cash contribution will continue to grow to meet the future health care needs of Canadians, and with the economy. The escalator formula recognizes that health care needs are not always synchronized with economic growth. In fact, it could be argued that in times of economic hardship (i.e., unemployment, stress, anxiety), a greater burden is placed on the health care system. Taken together, the above recommendations are a targeted approach to reinvesting in health care, and serve to re-establish the federal government's leadership role when it comes to the current and future sustainability of our health care system. It also signals that the federal government is prepared to address, in a focused and strategic approach, Canadians' number one concern - access to quality health care. Finally, it is important to note that in principle the above recommendations are consistent with those of other groups such as the provincial and territorial ministers of finance, the Canadian public and other national health organizations, who are not asking for new resources but an immediate restoration of monies that have been taken out of the federal/provincial/territorial transfer envelope over the past three years. Looking to the Future At the same time that the federal government reinvests to stabilize the health care system, it must also consider the broader spectrum of health care services that must be in place to ensure that Canadians do not fall through the cracks. In addition to the re-investment required to stabilize our Medicare system, there is also an urgent need for investments into other components of the health system. In many ways, this suggests that new transitional funding is required to ensure that as the system evolves, it remains accessible, and can do so with minimal interruption of service to Canadians. Proposed by the CMA, the Health System Renewal Fund, is time limited, sector-specific, and strategically targeted to areas that are in transition. Funding is intended to meet defined need and give the federal government sufficient flexibility in how the funds will be allocated, with full recognition for the investment. The CMA respectfully recommends: 4. That the federal government establish a one-time Health System Renewal Fund in the amount of $3 billion to be disbursed over the three-year period beginning April 1, 1999, for the following areas of need: a. Acute care infrastructure support: assist health institutions to enhance the delivery of a continuum of quality patient care by improving their access to necessary services including new technologies, and modernizing health facilities and upgrading infrastructure. b. Community care infrastructure support: to enable communities to develop services to support the delivery of home and community-based care in the wake of the rapid downsizing of the institutional sector. c. Support Canadians at risk: to provide access to pharmacotherapy and medical devices to those in need, who are not adequately covered by public or private insurance (pending the development of a long-term solution). d. Health information technology: to allow the provinces and territories to put in place the transparent, clinically driven health information infrastructure necessary to support the adequate and appropriate management of access and delivery of health care. In implementing the health information infrastructure scrupulous attention must be paid to privacy and confidentiality issues. The Acute Care Infrastructure Support program is designed to ensure that targeted reinvestments are made in the institutional sector such that it has the necessary physical capacity and infrastructure to deliver quality health care. In a world where downsizing has become the accepted wisdom, health care facilities need to be modernized in terms of new technology and equipment to ensure the full continuum of patient care is available. The Community Care Infrastructure Support program speaks to the important need to develop adequate community-based systems before any reforms are introduced in the acute care sector. It also recognizes that community-based programs should not be implemented at the expense of the acute care sector, but rather, should be designed such that both sectors complement one another and add value to the health care system. The Support Canadians at Risk program focuses on those who with inadequate coverage and have compromised access to needed pharmacotherapy and medical devices. Currently, drug coverage is not universal nor is it comprehensive. In many cases, the working poor, those that are self-employed or employed by small businesses do not have drug coverage (nor are they eligible for government sponsored plans). In other cases, co-payments/deductibles of some public plans are so high that individuals must pay out-of-pocket (e.g., $850 deductible, semi-annually, in Saskatchewan, then 35% co-payment) for all necessary prescription drugs. As a result, this patchwork coverage may inhibit Canadians access to quality care and may place additional demands on the acute care sector. Similarly, Canadians may not have access to medical devices covered by the public and/or private plans. The Health Information Technology program speaks to the critical need to develop and implement a transparent and clinically driven information systems that will support better management, measurement and monitoring of the health care system. At the same time, scrupulous attention must be paid to privacy and confidentiality issues. To this end, the CMA has taken a proactive approach in addressing these issues by developing a health information privacy code. Taken together, our recommendations are a powerful and strategic package. They speak to the need to immediately stabilize the health care system - which is in crisis, and the need to look at the broader spectrum of health care services to ensure that Canadians in need do not fall through the cracks. V. REINFORCING GOOD ECONOMIC POLICY WITH GOOD HEALTH CARE POLICY IN CANADA While the system-wide issues related to the federal role in funding health care is clearly of importance to Canada's physicians, there are also other important issues that the CMA would like to bring to the attention of the Standing Committee on Finance. As mentioned earlier in the brief, good economic policy and good health care policy should go hand-in-hand. They should serve to reinforce, not neutralize, one another. They should not be viewed as one gaining at the expense of the other. Viewed in their proper context, they can be balanced such that policy decisions produce outcomes that are fair to all parties. Tobacco Taxation Policy Smoking is the leading preventable cause of premature mortality in Canada. The most recent estimates suggest that more than 45,000 Canadians die each year due to tobacco use. The estimated economic cost to society from tobacco use in Canada has been estimated between $11 billion to $15 billion 13. Tobacco use directly costs the Canadian health care system $3 billion to $3.5 billion 14 annually. These estimates do not take into account intangible costs such as pain and suffering. CMA is concerned that the 1994 reduction in the federal cigarette tax has had a significant effect in slowing the decline in cigarette smoking in the Canadian population, particularly in the youngest age groups - where the number of young smokers (15-19) is in the 22% to 30% range and 14% for those age 10-14 15. The CMA congratulates the federal government’s February 13, 1998 initiative which selectively increased federal excise taxes on cigarettes and tobacco sticks. This is a first step towards an integrated tobacco tax strategy, and speaks to the importance of strengthening the relationship between good tax policy and good health policy in Canada. The CMA understands that tobacco tax strategies are extremely complex. Strategies need to consider the effects of tax increases on reduced consumption of tobacco products with increases in interprovincial/territorial and international smuggling. In order to tackle this issue, the government could consider a selective tax strategy. This strategy requires continuous stepwise increases to tobacco taxes in those areas with lower tobacco tax (i.e., Ontario, Quebec and Atlantic Canada). The goal of selective increases in tobacco tax is to increase the price to the tobacco consumer over time (65-70% of tobacco products are sold in Ontario and Quebec). The selective stepwise tax increases will approach but may not achieve parity amongst all provinces; however, the tobacco tax will attain a level such that inter-provincial/territorial smuggling would be unprofitable. The selective stepwise increases would need to be monitored so that the new tax level and US/Canadian exchange rates do not make international smuggling profitable. The selective stepwise increase in tobacco taxes can be combined with other tax strategies. The federal government should apply the export tax and remove the exemption available on shipments in accordance with each manufacturers historic levels. The objective of implementing the export tax would be to make cross-border smuggling unprofitable. The federal government should establish a dialogue with the US federal government regarding harmonizing US tobacco taxes with Canadian levels at the factory gate. Alternatively, US tobacco taxes could be raised to a level that when offset with the US/Canada exchange rate differential renders international smuggling unprofitable. The objective of harmonizing US/Canadian tobacco tax levels (at or near the Canadian levels) would be to increase the price of internationally smuggled tobacco products to the Canadian and American consumers. The CMA's comprehensive tobacco taxation strategy is designed to achieve the following objectives: (1) to reduce tobacco consumption; (2) to minimize interprovincial/territorial smuggling of tobacco products; (3) to minimize international smuggling of tobacco products from both the Canadian and American perspective; (4) to reduce and/or minimize Canadian/American consumption of internationally smuggled tobacco products. The CMA recommends: 5. That the federal government follow a comprehensive integrated tobacco tax policy: a. To implement selective stepwise tobacco tax increases to achieve the following objectives: (1) reduce tobacco consumption, (2) minimize interprovincial/territorial smuggling of tobacco products, and (3) minimize international smuggling of tobacco products; b. To apply the export tax on tobacco products and remove the exemption available on tobacco shipments in accordance with each manufacturers historic levels; and c. To enter into discussions with the US federal government to explore options regarding tobacco tax policy, bringing US tobacco tax levels in line with or near Canadian levels, in order to minimize international smuggling. The Excise Act Review, A Proposal for a Revised Framework for the Taxation of Alcohol and Tobacco Products (1996), proposes that tobacco excise duties and taxes (Excise Act and Excise Tax Act) for domestically produced tobacco products be combined into a new excise duty and come under the jurisdiction of the Excise Act. The new excise duty is levied at the point of packaging where the products are produced. The Excise Act Review also proposes that the tobacco customs duty equivalent and the excise tax (Customs Tariff and Excise Tax Act) for imported tobacco products be combined into the new excise duty [equivalent tax to domestically produced tobacco products] and come under the jurisdiction of the Excise Act. The new excise duty will be levied at the time of importation. The CMA supports the proposal of the Excise Act Review. It is consistent with previous CMA recommendations calling for tobacco taxes at the point of production. Support for Tobacco Control Programs Taxation should be used in conjunction with other strategies for promoting healthy public policy, such as public education programs to reduce tobacco use. The Liberal party, recognising the importance of this type of strategy , promised: "...to double the funding for the tobacco control programs from $50 million to $100 million over five years, investing the additional funds in smoking prevention and cessation programs for young people, to be delivered by community organizations that promote the health and well-being of Canadian children and youth." 16 The CMA applauds the federal government's efforts in the area of tobacco use prevention and cessation - particularly its intent to commit $50 million to public education through the proposed Tobacco Control Initiative. However, a time limited investment is not enough. Substantial and sustainable funding is required for programs in prevention and cessation of tobacco use. 17 A possible source for this type of program investment could be tobacco tax revenues or the tobacco surtax. The CMA therefore recommends: 6. That the federal government commit stable funding for a comprehensive tobacco control strategy; this strategy should include programs aimed at prevention and cessation of tobacco use and protection of the public from tobacco's harmful effects. 7. That the federal government clarify its plans for the distribution of the Tobacco Control Initiative funds, and ensure that the funds are invested in evidence-based tobacco control projects and programs. 8. That the federal government support the use of tobacco tax revenues for the purpose of developing and implementing tobacco control programs. Fair and Equitable Tax Policy? - The Goods and Services Tax (GST) and Harmonized Sales Tax (HST) When it comes to tax policy and the tax system in Canada, the CMA is strongly of the view that both should be administered in a fair and equitable manner. This principle-based statement has been made to the Standing Committee on a number of different occasions. While these principles are rarely in dispute, the CMA has expressed its strong concerns regarding their application - particularly in the case of the goods and services tax (GST) and the recently introduced harmonized sales tax (HST) in Atlantic Canada. By designating medical services as "tax exempt" under the Excise Tax Act, physicians are in the unenviable position of being denied the ability to claim a GST refund (i.e., input tax credits - ITCs) on the medical supplies necessary to deliver quality health care, and on the other, cannot pass the tax onto those who purchase such services. This is a critical point when one considers the raison-d'etre of introducing the GST: to be an end-stage consumer-based tax, and having not a producer of a good or a service bear the full burden of the tax. Yet this tax anomaly does precisely that. As a result, physicians are "hermetically sealed" - they have no ability to claim ITCs due to the Excise Tax Act, or pass the costs to consumers due to the Canada Health Act. To be clear, the CMA has never, nor is currently asking for, special treatment for physicians under the Excise Tax Act. However, if physicians, as self-employed individuals are considered as small businesses for tax purposes, then it only seems reasonable that they should have the same tax rules extended to them that apply to other small businesses. This is a fundamental issue of tax fairness. While other self-employed professionals and small businesses claim ITCs, an independent (KPMG) study has estimated that physicians have "overcontributed" in terms of unclaimed ITCs by $57.2 million per year. By the end of this calendar year, physicians will have been unfairly taxed in excess of $480 million. Furthermore, with the introduction of the HST in Atlantic Canada, KPMG has estimated that it will costs physicians an additional $4.686 million per year. As it currently applies to medical services, the GST is bad tax policy and the HST will make a bad situation worse for physicians. Last year, the Standing Committee, in its report to the House of Commons stated: "According to the CMA, the GST is fundamentally unfair to physicians and is a deterrent in recruiting and retaining physicians in Canada. This issue merits consideration and further study". 18 The CMA believes that it has rigorously documented its case and further study is not required - the time has come for concerted action from the federal government to alleviate this tax impediment. There are other health care providers (e.g., dentists, physiotherapists, psychologists, chiropractors, nurses) whose services are categorized as tax exempt. However, there is an important distinction between whether the services are publicly insured or not. Health care providers who deliver services privately have the opportunity to pass along the GST costs through their fee structures. It must be remembered that physicians are in a fundamentally different position given that 99% of their professional earnings come from the government health insurance plans: under the GST and HST, "not all health care services are created equal". There are those who argue that the medical profession should negotiate the GST at the provincial/ territorial level, yet there is no province that is prepared to cover the additional costs that are being downloaded onto physicians as a result of changes to federal tax policy. Nor do these governments feel they should be expected to do so. The current tax anomaly, as it affects the medical profession, was created with the introduction of the GST - and must be resolved at the federal level. As it currently stands for medical services, the GST and HST is not a tax policy that reinforces good health care policy in Canada. The CMA view is not unique. The late Honourable Chief Justice Emmett Hall recognized the principles that underpin the fundamental issue of tax fairness by stating: "That the federal sales tax on medical supplies purchased by self-employed physicians in the course of their practices be eliminated". 19 Even though Mr. Hall's recommendation was made prior to the introduction of the GST and HST, the principles outlined above are unassailable and should be reflected in federal tax policy. Canadian physicians work hard to provide quality health care to their patients within what is a publicly funded health care system. Physicians are no different from Canadians in that they, too, are consumers (purchasers). Why then, they ask, has the medical profession been singled out for such unfair treatment under the GST regime? The CMA respectfully recommends: 9. That health care services funded by the provinces and territories be zero-rated. The above recommendation could be accomplished by amending the Excise Tax Act as follows: (1). Section 5 part II of Schedule V to the Excise Tax Act is replaced by the following: 5. "A supply (other than a zero-rated supply) made by a medical practitioner of a consultative, diagnostic, treatment or other health care service rendered to an individual (other than a surgical or dental service that is performed for cosmetic purposes and not for medical or reconstructive purposes)." (2). Section 9 Part II of Schedule V to the Excise Tax Act is repealed. (3). Part II of Schedule VI to the Excise Tax Act is amended by adding the following after section 40: 41. A supply of any property or service but only if, and to the extent that, the consideration for the supply is payable or reimbursed by the government under a plan established under an Act of the legislature of the province to provide for health care services for all insured persons of the province. Our recommendation fulfils at least two over-arching policy objectives: (1) strengthening the relationship between good economic policy and good health policy in Canada; and (2) applying the fundamental principles that underpin our taxation system (fairness, efficiency, effectiveness), in all cases. Registered Retirement Savings Plans (RRSPs) There are (at least) two fundamental goals of retirement savings: (1) to guarantee a basic level of retirement income for all Canadians; and (2) to assist Canadians in avoiding serious disruption of their pre-retirement living standards upon retirement. Reviewing the demographic picture in Canada, we see that an increasing portion of society is not only aging, but is living longer. Assuming that current demographic trends will continue and peak in the first quarter of the next century, it is important to recognize the role that private RRSPs savings will play in ensuring that Canadians may continue to live dignified lives well past their retirement from the labour force. This becomes even more critical when one considers that Canadians are not setting aside sufficient resources for their retirement. Specifically, according to Statistics Canada, it is estimated that 53% of men and 82% of women starting their career at age 25 will require financial aid at retirement age - only 8% of men and 2% women will be financially secure. In its 1996 Budget Statement, the federal government announced that it froze the dollar limit of RRSPs at $13,500 through to 2002/03, with increases to $14,500 and $15,500 in 2003/04 and 2004/05, respectively. As well, the maximum pension limit for defined benefit registered pension plans will be frozen at its current level of $1,722 per year of service through 2004/05. This is a de facto increase in tax payable. This change in policy with respect to RRSP contribution limits run counter to the White Paper released in 1983 (The Tax Treatment of Retirement Savings), where the House of Commons Special Committee on Pension Reform recommended that the limits on contributions to tax-assisted retirement savings plans be amended so that the same comprehensive limit would apply regardless of the retirement savings vehicle or combination of vehicles used. In short, the principle of "pension parity" was endorsed. Furthermore, in three separate papers released by the federal government, the principle of pension parity would have been achieved between money-purchase (MP) plans and defined benefit (DB) plans had RRSP contribution limits risen to $15,500 in 1988. In effect, the federal government postponed the scheduling of the $15,500 limit for seven years - that is, achieving the goal of pension parity was delayed until 1995. The CMA has been frustrated that ten years of careful and deliberate planning by the federal government around pension reform has not come to fruition, in fact, if the current policy remains in place it will have taken more than 17 years to implement (from 1988 to 2005). As a consequence, the current policy of freezing RRSP contribution limits and RPP limits without making adjustments to RRSP limits to achieve pension parity serves to maintain inequities between the two plans until 2004/2005. This is patently unfair for self-employed Canadians who rely on RRSPs as their sole vehicle for retirement planning. The CMA recommends: 10. That the dollar limit of RRSPs at $13,500 increase to $14,500 and $15,500 in 1999/00 and 2000/01, respectively. Subsequently, dollar limits increase at the growth in the yearly maximum pensionable earnings (YMPE). Under current federal tax legislation, 20% of the cost of an RRSP, RRIF or Registered Pension Plan's investments can be made in "foreign property." The rest is invested in "Canadian" investments. If the 20% limit is exceeded at the end of a month, the RRSP pays a penalty of 1% of the amount of the excess. In its December 1998 pre-budget consultation , the Standing Committee on Finance made the following recommendation (p. 66): "...that the 20% Foreign Property Rule be increased in 2% increments to 30% over a five year period. This diversification will allow Canadians to achieve higher returns on their retirement savings and reduce their exposure to risk, which will benefit all Canadians." A recent study by Ernst & Young, demonstrated that Canadian investors would have experienced substantially better investment returns over the past 20 years with higher foreign content limits. As well, the Conference Board of Canada concluded that lifting the foreign content limit to 30% would have a neutral effect on Canada's economy. The CMA and believes there is sufficient evidence to indicate that Canadians would benefit from an increase in the Foreign Property Rule, from 20% to 30%. The CMA therefore recommends: 11. That the 20% foreign property rule for deferred income plans such as Registered Retirement Savings Plans and Registered Retirement Income Funds be increased in 2% annual increments to 30% over a five year period, effective 1999. As part of the process to revitalize the economy, greater expectations are being placed on the private sector to create employment opportunities. While this suggests that there is a need to re-examine the current balance between public and private sector job creation, the government, nonetheless has an important role to play in fostering an environment that will stimulate job creation. In this context, the CMA, strongly believes that current RRSPs should be viewed as an asset rather than a liability. With proper mechanisms in place, the RRSP pool of capital funds can play an integral role in bringing together venture capital and small and medium-size businesses and entrepreneurs. In this regard, the CMA would encourage the government to explore current regulatory impediments to bring together capital with small and medium-size businesses. The CMA, recommends the following: 12. That the federal government foster economic development by treating RRSP contributions as assets rather than liabilities and by exploring the regulatory changes necessary to ensure increased access to such funds by small and medium-size businesses. Non-Taxable Health Benefits In last year's federal budget, the CMA was encouraged by the federal government's announcement to extend the deductibility of health and dental premiums through private health services plans (PHSP) for the unincorporated self-employed. The CMA believes that this initiative is a step in the right direction when it comes to improving tax fairness. As well, the federal government is to be commended for its decision to maintain the non-taxable status of supplementary health benefits. This decision is an example of the federal government's serving to strengthen the relationship between good tax policy and good health care policy in Canada. If supplementary health benefits were to become taxable, it is likely that young healthy people would opt for cash compensation instead of paying taxes on benefits they do not receive. These Canadians would become uninsured for supplementary health services. It follows that employer-paid premiums may increase as a result of this exodus in order to offset the additional costs of maintaining benefit levels due to diminishing ability to achieve risk pooling. As well, in terms of fairness it would seem unfair to "penalize" 70% of Canadians by taxing supplementary health benefits to put them on an equal basis with the remaining 30%. It would be preferable to develop incentives to allow the remaining 30% of Canadians to achieve similar benefits attributable to the tax status of supplementary health benefits. The CMA therefore recommends: 13. That the current federal government policy with respect to non-taxable health benefits be maintained. Health Research in Canada At the same time that our health care system has been de-stabilized, so too has the role of health research in Canada. In response, the federal government announced in its 1998 budget that it would increase funding levels for the Medical Research Council of Canada (MRC) from $237.5 million (1997/98), to $267 million (1998/99), $270 million (1999/00) and $276 million (2000/01). While this is a step in the right direction, the $134 million over three years represents for the most part a restoration of previously cut funding - only $18 million would be considered new money. Furthermore, when compared against other countries, Canada does not fare well. Of the G-7 nations for which recent data were available, Canada ranks last in per capita spending for health research. France, Japan, the United States and the United Kingdom spend between 1.5 and 3.5 times more per capita than Canada. 20 In what is increasingly a knowledge-based world, the federal government must be reminded that a sustained and substantial commitment to health research in required. The CMA therefore recommends: 14. That the federal government establish a national target (either in per capita terms or as a proportion of total health spending), and an implementation plan for health research and development spending including the full spectrum of basic biomedical to applied health services research, with the objective of improving Canada's position relative to other G-7 countries. Brain Drain and Tuition Deregulation In June, 1998, the CMA met with the Standing Committee on Finance to discuss the issue of "brain drain" in Canada. At that time, the CMA expressed its serious concerns over the recent tuition deregulation policy in Ontario and its subsequent impact on the career choices of new medical graduates. Specifically, the CMA officially decries tuition deregulation in Canadian medical schools and believes that governments should increase funding to medical schools to alleviate the pressures driving tuition increases; that any tuition increase be regulated and reasonable; and that financial support systems be in place in advance of, or concomitantly with, any tuition increase. These measures will foster the education and training of a diverse population of health care givers, and will support culturally and socially sensitive health care for all Canadians. As new physicians graduate with substantial and growing debt loads, they will be attracted to more lucrative positions in order to repay their debts - particularly positions in the United States. As a consequence, tuition deregulation policies will have a direct and detrimental impact when it comes to retaining our best and brightest young physicians in Canada. The CMA is currently in the process of developing a position paper on this issue. VI. SUMMARY OF RECOMMENDATIONS With the future of access to quality health care for all Canadians at stake, the CMA strongly believes that the federal government must demonstrate that it is prepared to re-establish its leadership role and re-invest in the health care system that all Canadians cherish and closely identify with. The CMA therefore makes the following recommendations to the Standing Committee on Finance in its deliberations. Stabilize the System 1. That in order to ensure greater public accountability and visibility, the federal government introduce a health-specific portion of the cash transfers to the provinces and territories. 2. That in addition to the current level of federal cash transferred to the provinces and territories for health care, the federal government restore at a minimum $2.5 billion in cash on an annual basis to be earmarked for health care, effective April 1, 1999. 3. That beginning April 1, 2000, the federal government fully index the total cash entitlement allocated to health care through the use of a combination of factors that would take into account the changing needs of Canadians based on population growth, aging, epidemiology, current knowledge and new technologies, and economic growth. Looking to the Future 4. That the federal government establish a one-time Health System Renewal Fund in the amount of $3 billion to be disbursed over the three-year period beginning April 1, 1999, for the following areas of need: a. Acute care infrastructure support: assist health institutions to enhance the delivery of a continuum of quality patient care by improving their access to necessary services including new technologies, and modernizing health facilities and upgrading infrastructure. b. Community care infrastructure support: to enable communities to develop services to support the delivery of home and community-based care in the wake of the rapid downsizing of the institutional sector. c. Support Canadians at risk: to provide access to pharmacotherapy and medical devices to those in need, who are not adequately covered by public or private insurance (pending the development of a long-term solution). d. Health information technology: to allow the provinces and territories to put in place the transparent, clinically driven health information infrastructure necessary to support the adequate and appropriate management of access and delivery of health care. In implementing the health information infrastructure scrupulous attention must be paid to privacy and confidentiality issues. Tobacco Taxation Policy 5. That the federal government follow a comprehensive integrated tobacco tax policy: a. To implement selective stepwise tobacco tax increases to achieve the following objectives: (1) reduce tobacco consumption, (2) minimize interprovincial/territorial smuggling of tobacco products, and (3) minimize international smuggling of tobacco products; b. To apply the export tax on tobacco products and remove the exemption available on tobacco shipments in accordance with each manufacturers historic levels; and c. To enter into discussions with the US federal government to explore options regarding tobacco tax policy, bringing US tobacco tax levels in line with or near Canadian levels, in order to minimize international smuggling. Support for Tobacco Control Programs 6. That the federal government commit stable funding for a comprehensive tobacco control strategy; this strategy should include programs aimed at prevention and cessation of tobacco use and protection of the public from tobacco's harmful effects. 7. That the federal government clarify its plans for the distribution of the Tobacco Control Initiative funds, and ensure that the funds are invested in evidence-based tobacco control projects and programs. 8. That the federal government support the use of tobacco tax revenues for the purpose of developing and implementing tobacco control programs. Goods and Services Tax (GST) 9. That health care services funded by the provinces and territories be zero-rated. Registered Retirement Savings Plans (RRSPs) 10. That the dollar limit of RRSPs at $13,500 increase to $14,500 and $15,500 in 1999/00 and 2000/01, respectively. Subsequently, dollar limits increase at the growth in the yearly maximum pensionable earnings (YMPE). 11. That the 20% foreign property rule for deferred income plans such as Registered Retirement Savings Plans and Registered Retirement Income Funds be increased in 2% annual increments to 30% over a five year period, effective 1999. 12. That the federal government foster economic development by treating RRSP contributions as assets rather than liabilities and by exploring the regulatory changes necessary to ensure increased access to such funds by small and medium-size businesses. Non-Taxable Health Benefits 13. That the current federal government policy with respect to non-taxable health benefits be maintained. Health Research in Canada 14. That the federal government establish a national target (either in per capita terms or as a proportion of total health spending), and an implementation plan for health research and development spending including the full spectrum of basic biomedical to applied health services research, with the objective of improving Canada's position relative to other G-7 countries. 1 Angus Reid, February, 1998. 2 Angus Reid, February, 1998. 3 Canadian Medical Association. January 1998 Physician Resource Questionnaire. 4 39th Annual Premiers’ Conference, Saskatoon Saskatchewan, August 5-7, 1998. Press Communique. 5 Rock A. Speech to the Canadian Medical Association’s 130th General Council Victoria, Aug 20, 1997. 6 The Budget Plan, 1998. Building Canada for the 21st Century, February 24, 1998. 7 The tax point transfer refers to the dollar value of ?tax points? that were negotiated with the federal government and the provinces. Specifically, where the federal government reduced personal and corporate income tax rates, the ?tax room? that was created was then occupied by the provinces. This is an important point because even though the federal government collects taxes on behalf of the provinces (with the exception of Quebec), it is argued that the value of the tax point transfer belongs to the provinces and is not considered as a true “federal contribution”. The last time this issue was negotiated was in 1965. 8 Thomson A. Federal Support for Health Care - A Background Paper. Health Action Lobby, Ottawa, 1991. 9 Thomson, A., Diminishing Expectations - Implications of the CHST, [report] Canadian Medical Association, Ottawa. May, 1996. 10 Federal Department of Finance. 11 Thomson A. Federal Support for Health Care - A Background Paper. Health Action Lobby, Ottawa, 1991. 12 Currently, the CHST cash entitlement has an escalator attached to it, however, it is scheduled to begin in 2000/01, 2001/02, 2002/03, at a rate of GDP- 2% (year 1), GDP-1.5% (year 2), and GDP-1% (year 3). 13 Health Canada, Economic Costs Due to Smoking (Information Sheet). Ottawa: Health Canada, November 1996. 14 Health Canada, Economic Costs Due to Smoking (Information Sheet). Ottawa: Health Canada, November 1996. 15 Health Canada, Youth Smoking Behaviour and Attitudes (Information Sheet). Ottawa: Health Canada, November 1996. 16 Liberal Party, Securing Our Future, Liberal Party of Canada, Ottawa, 1997. p. 77. 17 In California, between 1988 and 1993, when the state was carrying on an aggressive public anti-smoking campaign, tobacco consumption declined by over 25%. Goldman LK, Glantz SA. Evaluation of Antismoking Advertising Campaigns. JAMA 1988; 279: 772-777. 18 Report of the Standing Committee on Finance. December, 1997. 19 Hall Emmett (Special Commissioner). Canada?s National-Provincial Program for the 1980s, p. 32. 20 Organization for Economic Cooperation and Development. OECD Health Data 97. Paris: OECD, 1997.
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CMA’s Annual Check-up of Canada’s Health Care System: Presentation to the House of Commons Standing Committee on Finance Pre-Budget Consultations

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

https://policybase.cma.ca/en/permalink/policy1954
Last Reviewed
2011-03-05
Date
2003-10-08
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2011-03-05
Date
2003-10-08
Topics
Health systems, system funding and performance
Text
The Canadian Medical Association (CMA) has prepared this submission for the Standing Senate Committee on Social Affairs, Science and Technology study on the governance and infrastructure of the public health system in Canada and its response during public health emergencies. We applaud this initiative and welcome the opportunity to present the views of Canada’s medical community. Introduction Canada has a distinguished history as one of the best countries in the world in which to live, ranking number one on the UN’s Human Development Report from 1994 to 2000. Our health care system was a major contributor to the country’s top position but in the past few years Canada has lost ground in international rankings on key health indicators. For example, although Canada’s infant mortality rate dropped by 22% between 1990 and 1999, other countries recorded greater declines in infant mortality over the same time period. As a result, Canada’s rank dropped from 5th to 17th among the 31 industrialized countries included in the Organization for Economic Cooperation and Development (OECD). In 1999, Canada ranked 5th in life expectancy at birth, down from 3rd in 1990. During the 1990-1999 period, total life expectancy increased by 1.8% in Canada but other countries made larger gains. The CMA believes that this worrisome turn of events needs attention. Delegates to its 2003 General Assembly called on the federal government to commit to the goal of establishing Canada as the top country worldwide, regarding the health status of its citizens, within ten years. To achieve this Canada will need a national strategy that defines national health goals and can seriously address the health inequalities that continue to exist in Canada. Improvement to health status in Canada will not be possible without a strong, effective and well-resourced public health system. Unfortunately we do not have that today. For years the CMA has been warning that our public health system is stretched to capacity in dealing with everyday demands, let alone responding to new and emerging health threats. 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 pre-budget 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 surge capacity. It also drew attention to the need for improved co-ordination and communication between jurisdictions. In February 2003, before the World Health Organization (WHO) issued a global alert about Severe Acute Respiratory Syndrome (SARS), the CMA again raised concerns about the capacity of Canada’s health system to handle emerging infectious diseases without being overwhelmed. This warning came in the CMA’s submission to the House of Commons Standing Committee on Health hearings on West Nile Virus. Most recently, in our submission to the National Advisory Committee on SARS & Public Health, Answering the Wake-Up Call: CMA’s Public Health Action Plan, the CMA called for a clearer alignment of authority and accountability in times of extraordinary health emergencies. The submission also recommended enhancement of the system’s capacity to respond to public health threats across the country. The Public Health Action Plan and accompanying technical backgrounders have previously been circulated to the Committee and are attached as Appendix 1. In this submission we will expand on the recommendations contained in Answering the Wake-Up Call: CMA’s Public Health Action Plan to focus on the federal government’s role in public health. Particular emphasis will be placed on legislative reform, human resource capacity enhancement, and surveillance and communications. Public Health in Canada Public health is the science and art of protecting and promoting health, and preventing disease and injury. 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. It is interesting to note that Canada’s current public health legislation was enacted more than a half century before our health care legislation. Public health is about ensuring 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 and healthy environments. It is also the systematic response to infectious diseases, there to protect Canadians when they face a public health threat like SARS. When the public health system is fully prepared to carry out essential services, communities across the country are better protected from acute health events. Unfortunately it is only when something goes terribly wrong, as in the Walkerton tragedy when 7 people died and 1,346 were affected by E. coli contamination of a community well, that the important role and contribution of public health is highlighted. Today’s reality is that Canada does not have a strong, integrated, consistently and equitably resourced public health system. 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. There was also concern for the resiliency of the system’s infrastructure and its ability 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 fulfil its responsibilities in public health: communication between multiple agencies was poor; and weaknesses in the key surveillance system impeded 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.” Public health systems across Canada are fragmented. It is less a system and more a patchwork quilt of programs, services and resources across the county. In truth, 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 input from health professionals via organizations such as the CMA, or its divisions and affiliates, 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 like the 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, or the respective roles and responsibilities of the different levels of government. In many cases, the assignment of authorities and accountabilities is anachronistic. The existing Emergencies Act gives the federal government the power 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.”1 However, in order to use this power, the federal government must declare a “public welfare emergency” which itself has political and economic implications, particularly from an international perspective, that mitigate against its use. CMA believes that this all-or-nothing approach is not in the public’s best interest and that the concept of national emergency in the context of public health requires a different and differentiated response from governments in the future. In its submission to the National Advisory Committee on SARS and Public Health the CMA called for the enhancement of the federal government’s “command and control” powers in times of national health emergencies through the enactment of a Canada Emergency Health Measures Act. The Act would give the federal government specific authority to act for a pre-determined, temporary period of time, during a declared extraordinary health emergency. It would also provide the authority for development of a graduated health alert system with corresponding public health interventions to enable a rapid co-ordinated response as a public health threat emerges. The declaration of a health alert would imply that financial, scientific and human resources from the federal government would be available as required to address the crisis. An incremental level of federal assistance should be associated with each of the five levels of health alert to help meet the basic costs of response and recovery when such expenditures exceed what an individual province or territory could reasonably be expected to bear on its own. For example at level three a 50/50 cost sharing arrangement could be envisioned with this increasing to 90/10 at level 5. At health alert levels 1 and 2 the financial contribution should be considered to be within the operational funds of the proposed Canadian Office for Disease Surveillance and Control. Financial assistance that may be required during health alert levels 3 to 5 should be submitted to and approved by the Governor in Council during the authorization for declaration of the health alert. The level of health alert and affected area would be reviewed regularly and modified as needed. The graduated system of health alerts proposed by CMA will ensure a more appropriate and effective response to public health emergencies than currently exists.2 The CMA has also brought the issue of emergency response forward on the international stage through its membership in the World Medical Association (WMA). At the WMA General Assembly in September 2003, delegates from over 50 countries supported a motion put forward by the CMA urging the WHO to enhance its emergency response protocol to deal with world epidemics such as SARS. (See Appendix ll.) The WMA agreed to establish a working group, headed by the CMA, to develop a public health risk alert plan. The report of the National Advisory Committee on SARS and Public Health has now been submitted to the federal health minister. The federal government must not let this report languish on the shelf. It must develop a plan to respond to its recommendations in order to create a strong and well-resourced public health system with adequate surge capacity and sufficient highly qualified public health professionals. The CMA has determined that a very targeted incremental investment of $1.5 billion over five years is needed to address the legislative reform and capacity enhancement required to bring our public health system into the 21st century. Simply re-allocating funds within existing health budgets is not sufficient and would only negatively impact efforts to shore the core of current health care services. Recommendation One The federal government rapidly move to enact a Canada Emergency Health Measures Act that would consolidate and enhance existing legislation. This new Act would allow for a more rapid national response, in co-operation 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. Recommendation Two The federal government invest in the country’s public health system with an immediate commitment of $ 1.5 Billion over five years to rebuild the public health infrastructure. An Action Plan for the Federal Government National leadership is critical to articulate the key issues and challenges facing public health today and to implement comprehensive strategies to address the deficiencies in the system’s infrastructure. The CMA has called for a renewed and enhanced national commitment to public health anchored in new federal legislation. Legislative Reform Canada’s response to SARS brought into stark relief the urgent need for national leadership and coordination of public health activity across the country, especially during such a serious health crisis. It was a wake-up call that highlighted the need for comprehensive legislative reform to clarify the roles of governments and public health officials with respect to the management of public health threats. The development of a national public health system ought not to occur by the instalment plan, provoked by SARS-like events. It must be carefully planned and evaluated. This, in turn, requires clear identification of key issues and mobilization of resources. A sustainable public health system also requires a critical mass of technical expertise to support essential public health functions3. The CMA believes that the federal government has a critical role to play in the development of a strong, co-ordinated pan-Canadian public health system. In both the United Kingdom and the United States, national leadership has been instrumental in clearly defining health goals for the population and stating the role of the public health system, its key infrastructure elements and the development of strategies to attain them. Canada does not have a formal national leadership position comparable to England’s Chief Medical Officer or the Surgeon General in the US. There is currently no single credible public health authority vested, through legislation or federal-provincial-territorial agreement, with the overall responsibility for pan-Canadian public health issues. The CMA has recommended the appointment of a Chief Public Health Officer of Canada with decision-making powers in areas of federal jurisdiction. Currently there is tremendous inequity in the public health system capacity among different provinces and territories. 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.4 The CMA has proposed the establishment of a Canadian Office for Disease Surveillance and Control (CODSC) as a key component of its public health action plan. A comprehensive centre of public health expertise allows for a strategic pan-Canadian approach to public health planning and services while developing a critical mass of scientific and public health expertise and resources that can be deployed to any region in the country when necessary. A first priority of the CODSC must be to facilitate pan-Canadian agreement on the definition of the core functions of the public health system as it will not be possible to assess and develop system infrastructure if these are not defined. (As noted earlier in this paper the Federal-Provinical-Territorial Advisory Committee on Public Health has suggested five core functions.) A follow-up step to the development of core functions for public health is to identify national health goals to improve health status and address health inequities within populations across the country. The impact of inequality in health on health status can be seen within the aboriginal population. The degree of ill health within their communities is one of Canada’s major unresolved challenges. Although there have been significant improvements over the past few decades, the overall health status of Aboriginal peoples falls well below that of others living in Canada. Mortality and morbidity records indicate that life expectancy, while varying among communities, remains significantly less than that of the average Canadian. And the incidence and prevalence of chronic and degenerative diseases (Type II diabetes mellitus, cardiovascular disease, cancer and arthritis) is increasing. The CODSC would be a key player in establishing health goals and supporting Aboriginal peoples with public health expertise and resources. The CODSC and the Chief Public Health Officer of Canada will also have a central role in providing public health services to those areas falling under federal jurisdiction where local and provincial Chief Medical Officers of Health do not have access or authority. Airports, railways, military bases, aboriginal peoples living on reserve, federal meat packing plants and national parks are examples of areas under federal jurisdiction. The delivery of public health in these jurisdictions has been especially compromised by the lack of comprehensive coordination between provincial and federal systems. The CODSC must address this issue. Under the CMA’s plan, CODSC would become the lead national agency on public health matters with a broad mandate to co-ordinate all aspects of planning for national public health emergencies. It would also provide ongoing national health surveillance and work closely with provinces/territories to reinforce other essential public health functions. The Chief Public Health Officer of Canada would head the CODSC and act as the lead scientific voice for public health in Canada. To effectively carry out its mandate the CODSC’s structure must respect five guiding principles. It must be: * Independent – At arm’s length from government, insulated from day-to-day vagaries of political pressures while remaining accountable to Canadians. * Science-based – Adherence to the highest standards of risk assessment and decision-making with a view to safeguarding the health of Canadians. * Transparent – Open to public scrutiny and encouraging public participation in its activities. * Responsive – Characterized by a nimble decision-making process and a capability of deploying resources and expertise quickly and efficiently to any part of the country. * Collaborative – Partnership-oriented, fostering collaboration with other federal, provincial and non-governmental partners. There are three main options for the governance structure of the CODSC. Canadian and international precedents exist for each of the options. 1. Federal departmental entity Under this option, the CODSC would be created under federal legislation as a departmental branch or agency with the minister of health having general authority for its management and direction. The chief public health officer would be answerable to the minister and to the Prime Minister for the quality of management and advice provided by the office and for any actions taken by agency officials. This would not be very different from what already exists at Health Canada. The critical difference is that the CODSC would be a separate entity reporting to the minister of health, as opposed to the current structure where the Population and Public Health Branch is an entity within the department. Canadian examples: Canadian Food Inspection Agency, Pest Management Regulatory Agency International example: U.S. Centres for Disease Control and Prevention 2. National arm’s length agency This option consists of incorporating the office as a not-for-profit entity under the Canada Corporations Act (Part II), with the federal and provincial governments as members/shareholders. The CODSC would be structured on a corporate model with a board, and the chief public health officer acting as CEO. However, instead of direct accountability to Parliament, the office would be accountable to the Conference of F-P-T Ministers of Health. This option would signal a more radical departure from current arrangements and would make CODSC more of a joint venture with the provinces and territories. While the concept is intriguing, this model might place the management of national public health concerns too far from the ambit of governmental accountability. Canadian examples: Canadian Blood Services, Canadian Institute for Health Information, Canada Health Infoway, Canadian Coordinating Office for Health Technology Assessment 3. Federal arm’s length agency This middle option would consist of creating a more independent entity within the purview of the federal government. Under this approach, CODSC would be structured on a corporate model in which decision-making powers are vested in a board. The board, in turn, would be accountable to Parliament and the public for the exercise of these powers. The chief public health officer would be CEO and would oversee the day-to-day operation of the office. CODSC would be created through new federal legislation but would remain under the health portfolio, with accountability to Parliament through the health minister. Canadian examples: Canadian Institutes for Health Research, Canadian Centre for Substance Abuse, Hazardous Materials Information Review Commission International example: U.K. Health Protection Agency While each of the options discussed has strengths and weakness, a federal arm’s length agency would be the best fit with the CMA’s vision for the CODSC. It would mark a departure from the status quo in that the level of professional autonomy would increase and the level of ministerial involvement in professional issues would be reduced. This would contribute to making the CODSC more credible as a science-based organization. The board governance structure would encourage participation from the broader public health community and could therefore be more effective in creating partnerships with other key players. Illustration of a federal arm’s length agency CMA is very encouraged with the strong support for a Canadian public health agency shown by federal Health Minister Anne McLellan and her provincial /territorial counterparts following their most recent meeting. We also welcome their recognition of the need for significant resources to deliver the kind of integrated, collaborative national public health infrastructure needed to protect the health and safety of Canadians. 5 We have estimated the incremental cost of establishing and operating the CODSC to initially be $20 million over five years, over and above existing funding for programs that could be transferred to the new office such as emergency preparedness and response, and surveillance co-ordination. In its recent brief to the House of Commons Standing Committee on Finance 2003 pre-budget hearings, CMA asked that these monies be allocated immediately to allow for the creation of the CODSC within the next fiscal year. Recommendation Three That the federal government create a Canadian Office for Disease Surveillance and Control led by a Chief Public Health Officer of Canada to be the lead Canadian agency in public health, operating at arm’s length from government. Recommendation Four That the federal government allocate at least $20 million / 5 years with appropriate ongoing funding, over and above the funding for existing national public health programs, for the creation and operating expenses of the Canadian Office for Disease Surveillance and Control. Health Human Resource Capacity Enhancement The CMA has been speaking out on the impact of the shortage of physicians and other health care professionals on the acute care system for the last five years. In prior submissions to this Committee, to the House of Commons Committee on Finance and to the Royal Commission on the Future of Health Care in Canada, the CMA called for increased funding for the recruitment, education and on going training of physicians to address the current crisis in the acute care workforce. The SARS outbreak has clearly demonstrated that Canada’s public health workforce is especially thin. The shortage of community medicine and infectious disease specialists, nurses and laboratory technicians affects our capacity to respond to health threats. For the essential functions of the public health system to be realized, public health agencies need a workforce with appropriate and constantly updated skills. As the first line of defence against threats to the health of Canadians, the public health system must be able to respond quickly to an emergency with a skilled and trained workforce with sufficient numbers to meet the demands of the crisis. While Health Canada has made some limited progress to help address ongoing education needs of public health practitioners, there are virtually no resources currently dedicated to address public health emergency response skills or the essential cross-training that is critical during a public health crisis. Effective cross-training boosts surge capacity by equipping public health practitioners with knowledge and skills that can be called upon in times of public health emergency while allowing them to fulfil essential public health services at other times. CMA’s submission to the National Advisory Committee on SARS and Public Health has called for investment in multidisciplinary training programs in public health and the dissemination of best practices to public health professionals.6 But our country’s response to SARS also confirmed the co-dependent nature of the public health and acute care systems. The scarcity of hospital-based infection control practitioners, emergency physicians, nurses and technologists in the clinical and laboratory arenas within the acute care system were particularly striking during the SARS outbreak. This clearly demonstrated the need for a pre-planned approach to support and augment the public health and acute care workforce during a crisis. With essentially no plan in place to systematically shift human resources within the public health and acute care systems, we were ill prepared to move health professionals from other jurisdictions to respond to the crisis. Consequently Toronto public health and acute care professionals were stretched to their physical and mental limits. Recruitment of health care professionals to assist in the Greater Toronto Area depended, to a large degree, on volunteerism rather than co-ordinated efforts. Therefore, the CMA has proposed the establishment of a Canadian Public Health Emergency Response Service to work in collaboration with non-governmental health organizations like the CMA and the Canadian Public Health Association and function under the auspices of the Canadian Office for Disease Surveillance and Control.7 The Canadian Public Health Emergency Response Service would be made up of a core group of highly trained and mobile public health professionals, employed by the CODSC, able to carry out emergency response interventions as directed by the Chief Public Health Officer of Canada. But what SARS also clearly demonstrated was the need to be able to support and provide respite to the physicians and nurses overwhelmed by the influx of patients to acute care facilities and the accompanying institutional infection control measures. The CMA believes that the federal government must have access to a predetermined cadre of health care professionals willing to be deployed to provide acute care “locum” services during health emergencies. The CMA is well positioned to play an important part in recruiting physicians for an Emergency Relief Network. CMA’s MedConnexions online job matching service for health professionals, developed in partnership with Industry Canada, is a tool that could be used to disseminate information on the Network and collect contact information from physicians interested in volunteering to be deployed to provide local services. Volunteers would be asked to provide services that they normally provide, (for example, emergency medicine, intensive care, respirology, infection control) or other general services in affected areas to provide relief to staff that are stretched to the limit. Training in outbreak investigation would allow these individuals to also supplement the public health workforce in times of crisis. CMA would maintain control of the volunteer list and establish procedures to ensure that the information on the list is accurate and current. CMA would also undertake to determine that issues such as compensation (payment services and lost time [e.g., because of quarantine]), licensing, liability, disability coverage, logistics (travel and accommodation) are covered. CMA would contact members of the list in response to a request from the federal government through the CODSC. Recommendation Five That the federal government invests $250,000/ year on an ongoing basis to establish, in partnership with the profession, an Emergency Relief Network of physicians able to provide “locum” services during health emergencies. Recommendation Six That the federal government under the auspices of the Canadian Office for Disease Surveillance and Control provide funding for the training of physician volunteers in outbreak investigation. Surveillance and Communications The effectiveness of the public health system is also dependent, in large part, on its capacity to communicate authoritative information in a timely manner. A two-way flow of information between experts and the practising community is necessary at all times but becomes especially crucial during emergency situations. A well-functioning public health system will allow for this two-way communication — disease information to a central body that can analyze the aggregate data, and a capability to share aggressively and in real time the resulting analytical assessment with front line workers. A pan-Canadian surveillance system must be a fundamental component of the public health system. One of the keys to building a strong surveillance system is a robust connectivity with all points of health care. This would ensure real time notification through a pan Canadian health surveillance system of the occurrence of reportable diseases by front line health care workers throughout the country. All jurisdictions have embarked on information technology strategies that will build the connectivity to points of care over time. It is estimated that this work will take up to 10 years to complete and will require a $4 billion investment. Provinces and territories are at different stages of advancing this agenda and Ontario probably has the most progressive initiative. (It has committed to spending approximately $1 billion to put in place the pipelines that provide the connectivity and will cover the costs to carry the information traffic.) It is also important to note that Canada, as a World Health Organization member state, has international obligations in public health surveillance under the International Health Regulations (IHR). The IHR, introduced in 1969 to help monitor and control four serious diseases which had significant potential to spread between countries, involve: i. Notification of cases: * WHO Member States are obliged to notify WHO for a single case of cholera, plague or yellow fever, occurring in humans in their territories, and give further notification when an area is free from infection. * These notifications are reported in WHO's Weekly Epidemiological Record. ii. Health-related rules for international trade and travel. iii. Health organization: Measures for deratting, disinfecting, and disinsecting international conveyances (ships, aircraft, etc.) are to be implemented at points of arrival and departure (ports, airports and frontier posts). The health measures called for are the maximum measures that a state may apply for the protection of its territory against cholera, plague and yellow fever. iv. Health documents required: Requirements are included for health and vaccination certificates for travellers from infected to non-infected areas; deratting/deratting exemption certificates; health declarations- Maritime Declaration of Health; Aircraft General Declaration. 8 The IHR are currently under revision to include mandatory reporting of “public health emergencies of international concern”. 9 The health consequences of new infectious diseases are magnified because these public health threats cross local, provincial/territorial and national borders. Decisions made by one government have a direct impact upon the activities of adjacent governments. Canadian jurisdictions must co-ordinate their approaches to public health challenges to ensure they are effectively managed. Canada must ensure that our surveillance networks and public health infrastructure are up to the challenge in order to meet our international obligations to recognize and deal with emerging infectious diseases. In our submission to the National Advisory Committee on SARS & Public Health the CMA argued for a $1 billion infusion to rebuild the capacity of the public health system. Part of this investment is to help with the communication dimension of the connectivity problem. SARS highlighted the fact that Canada does not have information systems in place to facilitate real time communication with front line health professionals. Gaps in the basic communication infrastructure prevented public health agencies from interacting with each other in a timely manner. They also hindered exchanges between public health staff, private clinicians and other allied health workers about the latest information on the management of the disease. In addition, contact information, when it was there, was found to be seriously out of date and communications methods were not appropriately targeted to the end users. CMA learned some valuable lessons about how to provide real time communications to physicians. The health crisis resulted in the CMA mobilizing our communication networks to provide physicians with critical information about the public health management of SARS. Over 50,000 physicians received pertinent information on SARS over a 24-48 hour period of time. In addition, over 1500 health care facilities received critical authoritative information on SARS via the Canadian Council on Health Services Accreditation. For the first time in Canadian history an e-grand rounds initiative was launched to provide on line advice to physicians across this country in a format that they are familiar with. While the CMA succeeded in getting the information to physicians virtually in real time it was clear that the current infrastructure was inadequate. The CMA had to jury-rig a system that tied together disparate information lists and communications channels to move the information out to physicians. There was no guarantee the approach would work and there was no guarantee it would be timely. Luck was on our side. But we cannot continue to rely on luck; we must rely on sound management and planning. A stronger and more complete communications capacity to move information to physicians needs to be in place as soon as possible. This system has to ensure that the information is shared in a manner that respects the confidentiality and modality of how physicians would like to receive time sensitive information. One of the key lessons drawn from this latest emergency is that information is taken up by physicians in different ways. Some like to receive it by e-mail, others by fax and still others by mail. Even those with e-mail have expressed a desire to get emergency information in a different format. Iterative research will provide the information necessary to construct a solution that best maps how physicians work. There is a critical need to invest in data management infrastructure to maintain physician contact information (over 20% changes yearly) and build the correct modality channel to forward emergency information. This is a labour intensive process without which the assurance of reaching the majority of physicians would be compromised. The CMA has carried out an internal assessment on how it can best mobilize its own outreach capabilities coupled with those of its 12 divisions and has determined that with a one time investment of $250,000 for research, development and implementation of internal IT systems and ongoing operational funding of $100,000 a more robust, timely and assured connectivity with physicians will result. It is estimated that this connectivity could be built within the next twelve months. Recommendation Seven That the federal government partner with the CMA and the Canadian Council on Health Services Accreditation to ensure the capacity to communicate with physicians in real time during health emergencies. Recommendation Eight That the federal government invest in communication between professionals within the health care system through immediate funding for dedicated internet connectivity for all physicians in Canada. Conclusion SARS brought out the best in Canada and Canadians’ commitment to one another. It also turned a bright, sometimes uncomfortable spotlight on the ability of this country’s health care system to respond to a crisis, be it an emerging disease, a terrorist attack, a natural disaster or a large-scale accident. We must learn from the SARS experience and quickly move to build the infrastructure of a strong public health system. Different parts of the country have developed particular public health strengths and we can build on these strengths. With national leadership, commitment and resources, Canadians can have a well-functioning pan-Canadian public health system. The CMA believes that the federal government has a critical responsibility to ensure that the infrastructure for a strong public health system to serve all Canadians is in place. Summary of Recommendations 1. That the federal government rapidly move to enact a Canada Emergency Health Measures Act that would consolidate and enhance existing legislation, allowing for a more rapid national response, in co-operation 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 federal government invest in the country’s public health system with an immediate commitment of $ 1.5 Billion over five years to rebuild the public health infrastructure. 3. That the federal government create a Canadian Office for Disease Surveillance and Control led by a Chief Public Health Officer of Canada to be the lead Canadian agency in public health, operating at arm’s length from government. 4. That the federal government allocate $20 million / 5 years with appropriate ongoing funding, over and above the funding for existing national public health programs, for the creation and operating expenses of a Canadian Office for Disease Surveillance and Control. 5. That the federal government invest $ 250,000/ year on an ongoing basis to establish, in partnership with the profession, an Emergency Relief Network of physicians able to provide “locum” services during health emergencies. 6. That the federal government under the auspices of the Canadian Office for Disease Surveillance and Control provide funding for the training of physician volunteers in outbreak investigation. 7. That the federal government partner with the CMA and the Canadian Council on Health Services Accreditation to ensure the capacity to communicate with physicians in real time during health emergencies. 8. That the federal government invest in communication between professionals within the health care system through immediate funding for dedicated internet connectivity for all physicians in Canada. Appendix l (These documents available on the CMA website, under Submissions to Government) Answering the Wake-Up Call: CMA’s Public Health Action Plan, June 2003 Technical Backgrounders, July 21, 2003 Appendix ll WORLD MEDICAL ASSOCIATION Latest releases: 15 September 2003 Action Urged to Improve Response to World Health Epidemics The World Health Organisation has been urged by physicians of the World Medical Association to enhance its emergency response protocol to deal with world epidemics such as Sars. Meeting in Helsinki for their General Assembly, WMA delegates from almost 50 countries were critical of the way in which the Sars epidemic was handled earlier this year and in particular the failure of WHO to involve physicians early enough. The WMA Assembly called on the WHO to provide for the "early, ongoing and meaningful engagement and involvement of the medical community globally, including initiating immediate discussion on the establishment of an effective and real time means of communicating reliable, evidence-based information to front line workers and the establishment of reliable sources of products and materials needed to safeguard the health of front line workers and their patients". The WMA has also agreed to develop a public health risk alert plan covering areas of communications, preventive measures for physicians and patients, best practice in terms of diagnostic and therapeutic methods and evidence-based travel advice for the public. The plan is to be drawn up by a working group headed by the Canadian Medical Association, which, at the height of the Sars epidemic in Canada, managed to contact 26,000 physicians via e mail and the internet. The CMA described the World Medical Association's new resolution as "a wake up call to the world". The WMA has now invited all national medical associations to share the lessons learned during the Sars epidemic by providing details of measures taken in their countries to strengthen the responsiveness of their public health systems. Printed from: http://www.wma.net/e/press/2003_20.htm 1 Emergencies Act, R.S.C. 1985, c.22 (4th Supp), s. 5. “National emergency” is defined in section 3 as “an urgent and critical situation of a temporary nature that (a) seriously endangers the lives, health or safety of Canadians and is of such proportions or nature as to exceed the capacity or authority of a province to deal with it, or (b) seriously threatens the ability of the Government of Canada to preserve the sovereignty, security and territorial integrity of Canada, and that cannot be effectively dealt with under any other law of Canada.” (Emergencies Act, R.S.C. 1985, c.22 (4th Supp) section 3). 2 See Appendix 1: Technical Backgrounders to Answering the Wake-Up Call: CMA’s Public Health Action Plan for details on the Emergency Health Alert System. 3 The FPT Advisory Committee on Population Health recommended the following as essential functions of the public health system: population health assessment; health surveillance; health promotion; disease and injury prevention; health protection. 4 Many countries (e.g., United States, United Kingdom, Norway and the Netherlands) have developed a critical mass 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. 5 McLellan promises health cash injection, A4, The National Post, 04-09-2003 6 Recommendation 4 of Answering the Wake-Up Call: CMA’s Public Health Action Plan: 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. 7 Recommendation Five of Answering the Wake-Up Call: CMA’s Public Health Action Plan: 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. 8 http://www.who.int/csr/ihr/current/en/print.html accessed September 15, 2003 9 (http://www.who.int/csr/ihr/revision/en/print.html) accessed July 4, 2003
Documents
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Expansion of the health care system through new funding

https://policybase.cma.ca/en/permalink/policy332
Last Reviewed
2019-03-03
Date
1998-09-09
Topics
Health systems, system funding and performance
Resolution
GC98-32
That expansions or broadening of the health care system should be done with new funding and not through reallocations from medical care budgets.
Policy Type
Policy resolution
Last Reviewed
2019-03-03
Date
1998-09-09
Topics
Health systems, system funding and performance
Resolution
GC98-32
That expansions or broadening of the health care system should be done with new funding and not through reallocations from medical care budgets.
Text
That expansions or broadening of the health care system should be done with new funding and not through reallocations from medical care budgets.
Less detail

Fees for on call service

https://policybase.cma.ca/en/permalink/policy442
Last Reviewed
2019-03-03
Date
1998-09-09
Topics
Health systems, system funding and performance
Health human resources
Resolution
GC98-44
That the Canadian Medical Association support in principle that fees be paid to physicians for the service of being on call.
Policy Type
Policy resolution
Last Reviewed
2019-03-03
Date
1998-09-09
Topics
Health systems, system funding and performance
Health human resources
Resolution
GC98-44
That the Canadian Medical Association support in principle that fees be paid to physicians for the service of being on call.
Text
That the Canadian Medical Association support in principle that fees be paid to physicians for the service of being on call.
Less detail

Primary care renewal

https://policybase.cma.ca/en/permalink/policy110
Last Reviewed
2017-03-04
Date
2003-08-20
Topics
Health systems, system funding and performance
Resolution
GC03-23
That Canadian Medical Association strongly advocate to federal/provincial/territorial governments and their agents that any new policy on primary care renewal/reform be based on evidence from valid studies that are formally, independently and objectively evaluated through pilot projects.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
2003-08-20
Topics
Health systems, system funding and performance
Resolution
GC03-23
That Canadian Medical Association strongly advocate to federal/provincial/territorial governments and their agents that any new policy on primary care renewal/reform be based on evidence from valid studies that are formally, independently and objectively evaluated through pilot projects.
Text
That Canadian Medical Association strongly advocate to federal/provincial/territorial governments and their agents that any new policy on primary care renewal/reform be based on evidence from valid studies that are formally, independently and objectively evaluated through pilot projects.
Less detail

Resources for health emergencies

https://policybase.cma.ca/en/permalink/policy115
Last Reviewed
2017-03-04
Date
2003-08-20
Topics
Health systems, system funding and performance
Resolution
GC03-28
That Canadian Medical Association urge governments at all levels to ensure adequate investments in the human infrastructure and training resources needed to maintain an effective, co-ordinated system for detecting and preventing and responding to health emergencies.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
2003-08-20
Topics
Health systems, system funding and performance
Resolution
GC03-28
That Canadian Medical Association urge governments at all levels to ensure adequate investments in the human infrastructure and training resources needed to maintain an effective, co-ordinated system for detecting and preventing and responding to health emergencies.
Text
That Canadian Medical Association urge governments at all levels to ensure adequate investments in the human infrastructure and training resources needed to maintain an effective, co-ordinated system for detecting and preventing and responding to health emergencies.
Less detail

Shortage of primary care physicians

https://policybase.cma.ca/en/permalink/policy124
Last Reviewed
2017-03-04
Date
2003-08-20
Topics
Health systems, system funding and performance
Health human resources
Resolution
GC03-69
That Canadian Medical Association in its strategic planning process identify as a priority the crisis in primary medical care delivery and study the ongoing loss of physicians providing comprehensive primary medical care and develop a strategy to reverse this pattern.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
2003-08-20
Topics
Health systems, system funding and performance
Health human resources
Resolution
GC03-69
That Canadian Medical Association in its strategic planning process identify as a priority the crisis in primary medical care delivery and study the ongoing loss of physicians providing comprehensive primary medical care and develop a strategy to reverse this pattern.
Text
That Canadian Medical Association in its strategic planning process identify as a priority the crisis in primary medical care delivery and study the ongoing loss of physicians providing comprehensive primary medical care and develop a strategy to reverse this pattern.
Less detail

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