Primary care is the backbone of our health care system in Canada and a national priority for this government.
The echoing words of the Speech from the Throne certify that the Government will strengthen health care and “Work with provinces, territories, health professionals and experts in industry and academia to make sure that all Canadians can access a primary care family doctor.” The Health Minister’s mandate letter further confirms that the Government will work “with the support of the Deputy Prime Minister and Minister of Intergovernmental Affairs, the Minister of Finance and the Minister of Seniors, to strengthen Medicare and renew our health agreements with the provinces and territories” to “ensure that every Canadian has access to a family doctor or primary health care team”.
We recognize that strengthening primary care through a team-based, inter-professional approach is integral to improving the health of all people living in Canada. This belief is consistent across our alliance of four major groups: the Canadian Medical Association, the Canadian Nurses Association, the Canadian Association of Social Workers and the College of Family Physicians of Canada. There is nothing more suiting or fortunate than for a team-based approach to be wholeheartedly supported by an even larger team of teams.
We commend the Government’s commitment
to increasing Canadians’ access to primary care.
We have a model to make it happen.
The Primary Health Care Transition Fund 2, a one-time fund over four years, would provide the necessary funding to help establish models of primary care based on the Patient’s Medical Home, a team-based approach that connects the various care delivery points in the community for each patient. This model is rooted in the networking of family physicians, nurse practitioners, nurses, social workers and other health professionals as a team. This is the only way to provide comprehensive primary care to patients. It will enable a more exhaustive approach to patient care, ultimately leading to increased prevention and better health outcomes for Canadians. Consider it the main artery
in meeting the needs of patients and communities.
A commitment to the Primary Health Care Transition Fund 2 gives substance to the promise of building a network of care that addresses immediate health needs while connecting to ongoing social and community health services. This Fund model bolsters Canadians. It is backed by doctors, nurses, and social workers. A phalanx of Canadian care providers stand behind it. An entire country will benefit from it.
In support of the federal government’s commitment to improve Canadians’ access to primary care,
we recommend a one-time fund in the amount of $1.2 billion over four years to expand the establishment of primary care teams in each province and territory.
The Canadian Medical Association (CMA) and its Quebec office are pleased to provide this submission to the Committee on Transportation and the Environment on Bill 44: An Act mainly to ensure effective governance of the fight against climate change and to promote electrification. The CMA maintains that governance of the fight against climate change will not be effective unless it integrates the health impacts on the Quebec population. Physicians in Quebec, across Canada, and around the world have a unique role to play in helping advance government and public understanding of the health consequences of climate change and in supporting the development of effective public health responses. The CMA’s submission provides recommendations to better prepare and mitigate the impacts of a changing climate on people’s health and the health care system in Quebec.
How Climate Change Affects Health
The World Health Organization has identified climate change as the biggest threat to global health.
1 In Canada, the immediate health effects of climate change are a growing concern. In this century, Canada will experience higher rates of warming in comparison to other countries around the world. Northern Canada, including northern Quebec (Nunavik), will continue to warm at more than triple the global rate. These warming conditions will lead to an increase in extreme weather events, longer growing seasons, melting of the permafrost, and rising sea levels.2
Physicians are at the front lines of a health care system that is seeing growing numbers of patients experiencing health problems related to climate change, including heat-related conditions, respiratory illnesses, infectious disease outbreaks and impacts on mental health. For example, the heat wave in southern Quebec in 2018 was linked to over 90 deaths.3
Examples of the extent of this issue include:
The number of extremely hot days is expected to double or triple in some parts of Canada in the next 30 years and will lead to an increase in heat-related impacts (e.g., heat stroke, myocardial infarction, kidney failure, dehydration, stroke).4
Air pollution contributes to approximately 2,000 early deaths each year in Quebec by way of heart disease, stroke, lung cancer, and respiratory disease (such as aggravated asthma).5
An increase in vector-borne diseases such as Lyme disease has increased significantly in Quebec, with the number of cases increasing from 125 in 2014 to 338 in 2018.6
Extreme weather events are increasing in frequency, intensity and duration across Quebec and can negatively impact mental health (e.g., anxiety, depression and post-traumatic stress disorder),7 as well as place additional strain on the health care system.
Increasing temperatures are affecting the ice roads used in winter, and other roads built on permafrost in northern Quebec, threatening food security.8
There are sub-populations that are more susceptible to the health-related impacts of climate change. For example, in northern Quebec, climate change is already increasing health risks from food insecurity due to decreased access to traditional foods, decreased safety of ice-based travel, and damage to critical infrastructure due to melting permafrost. For the rest of Canada, the health impacts vary by geographic region, but include a list of issues such as increased risk of heat stroke and death, increases in allergy and asthma symptoms due to a longer pollen season, mental health implications from severe weather events, and increases in infectious diseases, UV radiation, waterborne diseases and respiratory impacts from air pollution. 9
Seniors, infants and children, socially disadvantaged individuals, and people with existing medical conditions such as cardiovascular disease, are at greater risk of being affected by climate change. The susceptibility of a population to the effects of climate change is dependent on their existing vulnerabilities and their adaptive capacity. 10,11
Figure 1. Examples of Health Impact of Climate Change in Canada5
Climate Change: A Health Emergency
Recent polls have demonstrated that Canadians are very concerned about climate change and its impact on health. A 2017 poll commissioned by Health Canada revealed that 79% of Canadians were convinced that climate change is happening, and of those people 53% accepted that it is a current health risk and 40% believe it will be a health risk in the future.12 As well, a 2019 poll commissioned by Abacus Data reports that Quebecers are the most anxious about climate change and think about the climate more often than people living in the rest of Canada. The same poll reports that 59% of people in Quebec believe that climate change is currently an emergency and 12% reported that it will likely become an emergency in a few years.13 These numbers are not surprising considering the intensity and frequency of extreme weather events in Quebec in recent years. The CMA believes climate change is a public health crisis. Over the past few years in Canada, there have been numerous extreme climate events, such as wildfires in British Columbia,
extreme heat waves in Quebec, and storm surges on the east coast. In southern Quebec, a changing climate has also increased the range of several zoonoses, including blacklegged ticks, which are vectors of Lyme disease.14 Physicians across Quebec are seeing patient outcomes affected by the changing climate and are advocating for change. The health impacts of climate change were raised at last year’s COP25 meeting in Madrid, Spain, among an international group of leading environment and health stakeholders, including the CMA. The group collectively called on governments to broaden the scope of their climate change initiatives and investments to include health care.
A lack of progress in reducing greenhouse gas emissions and building adaptive capacity threatens both human lives and the viability of health systems, with the potential to disrupt core public health infrastructure and overwhelm health services, not to mention the economic and social costs. In Quebec, the research consortium Ouranos estimated in 2015 that extreme heat, Lyme disease, West Nile virus and pollen alone will cost the Quebec state an additional $609 million to $1,075 million,15 and could result in up to 20,000 additional lives lost within the next 50 years.
Canada is currently not on track to meet the international targets set out by the Paris Agreement.16 The 2019 report from Lancet Countdown, the largest international health and climate research consortium, states that continued inaction on meeting the targets set out by the Paris Agreement will result in the health of a child born today being impacted negatively by climate change at every stage of its life.
The CMA recommends that adaptation and mitigation measures be prioritized to limit the effects of climate change on public health.
Hearing Health Care Professionals on Climate Change Last June, the CMA was pleased with the announcement made by the Minister of the Environment and the Fight Against Climate Change, Benoit Charette, to create a task force to ensure effective governance of the fight against climate change, including meeting Quebec’s international climate targets.17 Climate change crosses multiple sectors and requires experts from diverse backgrounds to create solutions to adapt and mitigate the impacts of climate change. Considering the overwhelming evidence of the impacts of climate change on human health, it is paramount that a health representative sits on the committee that will be advising the Minister. Physicians and health professionals have a critical role to play in advancing public understanding of the potential impacts of climate change on health and promoting appropriate actions aimed at protecting the health of Canadians. Physicians believe that what’s good for the environment is also good for human health. Protecting human health must be at the core of all environmental and climate change strategies within Quebec.
Recommendation 2: The CMA recommends that a health representative sit on the committee that will be advising the minister.
Dedicated Funding for a Greener Health Care System
The 2019 Lancet Countdown on Health and Climate Change reports that Canada has the third-highest per capita greenhouse gas emissions coming from its health care sector in the world. Health care related emissions account for approximately 4.5% of the country’s total emissions. Hospitals produce a significant proportion of health sector emissions as they are always on, are resource intensive, and have strict ventilation standards. Hospital services also produce large amounts of waste through the use of single-use items (e.g., hospital gowns and surgical supplies).
To remedy this problem, the CMA recommends that experts from research, education, clinical practice, and policy work together to reduce greenhouse gas emissions and that funding be dedicated to measuring the carbon footprint of different institutions and addressing these issues. Health care providers are uniquely positioned to advocate for innovative solutions that will help reduce greenhouse gas emissions by the health sector and improve public health.18 By reducing greenhouse gas emissions from the health system, the Quebec government will better position itself to be consistent with the timelines and goals of the Paris Agreement for zero-emissions for healthcare by 2050.19
The CMA recommends that a portion of the Green Fund’s budget be dedicated to the greening of health systems.
The CMA’s submission highlights the need to better prepare and mitigate the health impacts of a changing climate, as well as the need for a health representative to advise the minister, and the allocation of funding for the greening of health systems in Quebec. Physicians are in a unique position to help the government develop strategies to mitigate the impacts of climate change and ultimately improve population health.
Summary of recommendations
The CMA recommends that adaptation and mitigation measures be prioritized to limit the effects of climate change on public health.
The CMA recommends that a health representative sit on the committee that will be advising the minister.
The CMA recommends that a portion of the Green Fund’s budget be dedicated to the greening of health systems.
1 Costello A, Abbas M, Allen A, Ball S, et al. The Lancet and University College London Institute for Global Health Commission, The Lancet, 2009;373( 9676):1693-1733. Available: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60935-1/fulltext (accessed 2020 Jan 25).
2 Government of Canada. Canada’s Changing Climate Report. Ottawa: Government of Canada; 2019. Available: https://www.nrcan.gc.ca/sites/www.nrcan.gc.ca/files/energy/Climate-change/pdf/CCCR_FULLREPORT-EN-FINAL.pdf (accessed 2020 Jan 25).
3 Institut national de santé publique du Québec. Surveillance des impacts des vagues de chaleur extrême sur la santé au Québec à l’été 2018 [French only]. Québec : Institut national de santé publique du Québec; 2018. Available: https://www.inspq.qc.ca/bise/surveillance-des-impacts-des-vagues-de-chaleur-extreme-sur-la-sante-au-quebec-l-ete-2018 (accessed 2020 Jan 25).
4 Guilbault S, Kovacs P, Berry P, Richardson G, et al. Cities adapt to extreme heat: celebrating local leadership. Ottawa: Health Canada Institute for Catastrophic Loss Reduction; 2016. Available: https://www.iclr.org/wp-content/uploads/PDFS/cities-adapt-to-extreme-heat.pdf (accessed 2020 Jan 25).
5 Health Canada. Health Impacts of Air Pollution in Canada--an Estimate of Premature Mortalities. Ottawa: Health Canada; 2017. Available: https://www.canada.ca/en/health-canada/services/air-quality/health-effects-indoor-air-pollution.html (accessed 2020 Jan 25).
6 Santé et services sociaux Québec. Maladie de Lyme. Tableau des cas humains – Archives 2014 à 2018. [French only]. Available: https://www.msss.gouv.qc.ca/professionnels/zoonoses/maladie-lyme/tableau-des-cas-humains-lyme-archives/ (accessed 2020 Jan 25).
7 Cunsolo A, Ellis N. Ecological grief as a mental health response to climate change-related loss. Nature Climate Change 2018;8:275-81.
8 Rosol R, Powell-Hellyer S, Chan HM. Impacts of decline harvest of country food on nutrient intake among Inuit in Arctic Canada: impact of climate change and possible adaptation plan. Int J Circumpolar Health 2016;75(1):31127. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4937722/pdf/IJCH-75-31127.pdf (accessed 2020 Jan 25).
9 Howard C, Buse C, Rose C, MacNeill A, Parkes, M. The Lancet Countdown on Health and Climate Change: Policy Brief for Canada. London: Lancet Countdown, Canadian Medical Association, and Canadian Public Health Association, 2019. Available: https://storage.googleapis.com/lancet-countdown/2019/11/Lancet-Countdown_Policy-brief-for-Canada_FINAL.pdf. (accessed 2020 Jan 25).
10 Canadian Medical Association (CMA). CMA Policy. Climate Change and Human Health. Ottawa: CMA; 2010. Available: https://policybase.cma.ca/en/permalink/policy9809 (accessed 2020 Jan 25).
11 Health Canada. Climate Change and Health. Ottawa: Health Canada; 2020. Available: https://www.canada.ca/en/health-canada/services/climate-change-health.html (accessed 2020 Jan 26).
12 Environics Health Research. Public Perceptions of Climate Change and Health Final Report. Ottawa: Health Canada; 2017.
13 Abacus Data. Is Climate Change “An Emergency” and do Canadians Support a Made-in-Canada Green New Deal? Ottawa: Abacus Data; 2019. Available: https://abacusdata.ca/is-climate-change-an-emergency-and-do-canadians-support-a-made-in-canada-green-new-deal/ (accessed 2020 Jan 26).
14 Howard C, Rose C, Hancock T. Lancet Countdown 2017 Report: Briefing for Canadian Policymakers. Lancet Countdown and Canadian Public Health Association. Available: https://storage.googleapis.com/lancet-countdown/2019/10/2018-lancet-countdown-policy-brief-canada.pdf. (accessed 2020 Jan 25).
15 Ouranos. Vers l’adaptation. Synthèse des connaissances sur les changements climatiques au Québec [French only]. Montreal: Ouranos; 2015. Available: https://www.ouranos.ca/publication-scientifique/SyntheseRapportfinal.pdf (accessed 2020 Jan 25).
16 Government of Canada. Greenhouse Gas Emissions. Ottawa: Government of Canada; 2018. Available: https://www.canada.ca/en/environment-climate-change/services/environmental-indicators/greenhouse-gas-emissions.html (accessed 2020 Jan 26).
17 Gouvernment du Québec. Press Release: Minister Benoit Charette announces an unprecedented process to develop the forthcoming Electrification and Climate Change Plan. Québec: Gouvernment du Québec;
2019. Available: http://www.environnement.gouv.qc.ca/infuseur/communique_en.asp?no=4182 (accessed 2020 Jan 26).
18 Eckelman MJ, Sherman JD, MacNeill AJ. Life cycle environmental emissions and health damages from the Canadian healthcare system: An economic-environmental-epidemiological analysis. PLoS Med 2018;15(7):e1002623. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6067712/pdf/pmed.1002623.pdf (accessed 2020 Jan 25). (accessed 2020 Jan 26).
19 Intergovernmental Panel on Climate Change (IPCC). Global Warming of 1.5C--Summary for Policymakers, France: IPCC; 2018. Available: https://www.ipcc.ch/sr15/ (accessed 2020 Jan 25).
Subject: Improving Long-term Care for People in Canada
Dear Minister Hajdu and Minister Schulte,
We are writing to you with recommendations for responding to the staggering effects COVID-19 has had on our health-care system, particularly in long-term care (LTC) homes across Canada. These recommendations were recently unveiled by the Canadian Nurses Association (CNA) on May 27 through a report entitled 2020 Vision: Improving Long-term Care for People in Canada (attached to this letter). We invite you to read it and consider the proposals we are bringing forward.
As you know, Canada has had unacceptable rates of COVID-19-related deaths in LTC; by late April, 79% of the country’s deaths due to COVID-19 were linked to outbreaks in these homes. These tragic numbers are in part a result of decades of neglect of the LTC sector and a growing mismatch between the level of care required by people living in those settings, and the level of care available. Furthermore, the recent reports from the military deployed to Ontario and Quebec’s long-term care homes have emphasized the shocking and horrific conditions that exist in some nursing homes in Canada.
We applaud the Prime Minster’s recent commitment to work closely and support the province’s efforts to improve standards of care for older people in long-term care
homes across the country. Moreover, further decisive action needs to be undertaken. To address the flaws COVID-19 has revealed in the support and care systems available to Canada’s older people, we recommend that your Government take immediate action on three important fronts:
The Government of Canada should immediately appoint a commission of inquiry on aging;
Federal public health leaders must work with provincial, territorial and Indigenous governments and public health leaders to review the country’s COVID-19 response and organize preparations for the next pandemic;
Federal, provincial and territorial governments must increase investments in community, home and residential care to meet the needs of our aging population.
As the Prime Minister indicated last week, providing support in the short term and having broader discussions in the long term is critical. We believe many solutions can be put in place now in some long-term care homes if they had better funding, for example. In the long term, a deeper look to identify the best models for delivering better health and social services will support safe and dignified aging for every person in Canada.
We recognize the challenges involved to address the issues in the support and care systems for older people in Canada. The benefits of redesigning how we provide care for older people (Canada’s largest growing demographic) and others with complex continuing care needs will go beyond improving their lives and health. A good long-term care system, in tandem with effective, well-organized community and home care, will ease pressure on the acute-care system and eliminate many of the gaps in the continuum of care that too often result in previously independent older people landing in the hospital or long-term care.
Acting on these three recommendations will help to provide a solid foundation on which to build a safe and dignified future for Canada’s older people. Canada is known
for its humanitarian work around the world. It’s time we brought those values home, to care for the people to whom this country and each one of us owes so much.
We look forward to discussing these proposals with you and your staff as soon as possible. Sincerely,
RN, MN, PhD, CCHN(C) President Canadian Nurses Association
RN, BSN, MN, PhD(c) President,
Canadian Association for Rural and Remote Nursing
Canadian Association of Social Workers
RN, BN, ASMH, Med President Canadian Family Practice Nurses Association
RPN, MN, PhD(c)President,
Lori Schindel Martin,
RN, PHD President
Canadian Gerontological Nursing Association
BN, RN, CPMHN(C) Past President
Canadian Federation of Mental Health Nurses
RN, BScN, President
Canadian Indigenous Nurses Association
MD CCFP (PC) FCFP President Canadian Medical Association
Canadian Public Health Association
Miranda R Ferrier
MD CM, CCFP, FCFP, CAE, ICD. D
Executive Director & Chief Executive Officer College of Family Physicians of Canada
Ontario Personal Support Workers Association
Canadian Support Workers Association
RPN-GPNC(C), BAHSc (Hons), MHSc(c)
Professional Advocacy Director
Gerontological Nursing Association
MN, NP, President NPAC-AIIPC
Nurse Practitioner Association of Canada
My name is Dr. Isra Levy, and as a public health physician and the Chief Medical Officer and Director in the Canadian Medical Association's Office for Public Health, I am pleased to be participating in your roundtable today. With me is Mr. John Wellner, Director, Health Policy at our sister organization the Ontario Medical Association.
CEPA is, of course, a key piece of Environmental Legislation, but we at the CMA see it to be primarily about health.
Similarly, Canada's doctors see the topic of today's hearings, "Measuring CEPA's Success" in terms of the impacts on our medical practices and, more particularly, on our patients. To us the measurement of success that matters is good health in our patients. And unfortunately I must tell you that we still see the negative impacts of environmental degradation on our vulnerable patients every day.
We are pleased to participate in this review of CEPA, because for us, the measure of health benefits and health outcomes, over the short or long-term that stem from reduced exposure to environmental contaminants is an important measure of our health as a nation.
The Canadian Medical Association, first founded in 1867, currently represents more than 63,000 physicians across the country. Our mission includes advocating for the highest standard of health and care for all Canadians and we are committed to activities that will result in healthy public policy. The environment, as a determinant of health, is a major concern for the general public as well as health care providers.
And health outcomes are directly linked to the physical environment in many, many ways. We know from the crises in Walkerton, Collingwood, North Battleford and many First Nations communities, the devastating effects that contaminated water can have on individuals and families.
We know from the smog health studies undertaken by the OMA, Health Canada and others, about the public health crisis of polluted air in many parts of Canada. And it is a crisis. We are now in a position where science allows us to more clearly show the long-term, lifetime burden of morbidity caused by some of these pollutants; we now know that there are thousands more premature deaths caused by air pollution in Canada than has previously been appreciated.
We are learning that central Canada is not the only place that has a smog problem. The OMA has shown, through its Illness Costs of Air Pollution model, that it is plausible to think in terms of substantial costs to the health and pocketbooks of Canadians because of environmental risks across the country.
The CMA has developed many environmental policies that are pertinent to our CEPA discussion today.
* Prior to Canada's ratification of the Kyoto Protocol, the CMA urged the Prime Minister to commit to choosing a climate change strategy that satisfies Canada's international commitments while maximizing the clean air co-benefits and smog-reduction potential of any greenhouse gas reduction initiatives.
We realize that pollution prevention initiatives can have many health benefits and that pollution sources seldom emit contaminants in isolation. The smoke that you see, and often emissions that you can't see, represent a cocktail of potentially harmful substances.
* The CMA has committed to working with the federal Ministers of health and the Environment to develop national strategies to reduce the unacceptably high levels of persistent organic pollutants amongst the peoples of the Arctic coast.
* We have asked Environment Canada and Health Canada to initiate a review of the current Canadian one hour guideline for maximal exposure level to both indoor and outdoor NO2 and recommend that the federal Environment and Health Ministers commit their departments to improved health-based reporting by regularly updating the health effects information for pollutants of concern.
Let me return to the issue of measuring success though -
Doctors understand the concept that success from an intervention can be nuanced. In the case of disease, physicians know and accept that the benefit of treatment is not always cure of a patient. Sometimes we just reduce their symptoms, or slow their rate of decline.
But when treating the natural environment, so critical to human health, we suggest that you cannot accept a palliative solution. We must aim for cure. We urge you to commit to measures of success in terms of real improvement, rather than merely accepting slight curtailments in the "inevitable increase" of environmental contamination.
The issue of greenhouse gas reduction is one that illustrates this point. Just as slowing the progression of a disease can never be considered a cure, referring to an "inevitable increase" in emissions and attempting only to limit the growth of those emissions, cannot result in true success by any measure.
We have seen 'good news' press releases on environmental initiatives from various federal and provincial governments, but the news isn't always worthy of praise.
Although there have been some great environmental successes that Canadians should be proud of, the measure of overall success - on all contaminants of concern - has only been incremental at best.
For example, when policy makers speak about industrial emission reductions of any kind, they often refer to "emissions intensity" - the emissions per unit of production, rather than total, overall emissions. To be health-relevant, the only meaningful way to report emissions reductions is to present them as "net" values, rather than the all-to-common "gross" valuation. An emission reduction from a particular source is only health-relevant if we can guarantee that there is not a corresponding emissions increase at another source nearby, because it is the absolute exposure that an individual experiences that affects the risk of an adverse health effect.
This issue becomes especially tricky with regional pollutants like smog precursors, because you may have to take the whole air shed into account. For this reason, cross- jurisdictional pollution control initiatives are very important in Canada - and that means federal oversight. In fact, to our understanding, that is what CEPA does, it gives the federal government jurisdictional authority, and, dare I say, obligation to act to protect the health of Canadians.
To the CMA, and we believe to most Canadians, the real measure of success is a reduction in the illnesses associated with pollution. It is not just important how we measure this ultimate success, but how we measure our progress towards it.
Environmentally related illness is essentially the combined result of exposure and vulnerability.
We are vulnerable because we are human beings; each human being has different physical strengths and weaknesses. Some vulnerabilities to environmental influences are genetic, and some the results of pre-existing disease. There is not much that government can do about this part of the equation.
Our exposure, on the other hand is related to the air we breathe, water we drink and food we eat. This is where CEPA comes in. This is where your role is critical, and where the measures of success will be the most important.
Proxy measures for the health outcomes that matter must be relevant from a health perspective. Health-based success can only be measured by quantifiable reductions in the exposure levels of contaminants in our air, water and foods.
Canada has historically relied only on guidelines for contaminants of concern, memoranda of understanding with polluters and voluntary goals and targets. Our American neighbours prefer legally binding standards, strict emission monitoring, and pollution attainment designations. While there may be some benefit to the Canadian approach, we are clearly behind in this area. In many parts of the U.S., counties try desperately to avoid "non-attainment" designations based on the ambient air pollution target levels. If they are designated to be a non-attainment zone they risk loss of federal infrastructure transfer payments.
In Canada, we have Canada-Wide smog Standards for 2010 - but of course these are non-binding, have no penalties for non-attainment, provide loopholes for any jurisdictions claiming cross-border pollution influences and allow provinces to opt-out with a mere three months notice. We must be more forceful. Indeed sufficient evidence exists on the health effects of a wide-range of CEPA-Toxic substances (smog precursors, for example) to justify more forceful action to reduce exposures. And there are many more chemicals of concern, for which all the evidence may perhaps not yet be in, but which require a precautionary approach in order to prevent potential human harm.
So, although the presentation of environmental information (e.g., ambient pollution levels in a State of the Environment report, or a health-based Air Quality Index) is beneficial and may provide information that enables Canadians to reduce their exposures, ultimately this is not enough.
The CMA believes that although enhanced environmental monitoring or pollutant exposure studies are important to our understanding of some contaminants, such studies in and of themselves will not improve the health of our patients. The true measure of success would go beyond reporting the danger, to actually reducing the danger. The CMA believes that is the purpose of CEPA.
We look forward to working with you to improve CEPA and ensure that the measures of CEPA's success will benefit the health of our patients across Canada.
Canadian Medical Association Ottawa, June 12, 2006
While my remarks today will focus on the recognition of foreign credentials, mainly with reference to the medical profession with which I am most familiar, I want to emphasize that this is just one element of assuring a sustainable health workforce in Canada as my colleagues will be amplifying in greater detail.
I want to impress upon Members of the Committee that the CMA does not test, credential, license or discipline physicians, nor is it empowered to act on complaints made by patients - this is the purview of the provincial/territorial licensing bodies. We are not directly involved in provincial or territorial benefit negotiations for physicians - this is the responsibility of our provincial/territorial Divisions. Nor do we control medical school enrolment or conduct clinical research.
What we do, is carry out research and advocacy on short, medium and long term health and health care issues to ensure we can meet the current and emergent needs of Canadians.
CONTRIBUTIONS OF INTERNATIONAL MEDICAL GRADUATES TO CANADA
I would like to begin by dispelling the popular myth that Canada is a "closed shop" to persons with international medical credentials. In fact Canada has always relied on International Medical Graduates to make up a significant proportion of the medical workforce; this proportion has remained fairly steady at about one in four physicians for the past few decades.
(Currently 23%). Our best estimate is that some 400 IMGs are newly licensed to practice in Canada each year. In fact, the College of Physicians and Surgeons of Ontario, has for the past two years licensed more IMGs that Ontario medical graduates.
A corollary of this myth is that IMGs are unable to access the postgraduate medical training system to complete any supplementary training they might need. In the Fall 2005, of the some 7,800 postgraduate trainees in Canada just over 900 or 12% were IMGs. Many more are participating in special assessment/supervised practice programs in the community.
The fact of the matter is that Canada has historically trained fewer physicians than we need to meet our population needs. This can be clearly demonstrated by looking at relative opportunity to enter medical school. In the most recent year (2005/2006) Canada had 7.1 first year medical school places per 100,000 population. This level is just over one-half of that of the United Kingdom, with its 12.9 places per 100,000 population. While the United States has the same ratio of medical school places per 100,000 population as Canada - it has 1.5 first year postgraduate places per medical graduate and relies on bringing large numbers of IMGs in to fill these places and supplement production in this manner.
Not only is Canadian undergraduate medical education capacity inadequate, but postgraduate medical training capacity is similarly insufficient to meet the demands of training Canadian medical graduates, providing training to IMGs, and permitting Canadians to retrain in specialties. In 2006 of the 932 IMGs registered in the second iteration run by the Canadian Resident Matching Service, just 111 or 12% were successful in obtaining a training position. There is clearly a backlog of IMGs who are eligible to receive the supplementary training they need to become eligible for licensure to practice in Canada should sufficient capacity be available.
For those who are not eligible, opportunities should be provided to achieve credentials in other health professions such as physician assistants or paramedics. A recent pilot project in Ontario was funded to allow IMGs to qualify and work as physician assistants in supervised practice settings.
Against this backdrop, it is no small wonder that Canada ranks 26th out of 29 OECD countries in the ratio of physicians per 1,000 population. For the past decade Canada's ratio has stood at 2.1 physicians per 1,000 population - one-third below the OECD average of 3.0 in 2003.
Over the years, medicine has worked hard to promote national standards for medical education and the practice of medicine in Canada.
Since 1912 the Medical Council of Canada (MCC) has been responsible for promoting a uniform standard qualification to practice medicine for all physicians across Canada. This qualification, known as the Licentiate of the Medical Council of Canada (LMCC) is obtained by being successful on a two-part Qualifying Examination.
While licensure of physicians is a provincial/territorial responsibility, there is a national standard for portable eligibility for licensure that was adopted in 1992 by the Federation of Medical Licensing (now Regulatory) Authorities of Canada (FMRAC), the Association of Canadian Medical Colleges (now Association of Faculties of Medicine of Canada) (AFMC) and the MCC. The basis of this standard is that "in all provinces except Quebec the basis for licensure for most trainees will be the successful completion of the two-part Qualifying Examination of the Medical Council of Canada plus certification by either the College of Family Physicians of Canada (CFPC) or the Royal College of Physicians and Surgeons of Canada (RCPSC)". A similar standard is applied by the Collège des médecine du Quèbec.
This standard also applies to IMGs, although the provincial/territorial licensing bodies have the ability to grant exemptions in particular circumstances.
SHORT, MEDIUM AND LONG TERM STRATEGY
The CMA has advocated a short, medium and longer term strategy for integrating more IMGs into the Canadian medical workforce.
In the short term the federal government should provide funding to clear the backlog of qualified physicians and other health professionals eligible to pursue supplementary training.
In the medium term the federal government needs to work with the provincial and territorial governments and key stakeholders in the development of sufficient health professional education and training opportunities to accommodate:
* Canadians who want to pursue careers as health professionals;
* Currently practising health professionals who require supplementary training or who wish to retrain;
* Internationally trained health professionals who are permanent residents and citizens of Canada who require supplementary training; and
* International trained health professionals, non-residents of Canada who wish to pursue postgraduate training as visa trainees.
In the long term Canada needs to adopt a policy commitment of increased self-sufficiency in the education and training of health professionals in Canada.
In progressing these strategies I would stress the importance of the need for the federal government to engage the national health professional associations, as this is critical in moving the agenda forward. I would cite as one success story the outcomes of the multi-partite Canadian Task Force on Licensure of International Medical Graduates, which brought together federal and provincial/territorial governments and key medical organizations.
Several initiatives are underway in follow-up to its 2004 report. An IMG database is being developed by the Canadian post-MD Education Registry of AFMC, sponsored by the federal government's Foreign Credential Recognition Program. The Physician Credentials Registry of Canada (PCRC) which is being developed under the leadership of the Medical Council of Canada (MCC) and the Federation of Medical Regulatory Authorities of Canada (FMRAC) will reduce duplication and increase the efficiency of data collection by providing a centralized uniform process to obtain primary source verification of a physician's diploma and other core medical credentials. Several provinces have greatly enhanced their ability to integrate IMGs, including supervised assessment programs in the community. We look forward to seeing results from a similar task force that is underway for nursing.
CANADIAN AGENCY FOR ASSESSMENT AND RECOGNITION OF FOREIGN CREDENTIALS
In conclusion, I would like to offer some ideas for the implementation of the Canadian Agency for the Assessment and Recognition of Foreign Credentials that was included in the 2006 federal budget.
The Constitution Act 1867 clearly assigns the majority of responsibility for the delivery of health care to the provinces. On this basis, the licensure of physicians and other health professionals should continue to be a matter of provincial/territorial jurisdiction. In the case of medicine however, Canada has been well-served by the national standard for medical licensure that has been promoted by the MCC in concert with the national certification standards that are set by the RCPSC and CFPC.
Based on the foregoing, it is proposed that the broad mandate for the Canadian agency is to promote and facilitate the adoption and awareness of national standards for certification and licensure with clearly articulated procedures for the assessment of the credentials of internationally trained professionals and pathways to licensure to practice in Canada. This might include the following activities:
* promote understanding among educational institutions and professional organizations about the implications of the various international agreements that Canada is party to (e.g., NAFTA, WTO);
* promote a sharing of leading practices between different disciplines;
* facilitate international exchanges with regulatory bodies, within and between disciplines;
* develop an evaluation framework that can assess the extent to which processes for the assessment of foreign credentials are fair, accessible, coherent, transparent and rigorous;
* develop template materials that will help promote international sharing of information about career prospects in Canada for various occupations;
* fund development and pilot projects on the application of information technology solutions; and
* serve as a focal point for federal/provincial/territorial administrative requirements.
I would stress that this will only be effective if representatives from the education and regulatory authorities and the practising community are at the table.
Canadian Medical Association Ottawa, September 21, 2006
Re: Recommendations for Canada’s long-term recovery plan
Dear Prime Minister Trudeau,
We would like first to thank and commend you for your leadership throughout this pandemic. Your government’s
efforts have helped many people in Canada during this unprecedented time and have prevented Canada from facing
outcomes similar to those seen in other countries experiencing significant pandemic-related hardship and suffering.
We are writing to you with recommendations as you develop a plan for Canada’s long-term recovery and the
upcoming Speech from the Throne on September 23rd.
The COVID-19 pandemic has further exposed and amplified many healthcare shortfalls in Canada such as care for
older adults and mental health-care. Added to that, the economic fallout is impacting employment, housing, and
access to education. These social determinants of health contribute to and perpetuate inequality, which we see the
pandemic has already exacerbated for vulnerable groups. Action is needed now to address these challenges and
improve the health-care system to ensure Canada can chart a path toward an equitable economic recovery.
To establish a foundation for a stronger middle class, Canada must invest in a healthier and fairer society by
addressing health-care system gaps that were unmasked by COVID-19. We firmly believe that the measures we are
recommending below are critical and should be part of your government’s long-term recovery plan:
1. Ensure pandemic emergency preparedness
2. Invest in virtual care to support vulnerable groups
3. Improve supports for Canada’s aging population
4. Strengthen Canada’s National Anti-Racism Strategy
5. Improve access to primary care
6. Implement a universal single-payer pharmacare program
7. Increase mental health funding for health-care professionals
We know the months ahead will be challenging and that COVID-19 is far from over. As a nation, we have an
opportunity now, with the lessons from COVID-19 still unfolding, to bring about essential transformations to our
health-care system and create a safer and more equitable society.
1. Ensure pandemic emergency preparedness
We commend you for your work with the provinces and territories to deliver the $19 billion Safe Restart Agreement
as it will help, in the next six to eight months, to increase measures to protect frontline health-care workers and
increase testing and contact tracing to protect Canadians against future outbreaks. Moving forward, as you develop a
plan for Canada’s long-term recovery, we strongly recommend the focus remains in fighting the pandemic. Beyond
the six to eight months rollout of the Safe Restart Agreement, it is critical that a long-term recovery plan includes provisions to ensure a consistent and reliable availability of personal protective equipment (PPE) and large-scale
capacity to conduct viral testing and contact tracing.
2.Invest in virtual care to support vulnerable groups
The sudden acceleration in virtual care from home is a silver lining of the pandemic as it has enabled increased
access to care, especially for many vulnerable groups. While barriers still exist, the role of virtual care should
continue to be dramatically scaled up after COVID-19 and Canada must be cautious not to move backwards. Even
before the pandemic, Canadians supported virtual care tools. In 2018, a study found that two out of three people
would use virtual care options if available.i During the pandemic, 91% of Canadians who used virtual care reported
We welcome your government’s $240 million investment in virtual health-care and we encourage that a focus be
given to deploying technology and ensuring health human resources receive appropriate training in culturally
competent virtual care. We also strongly recommend accelerating the current 2030 target to ensure every person in
Canada has access to reliable, high-speed internet access, especially for those living in rural, remote, northern and
3.Improve supports for Canada’s aging population
Develop pan-Canadian standards for the long-term care sector
The pandemic has exposed our lack of preparation for managing infectious diseases anywhere, especially in the longterm
care sector. The result is while just 20% of COVID-19 cases in Canada are in long-term care settings, they
account for 80% of deaths — the worst outcome globally. Moreover, with no national standards for long-term care,
there are many variations across Canada in the availability and quality of service.iii We recommend that you lead the
development of pan-Canadian standards for equal access, consistent quality, and necessary staffing, training and
protocols for the long-term care sector, so it can be delivered safely in home, community, and institutional settings,
with proper accountability measures.
Meet the health-care needs of our aging population
Population aging will drive 20% of increases in health-care spending over the next years, which amounts to an
additional $93 billion in spending.iv More funding will be needed to cover the federal share of health-care costs to
meet the needs of older adults. This is supported by 88% of Canadians who believe new federal funding measures
are necessary.v That is why we are calling on the federal government to address the rising costs of population aging
by introducing a demographic top-up to the Canada Health Transfer. This would enhance the ability of provinces and
territories to meet the needs of Canada’s older adults and invest in long-term care, palliative care, and community
and home care.
4.Strengthen Canada’s National Anti-Racism Strategy
Anti-Black racism exists in social structures across Canada. Longstanding, negative impacts of these structural
determinants of health have created and continue to reinforce serious health and social inequities for racialized
communities in Canada. The absence of race and ethnicity health-related data in Canada prevents identification of
further gaps in care and health outcomes. But where these statistics are collected, the COVID-19 pandemic has
exploited age-old disparities and led to a stark over-representation of Black people among its victims. We are calling
for enhanced collection and analysis of race and ethnicity data as well as providing more funding under Canada’s
National Anti-Racism Strategy to address identified health disparities and combat racism via community-led
5. Improve access to primary care
Primary care is the backbone of our health-care system. However, according to a 2019 Statistics Canada surveyvi,
almost five million Canadians do not have a regular health care provider. Strengthening primary care through a teambased,
interprofessional approach is integral to improving the health of all people living in Canada and the
effectiveness of health service delivery. We recommend creating a one-time fund of $1.2 billion over four years to
Page 3 of 4
expand the establishment of primary care teams in each province and territory, with a special focus in remote and
underserved communities, based on the Patient’s Medical Home visionvii.
6. Implement a universal single-payer pharmacare program
People across Canada, especially those who are vulnerable, require affordable access to prescription medications that
are vital for preventing, treating and curing diseases, reducing hospitalization and improving quality of life.
Unfortunately, more than 1 in 5 Canadians reported not taking medication because of cost concerns, which can lead
to exacerbation of illness and additional health-care costs. We recommend a comprehensive, universal, public system
offering affordable medication coverage that ensures access based on need, not the ability to pay.
7.Increase mental health funding for health-care professionals
During the first wave of COVID-19, 47% of health-care workers reported the need for psychological support. They
described feeling anxious, unsafe, overwhelmed, helpless, sleep-deprived and discouraged.viii Even before COVID-
19, nurses, for instance, were suffering from high rates of fatigue and mental health issues, including PTSD.ix
Furthermore, health-care workers are at high risk for significant work-related stress that will persist long after the
pandemic due to the backlog of delayed care. Immediate long-term investment in multifaceted mental health supports
for health-care professionals is needed.
We look forward to continuing to work with you and your caucus colleagues on transforming the health of people in
Canada and the health system.
Tim Guest, M.B.A., B.Sc.N., RN
Canadian Nurses Association (CNA)
Tracy Thiele, RPN, BScPN, MN,
Canadian Federation of Mental Health
Lori Schindel Martin, RN, PhD,
Canadian Gerontological Nursing
E. Ann Collins, BSc, MD
Canadian Medical Association (CMA)
Canadian Support Workers Association
Dr. Cheryl L. Cusack RN, PhD
Community Health Nurses of Canada
Lenora Brace, MN, NP
Nurse Practitioner Association of
~ r. Cheryl
Hon. Chrystia Freeland, Minister of Finance
Hon. Patty Hajdu, Minister of Health
Hon. Deb Schulte, Minister of Seniors
Hon. Navdeep Bains, Minister of Innovation, Science and Industry
Ian Shugart, Clerk of the Privy Council and Secretary to Cabinet
Dr. Stephen Lucas, Deputy Minister of Health
Dr. Theresa Tam, Chief Public Health Officer of Canada
The CMA has always taken an interest in and a stand on various health issues affecting the medical profession and patients. Access to health care is one such issue.
The CMA recently commissioned Ipsos to conduct an extensive survey on the population’s concerns regarding access to health care. The data indicates that Quebecers are the most pessimistic in the country—and this sentiment is even more pronounced when respondents think about the future. Forty percent of survey respondents are concerned about access to health care, and more than half (55%) have a negative perception of the future of the health care system, compared with 26% and 47%, respectively, for the rest of Canada.1 It also appears that Quebecers are significantly affected by the shortage of health professionals and the increase in system costs due to the aging population and the growing number of seniors with health care needs.
The public’s worries are also shared by our members and physicians in Quebec, who are concerned by the fact that their patients are not receiving the care and services they need in a timely manner.
The government of Quebec is making a significant investment in the health care network, a budget item that accounts for almost 50% of total program expenditures.2 The CMA applauds this effort.
The CMA submission proposes certain measures that have a two-fold objective: improving the health of Quebecers and ensuring the sustainability of the health care system for future generations.
The CMA submission is divided into three parts: improving support to elderly patients and caregivers; tobacco and vaping control; and reducing unnecessary examinations and treatments to optimize use of the health care system’s financial and human resources.
Seniors and caregivers
It is no secret that Quebec’s population is aging rapidly. According to data from the Institut de la statistique du Québec cited in the Plan stratégique du ministère de la Santé et des Services sociaux, seniors are expected to make up 25% of the population in 2031 and 28% in 2066, compared with 18% in 2016.3
Although aging is not necessarily synonymous with poor health or disability, the likelihood of both of these conditions increases with age. Close to seven out of ten Quebecers aged 65 and over report two or more long-term health conditions, and 93% of these individuals take medication.4 The most common health issues among people aged 65 and over are arthritis and hypertension.5 Moreover, the incidence of cancer rises significantly with age.6
The aging population thus exerts additional pressure on a health care system that is already stretched thin. The CMA has long been lobbying the federal government to increase the Canada Health Transfer to take into account the needs of the aging population when calculating the Transfer. Consequently, the CMA supports the Quebec government’s negotiations with the federal government to secure an increase in federal health transfer payments.
To ensure a sustainable health care system, it is important to invest in measures that will allow the public to maintain their health as they age, and that foster seniors’ independence—such as a healthy lifestyle, adequate nutrition and treatment adherence, where applicable. The Quebec government has already taken steps to foster the well-being of elderly persons, such as implementing the senior assistance tax credit and increasing support for home support services. The Minister Responsible for Seniors and Informal Caregivers has announced the development of a provincial policy for caregivers in 2020–2021, as indicated in the recently submitted strategic plan.3
These initiatives aimed at improving the lives of seniors and caregivers are to be commended. The CMA believes that the scope of these initiatives should be widened.
Support for seniors
In its economic update presented on December 3, 2018, the Quebec government announced a new tax credit for seniors over age 70. More specifically, this tax credit provides annual assistance of up to $200 per senior and $400 per couple.
The CMA welcomes this initiative, but it should be noted that seniors aged 65 and overspend more than $2,200 on health care fees each year7 (health care items, medication, dental care, insurance premiums, etc.). Given that this level of spending is significant and that 60% of seniors have an annual income under $30,000,8 this tax credit appears to be insufficient for those who have to bear these additional daily health expenses. We must collectively
ensure that certain seniors will not have to forego treatment because they cannot afford it.
Quebecers’ health care expenses have been increasing in recent years,9 and the CMA believes it is essential that this growing problem be dealt with right now. The CMA recommends that the Quebec government create an allowance for seniors aged 65 and over. This new allowance, which would be modelled after the family allowance, would provide financial assistance to low- and medium-income seniors to help them manage additional health-related expenses.
The CMA also believes that the senior assistance tax credit should be extended to people ages 65 to 69.
Like seniors’ advocacy groups, the CMA recommends greater recognition of family caregivers’ contribution to the Quebec health care system. This could take the form of a greater tax credit for caregivers offered in Quebec.
Family caregivers are an integral part of the health care system, as they play an active role in enabling seniors to stay at home—which is what most seniors prefer.10
The Ministère de la Santé et des Services sociaux plans to increase home support services as part of its 2019–2023 strategic plan.10 The CMA believes that this initiative should be combined with increased assistance for family caregivers.
In 2016, the demographic portrait of caregivers in Quebec indicated that 35% of Quebecers, or 2.2 million people, provided care to a senior. Of these, around 15% acted as caregivers for more than 10 hours a week. With the aging of the population set to accelerate in the coming years and decades, caregivers’ unpaid working hours will increase significantly. In Canada, according to a 2011 study, close to 80% of all assistance to recipients of long-term care was provided by family caregivers. This represents a contribution of over five billion dollars’ worth of unpaid services for the public health network.11
According to the CMA, the tax credit for caregivers is an indispensable and necessary financial contribution for these people and the seniors receiving care, but this measure in no way reflects the costs assumed by caregivers. More support should be provided to people who give their time every day, sustain financial losses and compensate for the lack of resources in the health care system.
Given the indispensable role family caregivers play, the CMA recommends that the government increase the tax credit for caregivers so that it better reflects their contribution to society—and this should apply to all four types of family caregivers defined by Revenu Québec:12
Caregivers who take care of a senior spouse who is unable to live alone
Caregivers who house an eligible relative
Caregivers who cohabit with an eligible relative who is unable to live alone
Caregivers who support an eligible relative whom they regularly and continuously assist in carrying out basic activities of daily living
The CMA recommends:
1. Expanding the senior assistance tax credit to support people who are between the ages of 65 and 69
2. Creating a seniors’ allowance to provide financial assistance to low- and medium-income seniors to help them manage additional health-related expenses
3. Increasing the tax credit for caregivers, for all types of family caregivers recognized by Revenu Québec
Smoking and vaping prevention
Although the government of Quebec must pay specific attention to seniors’ care to lighten the burden on the health care system, prevention is still just as important. Prevention has proven to be useful in reducing health care costs by eliminating the need for certain treatments and hospitalizations.13 Measures to control smoking and vaping fall under this category.
For decades, the CMA has been promoting the benefits of a smoke-free society with the support of our physician members, who are witnesses to tobacco’s harmful effects on health. The CMA issued its first public health warning on the risks associated with tobacco use in 1954, and since then has made a significant contribution to the development of public policies related to the industry. One needs only to think of the role that the CMA played in the federal government’s decision to require that tobacco products be sold in plain packaging and standard sizes.
Every government in the country has been actively committed to the fight against tobacco for years, and there has been a significant drop in tobacco use over time. However, regular tobacco use in Quebec has settled at around 15% of the population aged 12 or older.14 Unfortunately, this proportion is still too high.
There is another growing phenomenon among young people that we believe merits the attention of the Minister of Finance: e-cigarettes, also referred to as vaping devices. According to the Enquête québécoise sur la santé des jeunes du secondaire 2016-2017 [Quebec health survey of high school students 2016-2017], one third of youths have used e-cigarettes.15 Although these types of products do not contain tobacco, they do contain nicotine and aromatic substances that could be harmful to people’s health. The CMA recommends increasing research on the potential health consequences these devices can have on people, and the validity of claims that they are an effective means to quit smoking. We also support prohibiting e-cigarette sales to minors, enforcing strict regulation of the sale of these products and prohibiting vaping in locations where smoking is currently forbidden. We also recommend that the marketing restrictions on tobacco products be applied to vaping products and devices as well.
The CMA also believes that governments would be well advised to draw inspiration from strategies that have been successful in curbing tobacco use and reducing the appeal of e-cigarettes, particularly among young people. According to the World Health Organization (WHO), a 10% increase in the price of tobacco results in a 4% to 8% drop in consumption. Taxes on vaping products could therefore have the same deterrent effect, especially among young people, who are more sensitive to price variations.16 This is why it is imperative that we do not wait for the outcome of the work carried out by the special vaping intervention group led by the Ministère de la Santé et des Services sociaux (MSSS) before taking action.
Effective January 1, 2020, the government of British Columbia raised the sales tax on vaping products from 7% to 20%17 to prevent and reduce the use of these products by young people. The CMA recommends that the government of Quebec emulate this policy by increasing taxes on vaping and tobacco products.
The right care at the right time
According to data from the Canadian Institute for Health Information (CIHI), up to 30% of tests, treatments and procedures in Canada are potentially unnecessary. Unnecessary tests, treatments, and procedures not only add zero value to care, but they may also expose patients to additional risks and waste health resources.18
In 2012, as certain treatments were being overused or not adding value for patients, the CMA was a leading partner in the Choosing Wisely Canada campaign, which was launched in Quebec in 2014. This program helps health care professionals and patients engage in a dialogue about unnecessary tests and treatments and helps them make smart and effective choices to ensure quality health care. Guides and recommendations for patients and health
care professionals have been developed through this campaign to make them aware of overuse and overdiagnosis.
The ultimate goal of Choosing Wisely is to improve the performance of the health care system.
A survey indicates that almost half of physicians (48%) agree that they need more support and tools to help them determine which services are not suitable for their patients.19 The tools provided by the Choosing Wisely campaign have proven effective. The CMA believes that their use by Quebec physicians and patients is beneficial.
Publicizing campaigns and developing and updating tools and recommendations require significant financial resources. Elsewhere in the country, several provinces are providing financial support to Choosing Wisely. However, Quebec ended its financial commitment in the past year.
Given the Quebec government’s commitment regarding the appropriateness of care, the CMA recommends supporting the Choosing Wisely Quebec campaign with a long-term financial commitment.
Summary of CMA recommendations
Senior and caregiver support
The CMA is proposing three main recommendations to support seniors and their caregivers. The recommended measures are aimed at ensuring healthy aging and recognizing family caregivers’ economic and social contribution in Quebec.
1. Expand the senior assistance tax credit to support people who are between the ages of 65 and 69.
2. Create an allowance for seniors to help them manage private health care costs.
3. Increase the tax credit for caregivers, for all types of caregivers recognized by Revenu Québec.
Implementation of a tax on tobacco and vaping products
The government of British Columbia announced its intent to increase the sales tax on vaping products from 7% to 20%, effective January 1, 2020,20 to prevent and reduce the use of these products by young people. The CMA recommends that the government of Quebec emulate this policy by heavily taxing vaping and tobacco products.
Contribution to the Choosing Wisely Canada program
Given the Quebec government’s commitment regarding the appropriateness of care, the CMA recommends supporting the Choosing Wisely Quebec campaign with a long-term financial commitment.
1 Ipsos, Canadian Medical Association (CMA). Canadians are Nervous About the Future of the Health System. Ottawa: CMA; 2019. Available: https://www.cma.ca/sites/default/files/pdf/news-media/Canadians-are-Nervous-About-the-Future-of-the-Health-System-E.pdf (accessed 2020 Jan 13).
2 Gouvernement du Québec. Update on Québec’s Economic and Financial Situation. Quebec: Gouvernement du Québec; Fall 2019. Available : http://www.finances.gouv.qc.ca/documents/Autres/en/AUTEN_updateNov2019.pdf (accessed 2020 Jan 13).
3 Ministère de la Santé et des Services sociaux. Plan stratégique 2019-2023(French only). Quebec : Ministère de la Santé et des Services sociaux; December 2019. Available : https://cdn-contenu.quebec.ca/cdn-contenu/adm/min/sante-services-sociaux/publications-adm/plan-strategique/PL_19-717-02W_MSSS.pdf (accessed 2020 Jan 13).
4 Institut de la statistique du Québec. Enquête québécoise sur les limitations d’activités, les maladies chroniques et le vieillissement 2010-2011(French only). Quebec : Institut de la statistique du Québec; October 2013. Available: http://www.stat.gouv.qc.ca/statistiques/sante/services/incapacites/limitation-maladies-chroniques-utilisation.pdf (accessed 2020 Jan 13). 5 Statistics Canada. Table 13-10-0096-01 Health characteristics, annual estimates. Ottawa: Statistics Canada; 2019. Available: https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310009601&%3BpickMembers%5B0%5D=1.6&%3BpickMembers%5B1%5D=2.6&%3BpickMembers%5B2%5D=3.1&request_locale=en. (accessed 2020 Jan 13).
6 Canadian Cancer Statistics Advisory Committee. Canadian Cancer Statistics, September 2019. Toronto: Canadian Cancer Society; September 2019. Available: https://www.cancer.ca/~/media/cancer.ca/CW/cancer%20information/cancer%20101/Canadian%20cancer%20statistics/Canadian-Cancer-Statistics-2019-EN.pdf?la=en-CA (accessed 2020 Jan 13). 7 Institut de la statistique du Québec. Dépenses moyennes des ménages déclarants, selon le groupe d'âge de la personne de référence, Québec, 2006 (French only). Quebec: Institut de la statistique du Québec; 2006. Available: http://www.stat.gouv.qc.ca/statistiques/conditions-vie-societe/depenses-avoirs-dettes/depenses/depdeclar_age.htm (accessed 2020 Jan 13). 8 Santé et des Services sociaux. Les aînés du Québec - Quelques données récentes (2e édition)(French only). Quebec: Santé et des Services sociaux; June 2018. Available: https://publications.msss.gouv.qc.ca/msss/fichiers/ainee/aines-quebec-chiffres.pdf (accessed 2020 Jan 13).
9 Santé et des Services sociaux. Dépenses moyennes des ménages en dollars courants, selon le poste de dépenses, ensemble des ménages, Québec, 2010-2017(French only): http://www.stat.gouv.qc.ca/statistiques/conditions-vie-societe/depenses-avoirs-dettes/depenses/tab1_dep_moy_menage.htm (accessed 2020 Jan 13).
10 Ministère de la Santé et des Services sociaux, Plan stratégique 2019-2023 [2019–2023 Strategic plan] (French only). Quebec: Santé et des Services sociaux; December 2019. Avalable: https://cdn-contenu.quebec.ca/cdn-contenu/adm/min/sante-services-sociaux/publications-adm/plan-strategique/PL_19-717-02W_MSSS.pdf (accessed 2020 Jan 13).
11 Fast J, Lero D, Duncan K, et al. Employment consequences of family/friend caregiving in Canad. Population Change and Lifecourse Strategic Knowledge Cluster Research/Policy Brief, Vol. 1, No. 2 , Art. 2. Edmonton: Research on Aging, Policies and Practice, University of Alberta; 2011. Available: https://ir.lib.uwo.ca/cgi/viewcontent.cgi?article=1004&context=pclc_rpb (accessed 2020 Jan 13).
12 Revenu Québec. Tax Credit for Caregivers. Quebec: Revenu Québec; 2019. Available: https://www.revenuquebec.ca/en/citizens/tax-credits/tax-credit-for-caregivers/ (accessed 2020 Jan 13).
13 Public Health Agency of Canada. Investing in Prevention: The Economic Perspective. Ottawa: Public Health Agency of Canada; May 2009. Available: http://www.phac-aspc.gc.ca/ph-sp/pdf/preveco-eng.pdf (accessed 2020 Jan 13).
14 Statistics Canada. Table 13-10-0096-10 Smokers, by age group. Ottawa: Statistics Canada; 2018. Available:
https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310009610 (accessed 2020 Jan 13).
15 Institut de la statistique du Québec. Enquête québécoise sur la santé des jeunes du secondaire 2016-2017. Résultats de la deuxième édition. La santé physique et les habitudes de vie des jeunes, Tome 3 (French only). Quebec: Institut de la statistique du Québec; December 2018. Available: https://www.stat.gouv.qc.ca/statistiques/sante/enfants-ados/alimentation/sante-jeunes-secondaire-2016-2017-t3.html(accessed 2020 Jan 13).
16 World Health Organization (WHO). Tobacco Free Initiative: https://www.who.int/tobacco/economics/taxation/en/
17 Legislative Assembly of British Columbia, Bill 45 – 2019: Taxation Statutes Amendment Act. Geneva: WHO; 2019. Available: https://www.leg.bc.ca/parliamentary-business/legislation-debates-proceedings/41st-parliament/4th-session/bills/first-reading/gov45-1 (accessed 2020 Jan 13).
18 Choosing Wisely Canada. Implementing Choosing Wisely Canada Recommendations. Toronto: Choosing Wisely Canada; 2020. Available: https://choosingwiselycanada.org/implementation/ (accessed 2020 Jan 13).
19 Canadian Medical Association, e-Panel Survey Summary: Choosing Wisely Canada (distributed to 3,864 e-Panel members and completed in November 2016): https://www.cma.ca/e-panel-survey-summary-choosing-wisely-canada.
20 Legislative Assembly of British Columbia. Bill 45 – 2019: Taxation Statutes Amendment Act. Vancouver: Legislative Assembly of British Columbia; 2019. Available: https://www.leg.bc.ca/parliamentary-business/legislation-debates-proceedings/41st-parliament/4th-session/bills/first-reading/gov45-1 (accessed 2020 Jan 13).