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B Untuk UILDING
Pada
THE UT REOF E LTH RE F

VALUES H C
DI N C
ROY J. ROMANOW, QC
Komisaris
Laporan akhir
NOVEMB R20
B Untuk UILDING
Pada
Tje F
VALUES
Kitab2UT REOF
H ExLTH C xRE
In C xNxDx
Perpustakaan Nasional Kanada Katalog dalam publikasi data
Komisi masa depan perawatan kesehatan di Kanada
Membangun nilai: masa depan perawatan kesehatan di Kanada laporan akhir
Komisaris: Roy J. Romanow.

Diterbitkan juga dalam bahasa Perancis di bawah judul:
GuidÈ par NOS valeurs: l'Avenir des soins de SantÈ au Canada

termasuk referensi bibliografis.
Diterbitkan juga dalam format cetak.
ISBN 0-662-33043-9
Kucing. Tidak. CP32-85/2002E-DALAM
1. perawatan medis-Kanada.
2. kesehatan masyarakat-Kanada.
3. kebijakan medis Kanada.

4. administrasi pelayanan kesehatan-Kanada. II.
Romanow, Roy J.
II. judul.
RA 412.5 C2S52 2002 362.1 ' 0971 C2002-980275-X
November 2002
TO HER EXCELLENCY THE GOVERNOR IN COUNCIL
By Order in Council P.C. 2001-569, I was requested to inquire into and undertake dialogue
with Canadians on the future of Canada’s public health care system, and to recommend policies
and measures respectful of the jurisdictions and powers in Canada required to ensure over the
long term the sustainability of a universally accessible, publicly funded health system, that offers
quality services to Canadians and strikes an appropriate balance between investments in
prevention and health maintenance and those directed to care and treatment.
I am pleased to report that my Commission’s multi-faceted consultations with Canadians

demonstrated their commitment to the original ideals of medicare as well as their willingness to
change basic practices and approaches in order to make the system as a whole more sustainable
for the 21stcentury. I have relied upon their experience and wisdom as well as the best research
and evidence available in coming to my conclusions and recommendations.

I have been honoured to have the responsibility of working to fulfill this mandate and I am
pleased to submit for your consideration the Final Report of the Commission on the Future of
Health Care in Canada.
Respectfully submitted,
Roy J. Romanow, Q.C.

Commissioner
iii
C ONTENTS
MANDATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
A MESSAGE TO CANADIANS ......................................................... xv
EXECUTIVE SUMMARY .............................................................. xxiii
1 SUSTAINING MEDICARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
What is Sustainability? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Health and Health Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Health Care and the Canadian Constitution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Medicare and Beyond . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Private For-Profit Service Delivery: The Debate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Needs and Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Performance of the Canadian System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Responsiveness to Specific Illnesses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Disparities within Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Anticipating an Aging Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Resources in the System: The Case of Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Canada’s Reliance on Taxes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Use of Private Insurance and Out-of-pocket Payments . . . . . . . . . . . . . . . . . . . . . . . 24
The Balance between Public and Private Funding of Health Care . . . . . . . . . . . 26
Alternative Funding Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Sustaining Canada’s Health Care System – Looking Ahead . . . . . . . . . . . . . . . . . . . . . . 43
2 HEALTH CARE, CITIZENSHIP, AND FEDERALISM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Directions for Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
The Case for Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Establishing a Canadian Health Covenant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
A Commitment to Canadians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Achieving the Vision: National Leadership in Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
v
A New Approach to National Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Role of the Health Council of Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Health Council Operation and Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Modernizing and Updating The Canada Health Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
The Principles of a Modernized Canada Health Act . . . . . . . . . . . . . . . . . . . . . . . . . 60
Expanding Medicare Coverage: Short Term and Long Term . . . . . . . . . . . . . . . . 63
Clarifying Coverage under the Canada Health Act . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Providing Stable and Predictable Federal Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Introducing a New Canada Health Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Short-Term Funding Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
What Does This Mean for Canadians? ............................................. 72
3 INFORMATION, EVIDENCE AND IDEAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

Building Canada’s Health Information Technology Infrastructure . . . . . . . . . . . . . . . 76
Introducing Personal Electronic Health Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
A Leadership Role for Canada Health Infoway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Empowering Canadians and Protecting Their Privacy . . . . . . . . . . . . . . . . . . . . . . . . 80
Expanding Health Literacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Streamlining and Improving Health Technology Assessment in Canada ........ 83
The Growing Importance of Health Technology Assessment . . . . . . . . . . . . . . . . 83
Expanding Health Technology Assessment in Canada . . . . . . . . . . . . . . . . . . . . . . . 85
Building Canada’s Health Research Knowledge Base . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Taking the Next Steps to Expand Our Knowledge Base . . . . . . . . . . . . . . . . . . . . . 87
Forging Better Linkages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
What Does This Mean for Canadians? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
4 INVESTING IN HEALTH CARE PROVIDERS ..................................... 91

The Current Situation for Canada’s Health Workforce . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
The Nursing Situation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Access to Doctors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Paying for Nurses and Doctors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
International Mobility of Health Care Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Allied Health Care Providers and Managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
A National Effort Is Needed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Immediate Investments in People and Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Addressing Gaps in Supply and Distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
vi
Changing Roles and Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Planning for Change Over the Longer Term . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Improve Information about Canada’s Health Workforce . . . . . . . . . . . . . . . . . . . 108
Review and Renew Education and Training Programs
for Health Care Providers ................................................. 109
Develop a Comprehensive Plan for the Future of
Canada’s Health Workforce .............................................. 110
What Does This Mean for Canadians? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
5 PRIMARY HEALTH CARE AND PREVENTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

Directions for Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
The Case for Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Primary Health Care in Canada – Opportunities and Obstacles . . . . . . . . . . . . . . . . . 117
Primary Health Care Opportunities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Obstacles to Primary Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
Evolving Approaches to Primary Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Fast-Tracking Primary Health Care Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Using the Primary Health Care Transfer as a Catalyst for Action . . . . . . . . . . 121
Establishing Four Essential Building Blocks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Building National Momentum, Attacking Obstacles
and Reporting Progress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Building and Maintaining Momentum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Strengthening the Role of Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Promoting Good Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Addressing Leading Causes of Major Health Problems . . . . . . . . . . . . . . . . . . . . . 129
A National Immunization Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
6 IMPROVING ACCESS, ENSURING QUALITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

Reducing Waiting Times and Managing Wait Lists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Waiting for Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Managing Wait Lists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Considering Care Guarantees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Improving Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Assessing Quality in Canada’s Health Care System . . . . . . . . . . . . . . . . . . . . . . . . . 150
Setting a Vision for Quality in Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Measuring and Improving Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Linking Performance Measurement with Quality Improvements . . . . . . . . . . . 153
vii
Improving Access for Official Language Minorities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Improving Access and Quality for Official Language Minorities . . . . . . . . . . 154
Addressing the Diverse Health Needs of Canadians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
7 RURAL AND REMOTE COMMUNITIES ......................................... 159

Identifying the Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Disparities in Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Disparities in Access to Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Disparities in Access to Health Care Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Differences in Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Setting a Clear Vision and Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Improving Access to Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Expanding the Supply of Health Care Providers
in Smaller Communities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Expanding Telehealth Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Improving Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
8 HOME CARE: THE NEXT ESSENTIAL SERVICE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171

Home Care in Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Variations across the Country . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Funding for Home Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
Looking Ahead . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Making Home Care the Next Essential Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
Defining and Funding a National Platform of Home Care Services . . . . . . . 177
Home Mental Health Case Management and Interventions . . . . . . . . . . . . . . . . . 178
Post-Acute Home Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Palliative Home Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Improving Support for Informal Caregivers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Recognizing the Role of Informal Caregivers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Taking the Next Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Adequate and Appropriate Health Human Resources . . . . . . . . . . . . . . . . . . . . . . . 185
Continuity and Co-ordination of Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Integration with Primary Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
viii
Expanding Home Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
9 PRESCRIPTION DRUGS ........................................................... 189
A Snapshot of Prescription Drugs in Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
The Expanding Role of Prescription Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
Access to Drugs and Drug Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
The Cost of Prescription Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
Establishing a New Catastrophic Drug Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Establishing a National Drug Agency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
Identifying Problems with the Current Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
Roles, Responsibilities and Funding of the National Drug Agency . . . . . . . . 201
Benefits of a National Drug Agency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
Establishing a National Formulary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Integrating Prescription Drugs into the Health Care System . . . . . . . . . . . . . . . . . . . . 206
Medication Management and Primary Health Care . . . . . . . . . . . . . . . . . . . . . . . . . 206
Collecting and Sharing Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
Reviewing Aspects of Patent Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
10 A N EW APPROACH TO ABORIGINAL HEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211

Addressing the Aboriginal “Disconnect” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
Constitutional Assumptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
Funding for Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
Health Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
Access to Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
Cultural and Political Diversity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
The Northern Territories Issue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
An Innovative Solution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
A Partnership Approach to Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
Frameworks and Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
Creating Aboriginal Health Partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
How Partnerships Would Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Leadership and Accountability Structures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
Possible Scenarios for Aboriginal Health Partnerships . . . . . . . . . . . . . . . . . . . . . . 229
ix
COMMISSION ON THE FUTURE OF HEALTH CARE IN CANADA • FINAL REPORT
11 H EALTH CARE AND GLOBALIZATION ......................................... 233

Globalization and Its Impact on Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
Health Care and International Trade Agreements . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Trade in Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
Health as a Canadian Foreign Policy Priority ................................ 240
Preserving Canada’s Health System in Relation
to International Agreements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
Preventing Challenges under International Agreements . . . . . . . . . . . . . . . . . . . . 241
Building Alliances with Other Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
Improving Health in Developing Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
Playing an International Leadership Role . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
Building Health Care Systems in Developing Countries . . . . . . . . . . . . . . . . . . . . 243
Sharing Information with Other Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
Recommendations ..................................................................
Proposed 247
Timelines for the Implementation of the Recommendations ......... 255
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
A Submissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
B Consultations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
C The External Research Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
D Commission Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
E Statistical History of Health Expenditures and
Transfers in Canada, 1968 to 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
F Primary Care Organizations in Canada, 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
G Consultants’ Estimates on Costs of Targeted Home Care . . . . . . . . . . . . . . . . . . 325
H Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
LIST OF FIGURES, TABLES AND MAPS ............................................ 333
BIBLIOGRAPHY ........................................................................ 339
x
xi
xii
xiii
A M ESSAGE TO
CANADIANS
In April 2001, the Prime Minister established the Commission on the Future of Health Care
in Canada and gave me the privilege of serving as its sole Commissioner. My mandate was to
review medicare, engage Canadians in a national dialogue on its future, and make
recommendations to enhance the system’s quality and sustainability. At the time, I promised
Canadians that any recommendations I might eventually propose to strengthen this cherished
program would be evidence-based and values-driven. I have kept my word.
My team and I have worked hard to assemble the best available evidence. We began by
analyzing existing reports on medicare and by inviting submissions from interested Canadians
and organizations. To clarify our understanding of key issues, we organized expert roundtable
sessions and conducted site visits, both in Canada and abroad. Where we identified knowledge
gaps or needed a fresh perspective, we commissioned independent experts to conduct original
research. Finally, I met directly with Canada’s foremost health policy experts to hear their views,
challenge them and have them challenge me.
We also worked hard to engage Canadians in our consultations, because medicare ultimately
belongs to them. We partnered with broadcasters, universities, business and advocacy groups, and
the health policy community to raise awareness of the challenges confronting medicare. The
contribution of the health research community to this effort has been invaluable. We also
established formal liaison contacts with provincial governments to share information, and I spoke
with the Premiers and heard from many health ministers. I also had the privilege of leading one of
the most comprehensive, inclusive and successful consultative exercises our country has ever
witnessed. Tens of thousands of Canadians participated, speaking passionately, eloquently and
thoughtfully about how to preserve and enhance the system. We also sought advice from health
experts and from Canadians in interpreting the results of our processes. I am proud that respect,
transparency, objectivity and breadth of perspective have been hallmarks of this process. These
past 18 months have been among the most challenging and rewarding of my more than three
decades in public life. Having examined the research, and having met with Canadians from
sea-to-sea-to-sea, I am more confident than ever in the system’s potential to meet the needs of
Canadians, now and in the future. Canadians remain deeply attached to the core values at the
heart of medicare and to a system that has served them extremely well. My assessment is that,
while medicare is as sustainable as Canadians want it to be, we now need to take the next bold
step of transforming it into a truly national, more comprehensive, responsive and accountable
health care system. Making Canadians the healthiest people in the world must become the
system’s overriding objective. Strong leadership and the involvement of Canadians is key to
preserving a system that is true to our values and sustainable.
xv
Canadians Remain Attached to the Values at the

Heart of the System
In their discussions with me, Canadians have been clear that they still strongly support the
core values on which our health care system is premised – equity, fairness and solidarity. These
values are tied to their understanding of citizenship. Canadians consider equal and timely access
to medically necessary health care services on the basis of need as a right of citizenship, not a
privilege of status or wealth. Building from these values, Canadians have come to view their
health care system as a national program, delivered locally but structured on intergovernmental
collaboration and a mutual understanding of values. They want and expect their governments to
work together to ensure that the policies and programs that define medicare remain true to these
values.
Medicare Has Served Canadians Extremely Well

I am pleased to report to Canadians that the often overheated rhetoric about medicare’s
costs, effectiveness and viability does not stand up to scrutiny. Our health outcomes, with a few
exceptions, are among the best in the world, and a strong majority of Canadians who use the
system are highly satisfied with the quality and standard of care they receive. Medicare has
consistently delivered affordable, timely, accessible and high quality care to the overwhelming
majority of Canadians on the basis of need, not income. It has contributed to our international
competitiveness, to the extraordinary standard of living we enjoy, and to the quality and
productivity of our work force.
The System Is as Sustainable as We Want It to Be

For years now, Canadians have been exposed to an increasingly fractious debate about
medicare’s “sustainability.” They have been told that costs are escalating and that quality of
services is declining. They have heard that insatiable public expectations, an aging population
and the costs of new medical technologies and prescription drugs will inevitably overwhelm the
system. They have been warned that health spending is crowding out other areas of public
investment. Thus one of the fundamental questions my report must address is whether medicare
is sustainable? My answer is that it is if we are prepared to act decisively.
Governments talk about sustainability in terms of “costs” and financial impacts. This
discussion often has more to do with “who pays” than “how much” we pay. In listening to these
debates, it is sometimes hard to realize that health spending in Canada is on par with most
countries in the Western world, that it is substantially lower than in the United States, and that
we devote a smaller portion of our Gross Domestic Product (GDP) to health care today than we
did a decade ago.
More troubling is the notion that somehow our health care system is on “auto-pilot” and
immune to change. I believe this is fundamentally inconsistent with the ingenuity and innovation
that has for so long defined the Canadian way. It is baseless and false. Governments can make
informed choices about how and where to invest; they are not powerless to change current
spending trajectories. Better management practices, more agile and collaborative institutions and
a stronger focus on prevention can generate significant savings. Technological advances can also
help to improve health outcomes and enable a more effective deployment of scarce financial and
xvi
A MESSAGE TO CANADIANS
human resources. Indeed, our health care system is replete with examples of excellence in
innovation, many of them world-class. The bigger issue is whether we have the right information
and the courage we need to make the choices that support sustainability.
To be sure, the system needs more money. In the early 1990s, the federal share of funding
for the system declined sharply. While recent years have seen a substantial federal reinvestment
into health care, the federal government contributes less than it previously did, and less than it
should. I am therefore recommending the establishment of a minimum threshold for federal
funding, as well as a new funding arrangement that provides for greater stability and
predictability – contingent on this replenishment supporting the transformative changes outlined
in this report. Money must buy change, not more of the same.
But individual Canadians view sustainability from a very different vantage point. The key
“sustainability” question for the average Canadian is, “Will medicare be there for me when I
need it?” While it is very clear that a majority of Canadians support medicare in its current form,
it is not perfect. Some people, particularly Aboriginal peoples and those in rural and remote parts
of the country, cannot always access medical services where and when they need them. There
are also inefficiencies and mismatches between supply and demand that have resulted in
unacceptable times for some medical procedures. These problems must be tackled on a priority
basis or they will eventually erode public confidence in medicare and with it, the consensus that
it is worth keeping. I am therefore recommending new initiatives to improve timely access to
care, to enhance the quality of care the system provides, a more co-ordinated approach to health
human resources planning, and a special focus on the health needs of Aboriginal peoples.
We also need to renovate our concept of medicare and adapt it to today’s realities. In the
early days, medicare could be summarized in two words: hospitals and doctors. That was fine for
the time, but it is not sufficient for the 21stcentury. Despite the tremendous changes over the past
40 years, medicare still is largely organized around hospitals and doctors. Today, however, home
care is an increasingly critical element of our health system, as day surgery has replaced the
procedures that once took weeks of convalescence in hospital. Drugs, once a small portion of
total health costs, are now escalating and among the highest costs in the system. The expense
associated with some drug therapies or of providing extended home care for a seriously ill
family member can be financially devastating. It can bankrupt a family. This is incompatible
with the philosophy and values upon which medicare was built. It must be changed. I am
therefore recommending that home care be recognized as a publicly insured service under
medicare and that, as a priority, new funds be invested to establish a national platform for home
care services. I am also recommending the creation of a national drug strategy, including a
catastrophic drug insurance program to protect Canadian families.
I know these views will provoke a hot debate in Canada, particularly among those who
advocate “less government” and less government money in health care. The problem with these
arguments is that they are focused on the cost to governments, not Canadians. A more narrowly
structured system of medicare might free up governments to spend tax dollars on other priorities,
or simply on tax relief. But either way, individual Canadians would still be left to personally
bear the costs of services that are not covered. To me, that is contrary to the spirit and intent of
medicare. It is not the Canadian way.
xvii
Canadians Want and Need a Truly National

Health Care System
As I noted earlier, Canadians’ attachment to medicare is based on their understanding of it
as a right of citizenship. They connect with the values that define medicare, not the particular
features of the system in place in their province or territory. Canadians expect the system to
guarantee them relatively similar access to a common basket of medicare services of equal
quality, regardless of where they live. They expect governments, providers and caregivers to
work collaboratively to maintain a system with these attributes.
The fact that Canadians perceive health care as a national endeavour should not be
construed as an invitation for federal intrusion into an area of primary provincial jurisdiction.
Nor should it be interpreted to mean a “one-size-fits-all” approach to health care delivery. In a
country as geographically, economically, regionally and culturally diverse as ours, this is neither
realistic nor desirable. Medicare must be constantly renewed and continually refined, if it is to
remain relevant and viable. A new common approach is needed to encourage, not constrain,
innovation. If we allow medicare to become static, it will become brittle and eventually break.
Canadians realize that illness and injury know few boundaries; they afflict all of us. They
understand that organizing health care solely along constitutional lines or provincial boundaries
makes little practical sense. They recognize that sometimes by design, sometimes by financial
necessity, and more often by default, provinces are increasingly willing to go it alone insofar as
their respective health care “systems” are concerned. Today, we sit on the cusp. Left unchecked,
this situation will inevitably produce 13 clearly separate health care systems, each with differing
methods of payment, delivery and outcomes, coupled by an ever increasing volatile and
debilitating debate surrounding our nation, its values and principles.
This is no way to renew a program of such immense personal and national importance and,
for sure, it is no way to strengthen those foundations that unify us as a nation. It is time for
governments, caregivers and Canadian citizens to embark together on the road to renewal. The
reality is that Canadians embrace medicare as a public good, a national symbol and a defining
aspect of their citizenship. I am therefore recommending a series of measures to modernize the
legislative and institutional foundations of medicare that will better equip governments to move
forward together to provide Canadians with the health care system they want.
Canadians Want and Need a More Comprehensive

Health Care System
We must transform our health care “system” from one in which a multitude of participants,
working in silos, focus primarily on managing illness, to one in which they work collaboratively
to deliver a seamless, integrated array of services to Canadians, from prevention and promotion
to primary care, to hospital, community, mental health, home and end-of-life care.
Indeed, despite our common use of the term “our health care system,” the relevance of this
term is increasingly doubtful. A system where citizens in one part of the country pay out-of-
pocket for “medically necessary” health services available “free” in others, or where the rules of
the game as to who can provide care and under what circumstances vary by jurisdiction, can
scarcely be called a “system.”
There are many examples of the “disconnect.” Elderly people who are discharged from
xviii hospital and cannot find or afford the home or community services they need. Women – one in
five – who are providing care to someone in the home an average of 28 hours per week, half of
whom are working, many of whom have children, and almost all of whom are experiencing
tremendous strain. Health professionals, who are increasingly stressed, while performing tasks
ill suited to their abilities and training. Patients, who are forced to navigate a system that is a
complex and unfriendly mystery, in order to find the right specialist, the nearest facility, and the
best treatment. People who are forced to repeat lab tests, and to recount their medical histories
time and time again. We need clear and decisive action to modernize the system and make it
more durable and responsive. I am therefore recommending a series of measures to create a
more comprehensive system whose component parts fit together more seamlessly.
Canadians Want and Need a More Accountable

Health Care System
Accountability must also be improved. Health care in this country is now a $100 billion
enterprise, one of our society’s largest expenditures. Yet no level of government has done a very
good job accounting for how effectively that money is spent. Canadians still do not know who to
believe in the debate over which level of government is paying what share for health services.
Canadians are the shareholders of the public health care system. They own it and are the sole
reason the health care system exists. Yet despite this, Canadians are often left out in the cold,
expected to blindly accept assertion as fact and told to simply trust governments and providers to
do the job. They deserve access to the facts. Canadians no longer accept being told things are or
will get better; they want to see the proof. They have a right to know what is happening with
wait lists; what is happening with health care budgets, hospital beds, doctors, and nurses, and
whether the gaps in home and community care services are being closed; whether the number of
diagnostic machines and tests is adequate; and whether treatment outcomes are improving.
Information is a key ingredient. We live in an age of laser surgery and are unlocking the
mystery of the human gene, yet our approach to health information is mired in the past. We gather
information on some health issues, but not on others. And much of the information we gather
cannot be properly analyzed or shared. Indeed, we know far more about resources and the dollars
being spent than we do about the return on those investments. Better information will facilitate
evidence-based decision making. How can we hold health care managers accountable if what they
are managing cannot be measured? If we are to build a better health system, we need a better
information sharing system so that all governments and all providers can be held accountable to
Canadians. I am therefore recommending a series of measures to improve transparency across the
system, to make decision-making structures more inclusive, to accelerate the integration of health
informatics, to provide for a secure electronic health record for Canadians that respects their right
to privacy, and to give Canadians a greater say in shaping the system’s future.
Making Canadians the Healthiest People in the World

During our public hearings, many presentations focused on the need to improve our
understanding of the determinants of health. I heard that the quality of the air we breathe, of the
water we drink, and of the food we eat directly affects our health and our health care system. I
learned that educated, employed and physically active Canadians are far more likely to be
healthy than those who are not, and that spiritual, emotional and physical well-being are often
inextricably linked. I also heard that lifestyle changes can markedly reduce the incidence and
xix
severity of many major and debilitating diseases. Keeping people well, rather than treating them
when they are sick, is common sense. And so it is equally common sense for our health care
system to place a greater emphasis on preventing disease and on promoting healthy lifestyles.
This is the best way to sustain our health care system over the longer term.
The health care system must be on the front lines of this effort. However, we must also invest
in related areas of public life to create community mobilization, a sense of social inclusion and
provide the infrastructure that enables healthier lifestyle choices. Investing in public housing, a
clean environment and education are all part of the solution leading to a healthier Canada.
But we need more than rhetoric; we need action. I am therefore recommending a greater
emphasis on prevention and wellness as part of an overall strategy to improve the delivery of
primary care in Canada, the allocation of new moneys for research into the determinants of health,
and that governments take the next steps for making Canadians the world’s healthiest people.
A System Based on Canadian Values

Early in my mandate, I challenged those advocating radical solutions for reforming health
care – user fees, medical savings accounts, de-listing services, greater privatization, a parallel
private system – to come forward with evidence that these approaches would improve and
strengthen our health care system. The evidence has not been forthcoming. I have also carefully
explored the experiences of other jurisdictions with co-payment models and with public-private
partnerships, and have found these lacking. There is no evidence these solutions will deliver
better or cheaper care, or improve access (except, perhaps, for those who can afford to pay for
care out of their own pockets). More to the point, the principles on which these solutions rest
cannot be reconciled with the values at the heart of medicare or with the tenets of the Canada
Health Act that Canadians overwhelmingly support. It would be irresponsible of me to
jeopardize what has been, and can remain, a world-class health care system and a proud national
symbol by accepting anecdote as fact or on the dubious basis of making a “leap of faith.”
Some have described it as a perversion of Canadian values that they cannot use their money
to purchase faster treatment from a private provider for their loved ones. I believe it is a far
greater perversion of Canadian values to accept a system where money, rather than need,
determines who gets access to care.
It has been suggested to me by some that if there is a growing tension between the principles
of our health care system and what is happening on the ground, the answer is obvious. Dilute or
ditch the principles. Scrap any notion of national standards and values. Forget about equal
access. Let people buy their way openly to the front of the line. Make health care a business.
Stop treating it as a public service, available equally to all. But the consensus view of Canadians
on this is clear. No! Not now, not ever. Canadians view medicare as a moral enterprise, not a
business venture.
Tossing overboard the principles and values that govern our health care system would be
betraying a public trust. Canadians will not accept this, and without their consent, these “new”
solutions are doomed to fail. Canadians want their health care system renovated; they do not
want it demolished.
But we must also recognize that since the earliest days of medicare, public and private
sector care providers (including fee-for-service doctors) have been part of our health care
xx system. Our system was never organized according to a strict protocol; it evolved in accordance with the
existing capacity of public and private providers, changing notions of what constitute “core
services,” and the wishes of Canadians.
One of the most difficult issues with which I have had to struggle is how much private
participation within our universal, single-payer, publicly administered system is warranted or
defensible. On the one hand, I am confronted by the fact that the private sector is already an
important part of our “public” system. The notion of rolling back its participation is fraught with
difficulty. On the other hand, I am acutely aware of the potential risks to the integrity and
viability of our health care system that might result from an expanded role for private providers.
At a minimum, I believe governments must draw a clear line between direct health services (such
as hospital and medical care) and ancillary ones (such as food preparation or maintenance
services). The former should be delivered primarily through our public, not-for-profit system,
while the latter could be the domain of private providers. The rapid growth of private MRI
(magnetic resonance imaging) clinics, which permit people to purchase faster service and then use
test results to “jump the queue” back into the public system for treatment, is a troubling case-
in-point. So too is the current practice of some worker’s compensation agencies of contracting
with private providers to deliver fast-track diagnostic services to potential claimants. I agree with
those who view these situations as incompatible with the “equality of access” principle at the
heart of medicare. Governments must invest sufficiently in the public system to make timely
access to diagnostic services for all a reality and reduce the temptation to “game” the system. In
order to clarify the situation in regard to diagnostic services, I am therefore recommending that
diagnostic services be explicitly included under the definition of “insured health services” under
a new Canada Health Act .
Conclusion
Canada’s journey to nationhood has been a gradual, evolutionary process, a triumph of
compassion, collaboration and accommodation, and the result of many steps, both simple and
bold. This year we celebrate the 40 th anniversary of medicare in Saskatchewan, a courageous
initiative by visionary men and women that changed us as a nation and cemented our role as one
of the world’s compassionate societies. The next big step for Canada may be more focused, but
it will be no less bold. That next step is to build on this proud legacy and transform medicare
into a system that is more responsive, comprehensive and accountable to all Canadians.
Getting there requires leadership. It requires us to change our attitudes on how we govern
ourselves as a nation. It requires an adequate, stable and predictable commitment to funding and
co-operation from governments. It requires health practitioners to challenge the traditional way
they have worked in the system. It requires all of us to realize that our health and wellness is not
simply a responsibility of the state but something we must work toward as individuals, families
and communities, and as a nation. The national system I speak about is clearly within our grasp.
Medicare is a worthy national achievement, a defining aspect of our citizenship and an
expression of social cohesion. Let’s unite to keep it so.
Roy J. Romanow, Q.C.

Commissioner xxi
EXECUTIVE S UMMARY
Taken together, the 47 recommendations contained in this report serve as a roadmap for a
collective journey by Canadians to reform and renew their health care system. They outline
actions that must be taken in 10 critical areas, starting by renewing the foundations of medicare
and moving beyond our borders to consider Canada’s role in improving health around the world.
Chapter 1 – Sustaining Medicare

Chapter 1 argues that Canada’s health care system has served Canadians well and is as
sustainable as Canadians want it to be. In addition to the imperative for social consensus for a
public health system, the issue of sustainability needs to be assessed from three dimensions –
services, needs and resources. Effective governance is needed to bring equilibrium between
these dimensions.
Services: The practice of medicine and the range and nature of treatment options has
changed significantly since medicare was introduced 40 years ago. The biggest changes have
been outside the traditional medicare “core” of hospital and physician services, in areas like
pharmaceuticals and home care. Concerns also exist about timely access to existing services,
particularly in rural and remote areas, limited progress in advancing primary health care reforms
and growing wait lists, especially for diagnostic services.
Needs: Our health care system is adequately meeting our needs. Canada’s health outcomes
compare favourably with other countries and evidence suggests that we are doing a good job in
addressing the various factors that impact on overall health. But there is room for improvement.
However, there are serious disparities in both access to care and health outcomes in some parts
of the country, particularly for Aboriginal peoples and in the north, which need to be addressed.
Meeting the needs of an aging population will add costs to our system, but these can be managed
if we begin to make the necessary adjustments now.
Resources: Canada’s spending on health care is comparable with other OECD countries and
we spend considerably less per capita than the United States. All OECD countries are facing
increasing health care costs and experience suggests that the wealthier the country, the more it
spends on health care. While some have suggested that Canada relies too heavily on taxation to
support its health system, comparisons show we are not much different than other countries.
Alternative funding approaches currently under discussion in some circles have a number of
xxiii
problems and would shift the burden of funding from governments to individuals. Moreover,
there is no evidence their adoption would produce a more efficient, affordable or effective
system. There are, however, serious problems in the balance of funding between federal and
provincial governments. The federal share of health funding has dropped and health care is now
taking up an increasing portion of provincial budgets. Health care costs are likely to continue to
increase and choices will have to be made about how to manage them. Provided the system is
prepared to change to meet their needs and expectations, Canadians appear willing to pay more
for health care.
C h a p t e r 2 – H e a l t h C a r e,
Citizenship and Federalism
Chapter 2 lays the foundation for all other aspects of the report and recommends a renewed
commitment to medicare, new governance approaches, stable and predictable long-term funding,
and targeted funding to facilitate change in critical areas.
Directions for Change

Establish a new Canadian Health Covenant as a tangible statement of Canadians’
values and a guiding force for our publicly funded health care system
A proposed new Canadian Health Covenant would confirm our collective vision for the
future of health care in Canada and clearly outline the responsibilities and entitlements of
individual Canadians, health providers, and governments in regard to the system.
Create a Health Council of Canada to facilitate collaborative leadership in health

A new Health Council of Canada would help foster collaboration and co-operation among
provinces, territories, and the federal government. The Council would play a key role in setting
common indicators and benchmarks, in measuring and tracking the performance of the health
system, and in reporting results regularly to Canadians. Because of the important role of the
Council in measuring results, the Canadian Institute for Health Information (CIHI) should form
the backbone for the proposed new Council.
Modernize the Canada Health Act by expanding coverage and renewing its principles
While the Canada Health Act (CHA) has served us well and has achieved iconic status, this
does not mean it should be immune from change. The five principles of the CHA should be
reaffirmed, the principle of comprehensiveness updated and the principle of portability limited to
guaranteeing portability of coverage within Canada. A new principle of accountability should be
added to the CHA to address Canadians’ concern that they lack sufficient information to hold the
appropriate people accountable for what happens in our health care system. The current scope of
publicly insured services should also be expanded beyond hospital and physician care to include
two new essential services – diagnostic services and priority home care services described in
Chapter 8. Finally, the CHA should include an effective dispute resolution process.
xxiv
EXECUTIVE SUMMARY
Clarify coverage by distinguishing between direct and ancillary health services, and
change practices contrary to the spirit of medicare
The growing reliance on private advanced diagnostic services is eroding the equal access
principle at the heart of medicare. The CHA must include public coverage for medically
necessary diagnostic services. Governments have a responsibility to invest sufficiently in the
public system to make timely access to diagnostic services for all a reality. In a similar vein, they
should also reconsider the current practice by which some workers’ compensation agencies
contract with private providers to deliver fast-track diagnostic services to potential claimants.
Provide stable, predictable and long-term funding through a new dedicated cash-only
transfer for medicare
A new dedicated cash-only Canada Health Transfer should be established as part of the
Canada Health Act. It will require an increased share of federal funding and will include an
escalator provision that is set in advance for five years to ensure future funding is stable,
predictable and increases at a realistic rate, commensurate with our economic growth and
capacity to pay.
Address immediate issues through targeted funding

Five new targeted funds should be established:
• A Rural and Remote Access Fund: to improve timely access to care in rural and remote
areas.
• A Diagnostic Services Fund: to improve wait times for diagnostic services.
• A Primary Health Care Transfer: to support efforts to remove obstacles to renewing
primary health care delivery.
• A Home Care Transfer: to provide a foundation for an eventual national home care strategy.
• A Catastrophic Drug Transfer: to allow provincial drug programs to expand and improve
coverage for their residents.
These targeted federal funds and transfers should be provided to the provinces and
territories on the condition that they match or exceed federal support for these priorities. They
would be short-term (two-year) arrangements until the new Canada Health Transfer is
implemented. Thereafter, the Canada Health Transfer will fund these priorities directly.
Chapter 3 – Information,
Evidence and Ideas
Chapter 3 sets the stage for electronic health records, a more comprehensive use of
information management and technology, including health technology assessment, to provide
essential information throughout the health care system, and a targeted focus on applied research.

Enable the establishment of personal electronic health records for each Canadian
building on the work currently underway in provinces and territories
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Many provinces and territories have taken steps to develop electronic health records and all
agree that this is essential to improve how the health care system functions. Building on the
resources already available in the provinces and territories and through Canada Health Infoway, it
is important to accelerate the process and to make the promise of electronic health records a reality.
Take clear steps to protect the privacy of Canadians’ personal health information,
including an amendment to the Criminal Code of Canada
There are clear benefits to Canadians from electronic health records. They would have
access not only to their own health information but also to a comprehensive base of trusted and
reliable information about a variety of health-related issues. Canada Health Infoway should take
the lead in promoting harmonized privacy rules across the country, and breaches of privacy
should be treated as an offense under the Criminal Code of Canada.

Provide better health information to Canadians, health care providers, researchers
and policymakers – information they can use to guide their decisions
Health care providers, researchers and policymakers need better information to guide their
decisions. In addition to electronic health records, Canada Health Infoway should take the lead
in establishing a comprehensive source of trusted health information that could be used by a
variety of providers, decision makers and Canadians.
Expand the scope, effectiveness and co-ordination of health technology assessment

across Canada
Promising advances in medical technology are occurring almost daily. While they have the
potential to provide better treatments and cures, their costs are often substantial. Because of the
growing importance of health technology assessment and the need to link it with broader
assessments in the health care system, the current work of the Canadian Coordinating Office for
Health Technology Assessment should become a vital part of the Health Council of Canada and
provide a national focus for health technology assessment.
Create new research centres for health innovation

Canada has a solid base of research organizations but there are gaps in the applied research
agenda. To address those gaps, four new Centres for Health Innovation should be established
focusing on rural and remote health, health human resources, health promotion and
pharmaceutical policy.
Forge stronger linkages with researchers in other parts of the world and with
policymakers across the country
Canada’s health care system has much in common with other countries around the world,
especially European countries and members of the Organisation for Economic Co-operation and
Development (OECD). It is important to develop deeper linkages among researchers around the
world and to tap into available sources of information than can help support sound decision
making in Canada.
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EXECUTIVE SUMMARY
Chapter 4 – Investing in
Health Care Providers
Chapter 4 addresses the future for Canada’s health workforce, tackling immediate issues of
supply and distribution but also larger issues relating to their changing roles and responsibilities,
and the need for comprehensive, long-term national strategies.

Address the need to change the scopes and patterns of practice of health care
providers to reflect changes in how health care services are delivered, particularly
through new approaches to primary health care
Changes in the way health care services are delivered, especially with the growing emphasis
on collaborative teams and networks of health providers, means that traditional scopes of
practice also need to change. This suggests new roles for nurses, family physicians, pharmacists,
case managers and a host of new and emerging health professions.
Take steps to ensure that rural and remote communities have an appropriate mix of
skilled health care providers to meet their health care needs
A portion of the funds from the proposed new Rural and Remote Access Fund, as well as
those from the Diagnostic Services Fund, the Primary Health Care Transfer and the Home Care
Transfer, should be used to ensure that people in smaller communities across the country have
access to an appropriate mix of skilled providers.
Substantially improve the base of information about Canada’s health workforce

There are serious gaps in what we know about Canada’s health workforce. Concerted
actions should be taken through the Health Council of Canada to collect, analyze and provide
regular reports on critical issues including the recruitment, distribution, and remuneration of
health care providers.
Review current education and training programs for health care providers to focus
more on integrated approaches for preparing health care teams
One of the best ways of ensuring that health care providers are able to work effectively in
new, more integrated settings is to begin with their education and training. Education programs
should be changed to focus more on integrated, team-based approaches to meeting health care
needs and service delivery. The Health Council of Canada should help co-ordinate efforts to
achieve these changes.
Establish strategies for addressing the supply, distribution, education, training, and
changing skills and patterns of practice for Canada’s health workforce
Health workforce issues affect all provinces and territories. Changes are necessary to
facilitate concerted action at the national level, and long-term planning. The Health Council of
Canada can serve as an important catalyst in this regard.
xxvii
Chapter 5 – Primary Health Care

and Prevention
Chapter 5 outlines the need to accelerate ongoing efforts to reform how primary care
services are delivered in Canada and to improve their focus on wellness. It also identifies ways
to remove traditional obstacles to these reforms.

Finally make a major breakthrough in implementing primary health care and
transforming Canada’s health care system
The combined outcome of the actions proposed in this report must be to transform Canada’s
health care system and have it focus squarely on primary health care. Canadians should have
access to an integrated continuum of care 24 hours a day, 7 days a week, no matter where they live.
Use the proposed new Primary Health Care Transfer as the impetus for fundamental
change in how health care services are delivered across the country
The new Primary Health Care Transfer should provide the funding needed to accelerate
primary care beyond the stage of pilot projects to achieve permanent and lasting change.
Build a common national platform for primary health care based on four essential
building blocks
There is no single model for primary health care that captures the diversity of needs and
situations in Canada. However, a scattered approach with no consistency across the country is
not the solution. Instead, four essential building blocks should define primary health care across
the country: continuity of care, early detection and action, better information on needs and
outcomes, and new and stronger incentives for health care providers to participate in primary
health care approaches.
Mandate the proposed Health Council of Canada to hold a National Primary Health
Care Summit to mobilize action across the country, then maintain the momentum by
measuring progress and reporting regularly to Canadians
Overcoming the numerous obstacles to primary health care requires determined and
decisive action across the country. A national summit organized by the Health Council of
Canada should mobilize action and, more importantly, “shine the spotlight” on the obstacles to
change and set the stage for regular reports to Canadians on the progress being made.
Integrate prevention and promotion initiatives as a central focus of primary health

care targeted initially at reducing tobacco use and obesity, and increasing physical
activity in Canada
For too long, Canada’s health care system has been overly focused on treatment rather than
prevention. A central focus of primary health care must be on preventing illness and injury and
helping Canadians stay healthy. Targeted actions should be taken to reduce tobacco use, reduce
the alarming rates of obesity in Canada, and encourage more Canadians to live active lifestyles.
xxviii
EXECUTIVE SUMMARY
Implement a new national immunization strategy

Most Canadians remember being immunized against diseases like polio, measles or, more
recently, meningitis. Canada has a reasonable track record on immunizations compared to other
countries, but there is evidence that current programs are dated. We also need to take steps to
ensure that Canada is well prepared to face new and emerging problems resulting from
globalization and the evolution of infectious diseases.
Chapter 6 – Improving 2ccess,

Ensuring Quality
Chapter 6 directly tackles Canadians’ concerns about waiting times, access and quality in
our health care system.

Use the new Diagnostic Services Fund to shorten waiting times for diagnostic services
There is clear evidence that Canada has under-invested in diagnostic technologies in
comparison with other OECD countries and the result is long waiting times for essential
diagnostic tests. The new Diagnostic Services Fund should be used not only to purchase
equipment but also to train the necessary staff and technicians. Targeting this area as a
first priority, provinces and territories could free up additional resources to address wait
times for other essential services.
Implement better ways of managing wait lists

Wait lists in Canada are often poorly managed and there are few standard approaches in
place to assign people to a wait list or co-ordinate lists among different providers or facilities.
Steps must be taken to put centralized approaches in place within health regions, on a province-
wide basis or even, in some cases, on a national basis. Patients also have a right to good
information about how long they can reasonably expect to wait for treatment and what other
options are available to them.
Take deliberate steps to measure the quality and performance of Canada’s health
care system and report regularly to Canadians
We cannot expect to keep improving the health care system if we do not have the necessary
information to measure and track results. The proposed Health Council of Canada could play a
vitally important role, working with the provinces and territories to collect comparable
information and report regularly to Canadians on their health care system. This would include
information on waiting times and a variety of measures of the quality of the system.
Ensure that the health care system responds to the unique needs of official language
minorities
Being able to access health care in either official language is an important dimension of
Canada’s health care system. It is important not only from the perspective of access but also to
ensure that people can understand and respond to treatment. Steps should be taken to build on
the many successful approaches in place across the country to improve access to health services
in both official languages.
xxix
Address the diverse health care needs of Canadians

Canada is a diverse country, and that diversity should be reflected in our health care system.
The care we deliver should match the needs of different groups of Canadians, from men and
women, to new Canadians, to visible minorities, people with disabilities and others.
Chapter 7 – Rural and

Remote Communities
Chapter 7 establishes a new Rural and Remote Access Fund to improve access to quality
health care and services in smaller communities across the country.

Establish a new Rural and Remote Access Fund to support new approaches for
delivering health care services and improve the health of people in rural and remote
communities
A new Rural and Remote Access Fund should provide a catalyst for a range of actions to
improve access to, and the quality of, health in rural and remote communities. Provinces and
territories would be expected to work directly with communities to identify needs and choose the
best approaches for meeting those needs on a community-by-community basis.
Use a portion of the Fund to address the demand for health care providers in these
communities
One of the biggest challenges smaller communities face is attracting and retaining health
professionals. The issue is less about the sheer numbers of health care providers and more about
the preferences of many professionals to live in major urban centres. A portion of the proposed
new Fund could be used to develop a mix of strategies for attracting and retaining a mix of
skilled health care providers in rural and remote communities.
Expand telehealth to improve access to care

Telehealth uses information technologies to link patients and health care providers to a wide
variety of services outside their community. People in rural and remote locations can be linked
to family physicians, specialists and other health services in other centres where health care
providers can diagnose, treat and provide consultations at a distance. A portion of the Rural and
Remote Access Fund should be used to build on the work already underway in many provinces
and territories, and to expand the use of telehealth to improve access to health care services and
information.
Chapter 8 – Home Care:

The Next Essential Service
Chapter 8 outlines three critical areas where home care must become an essential service
under the Canada Health Act umbrella.
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EXECUTIVE SUMMARY

Use the proposed new Home Care Transfer to establish a national platform for home
care services
The proposed new Home Care Transfer should be used to ensure that all Canadians have
access to a common platform of essential home care services.
Revise the Canada Health Act to include coverage for home care services in priority
areas
Home care is an increasingly essential part of our health care system. While it is not possible
to include all home care services under the Canada Health Act, immediate steps should be taken
to bring services in three priority areas under the umbrella of the Canada Health Act – home
mental health case management and intervention services, post-acute home care, and palliative
home care.
Improve the quality of care and support available to people with mental illnesses by
including home mental health case management and intervention services as part of
the Canada Health Act
Mental health has been described as the “orphan child” of health care. Today, mental health
care is largely a home and community-based service, but support for it has too frequently fallen
short. It is time to take the long overdue step of ensuring that mental health home care services
are included as medically necessary services under the Canada Health Act, and available across
the country.
Expand the Canada Health Act to include coverage for post-acute home care
including medication management and rehabilitation services
Advances in medical technologies and treatments mean that many procedures that
previously required long hospital stays can be replaced by day surgeries or brief overnight stays.
But many patients still need follow-up care and rehabilitation services in their own home.
Providing coverage for post-acute home care services across the country on equal terms and
conditions through the Canada Health Act is a necessary and logical next step. Coverage for
post-acute home care should include case management, health professional services, and
medication management.
Provide Canada Health Act coverage for palliative home care services to support
people in their last six months of life
Given the option, information suggests that a growing number of Canadians with terminal
illnesses would choose to spend their final days at home surrounded by family and friends rather
than in an institution. Yet access to palliative care is uneven and depends very much on where
people live and the resources of their community. The option of dying at home should be
available to all Canadians in all communities. This step will make it easier for terminally ill
Canadians to opt to spend the last six months of their lives receiving care at home.
Introduce a new program to provide ongoing support for informal caregivers

With more and more Canadians being treated at home rather than in other care centres, the
burden on informal caregivers has grown significantly. Our health care system simply could not
function without the thousands of parents, loved ones, family and friends that provide direct
xxxi
support in the home. That support should be recognized by allowing informal caregivers to take
time off work and to qualify for special benefits under Canada’s Employment Insurance
program. Human Resources Development Canada, in conjunction with Health Canada, should
move forward with this initiative as a priority.
Chapter 9 – Prescription Drugs

Chapter 9 addresses the difficult issue of prescription drugs, takes the important first step to
integrate prescription drugs into Canada’s health care system, and proposes a new National Drug
Agency.

Take the first steps to better integrate prescription drugs into Canada’s health care
system
Prescription drugs are a large and rapidly growing component of the health care system. Some
have argued that prescription drugs should be brought completely under medicare while others
argue that would potentially bankrupt the system. The Commission’s view is that we need to begin
the process of integrating coverage for prescription drugs within medicare as part of a longer term
strategy to ensure all Canadians benefit from comprehensive prescription drug coverage.
Use the new Catastrophic Drug Transfer to offset the cost of provincial and
territorial drug plans and reduce disparities in coverage across the country
There are serious disparities across Canada in terms of catastrophic coverage for
prescription drugs. Under this proposed new program, provinces and territories would receive
additional funds to help cover the costs of prescription drug plans and protect Canadians against
the potentially “catastrophic” impact of high cost drugs. This measure provides a clear incentive
for provinces and territories to expand their coverage and will reduce inter-regional disparities.
Establish a new National Drug Agency to control costs, evaluate new and existing
drugs, and ensure quality, safety, and cost-effectiveness of all prescription drugs
A new prescription drug comes onto the market in Canada every four to five days, and
forecasts are that these numbers will increase rapidly. New research on genetic testing and
biotechnology will undoubtedly bring with it a host of complex and difficult social, ethical and
financial issues. Canada must have a comprehensive, streamlined and effective process in place
for addressing these issues and ensuring the safety and quality of all new drugs before they are
approved for use in Canada. But just as important, processes should be in place for reviewing
drugs on an ongoing basis, monitoring their use and outcomes across the country, and for
sharing timely and complete information and analyses. A new independent National Drug
Agency would perform these functions on behalf of all governments and all Canadians.
Establish a national formulary of prescription drugs to provide consistency across

the country, ensure objective assessments of drugs, and contain costs
Currently, each province and territory has its own list of prescription drugs that are covered
under its drug insurance plan. A national formulary, developed by the National Drug Agency in
conjunction with the provinces and territories, would support the goals of consistent coverage,
xxxii
objective assessments, and cost containment.
EXECUTIVE SUMMARY
Develop a new medication management program for chronic and some life-
threatening illnesses as an integral part of primary health care
Primary health care reform is an essential component of our vision for the future of
Canada’s health care system. Linking medication management with primary health care would
ensure that the effectiveness of prescription drugs could be monitored on an ongoing basis by
teams and networks of health care providers working with individual patients.
Review aspects of Canadian patent law

Like all other manufactured goods, patents protect new prescription drugs. The extensive
20-year guarantee of exclusive access to the Canadian market remains a matter of considerable
debate in Canada. Canada’s patent laws are consistent with international standards and our
prices are lower on average than in other countries. However, certain aspects of Canada’s patent
laws should be reviewed to improve access to generic alternatives and to contain costs.
Chapter 10 – 2 New 2pproach to

2boriginal Health
In Chapter 10, we address the serious disparities in health for Canada’s Aboriginal peoples
and propose a new approach that cuts across traditional boundaries and focuses squarely on
improving their health.

Consolidate Aboriginal health funding from all sources and use the funds to support
the creation of Aboriginal Health Partnerships to manage and organize health
services for Aboriginal peoples and promote Aboriginal health
Aboriginal health programs are funded from a variety of sources including the federal
government, provincial and territorial governments, local Bands and, in some cases, municipal
governments and regional health authorities. Unfortunately, the resources are split among different
organizations and objectives and, as such, their potential to benefit Aboriginal peoples cannot be
effectively leveraged. Under this new approach, funding from all sources would be consolidated
and allocated to new Aboriginal Health Partnerships (AHP), created solely and specifically to
organize health services and improve the health of the communities and people they serve.
Establish a clear structure and mandate for Aboriginal Health Partnerships to use
the funding to address the specific health needs of their populations, improve access
to all levels of health care services, recruit new Aboriginal health care providers, and
increase training for non-Aboriginal health care providers
This concept is a new one for Canada. It pools community-based expertise and resources
into a single organization whose sole mandate and purpose is to organize services on behalf of
Aboriginal peoples. These partnerships would be responsible for assessing needs, delivering
services or purchasing them from other organizations, assessing outcomes on an ongoing basis,
and providing public reports on the effectiveness and results of their efforts.
xxxiii
Ensure ongoing input from Aboriginal peoples into the direction and design of
health care services in their communities
Through the proposed new AHP, Aboriginal peoples would have direct input and would be
able to work with the AHP to ensure that programs are adapted to meet their needs and the needs
of their community.
Chapter 11 – Health Care and

Globalization
Chapter 11 moves beyond Canada’s boundaries to examine Canada’s role in the global context.

Take clear and immediate steps to protect Canada’s health care system from possible
challenges under international law and trade agreements and to build alliances
within the international community
There are no clear and definitive answers to the question of what international trade
agreements mean for Canada’s health care system. In the face of that uncertainty, the solution is
not to sit back and wait for the outcomes of potential challenges under the various trade
agreements. Rather, it is to take proactive steps to ensure that Canada can continue to make
whatever policy decisions it deems necessary to maintain or expand the public health care system.
Canada should build strategic alliances with other countries around the world that share this view.
Play a leadership role in international efforts to improve health and strengthen

health care systems in developing countries
It is time for Canada to use both its positive relationships with developing countries and its
considerable expertise in health care to contribute to health and health care around the world.
This would involve strengthening Canada’s role in foreign aid programs to assist in training
much-needed health care providers for developing countries and in promoting public health
initiatives designed to prevent the spread of illnesses such as polio, HIV/AIDS, and other
communicable diseases.
Reduce our reliance on the recruitment of health care professionals from developing
countries
Visit a small rural community and chances are good you will meet a doctor from a
developing country who has come to Canada to practice. Canada has made extensive use of
foreign-trained medical graduates, particularly in communities that have had trouble attracting
Canadian doctors. While Canada has a long-standing policy of welcoming immigrants from
around the world, we have an obligation to help protect health care systems in developing
countries. We must learn to solve our problems domestically rather than rely on luring
physicians away from developing countries where their services are desperately needed.
xxxiv
S USTAINING M EDICARE
1
The heart of the Commission’s mandate was to make recommendations “to ensure the long-
term sustainability of a universally accessible, publicly funded health system.” The rationale
behind this mandate was quite simple. For a number of years now, Canadians have been told by
some of their governments and a number of health policy experts that the system popularly
known as medicare is no longer “sustainable.”
At the same time, the Commission’s extensive consultations with Canadians and its
comprehensive research program clearly indicate that Canadians want the system to be
sustainable, not only for themselves but for future generations of Canadians. They want it to
change, and to change in some very fundamental and important ways. But they also want it to
endure and, indeed, to thrive.
Is it possible to reconcile these two perspectives? The place to start is with a clear
understanding of what makes a system sustainable and what needs to be done to ensure that
Canada’s health care system is sustainable in the future.
What Is Sgstainability?
In some ways, the word “sustainability” both illuminates and obscures the debate. It is a
word that is immediately understandable and yet open to multiple interpretations and
misinterpretations. Moreover, much of the recent debate on health care has focused on one
aspect only – namely costs. People conclude that the system is not sustainable because it costs
too much money, it takes too large a proportion of governments’ budgets, or it is an impediment
to lowering taxes. There are others who argue that the problem with the system is the way it is
organized and the inefficiencies that result. Reorganize the system, they argue, and there is more
than enough money to meet our needs. Still other voices have argued that the only problem with
the system is the lack of money provided in recent years. Restore and increase the financial
resources, they argue, and all will be well.
In the Commission’s view, this narrow focus on money is inadequate and does not help
inform the debates or enable an overall assessment of whether or not Canada’s health care
system is sustainable.
Instead, the Commission takes the view that:
Sustainability means ensuring that sufficient resources are available over the long term to
provide timely access to quality services that address Canadians’ evolving health needs. 1
For many years, health policy experts have focused on three essential dimensions that are
each key to sustaining the health care system:
• Services – A more comprehensive range of necessary health care services must be
available to meet Canadians’ health needs. The services must be of a high quality and
accessible on a timely basis. This aspect of sustainability involves looking at the
changing ways health care services are delivered, whether they are accessible for
Canadians, and whether they are efficiently and effectively delivered.
• Needs – The health care system must meet Canadians’ needs and produce positive
outcomes not only for individual Canadians but also for the population as a whole. This
dimension examines how Canada’s health care outcomes measure up to other countries,
identifying disparities in the health of different Canadians and looking at trends in health.
• Resources – This includes not only financial resources but also the required health care
providers and the physical resources (facilities, equipment, technology, research and
data) that are needed to provide the range of services offered.
There is no “invisible hand” that silently and unobtrusively keeps these elements in balance.
Decisions about providing adequate resources imply that there is political support by
governments and by Canadians to continue supporting the system through public funds and
public oversight. Maintaining the balance is, in fact, a deliberate act of will on the part of society
and, thus, it is the overall governance of the system at all levels that ultimately decides how
these elements are balanced.
Governance involves the political, social and economic choices that Canadians, their
governments, and those in the health care system make concerning how the system continues to
balance the health services, health needs, and resources that make up the system.
The following sections of this chapter address the complex and thorny issue of sustainability
from those three essential dimensions – services, needs and resources – and looks at the
changing way the health care system has been governed. What this review shows is that the
system continues to do many things well. At the same time, there are a number of things it can
and must improve. The system is neither unsustainable nor unfixable, but action is required to
maintain the right balance between the services that are provided, their effectiveness in meeting
the needs of Canadians, and the resources that we, as Canadians, are prepared to dedicate to
sustain the system in the future.
Ultimately, the question of whether and how the system is sustained comes down to choices
by those who govern the health care system – by providers, by governments, by administrators
and by Canadians themselves.
Health and Health Care Services

Canada’s health care system provides a range of services, some of which are covered by the
Canada Health Act and the well-known five principles, some that are covered by provinces and
territories, and some that are provided through the private sector. In large part, provinces and
territories are responsible for organizing and delivering health care services to people across the
country. Since medicare was first established, there have been considerable changes in both the
scope of health care services provided in Canada and the different ways they are organized and
2 delivered from relatively large regional health authorities to small clinics or doctors’ offices.
SUSTAINING MEDICARE
Services offered in our health care system can be differentiated by their complexity and
intensity: the more or less specialized nature of interventions to maintain or restore health and
the number of qualified health personnel needed to see the interventions through.
At one end of the spectrum are a wide variety of services that are covered by the public
health care system: public health programs aimed at the prevention of illness such as the
immunization of children; visits to family physicians, pediatricians or gynecologists; diagnostic
tests; and day surgery. Moving across the spectrum, we find the complex and intense care that
requires the increasing use of advanced technology as well as highly trained specialists and large
support teams. In addition, long-term or continuing care is typically provided in nursing homes or
other specialized residential settings for people who require ongoing medical attention and
support but who do not need to be treated in hospitals. Palliative care is provided to people who
are dying and is available in hospitals, hospices and, to a growing extent at home. Home care is
an increasingly important component of health care that can allow people to avoid hospitalization
or recover at home following a shorter hospital stay. At any point along the spectrum, people can
and frequently do receive prescription drugs.
The key question in terms of sustainability is whether this vast continuum of services
provided in Canada’s health care system meets the needs of Canadians, is accessible, and can be
adapted in the future to meet the changing needs of Canadians.
Health Care and the Canadian Constitution

The Canadian constitution does not address health and health care as a single subject nor
does it explicitly allocate responsibility to one order of government or another. Both provincial
and federal governments have varying degrees of jurisdiction over different aspects of the health
care system (Braën 2002; Leeson 2002). However, through a number of court cases and legal
interpretations, it is now well accepted that the provinces have primary jurisdiction over the
organization and delivery of health care services in Canada. In contrast, Yukon, Nunavut and the
Northwest Territories do not have formal constitutional powers over health care, although they
have assumed these responsibilities in recent years.
As Justice Estey of the Supreme Court of Canada pointed out in Schneider v. The Queen :
“Health is not a subject specifically dealt with in the Constitution Act either in 1867 or by way
of subsequent amendment. It is by the Constitution not assigned either to the federal or provincial
legislative authority” (quoted in Gibson 1996, 1). In Peter Hogg’s (1997, 485) words, “health is
an ‘amorphous topic’ which is distributed to the federal Parliament or the provincial Legislatures
depending on the purpose and effect of the particular health measure in issue.” The reason for
this is that the concept of health care is a modern one with assumptions and meanings that could
not have been predicted by the constitution. A simple analogy to “health and health care” would
be “the environment,” another contemporary concept foreign to 19
th century thinking and,
therefore, absent from the original constitutional division of powers.

While the provinces have primary responsibility for health care delivery, the federal
government has constitutional authority and responsibility in a number of very specialized
aspects of health care (e.g., the approval and regulation of prescription drugs) and in critical
areas of publicly funded health care, including the protection and promotion of health. The
federal government also is responsible for providing health services to specific groups of
Canadians, including First Nations and Inuit peoples as well as members and veterans of the
Armed Forces and members of the Royal Canadian Mounted Police. 3
Perhaps the most visible federal role in health care comes through its transfer of funds to the
provinces through what is called the “federal spending power.” This often-controversial power is
not specifically identified in the constitution but rests on court decisions that have upheld the
federal government’s right to spend money in areas of provincial jurisdiction.
The spending power can be used to provide direct payments to individuals (such as Family
Allowances in the past or the current Millennium Scholarships), to other third parties such as
universities (e.g., the Canada Research Chairs), or to the provinces for such things as post-
secondary education, social services or health care. Such transfers to the provinces often come
with “conditions” on how the money is supposed to be spent.
The spending power has been contested by some provinces, which argue that health care is
exclusively a provincial jurisdiction, that the “conditions” imposed by the federal government
distort their own spending priorities, and that Ottawa’s fiscal powers should be curtailed. In spite
of these objections, various legal cases have consistently upheld the constitutionality of the
federal spending power and, more specifically, the right to provide conditional funding to the
provinces (Braën 2002).
Medicare and Beyond

Most Canadians give little thought to the constitutional division of powers over health care.
When they think of medicare, they think, first and foremost, of the services that the system
provides. However, there are many misconceptions about what medicare is and what it is not –
and some of those misconceptions may stem from the complex relationship that has developed
between the federal and provincial-territorial governments for funding and organizing the
system.
In 1957, the federal government, under the Hospital Insurance and Diagnostic Services Act
(HIDSA), agreed to reimburse provinces for a portion of the cost of providing hospital insurance
to their residents. Some provinces had already created hospital insurance programs by this point
and the others were encouraged to do so by the offer of partial federal funding. In the late 1960s
and early 1970s, following the report of Justice Emmett Hall’s Royal Commission on Health
Services (1964) and building on the model introduced in Saskatchewan, the federal government
again used its spending power to encourage provinces to expand hospitalization insurance to
include basic physician services as well. They agreed to cover a portion of the cost of those
expanded services under the Medical Care Act of 1966. This expanded the program that became
known to the public as medicare. The result is complete coverage for all necessary hospital and
physician services through a publicly funded “single-payer” insurance system. As a result, no
Canadian has to pay for those services at the time he or she uses them.
In 1984, the Medical Care Act and HIDSA were replaced by the Canada Health Act (CHA),
which enumerated the five principles that have, in recent years, come to define the Canadian
health care system: public administration, universality, accessibility, portability, and
comprehensiveness. These principles have also become the conditions that the federal
government has placed on its transfer of funds to the provinces. The provinces must ensure that
their health insurance programs meets the conditions set out in the Canada Health Act in order
to receive their full share of federal funding, and they must report annually to the federal
government on how they meet the conditions of the CHA. In 2001/02, CHA services amounted
4 to almost $44 billion or 42.4% of total (public and private) health expenditures.
SUSTAINING MEDICARE
The federal government’s role in relation to hospital and physician services covered under
the Canada Health Act primarily involves transferring funds to the provinces and ensuring that
the conditions of the Act are met. Canada Health Act services are insured and administered by
the provinces and territories, and delivered through a variety of organizations such as regional
health authorities, hospitals, physician practices, and health clinics. As discussed in more detail
later in this chapter, the relative size of the federal transfer compared to the provincial cost of
delivering health services has become a dominant and disruptive theme of contemporary
intergovernmental relations in Canada.
In addition to hospital and physician services, provinces and territories provide a range of
additional health care services including prescription drug plans, home care, continuing care and
long-term care. The nature and scope of these services vary considerably depending on the
individual provincial and territorial plan. In addition, some provinces provide coverage for
services such as rehabilitation, physiotherapy or chiropractic care while others do not. Unlike the
single-payer system for hospital and physician services, provincial coverage for prescription
drugs and various other health services such as home care does not necessarily cover the full
costs. Instead, provincial plans supplement, to varying degrees, private insurance and private
payment. These services amounted to almost $26 billion, which was 25.2% of total health care
expenditures in Canada in 2001/02. Moreover, public coverage for these other health care
services is generally accompanied by co-payments, deductibles, and means testing and is, therefore, not
the type of fully insured coverage we have come to expect for Canada Health Act services.
The private sector also plays a role in Canada’s health care system. Private health care
services are those that we either pay for directly ourselves or are covered through private
insurance plans or employee benefit plans. For example, the vast majority of dental services in
Canada are paid for through employer-provided insurance coverage or by individuals directly.
Private services amounted to just over $33 billion in 2001/02, which was 32.4% of total health
care expenditures.
There is also a small area of overlap between public and private health care services. This
overlap includes two areas: services provided under workers’ compensation programs for
injuries sustained on the job, and tax subsidies to encourage the private sector to provide
supplementary insurance (largely for prescription drugs and dental services not covered in
provincial and territorial plans). Individuals also receive tax deductions if their medical expenses
are more than 3% of their income. In 1994, these tax breaks were estimated to be worth about
$2.5 billion (Smythe 2001). They have grown rapidly since that time and likely are worth closer
to $4 billion today, including roughly $3 billion given up by governments for not taxing private
health premiums paid by employers and a further $1 billion for the tax credits for individual
health costs as well as various disability allowances. These tax subsidies are not typically
included in estimates of public spending on health care.
The health care system has expanded considerably to respond to the changing nature of
health care and medical science, the wishes of Canadians in different provinces and territories,
and the availability of resources within any particular province. There are only minor differences
between provinces in terms of the Canada Health Act services that are covered. For example,
some provinces cover annual eye exams while some do not. Beyond these services, all provinces
provide some level of home care services, some form of public prescription drug insurance for
vulnerable populations, and some range of continuing or long-term care. 5
There are also similarities in the way provinces have chosen to organize the delivery of
health care services. The most prominent trend in recent years has been regionalization.
Provinces have created regional health authorities with responsibility for organizing, delivering
and co-ordinating public health programs, hospital services, community care and long-term or
continuing care services within a particular region of the province. The province of Quebec led
this move in the 1970s, but today every province has created health regions, although in Ontario
these regions have only a consultative role.
Private For-Profit Service Delivery: The Debate

One of the most contentious issues facing Canadians is the extent to which the private
sector should be involved in delivering health care services. Currently, provincial and territorial
governments provide coverage for a range of services and those services can be delivered in any
number of ways. Almost all Canadian hospitals are not-for-profit institutions and, in most
provinces, are operated by regional health authorities. Most physician services are delivered by
what are effectively owner-operated small businesses ranging from single-physician practices to
multi-provider clinics that may include a range of health care providers. Large for-profit
corporations deliver a narrower range of services including laboratory services and continuing
and long-term care.
In the face of continuing pressures on the health care system, some argue that more private
for-profit service delivery ought to be introduced in order to bring more resources, choice and
competition into the Canadian health care system and to improve its efficiency and
effectiveness. Others argue as strongly that the private sector should be completely excluded
from health care delivery, suggesting that private for-profit delivery runs counter to Canadians’
values, is inequitable, and less cost-effective than public delivery in the long run.
To try to make sense of this debate, it is important to distinguish between two types of
services: direct health care services such as medical, diagnostic and surgical care; and ancillary
services such as food preparation, cleaning and maintenance. An increasing proportion of
ancillary services provided in Canada’s not-for-profit hospitals are now contracted out to for-
profit corporations. Canadians seem to find this role for private sector companies acceptable and
some studies suggest that these enterprises achieve economies of scale (McFarlane and Prado
2002). Ancillary services are relatively easy to judge in terms of quality – the laundry is either
clean or it is not, the cafeteria food is either good or it is not. Consequently, it is relatively easy
to judge whether the company is providing the service as promised. Also, there is a greater
likelihood that there are competitors in the same business to whom hospitals can turn for laundry
or food services if their current contractor is unsatisfactory.
In terms of direct health care services, the precise number of for-profit facilities delivering
direct health care services is unknown. One estimate in 1998 (Deber et al.) suggested that there
were 300 private for-profit clinics in Canada delivering many diagnostic and therapeutic
services formerly provided in hospitals, including abortions, endoscopies, physiotherapy, new
reproductive technologies and laser eye surgeries. In addition, there are a growing number of
small private for-profit hospitals or stand-alone clinics in some provinces providing more
complex surgeries, some requiring overnight stays. These facilities vary considerably in terms
of the number of services they offer and their ownership structure. Furthermore, some provinces
have expressed an interest in contracting out an increasing number of surgical services to
6 private for-profit hospitals and clinics in the hope of realizing efficiencies.
SUSTAINING MEDICARE
Unlike ancillary services, direct health care services are very complex and it is difficult to
assess their quality without considerable expertise. Indeed, the effects of poorly provided service
may not be apparent until some time after the service has been delivered, as in the event of a
post-operative complication. This is what most clearly distinguishes direct health care services
from ancillary services – a poorly prepared cafeteria meal may be unpleasant, but poor quality
surgery is another matter altogether. It is also unlikely that there would be a significant number
of competitors able to offer health care services if a given for-profit provider is unsatisfactory.
There simply is not a significant surplus of health care administrators or providers waiting in the
wings to take over service delivery in a hospital. Thus, if services are of poor quality, it is going
to be much harder to find a replacement once public facilities have stopped providing the
services – the capacity that existed in the public system will have been lost.
Some suggest that private for-profit delivery is more efficient than not-for-profit delivery
(Gratzer 1999 and 2002). Given that most of the private facilities currently operating and being
planned focus only on providing a limited range of services, there are some important concerns
that must be addressed in terms of how these facilities interact with the more comprehensive
public system. In effect, these facilities “cream-off” those services that can be easily and more
inexpensively provided on a volume basis, such as cataract surgery or hernia repair. This leaves
the public system to provide the more complicated and expensive services from which it is more
difficult to control cost per case. But if something goes wrong with a patient after discharge
from a private facility – as a result, for example, of a post-operative infection or medical error –
then the patient will likely have to be returned to a public hospital for treatment insofar as
private facilities generally do not have the capacity to treat individuals on an intensive care
basis. Thus, the public system becomes liable for the care triggered by a poor quality outcome
within a private facility, yet under current arrangements there is no way for the public system to
recover those costs from the private facility. In other words, the public system is required to
provide a “back-up” to the private facilities to ensure quality care.
Proponents of for-profit care may insist that the quality of care is not an issue, but there is
evidence from the United States to suggest that the non-profit sector tends to have better quality
outcomes than the for-profit sector in such things as nursing home care (Harrington 2001;
Marmor et al. 1987) and managed care organizations and hospitals (Kleinke 2001; Gray 1999).
More recently, a comprehensive analysis of the various studies that compare not-for-profit and
for-profit delivery of services concluded that for-profit hospitals had a significant increase in the
risk of death and also tended to employ less highly skilled individuals than did non-profit
facilities (Devereaux et al. 2002).
For those reasons, the Commission believes a line should be drawn between ancillary and
direct health care services and that direct health care services should be delivered in public and
not-for-profit health care facilities.
There are, however, several grey areas around the issue of private for-profit delivery. First,
diagnostic services have expanded considerably in the past few years and, in many cases, these
services are provided in private facilities under contracts with regional health authorities or
provincial governments. Much of this involves relatively routine procedures such as laboratory
tests and x-rays that can be done with little delay or wait on the part of the patient. But there
appears to be a growing reliance on the private provision of more advanced and expensive
7
diagnostics such as MRIs (magnetic resonance imaging), for which the waiting times in the public
system can be frustratingly long because of what appears to be an under-investment in such
technology within the public system. The growth of private advanced diagnostic facilities has
permitted individuals to purchase faster service by paying for these services out of their own
pocket and using the test results to “jump the queue” back into the public system for treatment.
While this is not currently a common occurrence, Canadians made it clear to the Commission that
they are deeply concerned about the prospect of this becoming routine (Commission 2002a).
Medicare rests on the principle that an individual’s financial resources should not determine
access to services. In the Commission’s view, governments have a responsibility to guarantee that
the public system has sufficient resources to ensure appropriate access to advanced technology.
Increased investment within the public system for new diagnostic technology can remove the
temptation to “game” the system by individuals and health care providers through the private
purchase of diagnostic tests that could allow them to jump the queue.
The second grey area is services provided to workers’ compensation clients with job-related
injuries and illnesses. Because of the belief that it is important to get these people back to work
quickly, these clients get preferential treatment in accessing diagnostic and other health care
services over those whose illness or injury is not work related or who may not be formally
employed. As suggested in Chapter 2, this current exception under the Canada Health Act
should be reconsidered.
The third grey area is contracting out of surgical services. In some cases, regional health
authorities have contracted with private for-profit facilities that provide specific surgeries such as
cataract and some day surgeries. Again, there is no clear evidence that this practice is more efficient
or less costly than providing the services in an adequately resourced not-for-profit facility.
Services and Sustainability

Services are the first element in our definition of sustainability. The previous information suggests
that there are complex, and sometimes confusing, relationships between the federal, provincial and
territorial governments. Much has changed since medicare was first introduced. The range of services is
growing and changing with new advances in medicine and, as a result, the biggest growth in services is
outside of hospital and physician services. Subsequent chapters will show that there is tremendous
growth in home care and that prescription drugs have become the fastest growing part of the health care
system. Canadians also are only too well aware of the fact that services are not always available on a
timely basis. In areas like diagnostic services and some surgeries, people sometimes wait too long for
access to the services they need. People in rural and remote communities also have problems in accessing
services. In spite of what appears to be almost overwhelming support for primary health care, only
limited progress has been made in extending primary health care across the country. All of these issues
apply in every province and territory. The conclusion, then, on services and sustainability is that more
needs to be done to ensure timely access to quality services. The answer, however, is not to look to the
private sector for solutions. Instead, governments should seek the best solutions within the public system
and ensure that adequate resources are available and services are accessible to all.
8
SUSTAINING MEDICARE
The Commission is strongly of the view that a properly funded public system can continue
to provide the high quality services to which Canadians have become accustomed. Rather than
subsidize private facilities with public dollars, governments should choose to ensure that the
public system has sufficient capacity and is universally accessible. In addition, as discussed in
Chapter 11, any decisions about expanding private for-profit delivery could have implications
under international trade agreements that need to be considered in advance.
Needs and Ogtcomes

There is a direct and dynamic relationship between the services that are provided and
Canadians’ changing health care needs. The ability of health services to meet health needs is
affected by the following factors:
• Limited fiscal resources to address the range of health needs;
• Limited physical resources, equipment and new technologies;
• Imbalance in the supply, distribution and scopes of practice of health care providers;
• Demographic, societal, and technological changes that make some services (e.g., prescription
drugs and home care) more important or essential than they were in the past; and
• Canadians’ growing expectations that an increasing range of treatments will be provided
within the public system.
Balancing these various factors requires a high level of responsiveness and flexibility in the
health care system – something Canada’s system appears to have done reasonably well in the
past. The following sections describe the performance of the health system in meeting
Canadians’ needs as measured by the health status of Canadians, the responsiveness of the
system, disparities in health outcomes, and anticipating changing needs.
Performance of the Canadian System

Determinants of Health
In 1974, Canadian Minister of Health Marc Lalonde published a seminal report on the
determinants of health (Canada 1974). Determinants of health include a range of factors that
explain why a person is or is not healthy – biological factors, lifestyle choices, environmental
conditions, and the organization of the health care system itself. This broader approach to health
looks at not just the health of individuals but also at the health of the population, factors that
affect health overall, and trends in the health of different groups of people within our society.
The population health approach focuses on “upstream” determinants of health in order to

prevent or reduce “downstream” problems that have to be addressed by the health care system.
For example, individuals who live in a highly polluted environment tend to have greater health
care needs than those who live in cleaner environments. Conversely, if the environment is
healthy, then people are healthier and the burden on the health care system is reduced. People
who live in wealthier societies across the world also have significantly better health outcomes –
longer lives, lower infant mortality rates, fewer chronic illnesses – than those in poorer societies.
Other factors such as large disparities in the distribution of income and wealth, the level of
educational attainment, and the literacy rate also have an impact on the health of a population.
The greater the economic and social inequality within a society the lower the health outcomes
9
(Wilkinson 1996). To address issues related to population health, governments, health care
providers and policymakers look to injury and illness prevention programs, health protection and
promotion programs and services, as well as the many diverse programs, policies and initiatives
that support healthier social and physical environments. These initiatives can range from
encouraging healthier lifestyles among individual Canadians to programs to reduce poverty and
ensure a cleaner environment.
In the decades since the Lalonde report, Canadians have continued to be in the forefront of
population health thinking, as demonstrated by reports such as Achieving Health for All: A
Framework for Health Promotion (1986) by former federal Minister of Health Jake Epp, the
Ontario government’s Early Years Study (1999), and the pioneering work conducted by Fraser
Mustard and the Canadian Institute for Advanced Research. Not surprisingly, this population
health approach was endorsed in the recommendations of all recent Canadian reports on health
care, including the National Forum on Health (1997), Quebec’s Clair Commission (2000),
Saskatchewan’s Fyke Commission (2001), Alberta’s Advisory Council under Mazankowski
(2001), and recent work by the Senate Standing Committee on Social Affairs, Science and
Technology (2001, 2002).
Overall Performance
Eight countries – the United Kingdom, Sweden, Germany, France, Japan, Australia, the
Netherlands and the United States – have been selected for comparison with Canada based on
their size, wealth and health policy characteristics. These comparisons are used throughout the
report at various points in an effort to ensure that we compare relatively similar countries at all
times. These countries also display a broad range of public and private mechanisms, financing
and delivery of health services based on a classification developed for the Organisation for
Economic Co-operation and Development (Propper 2001). In addition, two composite indices
have been used. One measures the thirty countries that are members of the OECD that range
from mid-income countries such as Turkey and Poland to the high-income countries noted
above. The other index is the average for the G7 countries – the United States, Japan, Germany,
France, the United Kingdom, Italy and Canada – seven of the largest and wealthiest economies
in the world.
From a population health perspective, a number of indicators of the overall health of

Canadians can be considered. These broad measures address some of the key determinants of
health as well as track progress on international indicators of the health of Canada’s population
compared with others around the world.
Based on the United Nations Human Development Index of income per capita, literacy, and
life expectancy, Canada scores very high. For a number of years, Canada was ranked number
one in the world and, although it is currently in third position behind Norway and Sweden
(UNDP 2002), the system is clearly doing well. Other international yardsticks, however, such as
the United Nation’s Human Poverty Index (HPI), show a quite different picture. The HPI
measures relative deprivation in terms of standard of living, education and longevity. By this
measure, Canada is in 11
th place behind the Scandinavian countries, Germany, France, Japan and Spain,
among others (UNDP 2001). On this index, Canada is not doing as well as it should.
10
SUSTAINING MEDICARE
In many cases, precise indicators are not available to allow us to measure the state of health
and health needs in Canada, and compare our health outcomes with other countries. Because
health has frequently been defined as the absence of illness in an individual, only the most
serious problems – those that often lead to the death of patients – are generally tracked in health
statistics (Hadley 1982). Nonetheless, there are some important indicators that are consistently
tracked on a national and international basis.
Life expectancy at birth is one of the most established and widely available summary
measures of health status. Life expectancy at age 60 provides a measure of the health status of
the elderly population. Both measures (see Figures 1.1 and 1.2) reflect improvements in the
standard and quality of life, as well as the extent of our collective wealth and the way it is
shared. The quality of the health care system and its ability to provide people with the care they
need also has an impact on life expectancy.
Since the 1930s, the life expectancy of Canadians has increased by 17.7 years to 75.4 years
for men and 81.2 for women. Since the implementation of medicare at the beginning of the
1970s, Canadians’ life expectancy has risen approximately one year for every five calendar
years. In 1999, Canada’s life expectancy at birth was 5 th
among all OECD countries.
Another measure is the number of potential years of life lost (see Figure 1.3), that is,
preventable deaths that occur before people reach the age of 70. In large part, this measure
reflects the quality and accessibility of the health care system. Since the creation of medicare,
Canada’s performance has improved considerably, moving from a rate of 9,395 years lost per
100,000 people in 1960 to a rate of 3,803 years in 1997. With these results, Canada ranked
favourably in 8 position in comparison to all other OECD countries in 1998.
th
Since its 2000 report, the World Health Organization (WHO) has encouraged its members
to collect data on the number of disability-free years of life as a measure of whether societies are
adding not only to the length of people’s lives but also the quality of their lives (see Figure 1.4).
Both medical care and the effectiveness of prevention programs should have an impact on
increasing the number of years people live without disabling conditions. With an estimated
ranking of 9
th among 30 OECD countries (Mathers et al. 2000), this is also an area in which
Canada fares reasonably well, though it could do better.

One area where Canada has made some progress is in reducing infant mortality rates, an
almost direct reflection of improvements in education, health, housing and nutrition, and the
overall standard of living. Low rates also demonstrate the impact of primary health care
initiatives and, in particular, the quality of prenatal care. Canada’s infant mortality rate decreased
steadily from a rate of 27.3 deaths per 1,000 births in 1960 to 5.3 deaths per 1,000 in 2000 (see
Figure 1.5). In spite of this progress, there is still considerable room for improvement. Canada is
currently ranked 17
th among all OECD countries with a rate that is considerably higher than
Japan and most Western European countries (see Figure 1.6). Another measure of health status
is perinatal mortality – the number of deaths that occur between the 28 thweek of pregnancy and
the first month of a baby’s life. As with infant mortality, decreases in the perinatal mortality rate
reflect the living conditions of the mother and the quality of prenatal care. For example, a
non-smoking mother in good health and whose pregnancy is monitored by competent health care
professionals is far more likely to carry the pregnancy to term and to give birth to a healthy baby.
Perinatal mortality also varies according to the level of care available to a baby born prematurely,
with a low birth weight, or when complications arise during childbirth.
11
Figure 1.1 Figure 1.2

Life Expectancy in Years, by Sex, at Birth Life Expectancy in Years at Birth among
and at Age 60, Canada, Selected Years OECD Countries, 1999
80 81
1931 1961 1998
70 80
60 79
50
78
40
77
30
76
20
75
10
0 74
United States
G7 Average
United
Kingdom
Sweden
Netherlands
France
Germany
Japan
Australia
Canada
OECD
Average
Male at Birth Female at Birth Male at 60 Female at 60
Source: Statistics Canada 1983; OECD 2002b. Note: 1999 is the most recent year for which comparable data are
available.
Source: OECD 2002b.

Potential Years of Lost Life (Years Lost Disability Adjusted Life Expectancy in
per 100,000 People) among OECD Years at Birth among OECD Countries,
Countries, 1998 1999
6,000 75
74
5,000
73
4,000 72
71
3,000
70
2,000 69
68
1,000
67
0 67
United States
United
Kingdom
Sweden
Netherlands
France
Germany
Australia
Canada
OECD
Average
G7 Average
Japan
United
Kingdom
Sweden
Netherlands
France
Germany
Japan
Australia
Canada
OECD
Average
United States
G7 Average
Note: 1998 is the most recent date for which comparable figures Source: Mathers et al. 2000.
are available. Figure for Canada is 1997.
Source: OECD 2002b.
12
SUSTAINING MEDICARE

Infant Mortality (Rate per 1,000 Live Infant Mortality (Rate per 1,000 Live
Births) Canada, 1960 to 2000 Births) among OECD Countries, 2000
30% 8.0
7.0
25%
6.0
20%
5.0
15% 4.0
3.0
10%
2.0
5%
1.0
0% 0.0
Sweden
Japan
G7 Average
Kingdom
Germany
Australia
Canada
United
Netherlands
France
United States
OECD
Average
1960
1962
1964
1966
1968
1970
1972
1974
1976
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
Source: OECD 2002b. Note: Figures for Canada and the United States are for 1999.
Source: OECD 2002b.
.

Perinatal Mortality Perinatal Mortality (Rate per 1,000 Live
(Rate per 1,000 Live Births) Canada and Births) among OECD Countries, 1998
the United States, 1960 to 1998
35 9
Canada United States 8
30
7
25
6
20 5
15 4
3
10
2
5
1
0 0
OECD
Sweden
Japan
G7 Average
Kingdom
Germany
Australia
Canada
United
Netherlands
France
United States
Average
1960
1962
1964
1966
1968
1970
1972
1974
1976
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
Note: 1998 is the most recent year for which comparable data are Note: 1998 is the most recent year for which comparable data are
available. available.
Source: OECD 2002b. Source: OECD 2002b.
13
A decrease in the rate of perinatal mortality partially reflects the quality and, even more so, the
accessibility of specialized medical care. Compared to all other OECD countries, Canada’s
relative position is not exceptional, with a rate of 6.2 deaths per 1,000 births in 1998 and a
ranking of 10 th. However, compared with the United States, Canada’s perinatal mortality has
consistently been lower, suggesting that general access to hospital and medical care within the
Canadian system is a significant factor in our progress in reducing perinatal mortality (see
Figures 1.7 and 1.8).
Equity
A key consideration in addressing the performance of any health care system, including
ours, is equity. Equity means that citizens get the care they need, without consideration of their
social status or other personal characteristics such as age, gender, ethnicity or place of residence.
Equity addresses questions such as whether some groups in our society have better access to
health care or better health outcomes than others (Goddard and Smith 2001).
Spending on health care does appear to make a difference in health outcomes. Health
indicators such as life expectancy and infant mortality clearly show that problems are
ameliorated when spending increases (Crémieux et al. 1999). But the effect is neither immediate
nor direct. An inefficient system, for example, may use additional health resources to provide
higher salaries to health care providers without a corresponding improvement in services. A
system with poor accessibility may not assist people who could benefit most from the services.
These reasons are often used to explain why a system that spends a great deal of money, such as
that in the United States, does not produce the results that would be expected.
A multi-country coalition of researchers has focused on assessing equity in various OECD

countries for more than a decade. Their conclusions show that Canada compares favourably
with other countries and also highlight a number of areas where the results are very positive. For
example, there do not appear to be any equity problems in terms of accessing general
practitioners based on socio-economic status. In fact, people with lower socio-economic status
tend to have more visits to a family practitioner than the general population. In this respect the
absence of co-payments is also noted as one of the strong points of the Canadian system (van
Doorslaer et al. 2002). On the other hand, Canadians’ access to specialists appears to be easier
for people with higher incomes (Atler et al. 1999).
Responsiveness to Specific Illnesses

Another way of assessing the performance of the health care system in meeting Canadians’
needs is to look at how well it responds to a host of specific health problems, such as
cardiovascular disease, stroke and other cerebrovascular problems, serious respiratory ailments,
and cancer. On the whole, the picture that emerges is a positive one. Canada is generally above
or within the average range of OECD comparison countries (see Figures 1.9 to 1.12). In fact, as
with other countries, Canadian indicators are at times excellent (e.g., cerebrovascular accidents)
and at times poor (e.g., respiratory diseases). For example, in the case of cerebrovascular
problems, Canada is ranked 3 among all OECD countries while for cardiovascular disease, the
rd
situation is less favourable, with Canada ranking 13 th.
14
SUSTAINING MEDICARE

Potential Years of Lost Life: Malignant Potential Years of Lost Life: Diseases of
Neoplasms (Years Lost per 100,000 the Respiratory System (Years Lost per
People) among OECD Countries, 1998 100,000 People) among OECD
Countries, 1998
1200 250
1000
200
800
150
600
100
400
50
200
0 0
Kingdom
Germany
Australia
United
Netherlands
France
United States
OECD
Average
Sweden
Japan
Canada
G7 Average
Sweden
Japan
G7 Average
Kingdom
Germany
Australia
Canada
United
Netherlands
France
United States
OECD
Average

Potential Years of Lost Life: Cerebrovascular Potential Years of Lost Life: Ischaemic
Diseases (Years Lost per 100,000 Heart Diseases (Years Lost per 100,000
People) among OECD Countries, 1998
People) among OECD Countries, 1998
200 500
180 450
160 400
140 350
120 300
100 250
80 200
60 150
40 100
20 50
0 0
Japan
United States
G7 Average
United
Kingdom
Sweden
Netherlands
France
Germany
Australia
Canada
OECD
Average
United States
G7 Average
United
Kingdom
Sweden
Netherlands
France
Germany
Japan
Australia
Canada
OECD
Average
15
Disparities within Canada

Despite the fact that Canada’s health system compares well with those of other wealthy
industrialized nations, there are serious disparities in health outcomes within Canada. Depending
on where a person lives, there are real inequities in the way Canadians benefit from the public
health care system.
These disparities primarily reflect underlying economic, demographic and cultural realities
such as: the relative poverty or affluence of different regions; the degree of urbanization; the
population density; or the ethnic composition (Statistics Canada 2000). The disparities can also
reflect the different political culture or social cohesion of a province or region, varying levels of
public tolerance for certain risk behaviours such as smoking or alcohol abuse, the extent to
which comprehensive health policies are in place, and the degree of co-operation with and
among health professionals.
There are serious disparities between people who live in the northern part of Canada versus
the south and between people who live in Atlantic Canada and the rest of the country. In other
words, the lines of disparity not only run north and south but also east and west.
A recent study demonstrated that at one extreme, the inhabitants of the Nunavik region in
Quebec live an average of 15.8 years less than people who live in Richmond, British Columbia
(Statistics Canada 2002h). Given that it takes the passage of approximately five years to gain
one year of life expectancy, this translates into a difference between the two communities of
almost 79 years of history in terms of health status and social development. However, to put this
in perspective, even the very small difference between the neighbouring communities of
Vancouver (life expectancy of 78.6 years) and Richmond (life expectancy of 81.2 years)
translates into a difference of 13 years in health and social development. Figure 1.13 compares
life expectancy among all provinces and territories.
The availability of health care also varies greatly in Canada and there are obvious
disparities in access on north-south lines. To a great extent, population density determines
whether people have access to health care providers, medical resources, and advanced hospital
care. The northern regions of Canada are less populated and, as a result, they are relatively less
well served than the southern regions. At the same time, particular provinces such as
Newfoundland and Labrador and Quebec have chosen to provide more medical resources in
terms of physicians and facilities than the size or distribution of their populations would suggest (see Map 1.1).
There also are variations in the rates of different procedures that do not always reflect the
relative wealth or size of the population in different provinces and territories. For example, a
comparison of the number of hospitalizations following hip fractures in each of the provinces
and territories shows that the rates are higher in Alberta and British Columbia, in spite of the
fact that they have younger populations and wealthier economies than provinces like New
Brunswick or Nova Scotia where the rates are lower (see Map 1.2).
Another way of assessing the availability of health care is to ask Canadians whether they
think the health care system is meeting their needs. The answers to these questions are
sometimes difficult to interpret because they do not necessarily correspond to differences in
either the health status of the people surveyed or their needs. At the same time, these surveys can
potentially identify health needs that are not being met. Current surveys suggest that there are
16
SUSTAINING MEDICARE
Figure 1.13 80
Life Expectancy 78
in Years at
Birth, by 76
Province,
Territory and 74
Canada, 1996 72
70
68
66
64 Prince Edward
Island
Newfoundland
Alberta
Northwest
Canada
and Labrador
Nova Scotia
Quebec
British Columbia
Manitoba
New Brunswick
Saskatchewan
Yukon Territory
Territories
Nunavut
Ontario
Note: Life expectancy figures at the provincial and territorial level only available for 1996.
Source: CIHI 2002f.
very minimal variations across the country and most Canadians remain satisfied with the quality
of care they receive. Given the differences in availability of care across the country, the
uniformity of satisfaction may indicate that Canadians adjust their expectations to the level of
care that is available (see Figures 1.14 and 1.15).
Disparities in the quality of health care are more difficult to measure. One approach is to
track the number of interventions done in a hospital that could have been dealt with earlier or in
another way, before hospitalization was required. These types of interventions are measured in
terms of ambulatory care sensitive conditions (see Map 1.3) which are often considered to be
strong indications of the quality of the health care system (Brown et al. 2001; Billings et al.
1996). An adequate and well-functioning primary health care system is certainly one way of
preventing unnecessary hospitalizations. One of the paradoxes of the Canadian health system is
the fact that primary health care services are more fully developed in the richer and more
populated provinces that also have the most hospitals. In contrast, the provinces with the fewest
hospitals also have a limited capacity to prevent and resolve health problems before hospital
care is needed.
Disparities in the health of Canadians can also be measured by asking them what they think
of their own health status. Canadians tend to rate their own health status better than would be
expected based on objective measures. People in parts of the country with lower health status –
people who may have lower life expectancies or who are chronic smokers – tend to rate their
health status much the same as people in regions with higher life expectancies and more healthy
lifestyles. Clearly, people’s expectations and their assessments of health are affected by their
community and the part of the country where they live.
17
1999/2000 18
Map 1.1 Acute Care Facilities in Canada,

COMMISSION
ON
THE
FUTURE
OF
HEALTH
CARE
IN
CANADA
¥
FINAL
REPORT
Source: CIHI 2002.

Map 1.2 Hip Fracture Hospitalizations by Health Region, 1999/2000
A Hip Fracture Age Standardized Rate/100,000 People

Greater than or equal to 810
B 560 to less than 810
SUSTAINING MEDICARE
Less than 560

No data/data suppressed
Source: CIHI 2002.
19
COMMISSION ON THE FUTURE OF HEALTH CARE IN CANADA ¥ FINAL REPORT

Percentage of the Population Reporting Self-reported Health as “Excellent” and
“Unmet Health Care Needs,” by “Very Good,” by Province, Territory and
Province, Territory and Canada, 2000/01 Canada, 2000/01
20% 50%
Excellent Very Good
18% 45%
16% 40%
14% 35%
12% 30%
10% 25%
8% 20%
6% 15%
4% 10%
2% 5%
0% 0%
Prince Edward
Island
Ontario
and Labrador
Nova Scotia
British Columbia
Manitoba
Saskatchewan
Alberta
Yukon Territory
Canada
Newfoundland
New Brunswick
Northwest
Territories
Nunavut
Quebec
Ontario
Nova Scotia
Manitoba
Saskatchewan
Alberta
Yukon Territory
Canada
Newfoundland
Prince Edward
Northwest
Territories
Nunavut
Island
New Brunswick
and Labrador
Quebec
British Columbia
Source: Statistics Canada 2002f. Source: CIHI 2002f.
Anticipating an Aging Population

Much has been made of the fact that Canada’s population is aging and, for some, this is yet
another reason to worry that Canada’s health care system may not be sustainable. Demographic
trends show that the proportion of Canadians 60 years and older is expected to grow from 17%
today to 28.5% by 2031 (see Figure 1.16). Some think that this increase in the proportion of
older people means that health care spending will spiral out of control and the health care system
will be hard pressed to meet the increased demands for services. They point to the fact that more
money is spent on health care as people age. Table 1.1 shows that the average annual per capita
spending on health care for people 65 and over is roughly three times the amount spent on all
age groups. Health expenditures typically increase with age, although most analysts agree that
aging alone will only drive up costs by about 1% a year (Conference Board of Canada 2001).
The impact of aging on the health care system is not something that is unique to Canada. If
we look beyond our borders, other comparable countries have already experienced the aging of
their populations and have been able to manage their costs as well. As one study points out:
Much of the international evidence reviewed indicated that modest growth in economies
should insure that most countries are able to manage the growth in their elderly
populations and increased health care spending in the future. It is also worth
remembering that there are countries which already have significantly larger elderly
populations than Canada, spend significantly less and achieve similar health outcomes
in comparison to Canada (Rosenberg 2000, 20).
20
Map 1.3 Ambulatory Care Sensitive Conditions by Health Region, 1999/2000
A
ACSC Age Standardized Rate/100,000 People
B
SUSTAINING MEDICARE

550 to less than 910
Less than 550
Source: CIHI 2002.
21
Figure 1.16 35%

Population 60-69 70-79 80+
Projections 30%
for Canada,
8.71%
Percentage of 25%
6.24% 8.29%
the Population 4.53%
Aged 60 20%
4.06% 10.19% 9.98%
8.07% 9.43%
3.13%
15%
5.92%
and Over, 5.89%
10%
2001 to 2051
5% 7.83% 10.38% 12.75% 12.21% 11.35% 11.75%
0%
2001
2011
2021
2031
2041
2051
Source: Statistics Canada 2000.
Table 1.1
Average Annual per Capita Expenditure, by Age and Sector, 2000/01
Public Private Total

All age groups $2,243.56 $930.69 $3,174.24
65+ $10,834.02
$2,309.30
$8,524.72 65-74 $6,623.53
$1,648.37
$4,975.16 75-84 $10,083.36
$21,878.36
34.95 $5,256.59
535.27 85+
$27,1
$2,451.91 $12,
Source: Health Canada, 2001d.
There is another difficult but important question to address, namely, will future generations
of aging Canadians be in better health than preceding ones? Aside from problems related to poor
nutrition, notably obesity, Canada ranks within or above the average among leading industrialized
nations in terms of lifestyles and programs that are likely to have an effect on health. This
suggests a positive future, provided Canadians continue to take steps to improve their lifestyle
and stay healthy.
However we look at the evidence, it leads to the same conclusion. It is indisputable that
Canada will be “greyer” in the future than it is now but that reality is neither a catastrophe
waiting to happen nor an issue that simply can be ignored. The baby boomers of today will be
healthier in old age than their parents were, with fewer chronic health conditions, and fewer
health problems caused by smoking and other lifestyle factors. Even with this, however, the
demand for particular kinds of services will increase. For example, with an aging population
there will likely be an increase in the number of people who require joint replacement or suffer
22
SUSTAINING MEDICARE
from Alzheimer’s disease and other types of dementia. Provincial and territorial health care
systems have to be ready to respond. The process of adjusting health programs and financing
should begin to address the impact of aging, and in particular, the increase in demand for
services linked to a decrease in independence as people age (Hogan and Hogan 2002). Because it
may be impossible to accurately forecast the health needs of the population too far in advance,
however, flexible approaches need to be taken to avoid the trap of investing in facilities and
programs that may or may not be needed as Canada’s population ages. With foresight and
appropriate planning, the health care system can adapt in a timely manner to the new reality of an older population.
Needs and Sustainability

The second key dimension of assessing sustainability is needs, namely, does the health care system
adequately meet Canadians’ needs. The answer is a qualified yes. Canada’s health outcomes compare
favourably with other countries and evidence suggests that we are doing a good job of addressing factors
that affect the overall health of Canadians. There are, however, areas where there is room for
improvement. And there are serious disparities in both access to health care and health outcomes in some
parts of Canada. Clearly, more needs to be done to reduce these disparities and also to address a number
of factors that affect Canadians’ health such as tobacco use, obesity and inactivity. These factors are
addressed specifically in Chapter 5 of this report. The other conclusion is that aging is not the ominous
threat to future sustainability of our system that some would suggest. Aging will challenge and add costs
to our health care system, but those costs can be managed, particularly if we begin to prepare and make
adjustments to anticipate the impact of an aging population.
Resogrces in the System:

The Case of Fgnding
As was noted at the outset of this chapter, the third major component of the definition of
sustainability relates to the availability of necessary resources. The health care system needs a
variety of resources in order to deliver services and meet the health care needs of the population.
That includes not only financial resources but also human and physical resources such as
equipment, facilities and technology. Chapter 3 deals with the information resources that are needed
to allow providers, governments and citizens to make informed decisions about the system generally
and about their own personal care. Chapter 4 deals with the supply, distribution and changing role
of health care providers. Chapter 6 deals with the availability and accessibility of equipment and
facilities. All of these are essential for an efficient and effective health care system. However, the
primary focus of much of the debate about sustainability has been about money. Questions about
the increasing costs of health care, who pays for what aspects of the health care system, and
whether we will be able to afford the health care system in the future have played a significant part
in the debates about medicare’s sustainability. The debate has centered on whether there is too little
public money in the system, whether there should be different ways of raising those public funds
and whether the system as we know it is “affordable”
23
any longer. Because other chapters do not deal with these issues in detail, the remainder of this
chapter addresses the fiscal questions directly, beginning with how Canada’s funding for health
care compares with other countries, whether other options for funding should be considered, and
the relative shares paid by different governments.
Canada’s Reliance on Taxes

Canadians pay, directly or indirectly, for every aspect of our health care system through a
combination of taxes, payments to government, private insurance premiums, and direct out-of-
pocket fees of varying types and amounts. Some have suggested that Canada relies too heavily
on taxation to support its health care system.
As Figure 1.17 illustrates, 71% of the total funding for Canada’s health care comes from
taxation. In countries such as Germany, Japan, France and the Netherlands, the majority of
funding for health care comes from social insurance premiums in the form of employment
payroll taxes. In most developed countries (other than those that rely heavily on social
insurance), between 70 and 80% of total health care is funded through the taxation system
(Mossialos et al. 2002). Based on the comparisons in Figure 1.18, it is hard to conclude that
Canada depends too heavily on taxes to support health care.
Use of Private Insurance and Out-of-pocket Payments

One area where Canada differs from most OECD countries is in co-payments and user fees.
While Canada relies almost entirely on taxes to fund hospital and physician services, co-
payments and user fees for these services are common in most OECD countries. At the same
time, Canada relies more heavily on private insurance and out-of-pocket payments for health
care services that are not covered by the Canada Health Act.
Table 1.2 shows the percentage of costs for non-CHA health services that are paid for
privately, either through private insurance or direct payments by individuals. Dental services, for
Figure 1.17 Other

Total Health $2.1 billion
Expenditures (2%)
by Source of
Finance, 1999 Out-of-pocket
$14.2 billion
(16%)
Private Insurance Taxation

$9.8 billion (11%) $63.4 billion
(71%)
Note: 1999 is used here rather than forecasted data for 2000 or 2001. The ÒotherÓ component of private sector financing includes such
items as non-patient revenue to hospitals including ancillary operations, donations, and investment income.
Source: CIHI 2001e.
24
SUSTAINING MEDICARE
Figure 1.18 100%

Tax funded Social security funds
Public Share 90%
of Total Health
80%
Expenditures: as
Tax Funded and 70%
Social Security
Funds, 1998 60%
50%
40%
30%
20%
10%
0%
Kingdom
Japan
Australia
Netherlands
OECD
Germany
United
Sweden
France
Canada
United States
Average
G7 Average
Note: 1998 is the most recent date for which comparable figures are available.
Source: WHO 2001.
Table 1.2
Private Sector Health Expenditures, by Source of Finance and Use of Funds,
Canada, 1999
Private Sector
Private Sector
Households as Percent of
(Out-of- Private Public Total Goods
pocket) Insurance Total Sector and Services
($000,000) ($000,000)
Professional Services:
Dental care $2,870 $3,508 $6,378 $397 94
Vision care $1,701 $428 $2,129 $218 91
Other services $717 $482 $1,199 $546 69
Health Care Goods:
Prescribed drugs $2,302 $3,387 $5,689 $4,418 56
Over-the-counter drugs $1,641 .. $1,641 .. 100
Personal health supplies $1,575 .. $1,575 .. 100
Other health care goods $178 $50 $228 $435 34
Total $10,984 $7,855 $18,839 $6,014 76
Note: ÒOther servicesÓ include expenditures for chiropractors, massage therapists, orthoptists, osteopaths, physiotherapists, podiatrists,
psychologists, private duty nurses and naturopaths. ÒPersonal health suppliesÓ include items used primarily to promote or maintain
health (e.g., oral hygiene products, diagnostic items such as diabetic test strips, and medical items such as incontinence products). ÒOther
health care goodsÓ include hearing aids and other medical appliances.
Source: CIHI 2001e.
25
example, are almost entirely funded (94%) through private insurance and direct fees in Canada
but are often part of public coverage in many Western European countries.
In comparison with selected countries, only Japan and Australia have higher levels of out-
of-pocket expenditures than Canada while in the United Kingdom, Sweden, the Netherlands,
Germany, and France all have substantially lower levels of out-of-pocket payments (see Figure
1.19). This is because the fees charged in those countries are low and represent a relatively small
proportion of the real cost of the services provided. Canadians, however, pay relatively high co-
payments and deductibles for prescription drugs and health services outside the CHA and this
results in Canada having a higher percentage of out-of-pocket payments than other countries.
Even though the co-payments and deductibles are high, the percentage of out-of-pocket
payments in Canada accounts for a relatively small percentage of the total costs of health care
services and is lower than the OECD average. Canada, like most of the wealthier OECD
countries including the United States, relies primarily on funding provided through governments
or through insurers. In high-income countries, what we call “third-party” payments (i.e.,
payments made by governments or insurers) make up between 80 and 90% of health
expenditures (OECD 2002b). In less wealthy OECD countries, however, there tends to be a
much higher reliance on out-of-pocket payments.
The Balance between Public and Private Funding of Health Care

There is some debate in Canada about the appropriate balance between public and private
funding for health care. Recently, a number of Canadian providers, scholars and journalists
argued in favour of a greater private role in funding Canadian health care on the assumption that
Canadian health care spending is overly weighted to the public side (Gratzer 2002). However,
Figure 1.19 20%

Share of 18%
Total Health
Expenditures 16%
Paid “Out-of- 14%
pocket,” 12%
among OECD
Countries, 10%
1998 8%
6%
4%
2%
0%
Kingdom
Japan
Australia
United States
Netherlands
OECD
Average
France
Germany
United
Sweden
Canada
G7 Average
Note: All data obtained from OECD except Sweden. SwedenÕs out-of-pocket expenditure is based on data obtained from the European
ObservatoryÕs Health Systems in Transition profile for Sweden (2001). The Observatory remarks that private insurance expenditures in
Sweden comprise roughly 1% of total health expenditures. Using OECD figures for total and private health expenditures for Sweden, the
out-of-pocket figure represents the residual amount devoted to private health expenditures after the private insurance component has
been subtracted. This figure was then divided by the total health expenditure. The figure is approximately 15.2%. 1998 is the most recent
year for which comparable data are available. Figures for the United Kingdom are from 1996.
Source: OECD 2002b; Hjortsberg and Ghatneker 2001.

26
SUSTAINING MEDICARE
a comparison with other industrialized countries shows that Canada is hardly an exception in terms
of the public share of total health expenditures. The United Kingdom, Sweden, Germany, France,
Japan and Australia all have larger public health care sectors than Canada, while the Netherlands’
public share is slightly lower than Canada’s (see Figure 1.20). What is truly noteworthy is the
extent to which these countries’ public health care expenditures resemble each other.
While most wealthy countries rely heavily on public funding for health care, private
insurance plays a significant role in funding health care in the United States. Private insurance in
the United States is supported by tax breaks known as “tax expenditure subsidies.” These
subsidies exist, but to a much lesser extent, in all the comparison countries. Since these
subsidies are not generally included when public health care expenditures are tallied, they are
difficult to trace and are therefore referred to as “covert” expenditures (Mossialos and Dixon
2002). In fact, tax subsidies play an enormous role in providing health care coverage in the
United States. When these tax breaks are taken into account, the public share of health care
spending in the United States increases to nearly 60% of its total health care spending
(Woolhandler and Himmelstein 2002). This changes the common perception that the United
States has a predominantly private system of health care.
Even without including tax subsidies, the extraordinarily high level of total health care
spending in the United States translates into far more spending per capita than in Canada and the
other OECD countries. This has been described as tantamount to paying for national health
insurance and, in return, getting a fragmented system with significant gaps in coverage – the
worst of both worlds. While the United States’ “health care system is usually portrayed as
largely private,” a more apt description is “[p]ublic money, private control” (Woolhandler and
Himmelstein 2002, 22). Indeed, the larger the public share of health care financing beyond tax
expenditure subsidies, the more total health expenditures are capable of being controlled. In
contrast, the larger the private share of health care financing, the more difficult it is to control
health care expenditures (Majnoni d’Intignano 2001).
Figure 1.20 90%

Share of Total
Health 80%
Expenditures 70%
Paid by Public
Sector, 2000 60%
50%
40%
30%
20%
10%
0%
Kingdom
Japan
Australia
United States
Netherlands
OECD
Average
France
Germany
United
Sweden
Canada
G7 Average
Note: Figures for Australia, Germany and Sweden are for 1998.
Source: OECD 2002b.
27
Alternative Funding Sources

In recent years, a number of suggestions have been made that Canada should consider
alternative ways of paying for health care services. These proposals may be a reaction to the fact
that people see costs increasing, are worried about sustainability, and question whether we
should change the current funding system to look for additional sources of revenue. Undeniably,
each of these proposals has some potential to raise additional money to fund the health care
system. But some pose problems in terms of the impact they would have on access and equity. A
number of the most common proposals are critically examined below.
User Fees and Out-of-pocket Co-payments

User fees are definitely a “hot button” issue for many Canadians. While many are opposed
to user fees because they discourage poorer people from accessing health care services, others
see user fees as a necessary way of either raising additional funds for health care or curbing
abuse of the health care system. Interestingly, during the Citizens’ Dialogue sessions held by the
Commission, the interest in user fees was not aimed at raising more revenue for the system but
at curbing what some participants felt was abuse and unnecessary use of the system
(Commission 2002a).
There is overwhelming evidence that direct charges such as user fees put the heaviest
burden on the poor and impede their access to necessary health care. This is the case even when
low- income exemptions are in place. The result may be higher costs in the long run because
people delay treatment until their condition gets worse. In addition, user fees and co-payments
also involve significant administrative costs that directly reduce the modest amount of revenue
generated from the fees (Evans 2002a; Evans et al. 1993; Barer et al. 1993, 1979; CES 2001).
One of the key features of the Canada Health Act was its effective ban on user fees for
hospital and physician services. Given what we know about the impact of even relatively low
user fees, the Commission feels that this was the right decision then and remains the right
decision today.
Medical Savings Accounts

Perhaps no recent suggestion for raising additional revenue has attracted as much attention
as medical savings accounts, in part because they seem to address some of the criticisms of user
fees. Medical savings accounts (MSAs) can be designed in a number of different ways but the
fundamental concept is that individuals are allotted a yearly health care allowance and they can
use it to “purchase” health care services (Gratzer 2002, 1999; Migué 2002; Ramsay 2002). If
they have funds left in their MSA allowance at the end of the year, depending on how the plan is
designed, they may be able to keep the funds or save them for future years when their health care
costs may be higher.
MSAs are intended to provide patients with more control and to inject market forces into the
organization and delivery of health care services. They provide patients with an incentive to
“shop” for the best services and best prices, and to avoid unnecessary treatments, particularly if
they get to keep any surplus in their account at the end of the year. If the costs of health care
services people use in a year are higher than their yearly allowance, they would be required to
pay all or a portion of the additional costs, depending on how the plan was designed. Most MSA
28
SUSTAINING MEDICARE
proposals discussed in Canada involve a so-called “corridor” where people pay some of the cost
of health care expenses above their annual allowance up to a certain point before catastrophic
coverage funded entirely by government would cover any remaining costs (Mazankowski 2001).
Because medical savings account approaches are relatively new, we know very little about their
effects and the literature to date is contradictory. MSAs have been implemented on a small scale
in the United States, on an experimental basis in several cities in China, in South Africa where
they constitute half of the private for-profit health insurance market, and on a nationwide basis in
Singapore. It is difficult, however, to compare these experiences to the Canadian situation. With
the exception of China, these countries have predominantly private financing and private delivery
of health care services. This means people in those countries may have a much greater
opportunity to “shop around” for health care services. Singapore’s experience shows that
hospitals tend not to compete on the basis of price for necessary services, but aggressively
market expensive add-ons, some of which are of questionable value.
The limited evidence available suggests that medical savings accounts have a number of
shortcomings that have been understated or ignored by their proponents (Maynard and Dixon
2002; Shortt 2002; Hurley 2000, 2002; Barr 2001). Overall, MSAs are based on the assumption
that the use of necessary health care services is highly discretionary, when this is almost
invariably not the case.
MSAs are unlikely to effectively control overall spending on health care (Forget et al.
2002). Most health care costs are incurred by a small proportion of people who have very high
health care needs and they will continue to spend a lot regardless of whether or not they have an
MSA. Under some designs, costs could actually increase because governments would not only
provide the initial allowance but also continue to pay for catastrophic insurance to protect people
against very high costs. If people were allowed to keep the money left in their MSA at the end of
the year, this money would be lost to the health care system and would have to be made up
through other means.
MSAs may compromise equity in access to health care services. If individuals are required to
pay once they have used all of their MSA allowance, it could cause hardships for people with
lower incomes or higher health care needs due to chronic or life-threatening conditions. This is
precisely the reason why Canada’s medicare system was introduced – to avoid a situation where
wealthy people could get access to all the health care services they needed and poor people could not.
Tax-based Co-payments, Tax Credits and Deductibles

A number of recent articles have focused on the use of the tax system as a way of increasing
private payment in the health care system (Aba et al. 2002; Aba and Mintz 2002; Reuber and
Poschmann 2002). The simplest way of doing this would be to include publicly provided health
care services as a taxable benefit on individuals’ annual income tax returns (Kent 2000). People
would get something like a T4-H showing the cost of the health services they received in a year.
This amount would be added to their taxable income and they would pay additional taxes to
cover a portion of the cost of the health services they received.
On the positive side, this approach would raise additional revenues. People would know the
costs of the services they received, and any additional taxes would be based on their ability to
pay. On the other hand, the approach could potentially bankrupt people who had chronic health
29
conditions or who suffered a catastrophic illness or injury. To address this concern, the amount
of the co-payment or additional taxes a person paid could be capped at a certain percentage of
his or her income and very low-income people could be exempt (Aba and Mintz 2002).
Even with these conditions, there are concerns with this approach. Fundamentally, it means
that if people are sick or injured, they will be taxed more and pay more for health care. This is
counter to the basic premise in Canada’s health care system that access should be determined
only by need and not by ability to pay. As in the case of MSAs or user fees, it may result in
people not using needed health care services, a phenomenon that has been seen in a number of
European systems (CES 2001). It also raises the question of whether middle and higher income
earners, who currently pay the bulk of the costs of a universal health care system, will eventually
become dissatisfied when they also have to pay even more at tax time based on their use of the
health care system.
Public-Private Partnerships
While different options like user fees, taxable benefits or medical savings accounts are
designed to provide more private payments for health services, other approaches such as public-
private partnerships (P3s) are being considered as a way of supporting capital projects. P3s
involve a number of different options including long-term outsourcing contracts, joint ventures,
strategic partnerships, or private financing models. In the United Kingdom, under private
financing initiatives (PFI), private sector firms are awarded long-term contracts to design, build,
finance and operate hospitals.
While P3s may be a useful means of bringing the innovation of the private sector to bear,
they are not without their critics. In many cases, governments find P3s attractive because the
private sector company assumes the heavy capital costs of a project and governments are only
required to pay “rental fees” over the longer term. Unfortunately, while P3s may cost
governments and taxpayers less in the short term, these arrangements often cost more in the
longer term (Sussex 2001). The rental costs charged to governments must be high enough to
allow the private sector partner to recoup its costs and make a profit for its shareholders. The
cost of borrowing is often higher for the private sector than for governments. And P3s often
have higher administration costs. Critics also suggest that the quality of private for-profit run
facilities can be lower than publicly run facilities and that, in some cases, these arrangements
have resulted in beds being closed and staff being reduced (Pollack et al. 2001). This is not to
say that P3s are without a place (for example in the case of health information systems), but they
are no panacea and their use and value need to be carefully considered.
Should Canada Consider Alternative Funding Schemes?

Each of the alternative options outlined above would raise more money for the health care
system or free up money for governments to spend on other priorities such as lowering taxes or
paying down debt. However, many of the options also compromise the principles and values on
which Canadians built the health care system. Some of the options would simply shift the burden
of health expenditures from the public purse to individuals and would ultimately undermine the
equity that currently exists in both funding and access to needed health care services.
30
SUSTAINING MEDICARE
Through the Commission’s consultations, Canadians indicated that they were willing to pay
more in taxes to sustain the health care system, but only if changes are made to improve the
current system. Consistent with this view, some have suggested a dedicated tax for health care.
This could take a number of different forms. At one end of the spectrum is what public finance
experts call a hypothecated tax – a single-purpose tax that is formally separated from all other
revenue streams in a special fund similar to the Canada or the Quebec Pension Plans. At the
other end of the spectrum, a health tax or premium could be established, but the money flows
into the general revenue funds of governments. Both may satisfy the public’s desire to ensure
some degree of transparency and accountability but they provide less than perfect solutions in
other respects.
In the case of the hypothecated tax, the amount collected could only be used for health care
purposes, irrespective of shifting needs. This might be fine in normal years, but if any
government needed to suddenly shift resources from health care to another priority in the face of
an unexpected crisis, it would be prevented from doing so. In contrast to health care, pensions
are a relatively small part of government expenditures so the impact of having dedicated taxes
for pensions is not as great.
In the case of a notionally earmarked tax, given the sheer size of the health care system, it
would be almost impossible to raise the necessary funding for health care through a single,
dedicated tax. In fact, a number of provinces that once had sales taxes that were, in principle,
earmarked for health and education have since dropped this type of labeling. At the same time,
that is not to say that earmarked taxes could not be used to fund a portion of the health care bill
(Senate 2002c). During the Commission’s Citizens’ Dialogue, the idea of a dedicated tax was
strongly supported by many Canadians because it would provide assurance that additional taxes
paid by Canadians would, in fact, go to health care rather than other programs and services. It
also is a way of improving transparency and accountability for the additional funds raised from
taxpayers. Given this, it would be useful for governments to consider notionally earmarked taxes
for health in the future.
Based on evidence both in Canada and internationally, progressive taxation continues to be

the most effective way to fund health care in Canada. From what the Commission heard from
Canadians through the Citizens’ Dialogue and other consultations, the large majority of
Canadians do not want to see any change in the single-payer insurance principle for core hospital
and physician services. There also continues to be a strong consensus among Canadians that
“ability to pay” should not be the predominant factor in how we fund key aspects of our health
care system. Canadians want necessary hospital and physician services to be fully funded
through our taxes. This may be because our tax-funded, universal health care system provides a
kind of “double solidarity.” It provides equity of funding between the “haves” and the “have-
nots” in our society and it also provides equity between the healthy and the sick.
Future Sustainability
In many respects, the critical issue is not so much whether Canada’s health care system is
financially sustainable today but whether it will be sustainable in the future, given current trends
and increasing costs. Making projections about future costs and financial sustainability may
sound easy, but it is more than a simple accounting calculation. Forecasts of public revenues
31
have to take into account the potential growth of the economy combined with interest payments
on debt or long-term financial commitments as a result of past decisions. Forecasts depend on
how various cost factors are assessed including the evolving needs and expectations of people
served by particular programs. The projections also need to consider competing demands for
spending on other programs or on tax reductions. In many cases, political assessments and value
judgements of the relative merits of spending more in one area and less in another are very
difficult to factor into projections for future spending.
That being said, it is important to look at the issue of future financial sustainability by
examining Canada’s spending on health care compared to other countries as well as the trends
within Canada, both in terms of provincial-territorial funding and federal funding. It also is
important to consider the role of the health care sector in Canada’s economy, not just as a driver
of costs but also as a significant contributor to economic growth.
Comparisons with Other Countries

If we look back to 1970, total and public health care costs have increased in Canada as a
percentage of Gross Domestic Product (GDP). At the time medicare was introduced, Canada
spent about 7% of GDP on total health care costs. Thirty years later, Canadian health care costs
take up about 9.1% of our GDP. On the public side, Canada was spending approximately 5% of
GDP on health in 1970 and by 2000 this had grown to 6.5% (see Appendix E).
In terms of current comparisons with specific OECD and G7 countries, Canada’s spending
on health care on both a per capita basis and as a percentage of GDP is slightly higher than the
OECD average but very comparable to the G7 average (see Figures 1.21 to 1.24).
Looking at comparisons with the United States (see Figures 1.25 and 1.26), Canadian
spending closely tracked American spending until the early 1970s when the addition of
physicians’ services to single-payer insurance plans broke the pattern. Since that time, the long-
term trend in health care costs in Canada has been more in line with trends in European countries
while the United States has moved further away from the OECD average.
Canada’s proximity to the United States is both an opportunity and a challenge. The exposure
of Canadian scientists, researchers, patients and health care providers to American medical and
scientific innovations, American research organizations and high-end health care facilities (such as
the Mayo Clinic) raises expectations of what can be done in Canada. While all OECD countries
face increasing health care costs, Canada’s pressures will always be more intense because of our
relationship with, and proximity to, the United States.
Health Care Spending Trends in Canada

Like all other OECD countries, Canada’s spending on health care is increasing. But to
address the question of sustainability, it is important to break down the various components of
the health care system to see where the costs are increasing the most. The cost of hospital and
physician services has grown at a much slower rate than other health care services and programs
covered by the provinces and territories (see Figures 1.27 and 1.28). Both private and provincial
government per capita spending on non-CHA services has grown considerably in recent years
while per capita spending on hospital and physician services is currently no higher than it was in
1991 when it reached a peak of $1,265 per person. On a national basis, hospital and physician
32
SUSTAINING MEDICARE

Per Capita Total Health Expenditures Total Health Expenditures as a Percentage
(US$ PPP), 2000 of GDP, 2000
$5,000 14%
$4,500
12%
$4,000
$3,500 10%
$3,000
8%
$2,500
6%
$2,000
$1,500 4%
$1,000
2%
$500
$- 0%
United
France
United States
OECD
Average
Sweden
Japan
Kingdom
Germany
Australia
Canada
G7 Average
Netherlands
Netherlands
United States
G7 Average
United
Kingdom
Sweden
France
Germany
Japan
Australia
Canada
OECD
Average

Per Capita Public Health Expenditures Public Health Expenditures as a
(US$ PPP), 2000 Percentage of GDP, 2000
$2,500 9%
8%
$2,000 7%
6%
$1,500
5%
4%
$1,000
3%
$500 2%
1%
$- 0%
Netherlands
Sweden
Japan
G7 Average
Kingdom
Germany
Australia
Canada
United
France
United States
OECD
Average
United States
G7 Average
United
Kingdom
Sweden
France
Germany
OECD
Japan
Australia
Canada
Average
Netherlands
33

Total Health Expenditures as a Percentage Public Expenditures as a Percentage of
of GDP, Canada, United States and OECD, GDP, Canada, United States and OECD,
1970 to 2000 1970 to 2000
14% 8%
7%
12%
6%
10%
5%
8%
4%
6%
3%
4%
2%
2% Canada United States OECD Average Canada United States OECD Average
1%
0% 0%
1970
1972
1974
1976
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
1970
1972
1974
1976
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
services now constitute about 63% of total provincial-territorial health care spending compared
to 77% in 1975 (see figures 1.29 and 1.30). Thus the overall increase in provincial per capita
health care spending – which rose 15.6% between 1991 and 2001 – reflects the fact that the cost
of non-CHA services is rising faster than CHA services (CIHI 2002f) and is illustrative of the
way in which the use of health care services is changing.
Prescription drugs provide the most graphic example of the shift in the various components
of spending within the health care budget. In 1975, prescription drug costs made up a relatively
stable share of about 6% of health care spending. But by the mid-1980s, that share had begun a
steady climb and, by 2001, the share had doubled to 12% (CIHI 2002f). The rapid escalation of
drug costs has added over half a percentage point to the share of Canada’s national income
(GDP) that is spent on health care.
There also have been significant increases in other components of provincial and territorial
spending on health care since 1975, including public spending on:
• Home care services, which has increased from $26 million in 1975 to approximately $2.7
billion in 2001 (CIHI 2001d; HC 2002d);
• Other institutions such as nursing homes, which has grown from $800 million in 1975 to
$6.8 billion in 2001 (CIHI 2002f); and
• Non-physician professional health care services, which has increased from $120 million
in 1975 to $800 million by 2001.
This does not mean, therefore, that we can simply target growing costs in key areas – such
as prescription drugs and home care, as the culprits in increasing health care costs. Expanding
use of prescription drugs and home care has reduced the reliance on more expensive hospital
care and are part of changing trends in how health care services are delivered. These changing trends
34
SUSTAINING MEDICARE
Figure 1.27 $3,500

Per Capita Total health Provincial-Territorial CHA services
Total, Provincial- $3,000
Territorial and
CHA Health $2,500
Expenditures
(Constant $2,000
$1,500
1997 Dollars),
1975 to 2001 $1,000
$500
$-
2001
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
Note: Figures for 2000 and 2001 are CIHI forecasts.
Source: CIHI 2001e.
Figure 1.28 5.0

Average Annual 4.5
Rate of Change
in per Capita 4.0
Expenditures on 3.5
CHA and Non-
CHA Services 3.0
(Constant 2.5
2.0
1997 Dollars), 1.5
1976 to 2001 1.0
0.5
0.0
1976 to 1985 1985 to 2001 1990 to 2001
CHA services Non-CHA provincial- Private
territorial services non-CHA services
Note: Figures for 2000 and 2001 are CIHI forecasts.

Source: CIHI 2001e.
and the connections between various components of the health care system need to be
considered as part of any analysis of the future costs of the system.
Federal and Provincial-Territorial Shares of Health Care Spending

As noted earlier in this chapter, federal, provincial and territorial governments share
responsibility for funding health care. This partnership has changed over time as has the
benchmark for determining the appropriate contribution of each order of government. In the last
35

Distribution of Provincial-Territorial Distribution of Provincial-Territorial
Expenditures between CHA and Expenditures between CHA and
Non-CHA Services, 1975 Non-CHA Services, 2001 (Forecast)
Non-CHA CHA 77% Non-CHA CHA 63%

23% 37%
Source: CIHI 2001e. Source: CIHI 2001e.
decade or more, defining that balance in terms of funding has been the subject of considerable
acrimony and debate. Provinces accuse the federal government of no longer shouldering its
traditional share of the rising costs of health care while the federal government counters by
saying provinces have chosen to finance tax cuts over health care.
Since medicare began, there have been three major regimes through which the federal
government has provided funds to the provinces for health care. The first federal transfer regime
for health began in 1957 with the Hospital Insurance and Diagnostic Services Act. The formula
for federal funding involved matching the costs of providing hospital insurance in the provinces
on a per capita basis (half of which was based on their individual costs and the other half on the
national average). A similar cost-sharing arrangement was introduced (but calculated solely on
the basis of the per capita share of the national average) in 1966 with the passage of the Medical
Care Act that extended federal contributions to physician services in the provinces. These
funding arrangements were based on 50/50 cost sharing for eligible provincial hospital and
physician services, not all provincial health expenditures. The federal share in the final year of
this cost-sharing regime for total physician and hospital services was close to 47%, which can
easily be assumed to be close to 50% of eligible services.
These early pieces of legislation provided the dedicated funding for hospital and physician
services that were necessary to put medicare in place. Under the original design, however, the
financial cost of medical and hospital insurance posed significant problems for the federal,
provincial and territorial governments. For the federal government, a primary concern was that
relevant spending decisions were being made in the provinces and the federal government could
not control the level of transfers to the provinces under shared-cost arrangements.
Provincial and territorial governments also sought an increased degree of autonomy with
regard to the disbursement of federal funds. Funding was confined to hospital and physician
36 services at a time when provincial health systems were expanding beyond this narrow set of
SUSTAINING MEDICARE
services, and health services that were not eligible for federal funding under the original cost-
sharing arrangements were taking up an increasing share of provincial and territorial health care
spending.
To address these concerns, a new block transfer mechanism for funding both health and
post-secondary education was negotiated and introduced in 1977. This second transfer regime,
known as Established Programs Financing (EPF), effectively broke the link between actual
expenditures for hospital and physician services made by provinces and territories and the level
of federal transfers for health. From this point on, increases in federal funding were based on a
formula in which transfers increased in relation to growth in the economy (measured as per
capita Gross National Product) rather than based on actual provincial and territorial expenditures
for hospital and physician services. The importance of this change was that after EPF, provincial
expenditures on health that exceeded the rate of economic growth and population change were
borne exclusively by provincial governments, thus providing the federal government with the
predictability it sought in terms of its own expenditures. At the same time, EPF provided
provinces with increased flexibility because federal funds were no longer exclusively designed
to support hospital and physician services. In addition, under the new arrangements, the way in
which transfers were delivered was changed. In the first year of the agreement, provinces would
receive a cash transfer equal to one-half of the total value and the remainder would come in the
form of tax points: the federal government reduced its percentage of personal and corporate
income taxes to give room to the provinces to increase their own taxes. After 1977, the cash
portion would increase according to the escalator formula, while the tax points would increase in
accordance with growth in the provincial economy as reflected in increased tax revenues
collected. Since a tax point yields less revenue in low-income than in high-income provinces, the
value of the tax points were to be equalized to the national average.
These arrangements served the short-term needs of both orders of government, but there
were significant and unforeseen consequences to the new formula. Some provinces used this
new flexibility to allow physicians and hospitals to extra-bill or charge user fees to patients as a
means of offsetting increased health care costs and demands for increases in professional fees
paid to doctors. But what this did was shift a larger portion of those increasing costs to those
who most needed health care services – the poor and the sick. In response, Justice Emmett Hall
(1980) conducted a review of health services in Canada and reported to then federal Minister of Health,
Monique Bégin. The result was the creation of the Canada Health Act introduced by Bégin in
1984. It enumerated the five principles we know today and also allowed the federal government
to withhold a portion of cash transfers to provinces that allowed extra-billing or user fees.
As Table 1.3 indicates, the CHA was, in the years immediately following its passage, an
effective means for the federal government to discourage the use of extra-billing or user fees. By
initially reducing transfers to those provinces that allowed extra-billing but then restoring the
funding once provinces eliminated such charges, the federal government succeeded in rolling
back such practices. However, the federal government has proven to be reluctant to impose
penalties related to other provincial practices that could be seen to be in violation of the five
principles of the Act, but which did not involve user fees or extra-billing. Thus, while the CHA
was very successful in changing provincial behaviour in the narrow sense of eliminating user
fees and extra-billing, it was less successful as a general guarantor of medicare as a whole.
37
Table 1.3
Reductions in Federal Transfers Under the Canada Health Act ($Thousands)
1984/85 to 1989/90 1990/91 to 1994/95 1995/96 to 2000/01

Extra-billing $135,589 $1,982 $43
User fees $111,143 $0 $6,283
Total $246,732 $1,982 $6,326
Note: The above table shows only deductions under the Canada Health Act. Since 1984/85 to the present of the approximately $255 million
deducted $247 million have been refunded to those provinces which subsequently complied with the conditions of the Canada Health Act for
which the deductions had originally been made.
Source: Health Canada 2001a.
Another consequence of EPF became apparent in 1982 when the federal government
unilaterally changed the formula for its contribution. The total EPF transfer was now calculated
for each province on the basis of the per capita entitlement in the base year, escalated by nominal
GNP and population growth. The cash portion of the transfer was calculated as the difference
between the value of the tax points and the total provincial entitlement. In addition, the federal
government unilaterally reduced the value of the escalator formula, first in 1986 and again in
1989. In 1991, EPF entitlements were frozen at their 1989/90 levels. At the same time, the
notional value of the tax points continued to grow as a proportion of the total entitlement relative
to the cash portion. In one estimate, federal cash transfers for health were anticipated to
completely disappear for all provinces by 2010 (Smith 1995). By their very nature, tax point
transfers are essentially unconditional since there is no mechanism whereby the federal
government could withhold transfers in the event a province or territory failed to comply with
the conditions attached to federal dollars.
In 1995, the third federal transfer regime was introduced in the form of the Canada Health
and Social Transfer (CHST). The CHST has been a contentious program since it was introduced.
In addition to health care and post-secondary education that were part of EPF, social assistance
and social services were added to the new omnibus CHST transfer. Like EPF before it, only a
portion of the CHST is intended for health care and involves a mix of cash and the tax points. The
combination of funding three major social programs through a single block transfer, in addition to
the complexities of the cash and tax portions of the arrangements, make estimating the value of
the federal contribution to health care extremely obscure to even the most informed.
Historically, there has been a powerful and direct relationship between increasing health
care spending and the overall growth in the economy, with costs for health care services
increasing slightly more than increases in the nation’s wealth. This was captured under both the
original cost-sharing arrangements. As health expenditures at the provincial and territorial level
increased so too did the federal contribution. What the original cost-sharing arrangements
lacked, however, was an incentive for cost-containment as the relationship between federal
transfers and provincial and territorial expenditures was open-ended. EPF made the correlation
between economic growth and health services spending more direct by linking federal transfers
to growth in GNP. The escalator under EPF had the effect of restraining the growth of health
care expenditures to a level comparable to growth in the economy.
38
SUSTAINING MEDICARE
Figure 1.31 2.0

Ratio of Annual 1.25
Rate of Growth 1.8
Average
in Total per 1.6
Capita Health
Expenditures to 1.4
Annual Rate of 1.2
Growth in GDP
for Canada, 1.0
1960 to 1964, to 0.8
1995 to 2000
0.6
0.4
0.2
0.0
1960 to 1964
1965 to 1969
1970 to 1974
1975 to 1979
1980 to 1984
1985 to 1989
1990 to 1994
1995 to 2000
Note: The average value for elasticity appearing in the figure is based solely on calculations from 1960 through 2000 and projections for 2001 to
2005 are not included. In addition, two anomalous years have been excluded from the calculations. These are 1982 and 1991. In 1982, the
elasticity figure is 7.47 and the figures in the preceding and following years are 1.25 and 1.34; in 1991, the figure was 31.53 and in the preceding
and following year the rates were 2.55 and 2.73.
Source: CIHI 2002e; Statistics Canada 2002c.
Figure 1.31 shows the historic relationship between rates of growth in per capita health
expenditures and that of GDP. Since the 1960s, health expenditures have consistently grown at a
higher rate than growth in the economy. The very high ratio of health spending to economic
growth in the 1960s reflects the early stages of medicare as the system was being constructed.
However, the ratio moderated over time as the system matured. The relationship over the entire
period averages out to roughly 1.25, meaning that for every 10% increase in GDP our health
services expenditures have increased by 12.5%. This suggests that even the escalator formula for
EPF with its direct link to growth in the economy was not sufficient to keep pace with health
care costs. This became exacerbated by unilateral federal reductions in the escalator and finally
with the freeze on EPF increases.
Under the CHST, there is no mechanism for providing for natural increases in health care
spending in the calculation of federal transfers. Increases in CHST transfers are at the discretion
of the federal government. Since its inception there have been two increases, one in 1999 and
another in September 2000. The absence of an escalator formula for increases in federal
contributions to provincial and territorial health expenditures means that there is no link between
the growth in either health expenditures or the growth in the economy. This results in provinces
making regular demands for increases in the transfer and has contributed to the highly
politicized and acrimonious nature of the debate over health care funding in recent years.
This is the historical context in which the current debate over appropriate levels of funding
has taken place. Looking at the impact of these various shifts in funding arrangements over time,
39
the relative share between the federal and provincial governments has become increasingly
obscure. In part, the complexities of the arrangements themselves have largely contributed to
this confusion.
Health Care Spending as a Share of Provincial Budgets

As a result of growing costs, provincial governments have, in recent years, warned both
their residents and the federal government that health care spending is “crowding out” other
spending and policy priorities such as education, infrastructure, debt reduction and tax cuts.
Except for a short period in the early to mid-1990s, real provincial and territorial spending on
Figure 1.32 $2,500

Provincial-
Territorial $2,000
Government
Sector per $1,500
Capita Health
Expenditures
(Constant $1,000
1997 Dollars),
1975 to 2001
$500
$-
2001
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
Note: Figures for 2000 and 2001 are forecasts only.
Source: CIHI 2001e.
Figure 1.33 40%

Provincial-
Territorial 38%
Health 36%
Expenditures as 34%
a Percentage of
Program 32%
Spending, 30%
28%
26%
1975 to 2001
24%
22%
20%
2000/01
1974/75
1976/77
1978/79
1980/81
1982/83
1984/85
1986/87
1988/89
1990/91
1992/93
1994/95
1996/97
1998/99
Note: Figures for 2000/01 are CIHI forecasts only.

Source: CIHI 2001g.
40
SUSTAINING MEDICARE
health care has been climbing (see Figure 1.32). Adjusting for inflation, per capita provincial and
territorial spending on health care rose from an average of $1,200 per person in 1975 to almost
$2,100 per person in 2001 (CIHI 2001e).
Figure 1.33 illustrates that health care spending is taking up an increasing share of total
provincial and territorial spending on programs. In 1999/2000, health spending accounted for
35.4% of provincial and territorial program spending compared to 28% in 1974 to 1978. There
are a number of reasons why health care spending is taking up an increasing share of
governments’ budgets and the reasons vary among provinces and territories. However, three
reasons are common to all provinces:
• The impact of cost-cutting in the early 1990s compromised public confidence in the
system and created the need to reinvest in recent years (Tuohy 2002);
• The growing cost of prescription drugs, home care and other health care expenses is
constantly driving up provincial spending on health care even though hospital and
physician care may be growing at a more acceptable rate (Evans 2002b); and
• The cost of recent large increases in health care provider remuneration following years of
restraint in the 1990s.
However, not all commentators accept the provinces’ arguments that their current
expenditure patterns are unsustainable. Boychuk (2002) argues that provincial health
expenditures relative to GDP are the same now as a decade ago and that recent increases are a
result of unleashing the “pent-up demand” created by the expenditure cuts of the mid-1990s.
The system is only unsustainable, he argues, if we accept that:
• Spending will increase even faster than is necessary to deal with an aging population and
the increase in the cost of current services; or
• There is a consensus that the tax burden on Canadians is itself unsustainable and must be
lowered.
The perception that there is a fiscal crisis in health care is as important as the reality,
however, since the perception undermines the public’s confidence in the system regardless of
whether steps are taken to contain costs.
These issues are important ones for the provinces and territories. Shouldering the lion’s
share of risk for growing health care costs, they face far greater anxiety about their ability to
fund health care in the future. Furthermore, both federal and provincial governments now are
politically committed to a policy of phased-in tax reductions. These tax cuts are estimated to be
worth $40 billion in total in 2001/02 (Yalnizyan 2002) – one half from the federal government
and one half from the provinces. In comparison to these tax cuts, federal health funding
increased by $2.8 billion while provincial spending on health care increased by $4.8 billion in
the same year (see Appendix E).
Health as a Major Contributor to the Economy

Discussions about health care are most often focused on costs while, in fact, health care is
also a major contributor to Canada’s economy and economies around the world.
According to American economist William Nordhaus, the “medical revolution over the last
century appears to qualify, at least from an economic point of view, for Samuel Johnson’s
accolade as ‘the greatest benefit to mankind’” (2002, 38). This increase in economic value
comes from numerous directions including improvements in: 41
th
• Basic knowledge from the germ theory of disease at the beginning of the 20 century to
the more recent DNA revolution;
• Public health capital and infrastructure;
• Diagnostic tools and processes;
• Logistics in terms of obtaining critical care (e.g., emergency response);
• Treatment technologies and protocols including pharmaceuticals.
In the early 1990s, rising health care costs were seen in many countries as an obstacle to
balancing budgets and cutting taxes. This created the view that health care costs were a threat to
future national competitiveness. But based on Nordhaus’ calculations, it appears that health care
spending contributed at least as much to the American economy as spending on all other
consumption expenditures combined. Canadian economist Tom Courchene (2001) has made a
similar argument about viewing health care expenditures as a dynamic investment in the
economy rather than simply as consumption.
Health care investments not only lead to longer and more productive working lives on an
individual basis; properly targeted public health care investments can also provide countries with
a competitive advantage. According to the Canadian Council of Chief Executives’ submission to
the Commission (2002, 2), “Canada’s business leaders have been strong supporters of Canada’s
universally accessible public health care system” because it provides a “significant advantage in
attracting the people and investment that companies need to stay competitive.” Indeed, the “big
three” automakers (Ford, General Motors and Daimler-Chrysler) recently signed joint letters
with their largest union, the Canadian Autoworkers, expressing support for Canada’s publicly
funded health care system and noting that it provides an important competitive advantage to the
Canadian auto and auto-parts industries relative to their American counterparts. In short, it is
Log of per Capita Total Health Expenditures (US$ PPP)
Figure 1.34 9.0

Ratio of Total Canada
Germany Denmark
Health 8.5 Netherlands
France US
Expenditures Australia
8.0 Switzerland
to Economic Italy
Norway
Growth among UK Luxembourg
Iceland
OECD 7.5 New Zealand
Austria
Countries Greece
Portugal
Belgium
(US$ PPP), 7.0 Ireland
Czech Republic Japan
Hungary
2000 Korea Spain Finland
Sweden
6.5 Slovakia
Poland
6.0 Mexico
Turkey
5.5
5.0
8.5 9.0 9.5 10.0 10.5 11.0
Log of per Capita GDP (US$ PPP)
Note: Purchasing Power Parity (US PPP) is a currency conversion that equalizes the purchasing power of different currencies and expresses these in
terms of their US dollar value. This means that a given sum of money, when converted into different currencies, will buy the same basket of goods and
services in all countries. Thus PPPs are the rates of currency conversion that eliminate differences in price levels between countries.
Source: OECD 2002b.
42
SUSTAINING MEDICARE
more economical for the employers to pay taxes in support of medicare than to be forced to buy
private health insurance for their workers.
It is also true that health care is what economists call a superior good in that, as individuals,
we tend to spend progressively more on health care than other goods and services as our
incomes go up. Based on a series of international studies summarized by Gerdtham and Jönsson
(2000), higher income is the single most important factor determining higher levels of health
spending in all countries (see Figure 1.34). Indeed, the more economically developed the
country, the more pronounced the effect (Scheiber and Maeda 1997). According to Reinhardt et
al. (2002, 171), per capita GDP is without doubt “the most powerful explanatory variable for
international differences in health spending.”
Resources and Sustainability

What conclusions can we draw about resources and sustainability? Canada’s spending on health care
is comparable with other OECD countries although we spend considerably less per capita than the United
States. All OECD countries are facing increasing health care costs and experience suggests that the
wealthier the country, the more it spends on health care. Some suggest that Canada relies too heavily on
taxation, and yet, comparisons show that we are not much different from other countries. A look at
various alternative ways of funding health care shows that each option raises a number of problems and
many would simply shift the burden of funding from governments to individual Canadians. At the same
time, there are serious problems in the balance between federal and provincial-territorial funding for
health care, and health care is taking up an increasing proportion of provincial budgets. Later chapters of
this report address specific ways in which steps can be taken to control rising costs, especially for
prescription drugs. But the reality is that health care costs are likely to continue to increase and choices
have to be made about how those costs will be managed. Overwhelmingly, Canadians told the
Commission that they are prepared to pay more for health care to ensure the system’s sustainability,
provided the system is prepared to change to meet their needs and expectations.
Sgstaining Canada’s Health Care

System – Looking Ahead
This first chapter has provided a wealth of information that helps address three perspectives
on the sustainability of Canada’s health care system: the services it provides, its performance in
meeting Canadians’ health needs, and the availability of sufficient financial resources to fund the
system.
Taken together, these three dimensions allow us to draw an overall conclusion about
whether or not Canada’s health care system is sustainable. The Commission’s conclusion is that
the system is sustainable, but only if the system changes in some very important and crucial
ways. Services need to be reorganized, access needs to be improved, health needs must be met
and disparities reduced.
43
Sustainability relies on achieving the right balance among the services that are provided, the
health needs of Canadians, and the resources we are prepared to commit to the system. Finding that
balance is up to those who govern the health care system – individual Canadians, communities,
health care providers, health authorities and hospital administrators, and governments. The
decisions they make together will determine whether or not the system is sustainable in the future.
Their decisions should be guided by the values of Canadians who, as noted at the outset of this
chapter, want medicare to endure and thrive.
The ultimate purpose of the following chapters of this report is to remodel medicare for the
21stcentury – to make it sustainable for years to come. It begins in Chapter 2 with a call to
Canadians to renew our collective commitment to health care and put new governance
mechanisms in place to provide clear leadership on issues of national concern. It also calls on the
federal government to increase its share of funding for health care, put stable, sustainable
funding in place, and target specific funds to address pressing problems in the system. But the
message clearly is that more funding must not go simply to shore up the status quo – it must buy
change. The report then moves to some of the essential underpinnings of the health care system
– ensuring that we have better information and evidence to guide decisions and that we have
both an adequate supply and the right distribution of health care providers. It also includes a
clear message that the roles and responsibilities of health care providers need to evolve with
changing approaches to health care. The report then turns to some of the most crucial aspects of
how the system currently delivers health care services and provides concrete recommendations
on improving access, moving ahead with primary health care reform, and beginning the important
steps of integrating home care and prescription drugs under the Canada Health Act. Finally, the
report returns to the issue of governance in making recommendations, first, for a new approach
to the delivery of services for Aboriginal peoples in Canada (whose health status continues to be
perhaps the system’s greatest failure to date) and, second, for a positive and proactive approach
to the international governance of health care in a globalized world.
Taken together, these recommendations will allow the system to not only satisfy the health
needs of Canadians but, perhaps more importantly, to meet their expectations and restore their
confidence in medicare.
Sustaining the Canadian health care system has always been about the choices we make and
our understanding of what our responsibilities and entitlements are within the system. So it is
there that we must begin – by laying a new foundation for the governance of the system. With
that foundation in place, the challenge then is in the hands of governments, and all Canadians, to
seize on the opportunities for change, make the right choices, and ensure that Canadians get
what they truly want – an excellent health care system that is sustainable not only today but for
generations of Canadians to come.
44
H EALTH CARE,
C ITIZENSHIP AND
FEDERALISM

2
• Establish a new Canadian Health Covenant as a tangible statement of
Canadians’ values and a guiding force for our publicly funded health
care system.
• Create a Health Council of Canada to facilitate collaborative leadership
in health.
• Modernize the Canada Health Act by expanding coverage and renewing
its principles.
• Provide stable, predictable and long-term funding through a new
dedicated cash-only transfer for medicare.
• Address immediate issues through targeted funding.
The Case fSr Change

All aspects of the Commission’s review have pointed to an overriding conclusion that there
is no need to abandon the principles or values underpinning Canada’s health care system.
Medicare has served this country very well. But there have been many changes since the early
days and medicare needs to change to meet the new dynamics of Canada’s health care system.
Canadians understand and support the need for change. They are prepared to change their ideas
about how the health care system can and should work, but they are not prepared to abandon or
compromise their ideals, and rightly so.
Sustaining Canada’s health care system and ensuring that it remains true to its ideals
depends very much on the choices we make. The preceding chapter concluded that medicare is
sustainable if the health care system is prepared to change – if services are reorganized to meet
changing needs and if financing is adequate, stable and predictable.
As was noted in Chapter 1, achieving the right balance among services, needs and resources
in the health care system depends, in large part, on decisions that are made by those who oversee
the system, including providers, hospitals, health authorities and, of course, federal, provincial
and territorial governments. Throughout the course of the Commission’s public consultation
process and its dialogue with Canadians, significant frustration was expressed at the inability of
those charged with governing the system to handle and resolve their differences in a productive 45
manner. Different approaches, different priorities and different visions of what the health care
system should look like are part and parcel of living in a country as large and as diverse as
Canada. In some ways, a certain level of disagreement is always going to be present.
But disagreements can be handled in either a productive or unproductive manner. They can
lead to finger pointing and distrust where the goal is to lay blame for a problem rather than
resolve it. Alternatively, disagreements can lead to a tradition of compromise and negotiation
that results, in the end, in decisions that are in the best interests of Canadians and the health care
system itself. In the Commission’s view, those charged with the governance of the health care
system need to restore a level of mutual respect and trust that has been missing in recent years,
especially in the relationship between the federal government and the provincial and territorial
governments, and among the various actors in the health care system.
The corrosive and divisive debates must end. If the status quo continues, the result will be the
eventual unravelling of Canada’s health care system into a disparate set of systems with differing
services, differing benefits and differing ways of paying for health care across the country. This is
not what Canadians want or expect for their health care system or for their country.
Canadians expect both orders of government to respond to important social needs and
priorities, including health care. The role of each order of government in any particular social
policy area reflects different understandings of how best to separate or share responsibility for
meeting particular social needs. How governments do this reflects not only their formal
constitutional roles, but also considerations of efficiency, equity and how best to redistribute
resources. An effective federal role in health care can result in efficiency and equity gains as the
risks and costs of ill-health are redistributed nationally rather than borne individually or shared
only provincially (Banting and Boadway 2002). Notwithstanding, the primary responsibility of
provinces for delivering and organizing health services, effective federal government
involvement in health care can ensure the existence of relatively similar levels and quality of
service across the country.
Historically, the federal government encouraged the adoption of publicly administered

single-payer insurance systems in the provinces through the use of the federal spending power.
The success and longevity of medicare is in part due to the federal government’s ongoing social
program transfers, equalization payments, and its willingness to use its political capital to
promote and defend the system. It was federal legislation – first the Hospital Insurance and
Diagnostic Services Act (1957) and then the Medical Care Act (1966) – that, along with federal
money, established a national approach to health care in Canada. And when extra-billing and
user fees threatened the accessibility of medicare, the federal government responded with the
Canada Health Act . These actions reflect Canadians’ belief that access to health care services
was not only a personal, community or provincial issue, but also a national issue that demanded
active participation by the federal government.
But, in recent years, as discussed in more detail later in this chapter, the federal government
has attempted to maintain its role as the defender of medicare’s national dimensions while
simultaneously reducing its responsibility and risk for managing the increasing costs and
changing expectations within the system. This has put the federal government at odds with the
provinces. The Canadian public nevertheless remains committed to a national approach to health
care, and expects that a broad range of necessary and high-quality health services will be
available to all citizens of this country on an equal basis.
46
HEALTH CARE, CITIZENSHIP AND FEDERALISM
A fundamentally new approach is needed, not only to foster trust but

also to resolve disputes and conflicts in a productive and transparent “Medicare has as much iconic
manner. More importantly, Canadians want and expect to see their
force here as the Constitution
governments and those in the health care system working together to
address many of the pressing issues outlined in subsequent chapters of this does in the USA.”
report. What is needed is a truly national approach to medicare in the 21
st U NIVERSITY OF MCGILL, FACULTY
OF M E D I C I N E . P RESENTATION AT
century – an approach that sets aside the differences of provinces, MONTREAL PUBLIC HEARING.
territories and the federal government, and puts new and more effective
governance approaches in place.
Only by taking co-operative, deliberate, and decisive action on those issues, and setting
aside differences of the past can we hope to restore Canadians’ confidence in the future of their
health care system. To achieve these objectives, the following actions are required:
• A renewed commitment to a universally accessible, publicly funded health
care system – Canadians value the health care system, but there is some confusion over
what our collective vision is for the future. The obligations and responsibilities of
Canadians, health care providers, and governments also need to be clarified. This should
be done through a new Canadian Health Covenant, endorsed by governments and based
on the values Canadians share. The Covenant must be a clear statement – in essence, a
new “social contract” – that reflects our commitment to health care as a vital part of
society. It should serve as a guiding force in reforming and modernizing our health care
system and restoring Canadians’ confidence.
• Strengthening collaboration and leadership – Health care is a

partnership of individuals, health care providers and governments. “Cooperative federalism is the
While provinces and territories have primary responsibility for the
strategy that has always made
delivery of health care, the federal government also has important
responsibilities in terms of addressing issues that are national in Canada work most effectively.
scope and in providing a stable base of funding. The current
intergovernmental mechanisms for addressing health issues have All Canadians benefit when
become increasingly dysfunctional and characterized by fractious
the Federal and Provincial
debate between federal and provincial and territorial governments
over who is responsible for what and whether each party is paying governments join together
its fair share. A new Health Council of Canada – a creation of the
federal, provincial and territorial governments – should de- in agreement on policies
politicize this debate and provide a foundation for a more and programs.”
constructive and innovative partnership.
CANADIAN PENSIONERS CONCERNED
2001. W RITTEN SUBMISSION .
• A Canada Health Act for the 21 stcentury – The Canada Health

Act has served Canadians well. However, the definition of what is considered medically
necessary and covered under the Act needs to be updated to reflect the realities of our
contemporary health care system. Canadians also expect more accountability in how
their health care system is managed and this should be reflected in the Act. By updating the
Canada Health Act, we can ensure that it provides a solid foundation for managing our
health care system in the 21 stcentury.
47
• Adequate, stable and predictable funding arrangements –

Canadians are concerned about increasing costs and confused by
“‘Revisiting’ and ‘updating’ do continuing debates between the federal government and the provinces
and territories about their relative shares of funding and “how much is
not mean “abandoning” the enough.” The objective should be to establish new funding
Canada Health Act. They mean arrangements that are adequate, stable and predictable over the longer
term and de-politicize day-to-day health care issues. The federal
ensuring that the Act and its government should reinforce its funding for the health care system by
expanding its financial commitment to health care, replacing the
principles are relevant and current transfer system with a cash-only transfer, and building in
meaningful to the world we mechanisms for adjusting the transfer on an ongoing basis.
face today and the one we are

• Targeted efforts to address immediate priorities – Access to care is
heading into tomorrow.”
the number one concern for Canadians. Later chapters identify the need to take decisive action
C OLLEGE OF F A Mto I L Yimprove
P H Y S I C I A NCanadians’
S access to diagnostic services, primary health care, home care and
prescription drugs. People in rural and remote parts of Canada face particular challenges in
O F C A N A D A 2001.
accessing a range of health care services. Immediate, targeted funding from the federal
W RITTEN SUBMISSION .
government is essential to address these priorities. As these areas are critical to effective reform
of the health care system, they should also be considered as priority areas for funding under new
long-term funding arrangements for health.
These five steps are essential and lay the groundwork for the actions and recommendations
set out in the remainder of this report.
Establishing a
Canadian Health CSvenant
RECO MMENDATIO N 1:
A new Canadian Health Covenant should be established as a common declaration of
Canadians’ and their governments’ commitment to a universally accessible, publicly
funded health care system. To this end, First Ministers should meet at the earliest
opportunity to agree on this Covenant.
A Commitment to Canadians
Canadians’ confidence in the health care system must be restored. They need to know what
they can expect from the system and what the system expects from them. A critical step in
restoring their confidence lies in making a clear statement of values and expectations that
underlie the system and guide its future, as stated by Canadians during the Commission’s
consultations, and include the following:
• Universality – Everyone should be included and have access to the benefits of Canada’s
health care system on the same terms and conditions.
• Equity – Access to health services should be based on need and need alone, not on other
factors such as wealth, origin, the region where people live, their gender or age.
48
• Solidarity – As Canadians, we have a collective responsibility to

provide essential health care services to all Canadians, not for only “For my husband, the war
this generation of Canadians but for those who worked to build the against cancer ended on
system in the past and for generations of Canadians to come.
• Responsiveness – Canadians want and expect both quality of care February 11, 2000. When he
and timely access to care to be essential hallmarks of the health and I were married, we had
system.
made vows that each of us
• Wellness and responsibility – Canadians understand that they
have a personal responsibility for staying healthy and they want would stand by the other in
their health care system to put more emphasis on preventing illness sickness and in health, until
and injury.
death did us part. We also
• Efficiency and value for money – People see increasing costs
and, as taxpayers and owners of the health system, they expect held the belief that the health
efficiency and the best value for every dollar spent on health care. care system in this country had
• Accountability and transparency – People are no longer
prepared to simply sit on the sidelines and entrust the health a similar obligation to the people
system to governments and providers. They want to be involved, who paid taxes and spent their
engaged and acknowledged, and well informed as owners, funders,
and essential participants in the health care system. lives making this a better place.”
V I B E K E H L A D Y . P RESENTATION
Governments must now affirm those values and reasonable
AT
VANCOUVER PUBLIC HEARING.

expectations in a clear and tangible way. To that end, a First Ministers’
meeting should be called at the earliest opportunity to establish a new Canadian
Health Covenant. The Covenant should have the following objectives: •
To clearly state the objectives of the health care system for the public, for patients, and
for health care providers;
• To inform, educate and support better decision making in our health care system;
• To serve as a common foundation for collaboration among governments, the public, and
health care providers and managers.
During its hearings, the Commission heard suggestions that some sort of “Covenant” or
“Patient Bill of Rights” was necessary and should set out clear legal rights and obligations,
similar to those set out in the Canadian Charter of Rights and Freedoms. The value of a
Covenant lies, however, in the fact that it reflects the consensus of Canadians as affirmed by
their governments, not in the establishment of new rights that would be subject to legal
interpretation and ultimately decided by the courts rather than by Canadians themselves.
Ultimately, the Covenant should stand as a clear statement by and to Canadians – in
essence, a new “mission statement” for our health care system. It should be supported by First
Ministers, formally endorsed by a resolution of the federal government and each of the
provincial and territorial governments, and widely circulated to the public and health care
providers. The following proposed Covenant has been developed based on a wide range of
inputs and advice the Commission received from Canadians.
49
A Proposed Health Covenant for Canadians

Canada was founded on the basis of co-operation, perseverance and mutual respect. Canadians continue
to be recognized throughout the world for these qualities. Building from this solid foundation, as
Canadians, we agree to apply and be bound by the following in shaping our health care system:
Mutual Responsibility: The success of our health care system requires a balance between our personal
responsibility for our own health and our mutual responsibility for our health care system. All Canadians
share the responsibility for maintaining this system through their actions and tax dollars, and all should
contribute to it within their means.
A Public Resource: Our health care system is a public resource and a precious national asset.
Patient-centred Care: The direction of our health care system must be shaped around health needs of
individual patients, their families and communities.
Equity: All Canadians are equally entitled to access our health system based on health needs, not ability
to pay.
A Universal, Accessible, and Portable System: Public health insurance must be accessible to all
Canadians on uniform terms and conditions, regardless of where they live in the country. But the provision
of care should be sensitive to the race, colour, gender, sexual orientation, ability, disability, ethnic origin,
language, place of residence, social or economic status, and religion of those using the system.
A Respectful, Ethical System: Our health care system must be based on the highest ethical standards,
and must recognize the worth and dignity of the whole person including biological, emotional, physical,
psychological, social and spiritual needs.
Transparency and Accountability: The decisions governments and providers make in operating our
health care system should be clear and transparent. Canadians are entitled to regular reports on the status,
quality and performance of our health care system.
Public Input: Public participation is important to ensuring a viable, responsive and effective health care
system.
Quality, Efficiency and Effectiveness: The resources needed to support our health care system are
limited, and the system must be run as efficiently as possible. Care should be integrated, multidisciplinary,
timely and convenient, and services should be designed around the health of the population, with
emphasis on the physical, social, economic and environmental determinants of health. Wellness, public
health and prevention must be a major focus of the system. Decisions at all levels of the system must be
based on the best available information, and we must foster innovation and sharing of best practices.
Responsibilities and Entitlements of Individual Canadians

Canadians:
• have a responsibility to observe good health practices, and to promote and support the well-being
of their families and communities.
• have a responsibility to use the system prudently, and to support the system through their actions
and tax dollars.
50
• are entitled to health services based on health needs, not ability to pay.
• are entitled to timely, high quality care.
• are entitled to make informed decisions regarding their personal care, and to receive all information
and medical documentation related to them, while respecting the judgement and expertise of health
providers.
• are entitled to have appropriate input into, as well as to be informed of relevant policies and laws,
including procedures for complaints, and all Canadians are entitled to utilize appeals/complaints
mechanisms relating to the system.
• are entitled to be treated in a courteous, respectful and dignified manner, and consistent with
relevant legislation, should have their right to privacy respected.
Responsibilities and Entitlements of Health Care Providers

Health care providers:
• have a responsibility to ensure that the health care system places the highest priority on the
concerns and health needs of patients.
• have a responsibility to work with governments, the public and each other to continuously improve
the quality of services and maximize patient safety.
• have a responsibility to respect the confidentiality and privacy of individual patients.
• have a responsibility to provide information to patients on treatments, related services, and
available alternatives, while taking into account the preferences of their patients.
• have a responsibility to exercise prudent management and careful stewardship of resources in
support of our health care system, as these resources are finite.
• have a responsibility to uphold all professional standards.
• are entitled to professional recognition, the ability to exercise clinical judgement, and reasonable
compensation.
• are entitled to be treated with dignity and respect in the performance of their duties.
• are entitled to a meaningful role in making decisions related to the operation of the system.
Responsibilities and Entitlements of Governments

Governments:
• have a responsibility to develop and administer the health care system for the common good of all
and in a manner that provides equitable access and treatment for all Canadians.
• have a responsibility to dedicate adequate, stable and predictable funding for our health care system
in a manner transparent to Canadians.
• have a responsibility to work collaboratively with each other and with the public and health care
providers, as appropriate, to foster innovation and ensure the system remains responsive and
sustainable.
• have a responsibility to regularly review the performance and operation of the health care system
and report to the public so that Canadians can make informed decisions and contribute to the
system in an informed way.
51
• have a responsibility to ensure that decisions regarding the future direction of our health care system
are made with transparency and accountability to all; this means establishing goals, targets, and
benchmarks for the system, tracking performance and reporting to the public.
• have a responsibility to ensure that health services are delivered in a way that ensures the flexibility
necessary to reflect local needs and circumstances.
• have a responsibility to establish appropriate mechanisms that allow the public and health care
providers meaningful input into decisions on the future of our health care system.
• have a responsibility to develop healthy public policies that are designed and implemented in a
manner consistent with promoting the health of the population.
• are entitled to have their jurisdictional roles and responsibilities recognized and respected in
charting new directions for the health care system of the future.
Canadians and their elected representatives may choose to endorse or amend this proposed
Covenant. However the final statement is crafted, a Covenant is an essential step in restoring
Canadians’ confidence, reaffirming our collective commitment to medicare, and reflecting
Canadians’ values in a clear and compelling statement of our vision and expectations for
Canada’s health care system.
Achieving the VisiSn:

NatiSnal Leadership in Health
RECO MMENDATIO N 2:
A Health Council of Canada should be established by the provincial, territorial and
federal governments to facilitate co-operation and provide national leadership in
achieving the best health outcomes in the world. The Health Council should be built
on the existing infrastructure of the Canadian Institute for Health Information
(CIHI) and the Canadian Coordinating Office for Health Technology Assessment
(CCOHTA).
RECO MMENDATIO N 3:
On an initial basis, the Health Council of Canada should:
• Establish common indicators and measure the performance of the health care
system;
• Establish benchmarks, collect information and report publicly on efforts to

improve quality, access and outcomes in the health care system;
• Coordinate existing activities in health technology assessment and conduct

independent evaluations of technologies, including their impact on rural and
remote delivery and the patterns of practice for various health care providers.
52
RECOM MENDATIO N 4:
In the longer term, the Health Council of Canada should provide ongoing advice and
co-ordination in transforming primary health care, developing national strategies for
Canada’s health workforce, and resolving disputes under a modernized Canada
Health Act.
A New Approach to National Leadership

As noted in Chapter 1, federal, provincial and territorial governments share responsibility
for various aspects of our health care system. Unfortunately, in recent years, the ability of
governments to work together within this framework has been challenged by a number of high
profile disputes. The proposed Canadian Health Covenant can be a first step in addressing these
challenges and establishing a common vision.
The time has come for governments to focus on a collective vision for the future, rather than
the jurisdictional or funding issues that have been the focus of intergovernmental debate for
much of the past decade. This collective vision must focus on achieving effective reform and
modernizing the system. It must reflect the priorities of Canadians. Ultimately, the collective
objective of current and future Canadian governments should be to establish and maintain
Canada as the country with the healthiest population in the world. Achieving this objective will
take time as well as focused, collective action. But the goal is within our means if governments,
health providers and the public make a joint commitment and follow through with decisive
action.
At the same time, it would be unfair to assume that the problems facing the governance of our
health system are simply the result of a lack of clear vision. There are functional problems in how
our governments interact with one another that must be addressed. These problems are as follows:
•
Dysfunctional intergovernmental relations – No single government has clear
constitutional authority for our health care system. As a result, it is not always obvious to
Canadians which order of government is accountable for addressing specific issues and
ensuring good performance. In recent years, governments
have addressed this challenge by committing to “clarifying
“The pointing of fingers at one
roles and responsibilities” and “reducing duplication and
overlap.” While these are useful efforts to streamline the another must come to an end;
governance of our health care system, the reality is that the
nature of our constitution – and the nature of our health care governments must find a way
system itself – make it impossible to divide the management of
of working together or they
all aspects of health care into neat federal or provincial
“boxes.” Intergovernmental debate can be a healthy way of risk losing what Canadians
defining and achieving national goals, but in recent years these
debates have become complex and perhaps dysfunctional value most.”
(Boychuk 2002). Consistently, the Commission heard that A SSOCIATION OF CANADIAN
ACADEMIC HEALTHCARE
O R G A N I Z A T I O N S 2002.
intergovernmental conflict and mistrust are serious barriers to W RITTEN SUBMISSION .
the smooth functioning and sustainability of medicare.

• Intergovernmental mechanisms that lack public input – The “machinery” of
intergovernmental relations is cumbersome. In addition to regular meetings of health
ministers and deputy ministers, there currently is a dizzying array of dozens of working 53
groups and a number of arm’s length institutions that shape national health policies and
approaches. Few Canadians understand this system, and even fewer understand how
their needs, views or expectations are taken into account (O’Reilly 2001). Clearly, there
is value in streamlining the intergovernmental process, and more importantly, in
establishing new mechanisms to improve transparency and allow public input (Abelson
and Eyles 2002).
• Need for stable, long-term leadership – Establishing and implementing the national
vision for health care requires strong and consistent leadership. It means health care must
continue to be a priority not only for individual governments but also for all governments
working together (Adams 2001). Fortunately, we are halfway there. Given the importance
of health care, it is already a major focus of discussion among the cabinets of federal,
provincial and territorial governments. At the intergovernmental level, health is commonly
discussed by both health and finance ministers, and in recent years, by Canada’s first
ministers. Unfortunately, despite the high priority of health care on the agendas of our
governments, we lack a consistent approach that provides long-term leadership and
direction. All too often, straightforward tasks in managing the system get mired in politics
because of differing views on objectives and competing interests. Federal, provincial and
territorial ministers of health are in a unique position to establish strategic directions, but
ministers and their deputy ministers often change with such frequency that few stay in
their positions for more than a year or two. This underscores the need for a stable
mechanism like the proposed Health Council of Canada to provide an ongoing base of
“We haven’t reached aadvice
stage and information.
where we should neglect a
collaboration among the two
levels of government under the These concerns suggest that:

heading of health. We believe • achieving an effective national health care system will require
better collaboration between federal, provincial and territorial
that we must develop a collegiate governments on national priorities and key challenges, in order to
meet the needs of all Canadians;
health care system to permit
• a key objective in shaping any new intergovernmental process
both governments to assume the
should be restoring trust and implementing a national vision;
action that is necessary to • the intergovernmental process in health needs to be streamlined
and its accountability, transparency and ability to take account of
reform the system.”
and reflect the views of Canadians need to be improved; and
C ONS E I L D U PA T R O N A T D U QUÉBEC.
P RESENTATION AT QUEBEC CITY • strong, consistent and longer term leadership is needed from health
PUBLIC HEARING. ministers and deputy ministers in order to manage the system in the
interest of all Canadians.
Role of the Health Council of Canada

To provide national leadership, the mandate of the Health Council of Canada should be to: •
act as an effective and impartial mechanism for the collection and analysis of data on the
performance of the health care system;
• provide strategic advice and analysis to federal, provincial and territorial health ministers
and deputy ministers on important and emerging policy issues; and
54 • seek ongoing input and advice from the public and stakeholders on strategic policy
issues.
Ultimately, the Council should be a collaborative mechanism that can drive reform and
speed up the modernization of the health care system by “de-politicizing” and streamlining some
aspects of the existing intergovernmental process. The Council should also be a broadly based
mechanism that provides analysis and advice on key national health issues.
Immediate Priorities
The Council should immediately focus on three priority areas that are urgent in stabilizing
and improving the health system:
• Accelerating the establishment of common indicators and measuring the
performance of the health care system – Governments and health organizations need
better information to guide policy decisions, make choices and make the best use of
resources in our health care system. The public are demanding better accountability from
the system and regular information that allows them to judge the results that are being
achieved. As a priority, the Health Council of Canada must establish a national performance
review framework that builds on the existing work of the federal-provincial Performance
Indicators Review Committee (PIRC) in conjunction with the Canadian Institute for Health
Information and Statistics Canada. This framework should start with common definitions and
comparable performance indicators on health status, outcomes, quality of services, and
reporting requirements.
The work of the Council should culminate in annual reports to the public and
governments that are widely distributed, discussed and debated across the country. The
Council’s annual reports to Canadians should include the core components set out in the
following box.
Annual Performance Reports from the Health Council of Canada

Each year, the Health Council of Canada should report to Canadians on
• the health of Canadians, providing information on international comparisons, variations across the
country, and improvements over time;
• the performance of the health care system, again with international comparisons, noting significant
regional or other variations, and highlighting improvements over time;
• progress in developing common indicators and performance measures, including waiting times for
certain services and treatments as well as challenges in rural and remote areas;
• results achieved by intergovernmental structures, agencies and organizations as well as make
recommendations for improvement;
• trends in the supply and distribution of health care providers, including a progress report on activities
by the Council to address health human resources issues, outcomes, and best practices;
• best practices in Canada and initiatives to improve access, quality and efficiency;
• outcomes of technology assessments that are of broader interest;
• progress on primary health care initiatives;
• issues in dispute among governments and how they are resolved.
55
There is a significant overlap between the proposed work of the Health Council of
Canada in measuring and assessing performance and the work of the Canadian Institute
for Health Information (CIHI), which is itself a partnership between the federal and
provincial governments. In many ways, the existing, important work of CIHI must form
the statistical and analytical backbone for the work of the Health Council of Canada. For
this reason, CIHI should be formally integrated into the Council.
• Reporting on issues related to access and quality, and providers – Canadians are
worried about the accessibility and quality of their health care system as well as its ability
to provide safe and reliable care. The challenge of access to the system is particularly
significant in rural and remote parts of Canada, where resources are quite limited.
Dealing with this challenge also requires comprehensive and reliable data on the supply
and distribution of health care providers. Working with non-governmental organizations
such as the multi-stakeholder National Steering Committee on Patient Safety and the
voluntary Canadian Council on Health Services Accreditation, the Health Council of
Canada can play a critical role in data collection and analysis on all these important
issues, including national benchmarks for quality and patient safety and in-depth analysis
of how access in rural and remote areas can be improved.
Currently CIHI maintains databases on physicians, registered nurses and other

health care providers, including licensed practical nurses, midwives, physiotherapists,
pharmacists, occupational therapists, health administrators and executives, among many
others. This work would provide the foundation for the analytical expertise that the
Health Council of Canada should develop over time.
• Assessing new technologies – The use of technology in our health care system has
critical implications for the efficiency and effectiveness of the system. The existing
federal-provincial Canadian Coordinating Office for Health Technology Assessment
plays an important role in the collection, analysis and dissemination of information on
the cost and effectiveness of health technologies, as well as their impact on health
outcomes. CCOHTA’s role as a clearinghouse and disseminator of information on
technology assessment is critical in reducing overlap among provinces that have their
own technology assessment agencies, and in providing support to other provinces and
territories that lack this capability. With new advances in medical technology, technology
assessment will become increasingly important across the country. At the same time,
technology assessments should not be done in isolation of their impact on all aspects of
health and the health care system. Because of the importance of linking technology
assessments to the quality and effectiveness of the health care system, the Commission
believes that the mandate and resources of CCOHTA should be integrated with the
Health Council of Canada’s role in assessing the overall performance of the system. In
this way, Canadians, governments, and health care providers would have more
comprehensive assessments of all aspects of the health care system, including technology
assessment. The Council could also ensure that the outcomes of technology assessments
are widely shared with governments, providers and the public.
56
Medium- and Longer-term Priorities to Transform the Health Care System

The proposed Health Council of Canada is a new approach and care should be taken to
ensure that its work meets the needs of Canadians and their governments. Once the Council is
established and working effectively on the initial priority areas, the federal, provincial and
territorial governments may wish to expand its mandate to include the following key areas:
• Facilitating primary health care – New primary care approaches are being initiated in
every part of the country, and Canada’s First Ministers identified primary health care as a
priority in their September 2000 Accord. A subsequent chapter of this report outlines
actions that should be taken to build on that work and expand primary health care across
the country. The Health Council can play a key role in advising governments on
accelerating the ongoing development of a national framework for primary health care,
monitoring and measuring the success of new primary health care initiatives, and
identifying obstacles to progress.
• Providing advice and co-ordination related to the supply, distribution and changing
roles of health care providers – Many parts of Canada are facing both supply and
distribution problems with health care providers. This problem is of particular concern in
rural and remote parts of the country. On top of these challenges, the face of health care
is changing and the traditional roles of different health providers are becoming blurred.
Temporary and ad hoc approaches to these problems are not the solution. Building from
the recommendations set out in Chapter 4 of this report, the Health Council of Canada
can play a key role in providing advice on pressing national health human resources
issues. It can provide advice – developed independently from both governments and
provider organizations – on how these issues might be managed consistently and,
perhaps, collectively across the country. Over time, it could assist health ministers in
developing a national framework to deal with issues like compensation.
• Assisting in the resolution of disputes – Earlier this year, the federal Minister of Health
made a proposal for a new approach for avoiding and resolving disputes under the
Canada Health Act. Building from this proposal, and from proposed modifications to the
Canada Health Act set out later in this chapter, the Council could play an important role
in fact-finding and mediating disputes between governments. Ultimately, the Council
could play an important advisory role in helping governments decide how they can
resolve disputes between one another.
Health Council Operation and Structure

The Health Council of Canada is not intended to simply be another advisory body in the
already complex web of committees and expert panels that now exist in health. It should be a new
way of doing business. It should function as a broadly based mechanism for analysis and
assessment that looks at our national health care system as a whole. It also should provide an
effective mechanism for facilitating public input on critical health issues. Over time, it is
expected that the Health Council will play an important role in providing advice to governments
on health human resources issues, co-ordinating technology assessment, facilitating primary
health care reform, and in developing of effective means to measure the performance of the system.
57
In this context, the Council’s operating principles should be as follows:

• The Council should report to federal, provincial, and territorial health ministers.
• The Council should respect the constitution and the responsibilities of provincial,
territorial and federal governments.
• Reports and analyses prepared by the Council should be made public unless there are
exceptional circumstances as directed by ministers of health.
• The Council should place a high priority on public input into its work. It should explore
ways of regularly consulting with Canadians including the possibility of town hall
meetings and extensive use of the Internet. It should also consider an approach similar to
the Commission’s Citizens’ Dialogue to conduct an annual check-up with a
representative sample of Canadians from across the country. More importantly, it could
use this type of deliberative consultation to allow Canadians to propose policy options
and shape the policy dialogue (Dickinson 2002).
• The Council should establish mechanisms to regularly consult with stakeholders.

Specifically, it should establish a permanent advisory committee that includes a cross-
section of representatives from the major health professions, the scientific and academic
community, the business community, the volunteer sector, public and community health
groups, regional health authorities and hospital groups. Through this committee, the
Council should seek regular advice and feedback on its business plan, priorities and
special projects.
• It is critical that the proposed work of the Council remain relevant both to governments and
to Canadians. To this end, health ministers should review the work of the Council
periodically, perhaps every five years, to determine whether its role should be expanded or
adjusted.
The structure of the new Council will also be critical in determining its relevance and
effectiveness. In the Commission’s view, the Council’s Board should be appointed through
consensus of federal, provincial and territorial governments, and it should include:
• Representation from the public;
• Representation from the academic, scientific and professional community;
• Individuals with working knowledge in the area of governance and management of the
health system; and,
• Appropriate regional representation from across our country.
The following sets out one possible option for the structure of the Council’s Board. In addition
to a board, the Council would require a professional staff and support from a full-time executive
director. To avoid extra expenses and duplication, the existing staff and resources of CIHI and
CCOHTA should be integrated into the Council. The Council should be run as efficiently as
possible and its annual operating costs initially should not exceed the combined budgets of CIHI
and CCOHTA.
58
A Possible Model for the Health Council of Canada

Membership
• The Health Council of Canada should have a 14-member board appointed by consensus of federal,
provincial and territorial health ministers and comprised of the following:
– 3 representatives of the public
– 4 representatives of the provider and expert community recognized for their competence in
health policy and practice
– 7 government appointees selected as follows: •
1 appointed by consensus of the governments of the Yukon, Northwest Territories and Nunavut
• 1 appointed by the consensus of the governments of British Columbia, Alberta, Saskatchewan
and Manitoba
• 1 appointed by Ontario
• 1 appointed by Quebec
• 1 appointed by consensus of the governments of New Brunswick, Nova Scotia, Prince
Edward Island, and Newfoundland and Labrador
• 2 appointed by the Government of Canada.
Selection
• Board members would be appointed for a three-year term, with the possibility of one reappointment
for an additional three years.
• Board members would hold a formal fiduciary responsibility to the Health Council Board; Board
membership should be “personal” to the individual and should not depend on or change with a
change in the board member’s current employment.
• Regional appointees would require the consensus approval of the jurisdictions in that region, and all
participating jurisdictions should have an opportunity to have their representative sit on the Board
over time.
• To ensure that the Chair of the Board is clearly accountable to the Health Council and to signal the
independence of the Council, the Chair of the Board should be selected from among board members
by the Board itself. The nominee selected by the Board should be presented to federal, provincial and
territorial ministers for consensus confirmation.
MSdernizing and Updating the

Canada Heal h Ac
RECOMM E NDAT ION 5:
The Canada Health Act should be modernized and strengthened by:
• Confirming the principles of public administration, universality and
accessibility, updating the principles of portability and comprehensiveness, and
establishing a new principle of accountability;
• Expanding insured health services beyond hospital and physician services to

immediately include targeted home care services followed by prescription drugs 59
in the longer term;
• Clarifying coverage in terms of diagnostic services;

• Including an effective dispute resolution process;
• Establishing a dedicated health transfer directly connected to the principles and
conditions of the Canada Health Act .
The Canada Health Act has served Canadians well. In many respects, it has become an icon
to Canadians. They view it as a hallmark of Canadian society and the five principles closely
match their values. All of this has made the Canada Health Act virtually immune to change. In
fact, most Canadians would not stand idly by and accept changes that would destroy this symbol
of Canadian identity.
At the same time, Canadians understand that much has changed since the early days of
medicare when the health care system could largely be defined by two words – hospitals and
doctors. They see new technologies, new treatments and cures, new diagnostic tests, more
people being treated and cared for at home, and the burgeoning role of prescription drugs, and
they understand the need for the health care system to change and adapt with changing times and
changing care. Canadians understand that much can be done to prevent illness and injury, and
they expect to see a better balance in their health care system. In fact, the last thing Canadians
want is for their health care system to remain as a static entity, fixed in time and unable and
unwilling to change. The critical task, then, is to modernize the Canada Health Act while
remaining true to Canadians’ expectations and their values.
The Principles of a Modernized Canada Health Act

The principles of the Canada Health Act began as simple conditions attached to federal
funding for medicare. Over time, they became much more than that. Today, they represent both
the values underlying the health care system and the conditions that governments attach to
funding a national system of public health care. The principles have stood the test of time and
continue to reflect the values of Canadians. In particular, the public administration, universality
and accessibility principles are as relevant and necessary today as they were when first
introduced. The principles of portability and comprehensiveness need some fine tuning to fit the
realities of health care in the 21 century, while a sixth principle of accountability should be
st
added to a new Canada Health Act to reflect Canadians’ desire for more accountability in the
health care system.
Principle 1: Public Administration

The principle of “public administration” must be maintained. This establishes a single-payer
system for health care services covered under the Canada Health Act . It requires provincial
health care insurance plans to be administered and operated on a non-profit basis by a public
authority appointed or designated by the provincial or territorial government.
The principle of public administration ensures that a single-payer system will continue to be
the cornerstone of the Canadian system. A single-payer system has two great advantages over a
multi-payer, private insurance system. It does a better job of controlling costs and it facilitates
equitable access (Maynard and Dixon 2002).
60
On the cost-efficiency side, private insurance has very high administrative costs related to
billing, contracting, reviewing utilization, and marketing because of the large infrastructure
required to assess risk, set premiums, design complex benefit packages, review claims, and pay
(or deny) individual claims. Moreover, the tax subsidies used to encourage coverage through
private insurance and the use of tax revenue to cover the poorest (and generally sickest) people
in society are both inefficient and highly regressive (Mossialos and Dixon 2002).
A single-payer system is more efficient because it is administered by a single agent that is

either the government or a body delegated by the government. This means that substantial
resources are not wasted in processing insurance claim forms from multiple companies. It also
means that providers – particularly physicians and their employees – avoid the overhead
required to collect bills from their patients.
Over a decade ago, Woolhandler and Himmelstein (1991) estimated that Canadians spent
two-thirds less than Americans on health care administration. Their analysis was largely
confirmed by the U.S. General Accounting Office (1991) and the Congressional Budget Office
(1991). Their most recent work (Woolhandler et al. 2002) concludes that each Canadian pays
$325 per year (out of a total health administration bill of almost $10 billion) compared to $1,151
paid by each American per year (out of a total health administration bill of $320 billion).
Principle 2: Universality
This principle is widely valued by Canadians and should be retained as a hallmark of a
renewed Canada Health Act . This principle ensures that provincial and territorial health
insurance schemes cover everyone in the same manner and under the same terms and, together
with the principle of accessibility, marks the system’s commitment to preserving and promoting
equity for all Canadians.
Principle 3: Accessibility
Similarly, the Commission recommends keeping the principle of
accessibility in a new Canada Health Act . This principle is the “other “The role of the federal
half” of the system’s commitment to equity. Accessibility was added to government for me would be to
the guiding principles of the Canada Health Act in the 1980s as part of the
ensure that from sea to sea …
move to ban user fees and extra-billing. The principle ensures that there
are no barriers, particularly no financial barriers, to accessing the system. the basic things would be
To reinforce this principle, both user fees and extra billing should continue
the same.”
to be prohibited under a new Canada Health Act . Taken together, the
A SSOCIATION DES RÉGIONS
principle of accessibility and the principle of universality confirm the DU Q U É B E C . P RESENTATION AT
conviction of Canadians that essential health care services must be QUÉBEC CITY PUBLIC HEARING.
available to all Canadians on the basis of need and need alone.
Principle 4: Portability
This principle currently is included in the Canada Health Act . It addresses three situations:
• Health coverage if people get ill or injured in another province – If Canadians are
travelling within Canada and need medically necessary hospital and physician services
while they are in another province, those services must be covered by their province’s health
61
insurance plan at the rates approved in the province where the services were provided.
• Health coverage when people move within Canada – Canadians who move from one
province to another must be covered by their originating province until they meet the
minimum residency requirements for coverage in their new home province. The waiting
periods for coverage in their new province cannot be longer than three months.
• Health coverage outside Canada – If Canadians are travelling outside of Canada and
require services covered under the Canada Health Act, they must be reimbursed by their
respective province to the level that those services would have been covered by their
province’s provincial plan.
In reality, not all of these conditions are met by the provinces. All provinces respect the
limit on residency requirements and meet their obligations to people who move from their
province to another. And all provinces participate in reciprocal billing arrangements for hospital
services provided to visitors from other provinces. But not all provinces participate in similar
arrangements for physician services, meaning that individuals who see doctors while visiting
other parts of the country could find themselves having to pay for the service directly and then
seek reimbursement from their own province (HC 2001a). And for financial reasons, five
provinces refuse to provide out-of-country coverage as required under the Canada Health Act
(Flood and Choudhry 2002). In spite of these inconsistencies, the federal government has never
reduced cash transfers to provinces that do not meet the current portability requirements.
Portability is a key aspect of the mobility rights of Canadians. These rights are protected
under the Canadian Charter of Rights and Freedoms. A good argument can be made that failure
to provide continuing health care coverage when people move from one province to another
would seriously compromise Canadians’ mobility rights. The mobility of Canadians is also
important from an economic perspective, ensuring that people can move from province to
province for employment opportunities.
The same argument, however, does not apply to out-of-country coverage. In other social
programs, such as education, there is no expectation or guarantee that people can access these
services outside Canada at taxpayers’ expense. Out-of-country coverage for health care should
be considered a benefit if provinces choose to provide it but not entitlement under the Canada
Health Act. To make the best use of limited resources, the principle of portability should be limited
to supporting mobility within Canada and it should, in the future, be strictly enforced. At the same
time, the Canadian government should be encouraged to negotiate agreements to guarantee
emergency care for Canadians travelling abroad. Many OECD countries such as Australia, New
Zealand and the United Kingdom rely on this approach (Flood and Choudhry 2002).
Principle 5: Comprehensiveness
The current Canada Health Act includes the principle of comprehensiveness. However, for
the last 35 years, comprehensiveness has been limited to “insured health services” defined as
medically necessary hospital and physicians services (including dental surgery services
performed in hospitals). This is not how the average person would define comprehensive.
Despite this, comprehensiveness should be retained as a principle, not so much as a
description of existing coverage under the Canada Health Act but as a continuing goal. It should
be redefined to mean that, as financial resources permit and as the health care system changes,
the definition of comprehensiveness (and of services insured under provincial plans) should
62
continue to evolve to improve the continuum of care. Immediate changes

should be made to expand insured services to include medically necessary “Our system lacks
diagnostic and home care services. In the longer term, the principle of
comprehensiveness should be revisited and updated periodically. communication, lacks
clear accountability…”
Principle 6: Accountability W I L L I A M S I L V E R . P RESENTATION AT
REGINA PUBLIC HEARING.

Currently, there is no principle in the Canada Health Act that
addresses accountability. During the consultation process, Canadians
expressed their deep suspicions about the way governments have managed
their health care system and where the money goes.
As the owners, funders, and users of the health care system, “I hope you would understand
Canadians have a right to know how their system is being administered, our desire to have a more
financed and delivered, and which order of government is responsible for
responsible, accountable system
which aspects of the health care system. A new principle in the Canada
Health Act should confirm the importance of accountability in the health and that we are, as Canadians,
care system. In particular, provincial, territorial and federal governments willing to participate and be
have a collective responsibility to:
responsible for our health
• clarify the roles and responsibilities of governments as well as
intergovernmental processes and expected outcomes; as well. Hopefully, this will, in
• ensure adequate, stable and predictable funding;
the long-term, make effective
• explain in an open and understandable way where the money goes
in terms of the national dimensions of health care funding; and use of our resources.”
• inform Canadians on the performance of the health care system. INDIVIDUAL, CITIZENS’
This accountability can be reinforced through annual reports to the DIALOGUE, HALIFAX.
public provided by the proposed Health Council of Canada.
Expanding Medicare Coverage: Short Term and Long Term

The principle of comprehensiveness highlights the gap between what should theoretically be
included as part of medicare and the services that are actually included as “insured health
services” under the current Canada Health Act. This gap exists in the first place because of the
impossibility of the public purse covering all health services immediately. Financial probity
requires that services be added as fiscal resources permit. Public coverage in Canada began with
hospitals in the 1950s and physician services in the 1960s. Each new step has been preceded by
much discussion concerning the public resources required to fund such services.
At the same time, advances in medical technology and changes in health care delivery since
medicare was introduced have meant that many services can now be provided outside hospitals
and by professionals other than physicians. Since the 1990s, there has been much discussion
about expanding medicare coverage, particularly for home care and prescription drug therapies.
The Commission believes that the time has come for another major step forward. As outlined in
Chapter 8, a group of home care services has been identified for immediate inclusion in a
modernized Canada Health Act . These services include home mental health case management
and intervention services, post-acute home care and rehabilitative care, as well as palliative home
care. Other home care services can be added as public finances permit in the future.
63
Prescription drugs have been the subject of much debate in Canada both because of their
growing cost to governments and individuals and the lack of uniform national coverage. The
Commission believes that the recommendations provided in Chapter 9 set the stage for eventual
inclusion of prescription drug therapies under the Canada Health Act .
Clarifying Coverage under the Canada Health Act

If medicare is to thrive, it must adapt to the changing nature of health care. Diagnostic
services are a case in point. Many, perhaps most, diagnostic tests can now be performed safely
and efficiently outside hospitals. Blood tests and X-rays have been performed in this manner for
many years. More recently, a growing number of MRIs and CT scanning tests have been
performed in specialized, free-standing clinics. Diagnostic services are the essential “front end”
of medical care that precedes critical interventions, including, for example, surgery and
chemotherapy in cancer treatment.
Currently, there are serious backlogs in wait lists for access to advanced diagnostic services
across the country and evidence suggests that, compared with other countries, Canada may have
under-invested in some of the newer and more expensive diagnostic services. This has created a
‘private market’ for more timely diagnostic services. Patients who do not wish to wait in the
public sector queues may buy access (if they can afford to do so) to a diagnostic test such as an
MRI. But, if the test results reveal a serious condition requiring immediate treatment, the patient
who has privately purchased an MRI can queue-jump ahead of others waiting for diagnosis and
potential treatment. This raises a problem. Access to cancer treatment, for example, is on the
basis of urgency of need. But this cannot be determined without proper diagnosis through one or
more tests. If these can be purchased privately, then initial access is being determined by ability
to pay rather than need.
It is true that all medically necessary diagnostic services are within the principles and
conditions of the Canada Health Act in two ways. First, if they are provided within a hospital,
they are automatically considered to be “insured health services.” Second, if they are provided
or ordered by a physician as a “medically required service,” then they are also insured under the
terms of the Act. But the difficulty lies with the phrase “medically necessary.”
To clarify the situation, diagnostic services should be explicitly included under the
definition of “insured health services” under a new Canada Health Act. These front-end services
are an essential part of medicare and should not be the vehicle for queue-jumping in the public
system. As a result, all diagnostic services except those that are being performed for a clearly
non-medically necessary purpose, such as cosmetic surgery, should be subject to the conditions
and principles of the Canada Health Act , including the prohibitions on user fees (including
facility fees) and extra-billing. In other words, the Canada Health Act should be amended to
clarify that it covers all diagnostic services reasonably required to assess a patient’s need for
medically necessary hospital and physician services. In the event of any further violations, the
federal government would be obliged to withhold its medicare contributions by an amount equal
to that paid out-of-pocket by individuals for MRI and other diagnostic tests.
This recommendation, however, does not address the anomaly of access to diagnostic
services by workers’ compensation clients as discussed in Chapter 1. While workers’
compensation rules for health care performed an important function in the past, many would
64
agree with one physician’s assessment that today this preferential access amounts to “officially
sanctioned queue-jumping in the public system” (quoted in LeBourdais 1999, 859). Indeed, the
vast majority believe that all Canadians are equally entitled to timely service, regardless of their
employment status. The elderly and children, for example, are just as deserving of prompt
diagnosis as injured workers. For the same reasons that private payment for diagnostic services
is contrary to the basic principle of medicare, this “public” form of queue-jumping should be
redressed in a modernized Canada Health Act .
PrSviding Stable and Predictable

Federal Funding
RECOM MENDATIO N 6:
To provide adequate funding, a new dedicated cash-only Canada Health Transfer
should be established by the federal government. To provide long-term stability and
predictability, the Transfer should include an escalator that is set in advance for five
year periods.
RECOM MENDATIO N 7:
On a short-term basis, the federal government should provide targeted funding for the
next two years to establish:
• a new Rural and Remote Access Fund

• a new Diagnostic Services Fund
• a Primary Health Care Transfer
• a Home Care Transfer
• a Catastrophic Drug Transfer
As outlined in the first chapter of this report, the heart of the Commission’s mandate is to
make recommendations to ensure the long-term sustainability of the health care system.
Sustaining the health care system is fundamentally about making choices – getting the
governance approach right, and finding the right balance between services, needs and resources.
The primary objective must be stable, long-term, predictable and adequate funding for Canada’s
health care system. At the same time, there are immediate challenges that must be addressed to
improve Canadians’ access to health care services. The combination of a new funding
mechanism and short-term targeted actions should serve to meet both of these objectives.
Introducing a New Canada Health Transfer

The question of the respective federal and provincial shares of the health care “bill” has been
hotly contested over the past few years. The debate has not been helped by the complexity of the
Canada Health and Social Transfer (CHST) funding mechanism as discussed in Chapter 1 (also
see IIGR 2002). The Commission believes a dedicated health transfer must be created based
upon the existing “health” component of the CHST. While this would be a new federal transfer to
the provinces, it is essential that both orders of government agree to its structure and cash base. 65
Understanding the importance of creating a dedicated transfer requires a brief overview of

health transfers that have been at the heart of the debate. The original “medicare bargain”
involved the federal government sharing with the provinces all eligible hospital and physician
expenditures on a 50:50 basis. Historically the principle of cost sharing only covered what
would become known as Canada Health Act services. Over time, however, the public along
with governments increasingly debated cost sharing in the context of total provincial health
expenditures. Both are compared below.
Figure 2.1 illustrates the federal contribution for eligible services for the past three decades
(see Appendix E). The federal government argues that total federal expenditures (cash plus tax
points) must be considered in determining its share. Doing this, the federal share of provincial
hospital and physician expenditures has ranged from a high of almost 60% at the end of the
1970s to a low of slightly more than 41% at the end of the 1990s. The provinces generally view
federal funding commitments in terms of federal cash payments alone. Federal “cash only”
transfers for hospital and physician expenditures have ranged from a high of close to 47% in
1976/77 to a low of 14.6% in 1998/99.
Figure 2.2 demonstrates the extent to which the federal share of total provincial health
expenditures has always been well below the 50% line, even with tax points included. Reaching
a crest of a 43% contribution to total provincial and territorial health expenditures in 1979/80,
federal cash and tax point transfers allocated to health had sunk to a low of 27.5% by 2001/02.
As for cash, the highest point reached was an almost 38% contribution in 1971/72 which had
dropped to slightly less than 10% by 1998/99.
In their recent sparring over health transfers, Ottawa and the provinces have tried to put the
best possible spins on their respective versions of this history. For its part, Ottawa has
downplayed the fact that its contribution to provincial health expenditures has been declining as
a share of those costs for the past two decades. Just as importantly, the federal government has
successfully moved the risk of growing health expenditures to the provinces through its
occasional reductions in the cash portion of the transfer and the elimination of an escalator
when the CHST was introduced as described in Chapter 1.
Figure 2.1 70%

Cash Tax
Federal
Contribution 60%
to Provincial- 50%
Territorial
Expenditures 40%
on Hospital and
Physician 30%
Services,
1974/75 to 20%
2001/02
10%
0%
1974/75
1977/78
1980/81
1983/84
1986/87
1989/90
1992/93
1995/96
1998/99
2000/01
Source: Appendix E.
66
Figure 2.2 60%

Cash Tax
Federal
50%
Contribution
to Total 40%
Provincial-
Territorial 30%
Health
20%
Expenditures,
1968/69 to 10%
2000/01
0%
1968/69
1972/73
1976/77
1980/81
1984/85
1988/89
1992/93
1996/97
2000/01
Source: Appendix E.
For their part, the provinces have conveniently eliminated the tax transfer from their
calculations of the federal contribution despite the fact that they welcomed the original tax points
transfer in 1977, assuming as they did at the time that its value would eventually grow faster
than the cash contribution. In addition, they have continued the rhetoric that the original 50:50
cost- share bargain was for all provincial health expenditures even though it was only intended
to cover the narrower band of medicare services.
All of these arguments divert us from focusing on the most elemental aspects of the
Canadian system. They obscure the critical role that the federal government has played in the
past through health transfers in getting medicare off the ground on a national basis and in
protecting it when the system was threatened by user fees and extra-billing. They prevent us
from seeing the central and innovative role the provinces have always played in the
administration and delivery of health services, including establishing the first workable medicare model.
Whatever the actual value of the federal contribution, several points are clear. First, the
medicare bargain involved something closer to a 25% cash contribution to provincial Canada
Health Act expenditures after the provinces obtained the other half in the form of a permanent
tax transfer. Second, the tax transfer made the federal government’s contribution to medicare
extremely difficult to calculate by both governments and the general public. Third, the mixing of
policy purposes – health being mixed with post-secondary education (EPF) and later with social
assistance and social services (CHST) – only added to the lack of clarity. And fourth, the
freezing and subsequent elimination of a funding escalator in the 1990s, further reduced
predictability by leaving transfer increases to federal discretion.
The time has come for Ottawa to once again take on more of an equity position in the
medicare enterprise. For these reasons, a new Canada Health Transfer should be exclusively a
cash transfer, effectively dividing the CHST into a health transfer and a social transfer. This
would provide Canadians with greater assurance that a given amount of their federal tax money
is being used for health care rather than other programs or tax cuts. It would require that a
certain percentage of the revenue used to fund provincial and territorial health plans is collected on a
67
national tax base, thereby distributing the burden of financing Canada’s

“I don’t think many people most expensive social program. And it would automatically improve
accountability and transparency by allowing Canadians to clearly see
I talk to … know that CHST “where the money goes.” The time has come for the provinces to agree on
includes health care, post- a reasonable cash contribution by the federal government given the history
of the transfers, including the real and substantial contribution of tax
secondary education and social transfers. This reasonable cash contribution should also be stable and
predictable.
services.… Separating out health
care from the CHSTIn…concluding

would that the new federal transfer should be “all-cash,” the Commission carefully
be helpful for considered
accountabilityand rejected the idea of maintaining, or even expanding, tax point transfers. While a
tax transfer theoretically should provide stability and predictability (Rode and Rushton 2002), the
actual history
in health care [financing shouldof tax transfers for health indicates they are quickly ignored and discounted by the
jurisdictions that receive them. In addition, there is no guarantee that the revenue generated from
not be combined] in a federal
tax points will be used for health care. Finally, and most importantly however, tax point
transfers eliminate any possibility of the federal government facilitating future expansions of
funding omelet.”
medicare or helping to safeguard the fundamental principles underpinning the system. Ottawa’s
ability to act as a catalyst in protecting and extending the national dimensions of medicare is
PREMIER GARY DOER. PRESENTATION
AT WINNIPEG PUBLIC HEARING.
directly proportional to the size of its cash contribution to provincial expenditures (Maslove
1998).
The dedicated cash transfer should be directly written into a new Canada Health Act. This
would directly link the policy purposes of the Act with a stable funding mechanism in the same
way that transfer funding was part of the Medical Care Act. The new arrangement would replace
CHST contributions for health with an all-cash transfer.
What might be the agreed-upon cash floor of the proposed Canada Health Transfer? One
perspective is to accept the original 43% of the CHST notionally allocated to health when the
CHST was first introduced. As shown in Table 2.1, $8.14 billion would be extracted from the
current CHST, leaving approximately $10.16 billion cash in a future Canada Social Transfer.
The $8.14 billion includes the health cash increases agreed to by the provincial and territorial
governments as part of the First Ministers’ September 2000 accord (see Appendix E which
“An increase in the CHST is
sets out the manner in which the allocation was derived).
urgent to consolidate public
health services; opening up

The Senate Standing Committee on Social Affairs, Science and
negotiations on a new fiscal Technology in their final report (2002c), recently put forward a 62%
allocation based upon the federal Department of Finance’s most recent
sharing arrangement would lend
position that the CHST cash allocation for health should approximate the
a new dynamism to the relative share of current provincial spending for health care as a
percentage of all provincial spending for health care, post-secondary
federation.” education, social assistance and social services (including early childhood
C ONFƒDERATION DES SYNDICATS development). This would amount to an $11.35 billion cash floor using
NATIONAUX. P RESENTATION AT 2001/02 fiscal year calculations.
MONTREAL PUBLIC HEARING.
68
Table 2.1
Allocation Formulas for The Cash Base of Health and Social Transfers
Hypothetical Hypothetical
Canada Health Canada Social
Transfer Cash Value, Transfer Cash Value,
Allocation Formula Allocation Per Cent 2001/02 ($Billions) 2001/02 ($Billions)
Historic basis 43% $ 8.14 $10.16
Senate Committee 62% $11.35 $ 6.95
Source: Appendix E; Canada, Senate 2002c.
As Table 2.1 illustrates, however, the larger the cash floor for the proposed Canada Health
Transfer, the smaller the cash floor for the Canada Social Transfer, and if too small a cash
amount is left for post-secondary education, social assistance and social services, the result
might actually be detrimental to the health system in the long run. As noted in Chapter 1,
investments that improve the level of education and reduce income disparities can often have a
significant long-term impact on the health of the population, thereby ultimately reducing health
care costs. The clear danger in using the higher allocation is that it directly limits the cash
available to maintain these other programs. In addressing the apparent deficit in health funding,
that deficit should not be passed on to post-secondary education and social assistance. As a
result, the Commission has adopted a base health allocation for the cash value of federal
transfers of 43% of the current CHST cash contribution.
Using this allocation the cash value of the CHST contribution was $8.14 billion in 2001/02
and amounts to approximately 18.7% of current provincial-territorial expenditures on Canada
Health Act services. This is not enough. The Commission’s view is that, at a minimum, future
federal expenditures should be based on its past cash commitment of 25% of provincial-
territorial costs for services covered under the Canada Health Act.
Using the past fiscal year (2001/02) as the base line, achieving a 25% federal share would
have required a $10.87 billion federal contribution toward the estimated $43.48 billion worth of
provincial-territorial spending on current CHA services. Increasing federal funding
commitments to reach 25% would thus have required an additional $2.73 billion. By 2005/06
the value of CHST cash transfers for health are projected to be worth $8.82 billion or 16.7% of
provincial-territorial spending on Canada Health Act services. If provincial-territorial

expenditures climb to $53 billion (see Appendix E), a 25% federal share would mean a required
federal cash contribution of $13.19 billion by 2005/06.
As table 2.2 below indicates, moving to a 25% federal share by 2005/06 would require a
further investment of approximately $4.4 billion. This does not include, however, additional
investments by the provinces levered through new federal investments. Beyond these increases,
if the scope of eligible CHA services is expanded to include targeted home care services as well
as funding for a catastrophic drug transfer (as a type of extended health care service not yet
subject to all of the principles of the CHA, but as a candidate for full inclusion in the not-too-
distant future), the cash base will increase accordingly. Taking this into consideration, the
Commission believes that a minimum $6.5 billion federal contribution must be added into the
base by 2005/06 for a total cash base of $15.3 billion. 69
Table 2.2
Estimates of CHST Transfers and Required Additional Funding under
a Canada Health Transfer
Estimated Federal Share Canada Health

Provincial- of Provincial- Transfer – 25%
Territorial Territorial Federal Share
Hospital and Projected Hospital and of Hospital and Additional
Physician CHST Cash Physician Physician
Fiscal Expenditures Revenues
Year Expenditures Transfers Services Only Required
($Billions) ($Billions) ($Billions) ($Billions)

2001/02 $43.48 $8.14 18.7% $10.87 $2.73
2002/03 $45.52 $8.16 17.9% $11.38 $3.23
2003/04 $47.80 $8.41 17.6% $11.95 $3.54
2004/05 $50.24 $8.67 17.3% $12.56 $3.89
2005/06 $52.75 $8.82 16.7% $13.19 $4.37
Source: Appendix E.
This increased investment by the federal government is not only consistent with the original
medicare commitment, it is essential to protect, promote, and enhance the national dimensions of
public health care in Canada. The final recommendation is also consistent with a recent proposal
by Tom Kent (2002), one of the architects of medicare in the 1960s, who argued that such a
reinvestment would be a prerequisite to the federal government resuming a leadership role with
the provinces in shaping the future of medicare.
A core objective of any new transfer or any reinvestment of funds should be to create a
stable and predictable funding commitment for medicare in the future. In the Commission’s
view, increases to the transfer should be based on expenditure projections that are agreed upon
by both orders of government and forecast by a body that has the confidence of both. This cash
escalator should be expressed as absolute increases to the total transfer, and set out over a five-
year time horizon to provide predictability.
A preferable alternative to this approach may be a fixed escalator formula. Such a formula
could take into consideration not only the rate of growth in expenditures under the Canada
Health Act but growth in the economy. The escalator could be set at the rate of growth in
Canada’s economy (measured by a rolling five-year historic average of GDP) multiplied initially
by 1.25. The figure of 1.25 is based on the long-term trend (1960 to 2000) between growth in
total health expenditures relative to the growth of the Canadian economy as described in Chapter
1. The multiplier of 1.25 could be revised every five years to reflect more current data.
Some might argue that it would be preferable for any escalator to be set strictly at or below
the rate of economic growth. But as noted in Chapter 1, it has been the case for decades that the
more our income grows, the more of that income we choose to devote to health care, both as
individuals and collectively through our governments. This type of escalator would ensure that
the growth of the proposed Canada Health Transfer is tied to the rate of growth in the economy
in a realistic way.
70
The Covenant described earlier ensures that both orders of government agree on
fundamental principles and objectives. At the same time, however, governments will need to
agree on the changes that they are buying with their new investments both in terms of short-term
fixes to the system and, more importantly, long-term changes in direction. At this time, they
should also agree on the new cash basis of the proposed Canada Health Transfer and the
approach to its escalation over time. Failure to reach a formal agreement on these issues will
mean that the intergovernmental wrangling over who is paying what share for health will
continue into the future and this will mean that necessary health care reforms will continue to be
overshadowed by these debates. First Ministers in particular should be prepared to exercise the
requisite leadership that will establish the fundamental basis for medicare for the next 20 years.
Short-Term Funding Issues

A new Canada Health Act incorporating the proposed Canada Health Transfer may take
a year or two to prepare and pass. In the meantime, action must be taken. As a consequence, both
orders of government must commit to a common set of priorities. To facilitate this, the
Commission calls on the federal government to provide targeted, short-term funding for these
priorities. In turn, the provinces and territories must understand that this short-term federal
funding cannot be a “blank cheque” and must shape their health budgets in the immediate future
to reflect the agreed-upon priorities, matching or exceeding federal support for these priorities.
This will ensure that both orders of government are moving in the same direction as we chart a
course of reform and modernization of our health care system.
On a priority basis, targeted funding programs should be put in place to fix pressing
problems and gaps in the existing system (see Table 2.3). That includes a Rural and Remote
Access Fund as well as a Diagnostic Services Fund. The federal government should establish
these two funds as soon as possible, with $1.5 billion allocated to each fund. Funding should be
provided to the provinces and territories on a population health basis that takes into account the
size, demographics (including age and gender), and health of the population served.
Table 2.3
One Time Bridge Funding to the Canada Health Transfer ($Billions)
Cumulative Additional
Targeted Cash
2003/04 to Investment
2003/04 2004/05 2004/05 2005/06
Diagnostic Services 1.5 1.5
Rural and Remote Access 1.5 1.5
Primary Health Care Transfer 1.0 1.5 2.5 6.5
Home Care Transfer 1.0 1.0 2.0
Catastrophic Drug Transfer – 1.0 1.0
Total cash base for Canada Health Transfer 15.32
71
The Diagnostic Services Fund would allow provinces and territories to increase their
investment in advanced diagnostic services in order to improve access for their residents. Funds
could be used for purchasing this equipment as well as employing and training the necessary
personnel to operate and maintain this equipment.
The purpose of the Rural and Remote Access Fund would be to improve access in rural and
remote communities (see Chapter 7) by:
• addressing problems in the supply and distribution of health care providers;
• supporting expansion of innovative approaches to telehealth; and
• initiating broader, population-based demonstration projects.
In addition to these two targeted funds, an additional three transfers should be established to
jump-start major change in the system in the next two years. These transfers should be made
conditional on the provinces and territories using the funds for the three purposes described
below. Funds should be distributed to the provinces and territories on a per capita basis.
• Primary Health Care Transfer – This transfer should reflect the objectives and
framework presented in Chapter 5 and be used to spearhead primary health care change
on a large scale across Canada. The federal transfer should be set at $1 billion beginning
in 2003/04 with a further $0.5 billion invested in the following year. Provinces and
territories would be required to invest identical amounts in those years.
• Home Care Transfer – This transfer would support expansion of the Canada Health Act
to include targeted home care services and implementation of the recommendations set
out in Chapter 8. The federal investment in this transfer should be $1.0 billion annually,
beginning in 2003/04.
• Catastrophic Drug Transfer – This $1.0 billion transfer would cover 50% of the
provincial and territorial costs of their drug insurance plans above a pre-set threshold.
The transfer should begin in 2004/05 to allow sufficient time for planning and
negotiation. This new initiative is described in detail in Chapter 9, but its main purposes
are to offset the high cost of provincial and territorial drug plans and to provide the
provinces and territories with an incentive to expand their plans’ coverage.
The message from these targeted funds and transfers is clear. Additional funding cannot be
used simply to support or stabilize the status quo. New funding from the federal government
must, in effect, buy change – real and substantial change that reflects Canadians’ priorities,
addresses the most pressing needs, and sets the stage for ongoing and fundamental
transformation of Canada’s health care system.
What DSes this Mean fSr Canadians?

Canadians have said they want their health care system remodelled. They want it to meet
their needs today but more importantly, they want assurances that the system will be sustained
so that future generations of Canadians can share in the benefits of an efficient, high quality and
accessible health care system. To meet those expectations, we need to shore up the foundation
and make sure it reflects the changing nature of health and the health care system.
The recommendations in this chapter are the foundation for all other recommendations in
this report. First and foremost, they reaffirm and strengthen medicare with a shared vision for the
72
future. They mean all Canadians can look to a new Canadian Health Covenant as the
embodiment of their values and expectations for Canada’s health care system.
With a new Health Council of Canada in place, Canadians can expect to see strong
leadership across the country and collective efforts by governments and health providers to
improve health and health care.
Canadians will have better information about their health care system and the results that it
achieves. With this information, they will be able to hold their governments and those in the
health care system accountable for the results that are achieved and the progress that is made.
A renewed Canada Health Act with six solid principles will provide a strong foundation and
ensure that the health care system not only reflects Canadians’ values but also continues to
change and evolve to meet Canadians’ needs.
Consistent with recommendations in later sections of this report, targeted funding means
Canadians should begin to see almost immediate steps to improve access to diagnostic services,
home care, primary health care, and address access problems in rural and remote communities.
And it means all Canadians will be covered for the high cost of prescription drugs.
With co-operative actions by both federal and provincial-territorial governments, it means

the squabbles over who pays for what should be replaced by adequate, stable and predictable
funding over the longer term.
These are not vague promises that governments and health care providers can debate and
discuss in the years to come. Canadians have spoken. Now they expect to be heard. They expect
tangible proof that governments can and will work together to establish a new direction for
health care reflecting Canadians’ values and Canadians’ priorities. It is now up to the federal,
provincial and territorial governments to seize the opportunity, take action to put the necessary
agreements and funding in place, and show Canadians that they have every reason to be
confident about the future of their public health care system.
73
I NFORMATION,
EVIDENCE AND I DEAS

3
• Enable the establishment of personal electronic health records for each
Canadian, building on the work currently underway in provinces and
territories.
• Take clear steps to protect the privacy of Canadians’ personal health
information, including an amendment to the Criminal Code of Canada .
• Provide better health information to Canadians, health care providers,
researchers and policymakers – information they can use to guide their
decisions.
• Expand the scope, effectiveness and co-ordination of health technology
assessment across Canada.
• Create four research Centres for Health Innovation to address the gaps
in applied research in important areas of Canada’s health care system,
including rural and remote health, health human resources, health
promotion and pharmaceutical policy.
• Forge stronger linkages with researchers in other parts of the world and
with policymakers across the country.
The Case fWr Change

st
We repeatedly hear that the 21 century is the age of information and evidence – a time when
the keys to progress and success lie in our ability to innovate, to tap into new information and
evidence and transform ideas into exciting new developments, new services, and new solutions.
In health, information, evidence and ideas have the potential to unlock the cures to many of
today’s illnesses, identify the genetic source of chronic illnesses, give health care providers
access to the latest and best information on new treatments or drugs, improve the quality and
safety of care within the health care system, and most importantly, empower patients to manage
and maintain their own health.
Some might wonder why a chapter on information would figure so prominently and be
placed at the beginning of a report on the future of Canada’s health care system. The answer is 75
that leading-edge information, technology assessment and research are essential foundations for
all of the reforms outlined in subsequent chapters of this report. Furthermore, health research –
especially biomedical and scientific research – is an increasingly important component of
Canada’s knowledge economy and a source of high-skilled, well-paid employment for
thousands of Canadians.
To take full advantage of the potential of information, evidence and ideas in the health care
system, the necessary information infrastructure must be in place. This requires action on three
important fronts: putting essential information management and technology systems in place,
improving our ability to assess and manage the potential benefits of health care technologies,
and expanding our applied research capacity across the country.
These three aspects are clearly linked. Putting the information management and technology
infrastructure in place means that essential information can be collected, compiled and used to
make better decisions and improve quality and care within the system. Improving our ability to
assess new technology means that only the most effective new treatments, prescription drugs or
equipment would be purchased and used in Canada’s health care system. With better information
management and technology in place, researchers can assess the impact and value of different
treatments and approaches to delivering health care services in addition to developing and testing
new discoveries and cures. Together, these three “pieces of the puzzle” can create a 21 century
st
information and evidence infrastructure that will guide and inform the future of Canada’s health
care system, improve its efficiency, and most importantly, improve the health of Canadians.
Building Canada’s Health InfWrmatiWn

TechnWlWgy Infrastructure
R ECOMMENDATIO N 8:
A personal electronic health record for each Canadian that builds upon the work
currently underway in provinces and territories.
R ECOMMENDATIO N 9:
Canada Health Infoway should continue to take the lead on this initiative and be
responsible for developing a pan-Canadian electronic health record framework built
upon provincial systems, including ensuring the interoperability of current electronic
health information systems and addressing issues such as security standards and
harmonizing privacy policies.
R ECOMMENDATIO N 10:
Individual Canadians should have ownership over their personal health information,
ready access to their personal health records, clear protection of the privacy of their
health records, and better access to comprehensive and credible information about
health, health care and the health system.
R ECOMMENDATIO N 11:
Amendments should be made to the Criminal Code of Canada to protect Canadians’
privacy and to explicitly prevent the abuse or misuse of personal health information,
76
with violations in this area considered a criminal offense.
INFORMATION, EVIDENCE AND IDEAS
RECOMM ENDATIO N 12:

Canada Health Infoway should support health literacy by developing and maintaining
an electronic health information base to link Canadians to health information that is
properly researched, trustworthy and credible as well as support more widespread
efforts to promote good health.
Introducing Personal Electronic Health Records

Information technology has literally revolutionized the way information is collected, stored,
shared and used. It is one of the “four strong winds” forcing change in health care today (Decter
2000). Good information systems are essential to a high quality health care system. They allow
health care providers, managers and policymakers to share information and use the best
available evidence to guide their decisions. They can also forge a strong link between quality on
the one hand and accountability on the other.
Increased use of information technology in health care can also have important benefits for
patients. It can provide them with better access to their own health information as well as to
relevant health knowledge, which in turn allows them to play a more active role in maintaining
their health and making decisions about their medical care.
Provinces and territories, health regions, and health care providers understand and support
the need to make better, more effective use of information technology in addressing a number of
challenges in today’s health care system. Yet, despite this consensus, progress has been slow
and provincial and federal initiatives are being developed in isolation, despite the fact that the
costs of each government going it alone are very high. Initiatives in provinces are motivated by
different interests and objectives and it is not always clear if the projects are driven by
administrative priorities, commercial interests, or the interests of citizens. In addition, as
outlined in Chapter 7, there is much that remains to be done to provide rural and remote parts of
the country with the basic electronic infrastructure to facilitate developments such as telehealth.
Much of the focus in information technology applications in health care has been on
electronic health records. Why are electronic health records so important?

Electronic health records are one of the keys to modernizing Canada’s health system and
improving access and outcomes for Canadians. An electronic health record provides a
“collection of personal health information of a single individual, entered or accepted by health
care providers and stored electronically. The record may be made available at any time to
providers, who have been authorized by the individual, as a tool in the provision of health care
services” (HC 2001f). Data are entered on individuals’ personal health records every time they
visit their physician, have a prescription filled, have a lab test, or go to the hospital. The
electronic record provides a systematic, historic record of every interaction a person has with the
health care system.
Currently, much of the clinical and administrative information in the health system is
contained in files of paper records. In most cases, health care providers and their organizations
decide what information is relevant for their purposes and what form the information should
take. As a result, the current health record system can be described as an assortment of non-
standardized patient information stored in isolated patient records.
Paper records are increasingly becoming obsolete and inadequate. They limit the flow of
77
information, insufficiently document patient care, impede the integration of health care delivery,
create barriers to research, and limit the information available for administration and decision
making. They also limit Canadians’ ability to access their personal health records and use their
personal health information for making decisions about their own health and health care.
In contrast, electronic health records provide important advantages.
• Diagnoses, treatments and results can be improved when health care providers have
access to complete personal health information and can link that information to clinical
support tools. In a recent survey from the Canadian Medical Association, over 76% of
physicians agreed that improving how patient information is shared is an important or
very important potential benefit of electronic health records. Further, 68% agreed that the
use of electronic health records would result in improvements in clinical processes,
efficiency of workflow, and continuity of care. Almost 60% said that electronic health
records would improve the quality of care (Martin 2002).
• Accuracy of personal health records can be improved. With an electronic health record,
information from a variety of health care providers is collected and stored on a single
record, providing a more complete and more accurate record of an individual’s personal
health history.
• Efficiency can be improved. As one health region described it, roughly 30% of nursing
time is spent managing paper records. Just a 5% reduction in the time nurses spend doing
charts could free up the equivalent of 90 nursing positions and generate $5 million a year
in savings. They also point to potential efficiencies in managing chronic diseases by
targeting efforts to expand electronic health records at the primary health care level
(Calgary Health Region 2002a and 2002b).
• Electronic health records provide aggregate data that can be used in health research and
in health surveillance, tracking disease trends and monitoring the health status of
Canadians.
• Security can be improved. From the point of guaranteeing necessary access to health
records, precautions need to be put in place to ensure that electronic health records do not
become an obstacle when accessing health services. Necessary safeguards must be in place
to ensure that a network crash never serves as an obstacle to obtaining necessary care.
Furthermore, electronic health records bring together a host of health records that were
previously physically dispersed into a new comprehensive format. This change will have
important implications in terms of the physical security of personal health information.
“A jewel in our crown is our
electronic medical record

With a complete system of electronic health records in place, there are
system … We believe the M-R some important benefits for individual Canadians, for health care
providers, researchers and the system as a whole.
[Medical Record] is the key tool
Individual Canadians would have secure on-line access to their
in improving health outcomes for personal electronic health records. One potential scenario could involve the
our patients … and it saves
development of a Web site to access personal electronic health records
similar to on-line banking, where individuals could log onto the system
time and money.” using a personal identification number. At the click of a mouse, they would
have access not only to their personal health information but also to a
GROUP HEALTH CENTRE
S A U L T S T E . M A R I E . P RESENTATION AT
broader base of general information on health issues. With this information,
SUDBURY PUBLIC HEARING. individuals can play a more direct role in managing their own health.
78
Health care providers would have access to clinical decision support tools to assist them in
making decisions based on the best available evidence. Health care providers would be able to
access patient records at the point of a clinical encounter. It would help manage the massive
amounts of complex health information and ensure that health care providers have complete and
accurate information about patients’ health and health care histories. It also
would improve physicians’ ability to access the latest information, select

“There is no national,
the best course of action, and use evidence to guide their decisions.
Researchers and policymakers would have access to aggregate data interprovincial or cross-
compiled through the electronic health record system. These data could be
jurisdictional coordinating body to
extracted generically for health research purposes, without being linked to
any individual electronic health record. The Commission understands that ensure health practitioners have
researchers would, in many cases, prefer to have access to “person-
oriented” health information to allow them to track certain illnesses or cost effective and universal
health-related factors over time. Only when there are sufficient safeguards access to the best patient care
in place and the system has demonstrated its ability to protect the privacy
of individuals, should researchers have access to “person-oriented” data. and health research information.”
This information could be used to monitor and measure outcomes and
CANADIAN HEALTH LIBRARIES
allow increased health surveillance in the management and treatment of A S S O C I A T I O N 2001.
particular diseases, especially for patients with chronic illnesses. W RITTEN SUBMISSION .
Finally, the overall quality of the health care system can be improved. The electronic health
record system would enhance the ability of health care managers and researchers to identify and
respond to medical errors or problems that occur in the health care system, and improve patient
safety and quality of care. Currently, problems in the health care system related to patient safety
are not well monitored or identified for a host of reasons including the lack of information
technology to monitor and track errors and also the fear of blame and litigation.
A Leadership Role for Canada Health Infoway

Clearly, the benefits of electronic health records are substantial for Canadians, for health
care providers and managers, and for governments. While a number of electronic health record
initiatives are underway across the country, progress on the major provincial initiatives has been
slow and costs have been high. Greater collaboration among governments could both speed up
development and save costs for all Canadians.
Some intergovernmental co-ordination has occurred under the intergovernmental Advisory

Committee on Health Infostructure (ACHI). In December 2000, ACHI released a Blueprint and
Tactical Plan for a pan-Canadian Health Infostructure identifying the following three priorities
(HC 2000):
• developing an electronic health record system;
• developing integrated provider solutions, including clinical decision support tools and
ultimately an electronic provider portal; and
• providing relevant, credible and timely health information to the public to empower
individuals to manage their own health through a Canadian Health Network and self-care
and telecare services.
Following from the First Ministers’ Agreement in September 2000, the federal government
invested $500 million into Canada Health Infoway. Infoway is an independent, non-profit 79
corporation with responsibility for accelerating the development and adoption of modern
systems of information technology with the aim of providing better health care. Infoway is
currently attempting to build on existing initiatives and pursue collaborative relationships with
the provinces and with the Advisory Committee on Health Infostructure. The Commission
believes that, with continuing diligence, Infoway’s funding can go a long way in supporting the
necessary ongoing efforts to create a national electronic record system. Further funding, if
necessary, should come only after discussion by the federal, provincial and territorial health
ministers.
Given its mandate, Infoway is uniquely poised to provide overall leadership and to act as a
catalyst in moving forward on essential information management and technology initiatives. This
work will require ongoing support from provincial, territorial and federal governments to ensure
that decisive and timely action can be taken to put the necessary systems and networks in place.
There is wide consensus in the health care system that electronic health care records are essential
to future improvements in the system and in the quality of care. Deliberate action is needed on an
urgent basis to put the necessary systems in place and begin to see some tangible and concrete
progress. The proposed Health Council of Canada should conduct an assessment of Infoway’s
progress in this area in two years’ time and provide its findings and future recommendations in a
public report to Canadians and health ministers.
Empowering Canadians and Protecting Their Privacy

Moving to an electronic health records system provides important benefits to Canadians,
particularly in terms of giving them ready access not only to their own personal health care
information but also to a wealth of trusted, credible information on a variety of health topics.
At the same time, many Canadians worry that their personal health information could be
abused or misused. Issues surrounding protection of privacy are serious and complex. On the one
hand, Canadians need a strong assurance that their personal health information is used only by
those who need it and only under certain circumstances. The Privacy Commissioner of Canada
notes that there are privacy risks whenever personally identifiable information is stored
electronically. Therefore, rules need to be in place to ensure that personal health information is
carefully safeguarded. Most often, those rules focus on requiring individuals’ consent before their
personal information is accessed and shared. On the other hand, health care providers need access
to personal
“We are still very health information in order to provide the best possible care to patients, to guide their
concerned,
decisions, and ensure that they have a complete picture of an individual’s health needs. Privacy
rules
obviously, about haveofto strike the right balance between strict privacy protection procedures and the
privacy
legitimate and important need for health care providers to access personal health information,
information and personal health
often on an urgent or emergency basis.
information; but in order for the
system to function as efficiently
as possible … there needs to be
access and a flow through Consistent and clear privacy rules should be in place across the
country. With the aim of protecting individual health information to the
of the information.”
greatest extent possible, amendments should be made to the Criminal
C O N S U M E R S ’ A SSOCIATION OF
Code to make abuse or misuse of personal health information a criminal
C A N A D A . P RESENTATION AT
TORONTO PUBLIC HEARING. offense. Specifically, it should be a criminal offense for anyone to acquire,
80 use or share another person’s personal health information for purposes
that do not explicitly relate to the management of the health of the person to which the records
relate. These amendments should also prohibit authorized users of the information from utilizing
it for purposes other than this intent without the consent of the patient.
Expanding Health Literacy

Another important benefit to Canadians lies in the potential for the electronic health record
system to go beyond just a record system to provide comprehensive health information.
Increasingly, Canadians are turning to the Internet as a source of health
information. Roughly half of the people who use the Internet use it to search
for health-related information (Statistics Canada 2001d). Despite concerns “We need to do more than
that specific health information is difficult to access and may not be
disseminate reliable nutritional
credible, the majority agreed that the Internet, as a health resource tool, has
made them more knowledgeable about their health and health-related issues. information, we must also
To provide Canadians with the necessary tools and information about motivate Canadians to use
health and health issues, a multi-layered approach is needed – one that
that information.”
addresses not only how health information is packaged but also how it is
accessed, interpreted and used (Jadad 1999). Specifically, Canadians need: D IETICIANS OF N EWFOUNDLAND AND
• L A B R A D O R . P RESENTATION AT
comprehensive and integrated pools of credible information that ST. JOHN’S PUBLIC HEARING.
are presented in intellectually appealing and user-friendly formats;

• timely access to relevant and credible health information;
• optimal skills to process and understand the relevance of health information; and
• receptive environments where they are able to use information as part of decisions they
make about their health and health care.
Looking at the various Web sites of health information available today, it is obvious that the
public sector has played a limited role in providing health information to the public (HC 2001f).
In contrast, the private sector, in the United States in particular, has flooded the Internet with
electronic health information. Unfortunately, the credibility of this information is uncertain since
much of it is posted and sponsored by particular commercial enterprises.
To date, a primary source of electronic health information for

Canadians has been the Canadian Health Network. The network currently
provides 12,000 e-based English and French language health resources on “Canadians strongly value and
26 health topics ranging from health promotion and ways of staying
healthy to specific illnesses such as cancer. These resources reach beyond endorse individual responsibility
Canadian sites and material to include relevant international material. In
and accountability and want
addition, the network provides links to discussion groups on various topics
and offers users a guide for evaluating the quality and reliability of other information that will help them to
health information available on the Internet.
make educated life choices. They
Infoway should play a key role in promoting health literacy as it also believe that governments are
relates to the development of an electronic health record system by responsible for providing them
opening the door to a vast amount of trusted, credible health information
for Canadians. It should build on work already done by the Canadian with the information they need.”
Health Network and establish linkages to other reliable sources of FPT M I N I S T E R S R ESPONSIBLE FOR
P H Y S I C A L A C T I V I T Y 2001.
electronic health information. The Network could serve as the foundation W RITTEN SUBMISSION .
for the development of a comprehensive health information Web site with 81
links to a number of credible national and international Web sites. Infoway should also work
with the Canadian Institutes of Health Research to build up an electronic health information
evidence base and link it into current electronic health record developments. Linkages should be
made with existing health information sources at the provincial, territorial and regional levels,
particularly in the area of prevention and promotion.
The following vignettes provide examples of how access to personal health records,
combined with trusted sources of health information, can benefit individual Canadians.
A young woman learns from her doctor that she is pregnant for the first time. Her physician gives her
some good information about the things she needs to do to make sure she has a healthy pregnancy,
including taking vitamins, watching her diet, exercising regularly, and avoiding alcohol. She has heard
about several risk factors and wants to do as much as she can to avoid them. So she goes on the Internet,
enters her personal identification number, and has access to important facts from her personal health
history. She knows, for example, that a family history of diabetes might have an impact. She connects to
the health information side of the system and finds a wealth of reliable information about pregnancy and
diabetes, including the signs to watch for. She makes a list of some questions she wants to ask her doctor
at her next visit. She also finds links to other information and resources available in her community.
An elderly couple has led an active and independent life, but recently, the husband has been
showing persistent signs of forgetfulness and disorientation. The doctor confirms it is the early signs of
Alzheimer’s disease. Faced with this devastating news, they decide to learn as much as they can so they
can be well prepared for what is to come. They contact a local branch of the Alzheimer’s Society and
learn the latest and most accurate information is available through the electronic health records system.
They go to the local library and are able to access the information using the husband’s personal
identification number. Although the computer is in the library, they can use it in confidence because the
system protects their privacy. They find a lot of helpful information. They also get information on
personal directives and living wills that allows them to discuss the options and make decisions along with their children.
A 12-year-old boy has been diagnosed with juvenile diabetes. He needs to track his insulin levels and
other information about how he is feeling through the day and provide that information to the health
management team that is monitoring his care. With that information, they can regulate his dosage of
insulin, his diet, his activity levels, and help manage his care. The boy uses a mobile device like a Palm
pilot. He feeds information into the Palm pilot during the day, and at night, he hooks it up to his home
computer, types in his personal identification number, and sends it to the health management team.
During regular meetings, he and his parents go over the information with the health management team.
He and his parents can also use his personal identification number to access information about juvenile
diabetes, especially research that is underway to find a cure.
82
Streamlining and ImprWving Health

TechnWlWgy Assessment in Canada
RECOMM E NDAT ION 13:
The Health Council of Canada should take action to streamline technology assessment
in Canada, increase the effectiveness, efficiency and scope of technology assessment,
and enhance the use of this assessment in guiding decisions.
The Growing Importance of Health Technology Assessment

Advances in health technology have tremendous potential for changing the organization and
delivery of health care services and improving health outcomes for Canadians, but they come at
a price. More varied and sophisticated equipment and products come onto the market on an
almost daily basis. In making decisions about whether to purchase and use these new
technologies, health care managers and decision makers must rely on the best available
assessment of the impact, benefits and effectiveness of new technologies on health care and
health outcomes.
Health technology assessment is a comprehensive and systematic assessment of the

conditions for and the consequences of using health care technology. It provides relevant
information to managers, decision makers, and health care providers on the safety, economic
efficiency, clinical effectiveness, as well as the social, legal and ethical implications of using
new and existing technologies. Indeed, health technology assessment should be about what is
best for the patient – medically and economically – and not about technology for technology’s
sake. The assessment is intended to help health policymakers, providers, and especially, health
organization managers make decisions about whether to purchase and use new technologies,
whether to replace old technologies with new ones, and what benefits they can expect to see.
With continuing innovations in technology and mounting cost pressures, the need for
careful technology assessment will become even more acute. Suggestions have been made that,
with rapidly expanding and changing knowledge and new technologies and treatments, health
care providers have trouble keeping up with the knowledge being generated (Davenport and
Glaser 2002). The best way to enhance their use of information is to “make the knowledge so
readily accessible that it can’t be avoided” (Davenport and Glaser 2002, 108).
In a similar vein, Morgan and Hurley (2002a) suggest that the inflationary pressures
associated with health care technologies could be better controlled through policies that
influence decisions made by health care providers in their clinical encounters with patients. In
other words, for health care providers to use technology effectively, they need accurate and
relevant information and the right incentives for its use when they are dealing directly with
patients.
New health care technologies also have the potential to raise serious social and ethical
considerations, particularly in areas such as biotechnology where issues such as cloning,
eugenics or new genetic and reproductive technologies pose troubling and complex questions
that go well beyond science or medicine. Accordingly, suggestions have been made that
processes for technology assessment need to be transparent, accountable and allow for
meaningful input from Canadian citizens (Lehoux 2002).
83
Provinces, territories and the federal government understand the importance of carefully
assessing health care technology before it is implemented or used in the health care system. This
assessment is critical to ensure the safety and effectiveness of the technology and also to get the
best value and clear improvements in health outcomes for a substantial investment in new
technology.
At the provincial level, several provinces have established health technology assessment
agencies to provide policy advice and to guide decisions on health technology. These provincial
bodies have built a strong reputation for effective work, but they face two challenges: first, they
have limited assessment capacity (in both financial and human resources) and second, their
efforts to disseminate their assessments along with clinical practice guidelines and care protocols
are insufficient (Lehoux 2002). Consequently, there is a significant gap between the work of
these assessment agencies and the decision makers and planners making decisions on the uptake
of new and existing technology.
The provinces, territories and the federal government have also worked together to establish
and fund the Canadian Coordinating Office for Health Technology Assessment (CCOHTA).
CCOHTA’s role is to co-ordinate health technology assessment across the country, to facilitate
information exchange, pool resources, co-ordinate priorities for health technology assessments,
minimize duplication as well as conduct its own technology assessments in areas where gaps
exist. Despite its extensive mandate, several reports and studies have pointed to the need to
strengthen CCOHTA’s co-ordinating role (McDaid 2000; HC 1999a; Battista et al. 1995). As set
out in Chapter 2, this can be achieved by having the Health Council of Canada assume the
current responsibilities of CCOHTA.
Overall, there are a number of obstacles that prevent maximum utilization of health
technologies and their assessments in Canada.
• Not enough attention is paid to identifying and setting priorities for assessing emerging
health technologies. In particular, there is a need for a cross-country early warning
system to support future development and diffusion of new health technologies.
• The overall level and scope of health technology assessment has been limited compared
with other OECD countries. For example, there currently is no formal process for
evaluating all telehealth applications and there has been only minimal technology
assessment of PET (positron emission tomography) scanners, in spite of the fact the
equipment has been in use in Canada for over 20 years.
• Health technology assessments are often not sufficiently comprehensive, either because
they fail to fully consider the social, legal and ethical implications of the use of health
technologies, or because they fail to provide sufficiently detailed economic evaluations.
This may explain, in part, why health technology assessments have, so far, had a marginal
impact on resource allocation decisions. Assessment agencies have also had limited
contact with decision makers, planners and health care providers, and decision makers and
planners have not made effective use of the assessment materials provided to them.
• There is a lack of relevant research on the relationship between health technologies and
overall improvements in health outcomes. Decisions about purchasing new technology
are too frequently made without knowing the impact of that technology on addressing
population health needs.
84
• Decisions regarding the uptake and diffusion of technologies are primarily taken at the
provincial, territorial, regional health authority or individual hospital or health program
level with only limited co-ordination across or within jurisdictions.
Expanding Health Technology Assessment in Canada

The proposed Health Council of Canada should have a two-fold mandate in the area of
health technology assessment. First, it should increase the overall technology assessment
capacity in Canada. Second, with CCOHTA being folded into the Council, it will be able to
continue to share assessment information among jurisdictions. Clear linkages should be
developed between the Health Council of Canada and the current work being conducted at the
intergovernmental level in setting up shared sites of excellence for low volume surgeries such as
pediatric cardiac surgery and gamma knife neurosurgery (FMM 2002).
Given finite resources in the health care system, the Council should facilitate
intergovernmental collaboration in the development, co-ordination and implementation of a
health technology strategy to guide more efficient financing, management and utilization of
technologies within the Canadian health system, with a long-term goal of assessing all health
technologies in use across the country. This strategy would:
• Establish a framework for the overall management of technologies within the health
system, with priority on assessing health technologies that impact rural and remote health
delivery (e.g., telehealth applications) and primary health care change;
• Explore the possibility of harmonizing financing for the acquisition, upgrading and
maintenance of high-cost technologies such as diagnostic imaging technology, including
MRI (magnetic resonance imaging) and CT (computed tomography) scanners;
• Develop a targeted plan for the adoption of specialized technologies that takes into
account specific population needs, the availability of health human resources and the
necessary infrastructure to support these given technologies;
• Address current gaps in our knowledge about the clinical benefits and cost-effectiveness
of health technologies as well as the added value of improving health outcomes for
Canadians in general and for people with certain diseases;
• Support the development of clinical practice guidelines based on evidence derived from
health technology assessments either at the national or interprovincial level; and
• Strengthen training programs and ensure a stable health human resources supply to
manage and appropriately use health technology. (This links with the Council’s overall
work on health human resources as set out in the following chapter.)
Increased health technology assessment should serve as a driving force to encourage the
adoption and implementation of appropriate health technologies. It should ensure that provinces
and territories are keeping pace in adopting new technologies and that health professionals and
decision makers use technology assessments to guide their decisions. In future, the Health
Council may want to consider ways of seeking input from Canadians on issues where new health
technologies have significant ethical, moral or social implications.
85
Building Canada’s Health Research

KnWwledge Base
RECO MMENDATIO N 14:
Steps should be taken to bridge current knowledge gaps in applied policy areas,
including rural and remote health, health human resources, health promotion, and
pharmaceutical policy.
Canada’s health research infrastructure consists of a rich and diverse network of individual
scientists, academics and organizations. This research is conducted by individual university-based
scientists and researchers whether working alone, in groups or networks, in research and scientific
institutes, and perhaps most importantly, in teaching hospitals across the country. Funding for this
research comes from federal and provincial arm’s length granting bodies, from private sector
companies such as the pharmaceutical industry, and from non-governmental agencies such as the
Canadian Cancer Foundation and the Heart and Stroke Foundation that fund research on specific
diseases. The vast majority of this research, and the funding for it, are dedicated to biomedical
and scientific research aimed at disease prevention, treatment and analysis. Canada has a long
tradition in excellence in clinical research. From the historical achievements of Banting and Best
in discovering insulin to modern research on genetics, Canada has an impressive community of
dedicated clinical researchers. In 1997, the $36 billion life sciences industry in Canada accounted
for 86,000 jobs and is expected to grow to 130,000 jobs by 2003.
On the whole, Canada has seen an increase in health-related research and development
expenditures since the early 1990s (see Figure 3.1). Federal funding for health research and
development has risen from $255 million in 1988 to $674 million in 2001 (Statistics Canada
2001a).
Figure 3.1
Distribution of $2,500
Health-related Educational sector Private (business and non-profit)
$2,000 Federal government Provincial government
R & D Expenditures
in Canada
$1,500
($Millions), by
Source of Funds,
1988 to 2001 $1,000
$500
$-
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
Source: Statistics Canada 2001a.
86
In 2000, the federal government established the Canadian Institutes of Health Research
(CIHR) with the primary objective of strengthening and integrating the health research
infrastructure in Canada. CIHR is comprised of 13 organizations that support and link over
6,000 researchers across disciplines, sectors and regions. These organizations and researchers
address issues ranging from biomedical and scientific research into cancer, genetics and diabetes
to Aboriginal health, gender and health policy.
Taking the Next Steps to Expand Our Knowledge Base

Health research has played an essential role in the history of the public health system and
will continue to do so in the future. With the variety of different funding agencies and bodies in
place across the country, there are sufficient resources for institutes and their partners to conduct
necessary research and evaluations, and disseminate results. In spite of this, there are a number
of important problems and challenges within the health care system that currently receive
insufficient attention within the scientific community, among governments and health
researchers. On several occasions, the Commission was struck by the minimal amount of
information available on issues as vital as rural and remote health and health care delivery, or
interprofessional collaboration in primary health care settings. Health research challenges in
these and other applied research areas require immediate attention and an associated investment
of resources, both human and financial.
To this end, the Commission recommends that four Centres for

Health Innovation for applied policy research should be created as soon as “The biggest risk to public
possible by the Canadian Institutes of Health Research. The federal
government has increased CIHR funding substantially in recent years and medicare in Canada is, in fact,
appears sympathetic to CIHR’s desire to see that funding rise to $1 billion the risk of failing to innovate.”
per year in the next few years. The Commission supports this direction. If
this occurs, the CIHR should consider setting aside $20 million to fund DAVID MCKINNON, ONTARIO
the proposed Centres for Health Innovation, at a modest cost of $5 million for HOSPITAL ASSOCIATION.
SUSTAINABILITY POLICY DIALOGUE.
each centre per year. This cost is based upon the existing costs of the
current policy-related institutes of the CIHR. The following four centres should be established: •
Rural and remote health issues – The CIHR has already committed $5.2 million and
the federal government has committed $1 million to research related to challenges faced
by rural and remote communities. However, research to date has been conducted on a
piecemeal basis. Rural health researchers have tended to work in relative isolation, just
like the people and communities they study. A rural health agenda should be developed
to address issues like health conditions and determinants, healthy behaviours, delivery
and organization of services, and health status of people living in rural, remote and
northern communities.
• Interprofessional collaboration and learning – Despite increasing calls for

interprofessional collaboration, particularly in relation to primary health care, there is
limited research on effective ways of implementing new mixes of skills and providers in
health care delivery settings. New work environments and new divisions of labour call
for new approaches to collaboration among health care providers in order to maximize
the use of the health workforce. There also is limited information about the health care
workplace in terms of its organization, planning, the nature of group practice, payment
87
mechanisms and incentives, and professional responsibility. A Centre for Health

Innovation on interprofessional collaboration could go a long way in developing and
disseminating best practices in the area of interprofessional collaboration to support
primary health care.
• Health promotion – Despite numerous studies highlighting the merits of wellness and
prevention in improving the health of individuals, organizations have yet to devote
sufficient resources to make health promotion a priority. A centre for health innovation
focusing on health promotion would support the development of programs aimed at
improving individuals’ physical and mental health as well as targeting prevention efforts
and services in the Canadian population.
• Pharmaceutical policy – Greater emphasis needs to be placed on pharmaceutical policy

research in order to support integration of prescription drugs into the health care system.
Independent pharmaceutical policy research would help ensure that Canadians are
getting the best value for their investment in drugs. A new Centre for Innovation on
Pharmaceutical Policy would serve as a vehicle for evaluating pharmaceutical policy,
disseminating best practices, and providing objective and reliable knowledge to the
Canadian public. While pharmaceutical companies would continue to do their own
research and development activities, the Centre for Health Innovation on pharmaceutical
policy would ensure that policy-oriented research is as free from commercial influence as
possible. The Centre could also play an important role in issues related to ethics,
particularly in the relationship between the pharmaceutical industry and ongoing
pharmaceutical research.
As suggested by the CIHR, these Centres for Health Innovation

should be established with a mandate to “engage government, industry,
community groups, health charities and others to foster and disseminate a
“Research is essential to a culture of innovation and evidence-based decision-making across the
cost-effective, innovative and health care system” (CIHR 2002, 20). CIHR would be responsible for the
establishment, oversight and evaluation of the performance of these new
sustainable health care system.” centres. The Centres for Health Innovation should also be closely linked to
C A N A D I A N I NSTITUTES OF
the ongoing work of the Health Council of Canada, particularly in relation
H E A L T H R E S E A R C H 2002.
to its role in providing regular reports to Canadians on the performance of
W RITTEN SUBMISSION . the public health care system.
Once these initial Centres for Health Innovation have been established and have
demonstrated their effectiveness in encouraging and supporting both research and innovation in
key areas, consideration should be given to establishing future centres in the following areas:
• patient safety
• mental health
• telehealth
• genomics and proteomics
• chronic disease management
88
Forging Better Linkages

The primary value of these centres would be to inform and guide policy decisions.
Unfortunately, current structures and mechanisms within the health care system do not promote
this kind of linkage (Lomas 2000). The proposed Centres for Health Innovation will help to
bridge that gap in certain areas. In addition, there is a need for a more global approach to
establishing and maintaining linkages between researchers and policymakers. One way of doing
this is to encourage secondments of individuals to “work in each other’s world.” In this way,
researchers would gain experience in the policy environment and policymakers would gain a
better understanding of the research domain. Over the longer term, these secondments will help
to ensure more effective dissemination of research and analysis and its use in guiding health
policy decisions. The Canadian Health Services Research Foundation should be tasked with this
initiative.
Another important linkage is with research initiatives around the world. While much of our
focus is and should be on health and health care issues here in Canada, many of the issues we
face today are also faced by countries around the world. Much of what we hear on the research
front comes from studies in the United States. But the fact is, Canada’s health care system has
more in common with health care systems in European Union countries, Australia or New
Zealand. This sets us apart from other countries in North and South America and highlights the
need for us to look more carefully at work being done abroad. CIHR should be responsible for
establishing deeper linkages between Canadian research efforts and research efforts and results
in other countries around the world. In particular, linkages should be formed with the World
Health Organization, the European Observatory, and research organizations in the European
Union, Australia and New Zealand.
What DWes This Mean fWr Canadians?

Canadians understand the importance of knowledge and ideas in developing new solutions.
They understand the need to harness the combined potential of knowledge, information and
technology to improve health and health care for patients, permit better evidence-based decision
making to support citizens, health care providers, policymakers and managers, and find new
treatments and cures.
With the recommendations in this report, Canadians can expect:

2 st information and evidence infrastructure that is responsive, adaptable, and sustainable over the long term and meets
•A
1century
Ca
na
da’s health care system;
• More accessible access to information and analysis on the performance of the health care
system and the health of Canadians;
• Better access to personal health information as well as access to a wealth of trusted and
reliable health information to make informed choices about their own health;
• Clear rules for protecting the privacy and security of their health information;
• Assurance that their health care providers have access to complete information about
their health as well as the latest information on health treatments, protocols and
guidelines; and
89
• Access to the best and most appropriate health care technology combined with assurance
that new technology has been carefully assessed.
With the necessary investment and infrastructure, Canada can tap the full potential of
research, knowledge and technology. This comprehensive strategy will put Canada at the
forefront and ensure that we continue to develop, explore, and implement new ideas and new
technology to improve Canadians’ health and the health care system.
90
I NVESTING IN
H EALTH CARE PROVIDERS

4
• Address the need to change the scopes and patterns of practice of health
care providers to reflect changes in how health care services are
delivered, particularly through new approaches to primary health care.
• Take steps to ensure that rural and remote communities have an
appropriate mix of skilled health care providers to meet their health
care needs.
• Substantially improve the base of information about Canada’s health
workforce through concerted actions by the Health Council of Canada to
collect, analyze and provide regular reports on critical issues including
the recruitment, distribution, and remuneration of health care providers.
• Review current education and training programs for health care
providers to focus more on integrated approaches for preparing health
care teams.
• Establish strategies for addressing the supply, distribution, education,
training, and changing skills and patterns of practice for Canada’s
health workforce.
The Case f?r Change

The health care system is fundamentally about people. Its focus is on people. Every aspect
of the health care system is driven by, and dependent on, people, from an anxious mother talking
with a nurse to the heroic efforts of emergency staff. Health care is a cutting edge industry with
highly trained and skilled people – people with years of training and experience, and people who
care deeply about the future of the health care system.
For the past two decades, continuing changes in how health care services are delivered
combined with efforts to contain costs in every province and territory have taken their toll on
Canada’s health workforce. Although the problems differ for different health care providers, the
malaise is widespread and, in some cases, it has moved from mere discontent to outright anger
and frustration. Canadians are confronted with these problems on a regular basis both in their
interactions with the health care system and through regular media reports of the latest “crisis” in
91
health care.
Across Canada, every province and territory is looking for the most effective ways to
address the challenge of training, recruiting and retaining health care providers, and encouraging
them to practice in rural and remote communities. Competition between provinces and territories
is intense and, in many ways, counterproductive. While much of the focus is on immediate and
looming shortages of some health care providers, especially nurses, the deeper and more
complex issues relate to their changing roles, the need to re-examine traditional scopes of
practice, and the challenge of getting the right mix of skills from an integrated team of health
care providers to deliver the comprehensive approaches to health care that Canadians expect.
The solutions to these issues are not easy nor can they be achieved overnight. Targeted
funds in the proposed Rural and Remote Access Fund and the Diagnostic Services Fund should
be used to fast-track action in addressing pressing problems in rural and remote communities
and, ultimately, increase the supply of technicians and specialists to provide diagnostic services
and improve Canadians’ access to these important tests. The Primary Health Care Transfer and
the Home Care Transfer must be an investment in change – using the stimulus of these targeted
funds to address important issues related to changing scopes of practice and the emerging role of
new members of the health care team. The proposed Health Council of Canada should play a
leading role in substantially improving our base of information and understanding about
Canada’s health workforce. It should also review the way health care providers are educated and
trained. In the longer term, the Health Council should play an important role in helping to plan
for the future of Canada’s health workforce by examining trends in their roles, scopes and
patterns of practice, education, training, and remuneration.
Addressing these issues will take willingness on the part of all parties to set aside old
grievances and entrenched positions, and begin to trust one another again. Health care providers
and their organizations must be called upon to embrace far-reaching changes in the health
workplace, some of which may change the nature of their work and especially their relationships
with other health care providers. Provinces and territories must be willing to set aside their
competition for health care workers and instead be prepared to work together on comprehensive
strategies across the country. Sensitive issues such as wage settlements, scopes of practice, and
working conditions must be addressed in an open and direct way.
It is only through concerted, collaborative and decisive action across the country that we
will be able to address the pressing problems of today and ensure an adequate, productive, and
positive workforce for the future.
The Current Situati?n f?r

Canada’s Health W?rkf?rce
Across Canada, there were over 1.5 million people working in health care and social
services in 2000. Nurses (including registered nurses, licensed practical nurses, and registered
psychiatric nurses) made up 35% of the health workforce while physicians made up 8%. The
remaining 57% included a range of health care providers such as chiropractors, medical
radiation technologists, social workers, and home care workers (CIHI 2001b). The supply, mix
and distribution, and how these various health care providers work together are different in
different workplaces, communities, provinces, and territories.
92
INVESTING IN HEALTH CARE PROVIDERS
For Canadians, much of the concern relates to real and perceived shortages for certain
health care providers. This is a particular concern for nurses because their numbers have dropped
in recent years. Between 1991 and 2000, in effect, there was an 8% drop in the number of
registered nurses per 100,000 people and a 21% drop in the number of licensed practical nurses.
The decrease in licensed practical nurses is substantial in comparison with other health
professions whose supply has increased (Table 4.1).
For nurses and doctors, there are four related issues of concern in the current system: •
Supply and distribution – Whether the problems experienced by communities in
attracting and retaining health care providers are one of supply or distribution is really a
matter of perspective. For people in a rural community that cannot attract a general
practitioner, the problem is one of supply (i.e., they see a shortage of doctors as the
problem). From a province-wide or national basis, however, the problem is more one of
distribution of physicians (i.e., there may be enough doctors overall but not in certain
rural and remote and inner city communities). Canada has fewer nurses today than it did
a decade ago and this is also negatively affecting some communities.
• Skills and roles – There has been considerable discussion of the changing skills and roles
of nurses and doctors (and other health providers as well) in terms of what they are
trained to do as part of their professional roles. Nurse practitioners, for example, are
trained to provide some health services that used to be the exclusive responsibility of
physicians. Despite much rhetoric about interprofessional co-operation, in reality, the
professions tend to protect their scopes of practice. Each profession appears willing to
take on more responsibilities, but is unwilling to relinquish some duties to other professions.
Table 4.1
Percentage Change in the Number of Selected Health Professionals
(Number per 100,000 People), 1991 to 2000
1991 2000 Percent Change

Registered nurses 820 753 -8
Licensed practical nurses 298 236 -21
Physicians 187 187 0
Pharmacists 70 79 13
Dentists 51 56 9
Physiotherapists 38 46 21
Psychologists 34 43 25
Dental hygienists 34 48 42
Chiropractors 13 18 36
Optometrists 10 11 14
Note: Registered nurses (RNs) include the number of RNs employed in nursing, full-time and part-time, and all nurses who are involved
in direct patient care as well as administration, teaching and research. Licensed practical nurses include all registrants regardless of
activity or employment status. Physicians include those involved in clinical and non-clinical practice but exclude interns and residents.
Chiropractors include regular members, new graduates and special members.
Source: CIHI 2002d, 2001c.
93
• Patterns of practice and professional autonomy – Patterns of practice refer to how

health care providers deliver services within their workplace. For nurses, their pattern of
practice has changed, but they have had little control over those changes. Fewer nursing
administrators and less administrative support have resulted in an increased burden for
nurses, leaving less time for direct care. Nurses have also been shifted in and out of their
areas of expertise, from emergency rooms and intensive care to pediatrics and geriatrics,
and from practice in teams in hospitals to individual practice in home care. For
physicians, the situation is different. For the most part, physicians have considerable
control over their patterns of practice both as individuals and through their respective
professional organizations. Some physicians, for example, do limited work in hospitals.
Some choose to work in multidisciplinary primary health care settings while others
prefer a more traditional solo or group practice. Traditionally, decision makers have re-
organized the pattern of practice of nurses pretty much at will, but attempts to change the
pattern of practice of physicians are met with the stiff opposition of the medical
profession who see this as a threat to their professional autonomy.
• Quality of working life – For nurses especially, quality of work life is a serious concern.
Morale has declined substantially and nursing organizations point to this as one of the
reasons for a significant number of nurses choosing to leave their profession. They also
suggest that the persistent low morale has an impact on the quality of patient care.
Employers, unions and professional organizations are addressing these issues, but, in
recent years, the relationships between these organizations have been less than positive
and strikes have been regular occurrences in almost every part of the country. Physicians
also have concerns about quality of work life, but they tend to have more direct control
over their working conditions than do nurses.
The Nursing Situation

In the last 20 years, the supply of nurses has fluctuated significantly. From 1980 to 1991,
there was a steady increase in the number of nurses from a low of 629.1 per 100,000 people, or
one nurse for every 159 people, to a peak of 819.9 per 100,000, or one nurse for every 122
people. Since 1991, the ratio has steadily declined (CIHI 2002f) (see Figure 4.1). In OECD
countries, variations in the number of nurses per capita tend to reflect the way the health care
system is organized, which means there is no “natural” level of demand for nurses. Canada’s rate
of nurses per capita is low in comparison to the Scandinavian countries but higher than in Spain,
Greece or the United Kingdom (Saltman and Figueras 1997).
The overall numbers, however, are only part of the story. The supply of nurses varies
considerably across Canada. As shown in Figure 4.2, in 2001 the ratio of nurses to 100,000
people among provinces ranged from a low of 666.4 (one nurse for every 150 people) in British
Columbia to a high of 1,019.8 (one nurse for every 98 people) in Newfoundland and Labrador.
The Canadian average was 742.4 nurses per 100,000 Canadians (one nurse for every 135 people)
(CIHI 2002f). While these numbers may tell part of the supply story, they do not tell us how
many of these nurses are working, or are available to work, full time.
94
Figure 4.1 850

Total Number of
Registered Nurses
in Canada (per 800
100,000 People),
1980 to 2001
750
700
650
600
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
Source: CIHI 2002f.
Figure 4.2 1,200

Number of
Registered Nurses 1,000
(per 100,000
People), by
800
Province, 2001
600
400
200
0
and Labrador
Quebec
Manitoba
Brunswick
Saskatchewan
Newfoundland
Prince Edward
Island
New
Ontario
Alberta
Canada
Nova Scotia
British Columbia
Source: CIHI 2002f.
It also looks like the demand for nurses will increase even more in the future. The following
are some of the key problems that have been identified:
• Too few graduating nurses – There has been a reduction of over 50% in the number of
graduates from nursing schools in the past 10 years. On top of that, of those who
graduate, 3 in 10 either leave the country or leave the nursing profession within five
years of graduating (CNA 2001).
• Too many nurses leave the profession due to stress, poor working conditions and poor
morale – A number of submissions from nurses paint a picture of nurses who barely have
time to stop and think about what they are doing and why. Koehoorn et al. (2002, 6)
95
noted that “an increasing number of nurses in Canada have faced

mandatory overtime, mandatory on-call, refusal of holidays and time
“We are now in the winter of off for education and training, and placements in areas outside of their
specialty.” The strain of these working conditions leads to increased
nurses’ discontent. Without illness and injury, and an overall decline in morale among nurses.
Absenteeism among nurses rose steadily from 6.8% in 1986 to 8.5% in
dramatic action on the part of
1999 and has become a major expense for institutions and the health
all levels of government and care system (CHSRF 2001).
employer organizations,
• The nursing profession is aging – The average age of a Canadian
there’ll be no thaw soon.” registered nurse increased by 1.3 years from 42.4 years in 1997 to 43.7
C A N A D I A N F EDERATION OF years in 2001 (CIHI 2002d). Since most nurses retire in their mid-
N U R S E S U N I O N S 2001. fifties, a large group of nurses is expected to leave the profession in the
next decade (CHSRF 2001).
• Interprovincial rivalries for scarce resources – All provinces are in
a highly competitive race for every available nurse and nursing
graduate. The quick fix has been to increase remuneration in an
attempt to attract and retain nurses. Not surprisingly, provinces that can
“For nurses on the job right now, afford to pay more are luring nurses away from provinces that simply
work means mandatory overtime. cannot compete. The current gap between the highest and lowest
maximum annual salaries for registered nurses is $17,803, with salaries
Mandatory overtime means that ranging from a high of $63,784 in Ontario to a low of $45,981 in
Prince Edward Island (CFNU 2002).
you can be disciplined if you
refuse. It places an undue • Changes in health care delivery– Changes in how health care services
burden on nurses and our are organized and delivered in hospitals and other settings have had a
direct impact on the workload of nurses and the competencies they are
families, and it puts patient expected to have. In some cases, positions of head nurses and clinical
nurse specialists were eliminated or severely reduced as part of cost-
care in jeopardy …”
cutting measures. Combined with that, there have been extensive
C A N A D I A N F EDERATION OF reductions in other administrative and support services and, as a result,
N U R S E S U N I O N S 2001. many non-nursing functions have been transferred to nurses (Koehoorn
et al. 2002). As a result, nurses are spending less time nursing and are
not able to use their full range of skills.
Access to Doctors
While there is no consensus on whether or not we are facing an impending national “crisis”
in the supply of physicians, access to physicians is undeniably an issue in many communities
across the country.
Between 1980 and 1993, the number of general practitioners for every 100,000 people
increased from 76.4 general practitioners to a peak of 101.5. By 1999, the number had dropped
to 94.0 (one doctor for every 1,063 people) but it has been steadily increasing ever since. The
picture for specialists is somewhat different. Between 1980 and 1994, the number of specialists
per 100,000 Canadians increased steadily from 74.7 to 90.0. After a slight drop in 1995-96, the
number of specialists has been steadily increasing and, in 2001, the number of specialists per
100,000 people reached 92.7 (1 for every 1,077 people), the highest point in over 20 years (CIHI
96 2002f) (see Figure 4.3 and Map 4.1).
As in the case of nurses, looking at Canadian averages tells only part of the story. There are
significant differences among the provinces and territories in the supply of family physicians
and general practitioners, with Newfoundland and Labrador having the highest number per
100,000 people in 2001 and Prince Edward Island having the lowest (CIHI 2002f) (see Figure
4.4 and Map 4.2).
A number of factors have a direct impact on the supply of physicians including age,
speciality, clinical demands, community needs and size, place of graduation, and workloads. The
gender of the physician also has an effect. In 2000, women accounted for close to half (49.6%)
of all students graduating with medical degrees, an increase over 1980, when only 32% of
graduates were women (ACMC 2001). This shift in the mix of male and female physicians has
had an impact on changing trends in physician practice, with more female physicians choosing
general and family practice compared to medical specialities (Chan 2002).
While physician organizations (CMA 2002) and many communities point to serious
problems in meeting the need for physicians, other studies suggest that there is far less
consensus about whether or not we have a crisis in the supply of physicians. A recent report
prepared for the Canadian Institute for Health Information (Chan 2002) suggests that the
apparent shortage is more perceived than real. At the same time, access to physicians and
specialists varies significantly across the country, and some communities lack the supply of
health professionals necessary to ensure access to even basic health services.
Experience in many provinces and the territories, as well as in OECD countries, suggests
that short-term solutions aimed at increasing the supply of physicians do not translate into
improvements in the supply of physicians in communities in need, from rural and remote areas
to inner cities. In the past, the Canadian Medical Association (CMA 2001) has resisted
government action requiring physicians to practice in smaller communities, characterizing it as
both punitive and coercive. But the answer also does not lie in simply paying physicians more to
entice them to smaller communities. Research shows that: “Heavy workloads and high patient
Figure 4.3 110

Total Number
Number of specialists Number of general practitioners and family physicians
of General
Practitioners/ 100
Family Physicians
and Specialists
(per 100,000 90
People),
1980 to 2001 80
70
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2001
Source: CIHI 2002f.
97
98
Map 4.1 General/Family Physicians by Health Region, 1999
COMMISSION
ON
A
THE
FUTURE
OF
HEALTH
CARE
IN
B
CANADA
¥
FINAL
REPORT
A GP/FP crude rate /100,000 People

77 to less than 99
B Less than 77
Source: CIHI 2002.

Figure 4.4
Number
of General
120
Practitioners/ 1980 2001
Family Physicians 100
(per 100,000
People),
80
by Province,
60
1980 and 2001
40
20
0
and Labrador
Manitoba
Brunswick
Saskatchewan
Newfoundland
Prince Edward
Island
New
Ontario
Alberta
Canada
Nova Scotia
Quebec
British Columbia
Source: CIHI 2002f.
demands and expectations, lack of flexibility in working arrangements and [health services]
reorganization, as well as training and career development issues all appear to impact upon
recruitment and retention to a much greater degree than does remuneration” (Gavin and Esmail
2002, 77).
The education and training of physicians can have an impact on where they choose to
practice. With more exposure to and experience in rural settings as part of their education
programs, the likelihood of graduating doctors wanting to practice in rural settings increases
(BCMA 2002). Recent efforts by the Society of Rural Physicians of Canada and the College of
Family Physicians of Canada to develop national curricula and guidelines are a step in the right
direction. But there is much more to be done.
In their presentation to the Commission, the Professional Association of Internes and

Residents of Ontario noted that governments “… have tried to dictate through legislative and
bureaucratic fiat where new doctors can practice, regardless of the real community need for our
services. We successfully resisted these discriminatory and punitive measures, by working with
the communities themselves to identify real, effective, comprehensive, sustainable and non-
coercive solutions” (PAIRO 2002, 3). In their words, they represent the new “face of medicine”
– a new generation of physicians that is more open to working in a diversity of locations and
models of health care delivery.
While the Commission is encouraged by such sentiment, it remains to be seen just how open
the medical profession is to change. If the openness means only that “nature should take its
course” or that the scope of practice of physicians is sacrosanct, then this is clearly insufficient.
If it means a willingness to shift responsibility for some activities now performed solely by
doctors to other health care providers and to seriously consider how the mix of skills can be
adjusted and reformed, then the Commission sees some cause for optimism. The openness of the
99
100
Map 4.2 Specialist Physicians by Health Region, 1999
COMMISSION
ON
A
THE
FUTURE
OF
HEALTH
CARE
IN
B
CANADA
¥
FINAL
REPORT
Specialists Crude Rate/100,000 People

A 38 to less than 96
Less than 38
B No data/data suppressed
Source: CIHI 2002.

medical profession to change must begin to yield real results in the short
term if the medical profession is to forestall the kinds of government
action they see as coercive. “Turning to the commitment of
Furthermore, as the following sections suggest, salaries for both new doctors to medicare …
physicians and nurses have the potential to become significant cost drivers new doctors are passionately
in the health care system. The current fee-for-service approach to paying
physicians is seen by many as an obstacle to primary health care. committed to working in, and
Suggestions for addressing this issue are included in Chapter 5. Physician
organizations across the country play a powerful role in negotiating preserving and enhancing,
physician payments with governments. These negotiations take place a universal one-tier accessible
behind closed doors and, in recent years, have resulted in public acrimony,
threats and actual withdrawal of services by physicians. The focus has comprehensive public medicare
primarily been on money and less on identifying the deliverables
physicians are expected to provide in exchange for increasing payments. system, one in which
Some suggest that future negotiations with physicians should clearly all Canadians have equal access
outline the deliverables physicians are expected to provide such as
ensuring adequate access to health care services, changing their patterns of to physician, hospital and other
practice to facilitate primary health care or to meet changing needs in the
essential health care services.”
CANADIAN ASSOCIATION
OF I NTERNES AND RESIDENTS.
health care system, or achieving certain outcomes for their patients (e.g., P RESENTATION AT CHARLOTTETOWN
screening for certain tests). PUBLIC HEARING.
Paying for Nurses and Doctors

In recent years, there has been considerable focus on the salaries of nurses and the incomes
of physicians, largely as a result of negotiations between governments and provider
organizations.
From 1960 to 1992, the average rate of increase in the annual income of physicians was
slightly above 6%. Between 1993/94 and 1998/99, the rate of growth in the annual average
payment to fee-for-service physicians (which includes about 73% of physicians in Canada)
slowed to an average of about 1.5% a year (CIHI 2001a, 1999). However, recent negotiations
with provincial governments have resulted in substantially higher increases. In February 2001,
the Alberta government provided a 35% increase in its Medical Services Budget to pay for
physician services as a result of the latest agreement with the Alberta Medical Association
(AMA 2001). More recently, fee schedules negotiated in 2002 for physicians in New Brunswick
and British Columbia include increases of 15.0 and 20.6%, respectively (Morris 2002; British
Columbia Ministry of Health Services 2002).
Between 1966 and 1995, nursing incomes in Canada grew by an annual average of 6.3%
compared with a range of 6.1% in Germany and Sweden to 7.3% in Japan. Increases in nursing
incomes also slowed in the mid-1990s to 2% in 1995. But settlements in the past few years have
showed marked increases. In Alberta, the three-year collective agreement signed with the United
Nurses of Alberta in 2001 provided wage increases of between 17.0 and 20.5% in the first year
(UNA 2001). Similarly, in Saskatchewan and Manitoba, wage increases of 20% over three years
and 20% over two years have been granted since 2001 (MNU 2002; SUN 2002).
Recent trends in these negotiations and settlements threaten to become a major cost driver.
Even before the substantial increases in the past few years, the incomes of Canadian doctors and 101
nurses were at the very upper end of the OECD-country scale. In 1992, for example, physician
incomes in Canada were considerably higher than France, Australia, Japan, Sweden and the
United Kingdom. Only Germany and the United States had comparable or higher rates of
remuneration. The situation for nurses was similar. This leads the Commission to urge provider
associations and governments to consider the impact of future negotiations on the sustainability
of medicare.
International Mobility of Health Care Providers

Canadians are well aware of continuing stories of nurses, doctors and other health care
providers leaving Canada to work in other countries, particularly the United States. Health care
providers are part of an increasingly mobile workforce that is in high demand around the world.
In terms of physicians, in 1996, Canada lost a net 508 physicians to other countries, but by
2000, that number dropped to 164 (CIHI 2001f). The most recent information indicates that the
downward trend may have reversed and the net loss of physicians to other countries climbed to
275 in 2001 (CIHI 2002e) (see Figure 4.5).
Aside from physicians, there are large numbers of Canadian-trained health care
professionals – most of them registered nurses – that have moved to the United States to find
employment. Recent efforts by Canadian health care institutions to “repatriate” Canadian health
care providers working abroad have met with limited success since the system is not always
able to guarantee the kinds of opportunities that are being offered south of the border.
There also are significant numbers of international medical graduates who come to Canada
as immigrants. International graduates have to undergo an extensive assessment process before
they are allowed to practice in Canada. The approval and integration process spans several years
and is quite complex, causing significant delays. As a result, many health care professionals
from other parts of the world find it difficult to get meaningful work in the health care system.
Governments and professional organizations need to streamline the process for recognizing
foreign training and provide additional training for immigrant health care professionals where
necessary.
Figure 4.5 800

Canadian
600
Physicians Moving
Abroad and 400
Returning from
Abroad, 200
1996 to 2001 0
1996
1997
1998
1999
2000
2001
-200
Number of physicians moving abroad
-400
Number of physicians returning from abroad
Net loss of physicians
-600
Source: CIHI 2002e, 2001f.

102
In some cases, provinces and territories have actively recruited medical graduates from
developing countries in order to meet the needs for physicians in Canada, especially in rural and
remote areas. Until the late 1970s, Canada openly sought and recruited international graduates
from medical schools, giving them “preferred status” in our immigration policy. At that time,
international graduates made up 30% of our physician workforce, but that number has since
dropped to just under 23% (CIHI 2001e) (see Table 4.2). Despite this decline, some provinces
like Saskatchewan continue to rely heavily on international graduates to meet demands in their
communities while other provinces like Quebec depend far less on international graduates.
As noted in Chapter 11 on globalization, there are serious concerns about Canada’s practice
of recruiting physicians from developing countries. While international medical graduates who
want to immigrate to Canada should not be prevented from doing so, provinces and territories
should reduce their reliance on physicians from developing countries and take steps, instead, to
recruit and retain more physicians within Canada.
Allied Health Care Providers and Managers

While much of the focus is on nurses and doctors, there are numerous issues that affect
other health care providers as well, including workplace issues, scopes of practice, and the
impact of changing ways of delivering services. The multiplicity of health care providers is both
a tremendous resource and a challenge in terms of sorting out new models of primary health
care, new roles and responsibilities, and more collaborative ways of working together. Furthermore,
Table 4.2
Distribution of International Medical Graduates, by Province, 2001
Percent Distribution
Total Canadian International of International
Province/Territory Physicians MD Graduates MD Graduates MD Graduates
Newfoundland and
Labrador 945 531 395 41.8
Prince Edward Island 190 156 28 14.7
Nova Scotia 1,885 1,389 494 26.2
New Brunswick 1,179 923 251 21.3
Quebec 15,866 14,024 1,800 11.3
Ontario 21,482 16,206 5,268 24.5
Manitoba 2,093 1,366 613 29.3
Saskatchewan 1,549 743 796 51.4
Alberta 5,154 3,755 1,385 26.9
British Columbia 8,105 5,854 2,250 27.8
Yukon 54 35 9 16.7
Northwest Territories 37 28 6 16.2
Nunavut 7 4 3 42.8
Canada 58,546 45,014 13,298 22.7
Note: Excludes Òunknown place of

graduation.Ó Source: CIHI 2002e.
103
with advances in medical technology, the health care system will need an increasing supply of
highly specialized and skilled technicians.
In addition to allied health providers and professionals, health care managers are frequently
overlooked in the health care system, yet their work is vitally important to the overall
organization, planning, and funding of health care systems across the country. Often working
behind the scenes, health care managers are responsible for threading the pieces together,
organizing services, and trying to get the best value for the health resources available – in terms
of both people and dollars. Health managers are responsible for implementing difficult decisions
and managing complex and evolving organizations, but their jobs were made doubly difficult
during the fiscal restraints of the 1990s. As the Canadian College of Health Service Executives
notes, “excessively rapid and often unplanned change has undermined executives’ ability to
[manage] in a logical and rational manner.” They also point to a lack of consistency in
leadership and vision, and the negative impact this has on managers’ ability to understand their
roles and carry out a cohesive plan (CCHSE 2001, 4).
A National Effort Is Needed

No matter how you look at the information on the current situation for health care providers
in the country – whether you are a health professional, a health care manager, a provincial,
territorial or federal government official or leader, a patient waiting to see a doctor, or a
community desperately looking for a nurse – it is impossible to escape the following
conclusions:
• The current situation is serious and demands national solutions;

• Recruiting, training, and retaining more nurses and doctors over the next decade are
crucial, especially for remote, rural, and northern communities;
• The problem is only partly about supply. It also is about distribution, scope of practice,
patterns of practice, and the right mix of skills among various health care providers;
• Health care managers are under increasing strain and suffer from the lack of a clear
vision for moving forward;
• Primary health care will provide important benefits to Canadians and should give them
access to teams and networks of qualified health providers. But transformations in the
way health care providers work together will not happen overnight; and
• New approaches to education and training are needed in addition to a careful look at how
the roles and responsibilities of various providers are changing along with changing
patterns of care.
These challenges are significant and apply to every province and territory. This also is clearly
an area where actions in one province or territory have spillover effects in other provinces and
territories. Given this reality, the best approach is for provinces and territories to work together on
solutions that will address not only their own specific challenges but also ensure that Canada
continues to have an adequate, well-educated, and effective health workforce for the future.
104
Immediate Investments in
Pe?ple and Change
RECOM MENDATIO N 15:
A portion of the proposed Rural and Remote Access Fund, the Diagnostic Services
Fund, the Primary Health Care Transfer, and the Home Care Transfer should be
used to improve the supply and distribution of health care providers, encourage
changes to their scopes and patterns of practice, and ensure that the best use is made
of the mix of skills of different health care providers.
The health care system depends on people, and the ability of the system to move ahead with
the reforms envisioned in this report will depend not only on having an adequate supply and the
right distribution of health care providers, but also on their willingness to look at new
approaches to how they deliver care.
There is little doubt that the fluctuations in funding for health care in the late 1980s and
throughout the 1990s had some negative effects on Canada’s health workforce. As provincial,
territorial and federal governments struggled to balance their books, “stop and go” funding
negatively affected the supply of health care providers and seriously hampered attempts at long-
term planning. This lack of continuity and predictability in funding has had a lasting impact on
the delivery of health care services and the quality of work life for health care providers and
professionals.
Immediate action needs to be taken on two fronts:

• Improving the supply and distribution of health care providers in two priority areas –
ensuring that rural and remote communities have the right mix of skilled health care
providers to meet their needs, and improving the supply of specialized technicians to
keep pace with increasing demands for diagnostic testing; and
• Transforming the skills and roles of health care providers consistent with the overall
directions for change outlined in this report.
Recommendations outlined in Chapter 2 propose a series of targeted funds and transfers to
address priority areas and provide the transition to a new dedicated health transfer. Several of
these funds, particularly the Rural and Remote Access Fund, the Diagnostic Services Fund, the
Primary Health Care Transfer and the Home Care Transfer, should be used to address challenges
in the supply, distribution and mix of skills of health care providers.
These additional funds should be specifically targeted to the most effective ways of
addressing the most pressing problems. However, the Commission strongly feels that the
additional funds should not become a target for increasing salary pressures from health care
providers. There is a serious political risk to all parties – governments, health care providers and
their organizations, and regional health authorities – if the bulk of the additional funds simply
goes to pay more for the same level of service, the same access, and the same quality. This
simply will not be acceptable to Canadians.
To address and resolve issues with today’s health workforce, it is important to go beyond
what health care providers are paid and address the more complex but important issues of what
they do, and how their roles must change to reflect new ways of delivering health care services.
105
Addressing Gaps in Supply and Distribution

Problems of rural communities in attracting and retaining an adequate supply of health care
providers are well known and are discussed in Chapter 7. One of the major obstacles to
improving access to essential health care services in rural and remote communities is the serious
challenge these communities face in attracting and retaining health care providers. Over the next
two years, expanding the supply of health care providers in these communities should be a
major objective of the proposed Rural and Remote Access Fund. That may mean that a portion
of that fund goes to creating incentives, financial and otherwise, to attract and retain the right
“It is partially a myth to say that
mix of professional skills in those communities.
we are lacking doctors in the
province of Quebec. Why?

In the case of diagnostic services, information provided in Chapter 6
Because we don’t have the shows that Canada has fallen behind in its investment in diagnostic
courage to ask them to serve technology and, as a result, waiting times for access to MRI (magnetic
resonance imaging) and CT (computed tomography) scans are increasing.
where and when we need them.” However, purchasing the equipment is only one part of the solution. A
C ONSEIL PROVINCIAL POUR
portion of the proposed new Diagnostic Services Fund should be used to
LA P ROTE C T I O N D E S M A L A D E S .
recruit and train the necessary supply of technologists and specialists
P RESENTATION AT MONTREAL needed to meet the demands and improve Canadians’ access to these
PUBLIC HEARING. essential services.
Changing Roles and Responsibilities

Issues related to health care providers are more complex than simply whether we have
enough nurses, doctors, pharmacists, or dentists. The roles of various health care providers are
changing as new models of delivering care are explored and implemented. The appearance of
new professionals and new modes of health care delivery, not to mention the appearance of new
needs within the health care system, involve major changes in the scope of practice of each
health profession. The attempt to create a health care system that is more “patient-centered”
leads inevitably to the desire to change the way health professionals are trained, the way they are
paid, and the way in which they work together (Lissauer 2002).
If Canada is to move ahead on major reform to its health care system, the mix and skills of
health care providers and how they work together must be addressed. As Jane Salvage (2002,
16) has written:
Tinkering with the boundaries while failing to examine the core of what health workers do
and how they do it is like rearranging the deckchairs on the Titanic. Allocating the tasks
differently is the easy bit, and that is hard enough. The division of labour may have
changed dramatically over the years, but the core assumptions about how professionals
work have remained very largely intact.
The nursing situation is a case in point. Across Canada, there has been an increasing
emphasis on the role of nurse practitioners who can take on roles that traditionally have been
performed only by physicians. This could even include providing nurse practitioners with
admitting privileges to hospitals so that they could refer patients and begin initial treatment in
hospitals. But, while nurses have eagerly embraced an expanded role at one end of the spectrum
of their responsibilities, they have been less inclined to give up some responsibilities to licensed
practical nurses, for example, and others with a similar mix of skills to provide direct care for patients.
106
The same can be said of physicians. There is little doubt that the doctor-patient relationship
is central to the care physicians provide. Yet it also means they have often been unwilling to
share responsibility for the care of their patients with others who are in a good position to co-
ordinate care across the different aspects of the health care system, from diagnostic tests, to
acute care and home care. An increasing emphasis on primary health care – where physicians are
expected to participate in and share responsibilities with a team of different health care
professionals – will also have an impact on patterns of practice for physicians as well as the way
they are paid for their services.
As outlined in both subsequent chapters on primary health care and home care, new roles
are also likely to emerge as the health care system continues to change. Case managers, for
example, will play an increasingly important role in co-ordinating and
managing primary health and home care services for their patients. The
case manager would provide a critical point of contact for patients and for “You have to use your workforce
other health care providers. In the past, physicians have traditionally
adequately.… You shouldn’t hire
played this “gatekeeper” role, deciding what types of services a patient
needs and where those services should be provided. Not surprisingly, nurses as receptionists.”
nurses have suggested that this is a role they could play. However, case
managers do not have to be either doctors or nurses, provided that they are U N I O N Q UƒBECOISE DES INFIRMIERS
ET INFIRMIé R ES AUXILIAIRES DU
Q UƒBEC . P RESENTATION AT Q UƒBEC

in a position to co-ordinate care and ensure timely access to the care CITY PUBLIC HEARING.
people need. As primary health care and home care expand in the future,
it is likely that the role of case managers will have a direct impact on the
working relationships of different health care providers.
Primary health care also places a clear emphasis on flexible responsibilities and the
importance of multidisciplinary teams and networks of providers working together to address
their patients’ health needs. This will affect not only nurses and doctors but other health care
providers as well. Both Chapter 9 on integrating prescription drugs and Chapter 8 on home care
reflect a growing emphasis on medication management programs. This is likely to have a direct
impact on the role of pharmacists and make it possible for them to play an increasingly important
role as members of the health care team. With the emphasis on prevention and promotion, various
health care providers and others in the community can be expected to play a more active role.
There also are a number of new and emerging health professions such as children’s nurse
practitioners, physician’s assistants, and clinical children’s nurses. The emergence of these and
other new, highly trained professions requires an ongoing reassessment of the scopes of practice
of existing health care providers and a re-balancing of the mix of skills among the various
providers. In fact, the more the health care system changes, the more likely it is that traditional
scopes and patterns of practice will be challenged.
Two of the proposed new Transfers – the Primary Health Care Transfer and the Home Care
Transfer – are intended to significantly change how health care is delivered in Canada. Both will
require changes in how health care providers work together, share responsibilities, and combine
a mix of different skills in order to provide the best outcomes for patients.
In terms of primary health care, the new transfer is intended to kick-start widespread change
and expansion of primary health care approaches across Canada. In the case of the Home Care
107
Transfer, there will be an increasing emphasis on post-acute care, palliative care, and mental
health case management and interventions. A portion of both of these transfers should be used to
address the necessary changes in scopes of practice and to facilitate teams of health care
providers.
Planning f?r Change ?ver the

L?nger Term
The Health Council of Canada should systematically collect, analyze and regularly
report on relevant and necessary information about the Canadian health workforce,
including critical issues related to the recruitment, distribution, and remuneration of
health care providers.

The Health Council of Canada should review existing education and training
programs and provide recommendations to the provinces and territories on more
integrated education programs for preparing health care providers, particularly for
primary health care settings.

The Health Council of Canada should develop a comprehensive plan for addressing
issues related to the supply, distribution, education and training, remuneration, skills
and patterns of practice for Canada’s health workforce.
Improve Information about Canada’s Health Workforce

Comprehensive and national data on the state of the health workforce are critical. At the
outset, the Council should take steps to address the serious gaps in information about Canada’s
health workforce. Beyond basic data on the supply and distribution of nurses and doctors, little is
known about other health professionals and providers. Only limited information is available on
effective strategies for encouraging different members of the health workforce to work together.
Furthermore, standardized information is not available across the country so it is difficult to
track trends, gather comparable information on the supply of health care providers, or assess
whether the current mix of health care providers will meet the current and future health needs of
Canadians (CIHI 2002b).
These major gaps in information need to be addressed. Standards must be set for collecting
data across the country so that the situation in different provinces and territories can be
compared, and trends in supply, distribution, mobility, and composition can be monitored and
analyzed on an ongoing basis. This information base is essential for long-term effective planning
for the future of Canada’s health workforce.
The Canadian Institute for Health Information (CIHI) has begun important work in this
area, but much more needs to be done. The new Health Council of Canada, with CIHI as its
information backbone, could become a world leader in data collection and analysis in health
human resources planning and development. As part of this work, the Health Council should
108
collect and assess national and international data on remuneration, conditions of work, the
quality of work life for health professionals, workload, and other issues that affect Canada’s
workforce. This information should assist governments, health providers and their organizations
in addressing these issues on a longer-term basis.
Review and Renew Education and Training Programs for

Health Care Providers
Current initiatives in primary health care highlight the need for providers to work together
in integrated teams and networks focused on meeting patients’ needs. In recent years, some have
suggested that the education and training of providers is falling short of meeting Canadians’
health care needs. A host of reasons have been offered for the need to change how health care
providers are educated today, including the following:
• Health care is a dynamic environment that calls for constant learning and change;
• A shift to evidence-based health care requires new skills;
• Changes are needed in the relationship between providers and patients as patients take a
more proactive role in their health and health care;
• Changes in how health care services are delivered have a direct impact on the mix of
skills expected of health care providers;
• New role models are needed to reflect the different ways of delivering health care
services; and
• Canadians expect more emphasis on health promotion, wellness and disease prevention
as an essential part of their health care system.
In view of these changing trends, corresponding changes must be made in the way health
care providers are educated and trained. As one presenter described it, we have largely been
training our health care professionals in silos. Then when they graduate, we call on them to work
together (Bowmer 2002). If health care providers are expected to work together and share
expertise in a team environment, it makes sense that their education and training should prepare
them for this type of working arrangement.
Some work on interprofessional education is already underway in Canada, including the

recent collaboration between the Canadian Nurses Association, the Association of Canadian
Medical Colleges, and the Canadian Association of University Schools of Nursing in partnership
with Health Canada. The College of Health Disciplines at the University of British Columbia is
also doing important work in this area. In a submission to the Commission, they indicated that
“The basic notion that underpins the College is that interprofessional education and
collaboration is essential to achieving effective delivery of health care” (University of British
Columbia College of Health Disciplines 2001). They describe interprofessional education as “a
learning process in which different professionals learn from, learn about and team with each
other in order to develop collaborative practice.” While these developments are a step in the
right direction, a presenter from the School of Nursing in Victoria acknowledged that there is
considerable room for improvement. She urged governments to help the professions evolve,
while at the same time cautioning them to avoid destructive top-down approaches that work
against the very relationships they are trying to promote (University of Victoria School of Nursing 2002).
The Health Council of Canada, with representation from health care providers, could play
an important role in examining current programs for educating and training the mix of health 109
care providers in Canada and recommending an integrated educational curriculum for future
health care providers. It could also explore a range of issues including barriers to entry to
education programs, especially medical schools, ways of recruiting more Aboriginal health care
providers (as discussed in Chapter 10), and ways of expanding experiences in rural and remote
communities (as discussed in Chapter 7).
Develop a Comprehensive Plan for the Future of

Canada’s Health Workforce
As one report described it, health human resources planning is like a “classic soap opera –
tune out for years, and there is a reasonable chance that not much will have changed when one
returns” (Barer et al. 1999, 3). It is time to bring this soap opera to a satisfying conclusion.
Throughout its consultations, the Commission repeatedly heard calls for leadership and a more
concerted effort across the country to address not only the immediate issues but also to initiate a
national discussion about future needs, and the best ways of optimizing Canada’s health
workforce.
In the work done for the Commission by the Canadian Policy Research Networks, the
researchers quickly came to the conclusion that there is “… one key thing that must take place if
we are to get anywhere with improving health human resource planning capacity. Over and over
again in this project, we were told that there is currently no viable mechanism for health human
resource planning in Canada and therefore, human resource issues go round in circles, never
really getting to the heart of the matter” (CPRN 2002, 36).
Experience with health human resources (HHR) planning in Canada has been plagued by the
following problems:
• Planning is intermittent at best – There is little evidence that planning adequately
considers population demographics and trends, the broader determinants of health, the
specific needs of patients, or the unique and shared knowledge and skills of health care
providers. Further, planning approaches are frequently based on one-time estimates
focusing on a single discipline.
• Too often, the emphasis is on quick fixes – According to a roundtable on health human
resources sponsored by the Commission, Canada has a relatively poor track record in
health human resources planning because its policies have tended to focus on quick-fix
solutions. As British Columbia’s Minister of Health Planning pointed out, we are
currently paying the price for decades of patchwork vision (British Columbia 2002).
• The lack of adequate planning has contributed to the declining quality of work life
for health professionals – Our over-reliance on part-time, casual and overtime work has
created a health care workforce that is extremely dissatisfied with its work environment.
The Clair Commission in Quebec observed that “Recent years have been difficult for the
people who work in the health and social services network. To this day, overwork, the
instability of work teams and shortages in some professional categories, in particular
nurses, along with all sorts of inflexibilities, continue to create the general feeling of
dissatisfaction, exhaustion and gloominess that too often prevail in the network’s
institutions” (Clair 2001, 106). The declining quality of the health care workplace,
especially in nursing, has also created further pressure on salary rates across the country.
110
• Planning has been limited to individual provincial and territorial initiatives – In

isolation, provinces, territories and individual communities are developing their own
solutions to many of the challenges facing their health workforce, from specific
initiatives to recruit and retain professionals in rural and remote communities to targeted
education and training programs. The result is considerable duplication in efforts across
the country. Barer et al. (1999, 39) suggested that our lack of a national approach to
health human resources planning, coupled with limiting and narrow perspectives from
individual provinces concerned with their own supply issues, has resulted in “a history of
destructive competition rather than cooperation.” Some also have suggested that the
decisions of some provinces result in effectively “poaching” scarce health professionals
from other provinces. As was observed at the Commission’s expert roundtable in
Halifax, “Across the board, we have a national pool of trainees – yet provinces are
working in isolation without a national presence. There is an irony in Nova Scotia
increasing enrollment in medical schools when what we are training is more doctors for Alberta.”
• Planning is complicated by the interdependency of issues and the significant

number of actors involved – Workforce planning is affected by a number of interrelated
issues including education and training, scopes of practice, different regulations in the
various provinces and territories, and continuing workforce tensions in the health care
system. Combined with that, there is a multiplicity of actors involved from provincial
and territorial governments to universities, regulatory bodies, unions, and individual
employers (see Table 4.3). As CPRN (2002, 40) notes, “Historically, Canada has had a
situation in which governments do one thing, educational institutions do another, and
regulatory authorities do a third.”
Provinces, territories and the federal government understand the seriousness of the issues
and are prepared to work together on solutions. In September 2000, First Ministers agreed to
work together to “coordinate efforts on the supply of doctors, nurses and other health care
personnel so that Canadians, wherever they live, enjoy reasonably timely access to appropriate
health care services” (FMM 2000). The need for collaborative action was echoed by provincial
Premiers at their annual meeting in the Fall of 2001. They agreed that “Provinces and territories
should utilize a common approach … in the determination of the scope of practice amongst
health professionals.” They also agreed that “There must be better planning and inter-provincial
cooperation in training and recruiting health professionals to ensure that there is an adequate
level of health care professionals available” (APC 2001).
The proposed Health Council of Canada, with expertise drawn from providers, is the best
vehicle for addressing health human resources issues and driving the process forward over the
longer term. It can serve as a focal point for facilitating co-operation among governments, health
providers and the public. It can address sensitive issues such as demands from various health
provider organizations and changing scopes of practice through an arm’s length, independent
body. The Health Council should also be able to independently examine the relationships
between health professions and encourage better communication.
To fulfil this role, the Health Council of Canada should expand on the work of the current
intergovernmental Advisory Committee on Health Human Resources. It should draw on the
expertise of people outside of government and undertake the necessary research and analysis to
111
Table 4.3
Policy and Planning Responsibilities across Canada
Policy Levers Employed for

HHR Planning Provincial/Local National
Data collection and Ministries of Health CIHI

monitoring Research organizations Stakeholder organizations
Local communities
Setting number of undergraduate Ministries of Health

positions Ministries of Colleges/
Universities
Faculties of medicine/nursing/
other health sciences
Setting number and mix Ministries of Health

of post-graduate positions Faculties of medicine/nursing/
Setting tuition costs Universities

Ministries of
Colleges/Universities
Determining education curriculum Faculties of medicine/nursing/ Medical Council of Canada

Determining training curriculum Faculties of medicine/nursing/ Royal College of Physicians

other health sciences and Surgeons of Canada
Academic health science College of Family Physicians
centres of Canada
Registration and licensing Regulatory bodies

standards
Ongoing competency assessment Regulatory bodies Royal College of Physicians

Employers and Surgeons of Canada
College of Family Physicians
of Canada
Practice standards Regulatory bodies Royal College of Physicians

Professional associations and Surgeons of Canada
Employers College of Family Physicians
of Canada
Professional associations
Scopes of practice Regulatory bodies
Immigration policy Provincial governments Government of Canada
System financial incentives Ministries of Health

Bargaining agents
Recruitment and retention Ministries of Health

programs Local communities
Employers
Job design Unions

Employers
Collective agreements Provincial governments

Bargaining agents
Source: CPRN 2002.

112
fill the gaps in what we know today. To support this important work, the Health Council of
Canada will be able to build on the current expertise of CIHI, draw upon existing sources of
information, and work closely with the Canadian Health Services Research Foundation and other
relevant research and policy organizations in Canada.
Overall, what is needed is “a fundamentally new approach to the

people side of the health care system – treating employees as assets that “People on the front lines of
need to be nurtured rather than costs that need to be controlled”
(Koehoorn et al. 2002, 2). Experience has shown that there is little chance providing care don’t feel they’re
of success if the key actors are not directly involved in the process of being listened to.”
change in health care. Too often, health human resources have been
treated as a cost that needs to be contained as opposed to a means by DR. DENISE BOWES. PRESENTATION
which the system can realize its objectives (Dallaire and Normand 2002). Through its leadership
AT OTTAWA PUBLIC HEARING.
role, the Health Council of Canada can bring together health care providers, provinces and
territories, and other key players in the health care system to address long-term issues and make
a lasting and profound change in the future of Canada’s health workforce.
What D?es This Mean f?r Canadians?

Canadians are concerned about the supply and distribution of nurses, doctors and other
health care providers. They have listened to fears of an impending crisis and expect something to
be done. They have heard about the need for better planning, but too frequently, they have not
seen this translated into action. Too many Canadians still do not have a doctor in their
community, have to wait to see a specialist, or find too few nurses in the emergency department
when they need urgent care.
Beyond those immediate concerns, health care providers have serious concerns about the
quality of their work life and have repeatedly called for action to improve morale and day-to-day
working conditions. Furthermore, continuing changes in how health care services are provided –
particularly the move to primary health care – mean that many of the traditional barriers between
health care providers need to be broken down. While overnight solutions are simply not
possible, Canadians deserve nothing less than a full-scale national effort to address these
pressing issues on an urgent basis.
With the actions outlined in this chapter, Canadians can expect to see: •
Immediate, targeted actions to expand the supply and distribution of health providers and
professionals, especially in rural and remote communities;
• A stable and sustainable supply of health care providers and professionals in the future;
• Better use of the mix of skills of various health care providers, going beyond the
boundaries of traditional scopes of practice;
• Health care providers who are educated, willing and able to work together as teams and
networks to meet their patients’ needs;
• Regular reports on the progress being made on today’s pressing issues and the plans for
the future.
113
There is also a direct message for health care providers in these recommendations. Action
must be taken to address their concerns about growing stress and tension in the workplace. But,
in return, health care providers must be prepared to set aside old practices, old ways of thinking
and old complaints about past problems.
All players in the health care system – from governments to front-line health care providers
– need to focus firmly on the future, embrace the need for change, and begin the process
immediately.
114
PRIMARY H EALTH CARE
AND PREVENTION

5
• Finally make a major breakthrough in implementing primary health
care and transforming Canada’s health care system.
• Use the proposed new Primary Health Care Transfer as the impetus for
fundamental change in how health care services are delivered across the
country.
• Build a common national platform for primary health care based on four
essential building blocks.
• Mandate the proposed Health Council of Canada to hold a National
Primary Health Care Summit to mobilize action across the country, then
maintain the momentum by measuring progress and reporting regularly
to Canadians.
• Integrate prevention and promotion initiatives as a central focus of
primary health care targeted initially at reducing tobacco use and obesity
and increasing physical activity in Canada.
• Implement a new national immunization strategy.
The Case fMr Change

There is almost universal agreement that primary health care offers tremendous potential
benefits to Canadians and to the health care system. The majority of policy experts and health
care professionals consider primary health care to be an absolute priority. In September 2000,
federal, provincial and territorial First Ministers agreed to work together on a primary health
care agenda. In the words of the First Ministers’ agreement: “Improvements to primary care are
crucial to the renewal of health services. Governments are committed to ensuring that Canadians
receive the most appropriate care, by the most appropriate providers, in the most appropriate
settings” (FMM 2000).
115
Canadians, too, appear to support primary health care change. While they may not
understand all the details of what primary health care means, recurrent themes in the
consultations and opinion polls conducted by the Commission underscore the importance they
place on health promotion and prevention, their hope for strong and accessible primary health
care services, and their desire to have a long-lasting and trusting relationship with a health care
professional (EKOS 2002). At the public consultations and expert roundtables, a remarkable
number of people told the Commission that they would like to see the development of a
complete and effective primary health care system. Most of the presentations to the Commission
captured, in one way or another, either of these two important themes: continuity and
co-ordination of health care and health services; and action on individual and population health.
For health care, it is remarkable to see such a high degree of agreement. The issue, then, is
not whether primary health care is the right approach to take but, rather, removing the obstacles
and actually making it happen.
Unlike other initiatives described in this report, primary health care is not a single program
that can be designed, developed, and implemented. Primary health care is about fundamental
change across the entire health care system. It is about transforming the way the health care
system works today – taking away the almost overwhelming focus on hospitals and medical
treatments, breaking down the barriers that too frequently exist between health care providers,
and putting the focus on consistent efforts to prevent illness and injury, and improve health. In
fact, no other initiative holds as much potential for improving health and sustaining our health
care system. By making primary health care the central point of our health care system, we
can:
“The system becomes bogged
down when people go for

• Take immediate action to prevent illness and injury, and improve the
secondary treatment when they health of all Canadians;
could use primary care. • Reduce costly and inefficient repetition of tests and overlaps in care
provided by different sectors and different providers;
If we corrected this, we could
• Replace unnecessary use of hospital, emergency, and costly medical
achieve savings.” treatments with comprehensive primary health care available to
Canadians 24 hours a day, 7 days a week;
A SSOCIATION DES OPTOMÉTRISTES
DU Q U É B E C . P RESENTATION AT • Break down the barriers between health care providers, facilities, and
QUÉBEC CITY PUBLIC HEARING. different sectors of the health care system and concentrate on the
common goal of improving health and health care for Canadians.
It is impossible to put a dollar figure on these benefits, but there is every reason to believe
that primary health care would not only save Canadians money in terms of their future
investment in the health care system but also improve health and save lives. In short, primary
health care is essential to transforming Canada’s health care system.
The Commission shares the frustration of many that progress to date has been fragmented
and far too slow. The proposed new Primary Health Care Transfer is critical to kick-start the
process and move beyond a series of isolated, short-term experiments in primary health care to
true and lasting reform. The transfer to the provinces and territories should be tied to the clear
condition that provinces and territories will move ahead with primary health care based on four
essential building blocks – continuity of care, early detection and action, better information on
needs and outcomes, and new and stronger incentives. A National Primary Health Care Summit
116
PRIMARY HEALTH CARE AND PREVENTION
would then mobilize action across the country and focus concerted efforts on identifying and
removing obstacles to implementation of primary health care. The proposed Health Council of
Canada should be called upon to track and measure progress, and provide independent reports to
Canadians on the progress of primary health care reform. These actions, combined with
deliberate steps to integrate prevention with primary health care, should result in the kind of
breakthrough that is needed to transform Canada’s health care system and improve the health of
Canadians for generations to come.
Primary Health Care in Canada

– OppMrtunities and Obstacles
Primary Health Care Opportunities

In recent years, there has been a great deal of focus on primary health care in Canada and
some confusion about what it means. Primary health care is actually made up of the following
diverse and complex components:
• It combines high quality comprehensive medical, nursing and other health care services
with disease prevention and health education programs;
• Services are provided not only to individuals but also to communities as a whole,
including public health programs that deal with epidemics, improve water or air quality,
or health promotion programs designed to reduce risks related to tobacco, alcohol and
substance abuse;
• Services are organized so that they address the needs and characteristics of the
population that is served – either a group of people living in a defined location (territorial
approach) or a group of people who belong to a particular social or cultural group
(population approach);
• Teamwork and interdisciplinary collaboration are expected from health care providers
either working in primary health care organizations or participating in networks of
providers;
• Services are available 24 hours a day, 7 days a week;
• Decision making is decentralized to community-based organizations to ensure that
services are adapted to the needs and characteristics of the population served and that
communities can be mobilized around health objectives that directly affect their
community.
The overall aim of primary health care is to significantly increase the importance of the first
line of care and those who deliver these “first contact” services. In effect, primary health care is
“the central function and main focus” of the health care system (WHO 1978).
There are a number of benefits to primary health care.
• More co-ordinated care – For individual Canadians, primary health care means they
have access to a team or network of health care providers working together on their
behalf to co-ordinate their care across different aspects of the health care system from
counselling them on how to stay healthy or quit smoking to treating illnesses, providing
hospital care, following up with home care services, or monitoring people’s use of
prescription drugs. 117
• Better quality of care – More effective care can be provided at the front lines where
people first come in contact with the health care system. Teams and networks of health
care providers and other agencies can work together and share responsibility for an
individual’s care. With comprehensive information provided through electronic health
records as outlined in Chapter 3, health providers can continuously monitor people’s
health, track their progress if they have certain illnesses, and take a broader approach to
helping them stay healthy.
• Better use of resources – Emergency and hospital care are among the most expensive
aspects of the health care system. With effective primary health care in place, people
would be less likely to rely on emergency departments to get advice or assistance with
relatively minor ailments or persistent health conditions that cannot be properly dealt
with in busy emergency departments. By emphasizing prevention of illness and wellness,
the long-term result should be less need for expensive hospital treatments especially for
treating heart disease, some cancers, or a host of other illnesses that are directly related to
lifestyle factors. Even when hospital treatments may be required, effective primary health
care will ensure that people’s care after they leave hospital is well co-ordinated with
home care, prescription drug use, and rehabilitation to minimize the chances people will
need to be re-admitted to hospital.
Obstacles to Primary Health Care

In the face of widespread agreement about the potential benefits of primary health care,
some would ask why we are still at the pilot project stage 30 years after primary health care
reform was actively promoted in Canada (Hastings 1972).
In part, some of the obstacles and delays in implementation are inherent in any process of
change. Transforming the health care system to focus on primary health care is not a simple task.
Refocusing a system as large and complex as health care means revisiting decisions that were
made many years ago about how the system should be organized and what types of services
should be provided.
The desire for perfection is also an obstacle to change. Primary health care advocates have
pushed their own ideal models and solutions. But for a number of reasons, these ideal
approaches are not always practical in the real world, primarily because they require too many
changes at the same time – changes in training and the scope of practice of health care providers,
in health care organizations, in patient attitudes, in the level of preparation of decision makers, in
funding requirements, and in lifestyles. Experiments in Canada and abroad in the 1990s have
shown that it is impossible to act on such a wide front without jeopardizing the quality of life of
health professionals, the support of the population, or even the quality of care (Rochefort 2001).
In addition to these issues, primary health care faces six concrete obstacles: •
The central and predominant focus on hospital and medical care – Canada’s health
care system is focused primarily on hospitals and medical treatments. These areas are
often identified with the greatest successes of modern medicine. But they also involve
the most invasive and most costly solutions. Primary health care means striking a better
balance between efforts to prevent illness and injury and those that cure people when
they are sick.
118
• Increasing professional specialization and protection – Health care providers are

becoming increasingly specialized and there is a long-standing tradition of carefully
guarding their professional scope of practice. The development of primary health care
runs against this trend and demands flexible working arrangements and shared
responsibilities among health care providers.
• Fragmented health care delivery – Health care services are
“Health care should be perceived
typically organized around fragmented “silos” based on who
delivers the service and where it is delivered. Primary health care as a continuum, not a series
emphasizes the continuity of care across the various sectors.
of vignettes.”
Providers and organizations are encouraged to integrate services
from the first contact with a physician or nurse practitioner to F ACULTY OF MEDICINE, MCGILL
U N I V E R S I T Y . P RESENTATION AT
services for people who are convalescing, have chronic illnesses, MONTREAL PUBLIC HEARING.
or who need acute or specialized services.

• Lack of health information – Comprehensive, timely and accurate information is
lacking and is not used effectively to guide decisions in our health care system. Using the
new technologies and approaches to electronic health records outlined in Chapter 3,
primary health care can improve the quality of care and ensure that information is
available to health care providers and decision makers and, in particular, individual
Canadians using the system.
• Limited control by patients over their own care – Currently,

most patients have only a passive role in decisions about their own “I think that if we could have
health care and are able to exercise only limited control. The a heath care system that would
development of primary health care focuses on patients and gives
them a dominant role in decision making. listen more to the people that
• Marginal prevention and promotion – In the current system, it’s providing care to, that we
prevention and promotion activities are a small fraction of the would probably be doing
work of governments, regional health authorities and health care
providers, and investment in disease prevention remains a low a whole lot better.”
priority for government spending (Majnoni d’Intignano 2001).
JOANNE NEUBAUER. PRESENTATION
Primary health care puts a major emphasis on prevention and AT VICTORIA PUBLIC HEARING.
promotion activities ranging from national programs to a battery

of local and regional initiatives.
To make progress in overcoming any one of these obstacles is a major challenge, let alone
all six areas at once. In many respects, primary health care goes against the grain. It goes against
entrenched practices in the prevailing culture of our health care system and it sometimes runs
into powerful interests and long-standing privileges. The various obstacles cannot be overcome
through a single, rigid approach. Given the diversity of communities and circumstances across
the country, it makes good sense to take a flexible approach that can be adapted to different
communities and different groups of people.
Evolving Approaches to Primary Health Care

A number of different approaches to primary health care have been developed in Canada
and in other jurisdictions around the world. It is a case where many paths can lead to the same
destination. 119
Following the First Ministers’ agreement in September 2000, an $800 million Primary
Health Care Transition Fund was established to support primary health care projects across
Canada. To date, the Fund has supported a number of pilot projects and the evaluation of their
effectiveness. The Fund established a model for primary health care that included the following
conditions:
• An increase in community-based primary health care organizations that provide

comprehensive services to a certain population;
• More interdisciplinary teams with enhanced roles for nurses, pharmacists and other
providers;
• Better linkages to hospitals, specialists, and other community services;
• An increased emphasis on health promotion, disease and injury prevention, and
management of chronic illnesses;
• Expanded access to essential services 24 hours a day, 7 days a week (HC 2002a).
This model reflects the general consensus around primary health care and leaves
considerable flexibility for provinces and territories to design and implement various
approaches consistent with the overall model. It also has resulted in a number of different pilot
projects across Canada.
While the approaches to primary health care continue to evolve, a number of concerns have
been identified. Some aspects of primary health approaches are not necessarily grounded in
research and evidence but, rather, appear to be based on good ideas or preferences. In fact, there
are “enough examples of well meaning interventions with adverse effects” to suggest that “good
intentions [are not] a sufficient basis for policy making” (MacIntyre and Petticrew 2002, 802).
Additionally, merely adding more primary health care organizations without an overriding plan
may not result in the kind of comprehensive change that many would like to see. The Quebec
example is a case in point. The comprehensive network of clinics (CLSCs) in Quebec – some of
which combine both health and social services – was established without ever fundamentally
altering the structure of the health care system or affecting the priorities of decision makers and
users of the system. Finally, there is a tendency with some models to consider each condition of
the model as an end in itself. As a result, the entire project can be compromised if any one
condition is not met.
As indicated in Appendix F, there are hundreds of primary health care organizations in

place across the country and numerous initiatives underway to create more. Unfortunately, for
the most part, efforts made across Canada to implement primary health care have concentrated
on isolated pilot projects with short-term funding. The approaches are fragmented and piecemeal
and have not been able to capitalize on the potential for transforming the health care system.
Delays in moving ahead with primary health care have had a ripple effect across the health care
system. The case of emergency departments in Canada offers a startling illustration. In the
absence of primary health care alternatives, patients and health care providers have few options
other than using emergency departments (Canadian Association of Emergency Physicians 2001).
This problem is made even worse if hospitals are unable to make the best use of their available
beds due to a lack of community-based programs to provide home care support for people who
are recuperating.
120
All of these experiences with primary health care to date have provided a good beginning,
but together, they have not created the major breakthrough in primary health care that is needed
to transform the health care system. The best approach, in the Commission’s view, is to:
• Provide targeted funding tied to a common national platform of essential building blocks
for primary health care;
• Create an impetus and the right incentives for widespread change;
• Clearly identify and remove obstacles; and
• Openly report to Canadians so they can hold their governments and health care providers
accountable if progress is not made.
Fast-Tracking Primary
Health Care Change
The proposed Primary Health Care Transfer should be used to “fast-track” primary
health care implementation. Funding should be conditional on provinces and
territories moving ahead with primary health care reflecting four essential building
blocks – continuity of care, early detection and action, better information on needs
and outcomes, and new and stronger incentives to achieve transformation.
Using the Primary Health Care Transfer as a Catalyst for Action

Several important points are clear from the experience in Canada and around the world.
Primary health care has the potential to fundamentally transform the way health care is delivered
in Canada. The benefits to individual Canadians and to the health system would be enormous
both in terms of improving health and in sustaining the health care system. There is almost
unanimous agreement that this is the direction we should be headed. The difficulty lies not in
choosing the destination but in overcoming the obstacles that stand in the way of making
primary health care the fundamental pivot of Canada’s health care system.
Establishing Four Essential Building Blocks

In the Commission’s view, the following four building blocks, set out in order of priority,
are essential to primary health care in Canada and cut across all potential models of care:
1. Continuity and co-ordination of care
2. Early detection and action
3. Better information on needs and outcomes
4. New and stronger incentives
Within the scope of these four building blocks, there is considerable room for action and
flexibility. The Commission does not believe that there is a single model for primary health care.
However, given the importance of these four building blocks and the need to move ahead in the
concerted way across the country, funding from the Primary Health Care Transfer should ensure
that these conditions are met through a variety of approaches that are developed and
implemented in provinces and territories.
121
Continuity and Co-ordination of Care

Too often, Canadians are left to fend for themselves and find their way through a maze of
services and providers to get the best information and the full range of services they might need.
This fragmentation is also a source of needless cost. It leads to a multiplicity of repeated tests
and consultations. It is often accompanied by “horizontal” rigidity between medical specialities
(e.g., endocrinology and cardiology independently providing care for a person with diabetes) or
by “vertical” rigidities between levels of care (e.g., institutional care and home care for an
elderly person). Other costs are generated by poor patient care or by care that is not at an
adequate level (Kohn et al. 2000).
Some important steps must be taken through primary health care to address this problem and
provide continuity of care.
• Case managers – A case manager is someone who guides individual patients through the
various aspects of the health care system and co-ordinates all aspects of their care. The
objective is to personalize care for patients and to provide appropriate linkages between
different levels and types of care. In many models, family physicians play the role of
case manager. Proponents of “advocacy nursing” see nurses as the patient’s key contact
point and guide through the health care system. However, a very successful Health
Transition Fund project demonstrated that the case manager does not necessarily have to
be a doctor or a nurse as long as access to required medical and nursing services is
assured without untimely delays and unnecessary restrictions (Durand et al. 2001). The
important role of case managers is also highlighted in Chapter 8 on home care.
• Service integration – Primary health care organizations can take on different aspects of
diagnosis, treatment, and rehabilitation for patients in addition to new responsibilities in
prevention and health promotion (Shortell et al. 1994). This concept of service
integration is at the heart of initiatives in many provinces to regionalize services.
• Care networks or health management programs – These networks typically focus on
providing ongoing care for people with chronic health conditions. In this approach, teams
of health care professionals participate in developing and implementing plans for a
patient’s care, making sure he or she receives all the appropriate services including
medications, prevention or education activities, and medical treatments.
Early Detection and Action

Along with the development of primary health care, there is a growing recognition of the
need to integrate public health perspectives with front line medical care. In the United States, for
example, experience has shown that the separation of prevention from medical treatment at the
clinical level leads to poorer treatment and lower quality preventive care in terms of screening.
As one expert suggests, “Too many things can go wrong when a woman’s physician is not held
responsible for making sure she gets regular mammograms and Pap smears and following up to
ensure that abnormal findings are dealt with promptly” (Davis 2002, 125). General practitioners
or nurse practitioners should systematically assess their patients’ risk factors including smoking,
nutrition and physical activity. In certain European models, primary health care organizations
are also given the responsibility for immunization campaigns that have led to impressive success
rates (Saltman and Figueras 1997).
122
Primary health care can play an important role in preventing illness and injury, and
improving health over the long term. Two types of actions are critical – those that are designed
to encourage people to adopt healthier lifestyles such as programs to improve cardiovascular
health or reduce smoking, and those that are targeted at specific risks and preventing certain
illnesses through screening, immunization, and infant care.
Better Information on Needs and Outcomes

Information is critical for primary health care, particularly given the flexible options,
different types of care, and different health care providers involved. As Hutchison and Abelson
(1996) suggest, information is essential to primary health care because:
• It helps patients make informed choices on available services as well as on diagnostic,
therapeutic and preventive options;
• It gives health care providers the information they need about their patients and their care
so that they can provide continuity of care, monitor their health and provide appropriate
prevention programs when necessary;
• It allows health care professionals to keep up with the immense amount of knowledge
necessary for good practice and to apply this knowledge to their patients’ specific
circumstances;
• It gives health care administrators the information they need to ensure that communities’
needs are addressed and that resources are allocated to priority needs;
• It provides in-depth knowledge of the health needs and expectations of the population
and, at the same time, allows policymakers to assess the impact of different approaches
on improving the quality of primary health care services.
For these reasons, primary health care should be a major focus for actions designed to
implement electronic health records and link patients and health care providers not only to
patient records but also to comprehensive sources of reliable information about illnesses,
prevention, and prescription drugs. Recommendations in this area are highlighted in greater
detail in Chapter 3.
New and Stronger Incentives

The best way of implementing primary health care and making it the central focus of the
health care system is to have appropriate incentives in place. These include: •
Financial incentives – Under the current system, the way in which physicians are paid
and the lack of appropriate mechanisms for paying other health care providers in primary
health care settings are significant obstacles. Incentives need to be put in place for health
care providers to work in primary health care settings and be paid appropriately for the
comprehensive care they provide.
• Certainty and stability – Primary health care initiatives to date have been uncertain and
limited in time and scope. Some assurance that primary health care is “here to stay” and
that new models will not quickly be replaced once temporary funding runs out would
encourage more health care providers and health regions to pursue these approaches. It
also would provide more time for primary health care organizations to build strong
relationships with patients, their families and their communities, and allow professionals
to develop their skills and competencies in a primary health care environment.
123
• Recognition of front line staff – In primary health care, health care providers who are
the front line of service are critical. Their role should be valued as an essential part of the
health care team.
• Work-life conditions – Primary health care organizations should
“There should be a shift from
provide more flexibility for health care providers in terms of how
services are organized and delivered, less rigid scopes of practice,
fee-for-service to salary and many more variety in the type of work, and shared responsibilities for
patients and their health.
young doctors would actually
• Quality of care – Many health care providers understand that primary
prefer this to being concerned
health care can provide better quality of care because they are able to
with overhead.” spend more time with patients and give them more attention, develop
personal and stable relationships, reduce the risk of errors, and achieve
ROBERT YOUNG. PRESENTATION
AT HALIFAX PUBLIC HEARING.
better health outcomes. This is a strong incentive for both health care
providers and patients.
The issue of how physicians are paid has been the subject of much debate. Many suggest
that one of the key obstacles to further development of primary health care is the persistence of
fee-for-service payments for physicians. Paying physicians for each separate service they
provide can create a perverse incentive to focus on the quantity of services provided rather than
on the quality of services in order to maximize a physician’s income. The other problem is that
current fee schedules often do not provide a mechanism for paying physicians for providing
more comprehensive care focused on prevention. There are some situations where fee-for-
service payment may be the most appropriate approach, such as payments for specialist services.
However, for general practitioners and family physicians, fee-for-service payment plans can be
a major obstacle to primary health care.
Most primary health care models focus on alternative payment schemes for physicians, such
as salaries or rostering in which physicians are paid a set annual amount for each individual who
signs up as their patient. These alternatives would allow physicians to spend more time with
their patients, learn more about their health and their lifestyle, and develop a more holistic
approach to their treatment that no longer focuses on the number of billable services provided.
No single payment scheme is without its downside. Salaried doctors may choose to provide only
the minimum service required knowing it will not affect their income, and capitation can
provide an incentive for doctors to only accept healthy patients on a roster because they will
require less time for care. Indeed, there is some evidence to suggest that mixed payment
schemes may offer the best compromise for securing doctors’ incomes and allowing them more
time to care for individual patients (Mathies 2000).
Some would go even further in terms of changing how physicians are paid. Currently,
regional health authorities in most provinces are responsible for the organization and delivery of
health care services, including primary health care. Physicians directly affect much of the
services regional health authorities are expected to provide from diagnostic tests to surgical
time. Yet, fee-for-service physicians bill directly to the provincial government insurance plan
for payment. Arguments have been made that this separation between the people in charge of
“organizing services” and the people in charge of “paying doctors” further inhibits the
development of primary health care and must be resolved.
124
Two recent provincial health care reviews suggested that provincial

governments give serious consideration to making regional health
authorities responsible for paying some fee-for-service doctors in order to “Primary health care does not
allow them greater flexibility in developing primary health care initiatives simply mean changing the way
and alternative payment schemes (Fyke 2001; Mazankowski 2001). The
Commission agrees that this option deserves further investigation by we pay physicians – rather,
provincial governments.
it includes determinants
The intent of the Primary Health Care Transfer is to provide a major [of health]….”
catalyst for primary health care reform across the country. The goal is not V I C T O R I A C OALITION FOR
hundreds more small-scale experiments with primary health care but HEALTHCARE REFORM. PRESENTATION
VICTORIA PUBLIC HEARING.
fundamental, lasting transformation of the health care system.
AT
With these building blocks in mind, funds from the Primary Health
Care Transfer should be allocated to provinces and territories to address the following: •
Providing training and retraining for health care providers to work in primary health care
environments. This would also include training for case managers whose role will be
vitally important to the success of primary health care approaches;
• Implementing new approaches for paying physicians and other health care providers so
that the best use can be made of the mix of skills of various health care providers;
• Substantially expanding health promotion and prevention programs. (Further information
about targeted areas for these investments is provided in subsequent recommendations in
this chapter); and
• Collecting information, evaluating results, assessing outcomes and sharing best practices
in primary health care.
The proposed Primary Health Care Transfer would provide $1 billion to the provinces and
territories on a per capita basis for the next two years. Provinces and territories would be
expected to match the federal Transfer using new and existing resources already allocated to
primary health care initiatives. Funds should be provided on the condition that provinces and
territories would allocate funding to the priorities noted above and implement primary health
care approaches.
Building NatiMnal MMmentum, Attacking

Obstacles and RepMrting PrMgress
The Health Council of Canada should sponsor a National Summit on Primary Health
Care within two years to mobilize concerted action across the country, assess early
results, and identify actions that must be taken to remove obstacles to primary health
care implementation.

The Health Council of Canada should play a leadership role in following up on the
outcomes of the Summit, measuring and tracking progress, sharing information and
comparing Canada’s results to leading countries around the world, and reporting to
Canadians on the progress of implementing primary health care in Canada. 125
Building and Maintaining Momentum

Provinces and territories have primary responsibility for deciding how health care services
are organized and delivered in their health care system, including primary health care. It is up to
them to decide which of the different approaches to primary health care is most appropriate and
most viable for their residents.
Nonetheless there is considerable room for collaboration and co-operation. For many years,
the provinces and territories have worked together on common issues of concern, sharing ideas
and learning from each other’s experiences. Furthermore, the potential for primary health care
and the important role it can play in transforming the health care system demands national
leadership and national action.
For these reasons, the Commission calls on the provinces and territories to join forces to
galvanize the energy and ideas of health care providers and others through a National Summit on
Primary Health Care to be organized by the proposed Health Council of Canada. The Health
Council would then be responsible for following up on the outcomes of the Summit, measuring
progress and providing regular reports to Canadians.
The proposed Summit should bring together representatives of the federal, provincial and
territorial health ministries, as well as representatives of the key health professions, regional
health authorities across the country and people with front line experience in primary health
care. Other organizations from the public and private sector, including regulatory bodies,
voluntary organizations and unions, should also be involved. And ample opportunity should be
provided for a cross-section of Canadians to participate in this important event.
The purpose of the Summit should be to:

• Critically examine achievements to date in terms of implementing primary health care
consistent with the four building blocks identified by the Commission;
• Identify the barriers and the actions that need to be taken to overcome them;
• Mobilize concerted action on best practices on primary health care;
“Shine
• the spotlight” on those responsible for primary health care, identify where progress is or is
not being made, and lay the groundwork for measuring future results. The Summit must be more
than just a gathering of advocates for primary health care. Its focus must be on action and
implementation. The participants need to confront the difficult challenges, including scope of
practice issues, and should clearly highlight the remaining obstacles to change. The Summit
should bring experts from other countries to assess the current situation in Canada and provide
their insights. The recommendations from the Summit must set the stage for concerted action
across the country. Much like the World Health Organization and UNICEF conference on primary
health care in 1978 spurred action around the world, the national Summit in Canada should help
build momentum for change.
To follow through on the outcomes of the Summit, the Health Council of Canada should
play a crucial leadership role, working with provinces and territories to measure and report on
progress. Specifically, the Health Council should:
• Develop indicators and measure progress in key areas including integration of prevention
into medical care, retention of health professionals, adoption of alternative modes of
remuneration for health care providers, and effectiveness of primary health care
approaches in improving health outcomes;
126
• Report regularly and clearly to Canadians on the progress of their governments and
health care providers in removing obstacles to widespread implementation of primary
health care;
• Expand primary health care research on controversial issues such as the remuneration of
health care professionals, work organization, funding of primary health care
organizations, and registration (rostering) of patients;
• Compare outcomes in Canada with best practices in other countries around the world;
and
• Assist in the development of health promotion and prevention initiatives to ensure that
information is shared with the general public through a variety of media.
The Health Council should also be in a good position to support the provinces and territories
as they move ahead with strategies for implementing primary health care. Those strategies
should focus on four conditions that are necessary for successful change (Nestle 2002).
• Proposals based on evidence – As noted earlier, there is insufficient and even
contradictory evidence on important characteristics of primary health care including
work organization, professional remuneration, the quality of care or patient satisfaction
(Hutchison et al. 2001; Abelson and Hutchison 1994). This leaves a number of issues
open for endless debate and discussion. The Health Council of Canada can play an
important role, working with major research organizations to expand targeted research in
these areas.
• A clear message – One of the difficulties with primary health care is that the message is
not always clear in terms of what primary health care is intended to do and why it is a
preferred approach for our health care system. Based on the outcomes of the Summit, the
Health Council should work with the provinces and territories to develop and
communicate a consistent message to Canadians about the objectives and benefits of
primary health care.
• Well-identified targets – The Health Council of Canada should take the lead in
developing appropriate targets, tracking results and measuring progress in achieving the
targets. This should build on the development of electronic health records and the overall
work of the Council in developing and reporting on key health indicators.
• Targeted approaches to individuals and communities – Primary health care initiatives
should be focused on individuals and their communities. This means being clear on
objectives and expectations and the benefits primary health care can provide. This is true
for health care providers as well. At the end of the change process, primary health care
providers need to understand that they will have a broader role in the health care system,
better working conditions, and a greater ability to respond to their patients’ needs and
improve their health. The public needs to see that primary health care is living up to its
promise of providing better access, better integration and better care. The Health
Council, provinces, and territories need to reinforce these messages with Canadians as
we move ahead with transforming Canada’s health care system.
127
Strengthening the RMle Mf

PreventiMn
Prevention of illness and injury, and promotion of good health should be strengthened
with the initial objective of making Canada a world leader in reducing tobacco use
and obesity.

All governments should adopt and implement the strategy developed by the Federal,
Provincial and Territorial Ministers Responsible for Sport, Recreation and Fitness to
improve physical activity in Canada.

A national immunization strategy should be developed to ensure that all children are
immunized against serious illnesses and Canada is well prepared to address potential
problems from new and emerging infectious diseases.
Promoting Good Health

One of the key objectives of primary health care is to prevent illness and injury, and
improve the overall health of Canadians. There is a growing awareness that many illnesses can
be prevented if people take better care of their health. For example, over 90% of type II (or
adult- onset) diabetes and 80% of coronary heart disease could be avoided with good nutrition,
regular exercise, the elimination of smoking, and effective stress management (WHO 2002).
Over 90% of lung cancer deaths and 30% of all other cancer deaths could be prevented in a
tobacco-free society (Statistics Canada 2002d).
There also is a growing understanding that broader determinants of health such as lifestyle
factors, adequate housing, a clean environment and good nutrition have an important impact on
the health of individuals and communities, and also hold tremendous potential for improving
health and preventing illnesses. Primary health care organizations and providers need to pay
more attention to the impact these broader determinants of health can have both on individuals
and communities. A focus on the determinants of health at the community level can result in
“Healthy populations need
actions to strengthen social support mechanisms (Mechanic 2000). Many types of health
treatment organizations,
less often, including medical clinics and hospitals, have been engaged in all sorts of
partnerships with social agencies in their communities (Gamm 1998). In fact, health
organizations
and respond more effectively have the same responsibility to the communities they serve as physicians have
toward their patients – they must prevent illness as well as heal and provide support and
when treatment is required.”
advice as well as treatment.
CANADIAN PUBLIC HEALTH
A S S O C I A T I O N 2001.
The impact of determinants of health and lifestyle choices is well known to governments
and to health care organizations. Unfortunately, the key problem lies in turning this
understanding into concrete actions that have an impact on individual Canadians and communities. In many
128
areas in public health, the gap between knowledge and practice is still too great. Too often, to
paraphrase the World Health Organization’s definition of public health, “a comprehensive
understanding of the ways in which lifestyles and living conditions determine health status,” is
not followed by a corresponding urge “to mobilize resources and make sound investments in
policies, programmes and services which create, maintain and protect health by supporting
healthy lifestyles and creating supportive environments for health” (WHO 1998, 3).
A portion of the proposed new Primary Health Care Transfer should

be targeted to expanding efforts by provinces and territories to prevent
illnesses and injuries, promote good health, and integrate those activities “According to the World Health
with primary health care. The Health Council of Canada can also play a
Organization, much of the
major role in identifying and promoting healthy living conditions and the
adoption of healthy lifestyles. By integrating the Canadian Institute for world’s future health burden will
Health Information with the Health Council, the Council would assume
responsibility for CIHI’s work on the Canadian Population Health be a result of lifestyle practices.”
Initiative, a special program intended to provide information on the FPT M I N I S T E R S R E S P O N S I B L E
determinants of health, contribute to the development of population health FOR P H Y S I C A L A C T I V I T Y 2001 .
information infrastructure, support policy analysis, and share new

knowledge with decision makers and the public.
Another important initiative is the proposed creation of a new Centre for Health Innovation
focusing on health promotion outlined in Chapter 3. This Centre would provide reliable and
objective information on best practices across the country, trends in health risks and behaviours
that threaten or compromise health, and work with provinces, territories and the Health Council
of Canada to develop effective health promotion strategies.
Addressing Leading Causes of Major Health Problems

Behaviours such as smoking, lack of physical activity, poor diet, and alcohol use have
profound effects on health, largely because they are related to the leading causes of death, illness
and disability such as heart disease, cancer, stroke, respiratory disease, diabetes and injuries.
Recent increases in certain forms of cancer and diabetes can largely be attributed to individual
health practices such as smoking, diet, and physical activity. Provinces, territories and the
federal government have taken action to put health promotion strategies in place to address these
concerns and some good progress has been made. Yet Canada continues to have high rates of
heart disease, some cancers and other diseases that could be largely prevented.
Consider these facts about smoking (see Maps 5.1 and 5.2):
• Estimates are that smoking costs our economy more than $16 billion each year, including
$2.4 billion in health care costs and $13.6 billion due to lost productivity through sick
days and early death (Stephens et al. 2000);
• One study suggests that an effective school-based smoking prevention program could
potentially result in an initial 6% reduction of smoking and 4% over the long term. It
estimates the cost-benefit of such a program could mean net savings of up to $619
million annually (Stephens et al. 2000);
• Smoking also takes a horrible toll on Canadians; up to 45,000 Canadians die each year
from smoking (Makomaski-Illing and Kaiserman 1999);
129
130
Map 5.1 “Former” Smokers, by Health Region, 2000/01
B
A Proportion of the Population Aged 12 or Over

Who Are “Former” Smokers
Below the Canadian average
B About same as Canadian average
Above Canadian average
No data

Map 5.2 “Current” Smokers, by Health Region, 2000/01
A Proportion of the Population Aged 12

or Over Who Are “Current” Smokers

About same as Canadian average
B Above Canadian average
No data
131
• In the late 1990s, 19.2% of Canadian women were daily smokers. This number compares
favourably with rates in other OECD countries but it is significantly higher than rates in
Japan where only 14.5% of Japanese women smoke. Twenty-two percent of Canadian
men smoked daily in the late 1990s compared to 19.2% in Sweden (OECD 2001a).
Obesity is also becoming a major threat to the health of many Canadians. •

In 1997, obesity resulted in $1.8 billion in medical costs (Birmingham et al. 1999).
• Since 1994/95, the percentage of the population aged 20 to 64 (excluding pregnant
women) reported as obese has increased from 13.4 to 15.2% in 2000/01 (Statistics
Canada 2002g).
• Canadians are now more likely to be obese than adults in most other OECD countries.
Countries such as the Netherlands, Norway, Sweden and Switzerland have adult obesity
rates more than one-third lower than Canada (OECD 2001a). On the other hand, the
United States and the United Kingdom have higher obesity rates.
• While obesity can be influenced by genetic factors, physical inactivity and poor diet are
clearly significant factors (McDonald 1995).
• Nine percent of Canadians age 12 and over are concerned about the amount of fat in their
diet but are not taking any action to reduce it (FPT Advisory Committee on Population
Health 2000).
Evidence also suggests that Canadians are not as physically active as
they should be in order to maintain good health (see Map 5.3). Fifty-seven
“Physical inactivity costs the percent of Canadians 18 and over do not meet minimum recommended
Canadian health care system guidelines for physical activity, down from 79% in 1981. In 2000, over
one-half of children aged 5 to 17 did not meet recommended levels of
at least $2.1 billion annually physical activity (Canadian Fitness and Lifestyle Research Institute 2002).
Physical inactivity cost the health care system an estimated $2.1 billion in
in direct health care costs.”
1999. Reducing the prevalence of physical inactivity by 10% would save
F PT M I N I S T E R S R E S P O N S I B L E $150 million in health care costs per year. Approximately 21,000 lives
FOR P H Y S I C A L A C T I V I T Y 2001. were lost prematurely in 1995 because of physical inactivity (Katzmarzyk
et al. 2000).
The Federal/Provincial/Territorial Ministers Responsible for Sport, Recreation and Fitness
presented a strategic blueprint to the Commission on April 7, 2002, in Iqaluit, to increase the
level of physical activity in Canada by:
• Increasing the time devoted to physical education and sport in schools;
• More systematically educating all Canadians on the value of physical exercise;
• Encouraging more active forms of recreation through community-based programs; and
• Supporting healthier workplaces that encourage less sedentary lifestyles.
The Commission wholeheartedly supports the thrust and objectives of this strategy. Clearly, these
three areas – tobacco use, obesity, and physical inactivity – are priority areas that must be
addressed in order to improve the health of Canadians and prevent illness in the years to come.
Tackling these issues will take a concentrated effort and investment on the part of all governments.
The Health Council of Canada can play a leading role in sharing information about best practices
and working with provinces and territories on effective, targeted promotion strategies. Dedicated
promotion strategies supported by the new Primary Health Care Transfer can
132
Map 5.3 Leisure Time Physical Activity, by Health Region, 2000/01
Proportion of the Population Aged 12 or Over

A Who Are at Least Moderately Physically Active

About same as Canadian average
Above Canadian average
B No data
133
make Canada a leader in reducing smoking and obesity, increasing physical activity, and reducing
the incidence of serious illnesses such as heart disease, cancer, and respiratory disease. A recent
survey report by the Canadian Cancer Society indicated that efforts to raise awareness of the
health risks of smoking can have positive results. In a Fall 2000 survey, 43% of smokers said the
graphic health warnings on cigarette packages raised their concerns about the health risks of
smoking and 44% said they were motivated to quit (Martens 2002). These and other efforts to
reduce smoking and address the growing problem of obesity should be expanded across Canada.
As noted in Chapter 2, the proposed Health Council of Canada would include the important work
underway by the CIHI. One of its current initiatives is the Canadian Population Health Initiative.
This intergovernmental work should continue under the Health Council of Canada and should
assist in assessing health promotion initiatives and measuring the benefits of integrating
prevention with primary health care. Important links should also be established with the proposed
Centre for Health Innovation focusing on health promotion outlined in Chapter 3.
A National Immunization Strategy

Immunization is one of the most effective illness prevention strategies. Canada has a solid
record in this area and immunization rates for most infectious diseases compare favourably with
other OECD countries.
In the past few years, however, the cost of new vaccines and the lack of accurate information
on their effectiveness and safety have worried public health specialists. The fact that
Canadian immunization programs are dated and have been in place for many years adds to
“Vaccination is onethe
of concern
the that Canada is not well prepared to face new and emerging problems due to
globalization and the evolution of infectious diseases. In addition, in some regions of the
most cost effectivecountry,
health immunization rates have deteriorated as a result of public fear of vaccines as well as
lack of attention by health care professionals.
interventions available.”
T O R O N T O P U B L I C H E A L T H 2002.
The National Advisory Committee on Immunization has facilitated discussion about these
issues with the provinces, territories and federal government. But even the specialists who
participate in this committee admit that the time has come to move to another stage in which
some form of joint planning is done in addition to sharing information. Some specific
measures have been suggested (Canadian Public Health Association 2002; Embree 2001)
including:
• Establishment of an immunization registry

• Harmonization of immunization schedules
• Identification of national standards in terms of coverage
• Vaccine safety monitoring
• National procurement and evaluation policies
• National information and awareness campaigns.
The proposed National Drug Agency outlined in Chapter 9 should be responsible for
developing guidelines and purchasing vaccines as part of a new national immunization strategy.
134
What DMes This Mean fMr Canadians?

The objective of moving ahead with primary health care is nothing short of transforming
Canada’s health care system. It means that the promise and potential benefits of primary health
care can be achieved – not overnight, and not in some hasty, haphazard way, but in a practical,
deliberate, and consistent way across the country.
The Commission calls on provinces and territories to take the next essential step to move
forward with a national platform for primary health care in place – a platform that is built on
four essential building blocks. The proposed Primary Health Care Transfer should provide the
financial incentive and support for provinces and territories to move, and move quickly, with
major steps to implement primary health care approaches and begin work on the important goal
of preventing major illnesses over the longer term.
For Canadians, the benefits are clear:

• All Canadians will have better access to primary health care approaches focused
specifically on maintaining and improving their health.
• Their experiences with the health care system will no longer be isolated events but will
be linked by a common thread – primary health care – bringing together all aspects of the
care they need from dealing with minor illnesses to managing prescription drug use,
screening for cancer, ensuring that home care is available, or providing support in
people’s last months of life.
• The health care system will have a better balance between preventing illness and injury
and taking action when people are sick.
• With deliberate actions to prevent illness and injuries, promote good health, and give
people access to appropriate care, better use can be made of available resources, and
costs can be contained.
• Teams and networks of health care providers can work together to address health
problems, reduce and prevent the incidence of leading diseases, co-ordinate care for their
patients, and share responsibility for providing comprehensive care for Canadians.
• People who are chronically ill or who have ongoing mental health problems will get the
care and support they need through a variety of primary health care approaches.
• Rates for certain preventable illnesses and injuries should go down as a result of
dedicated efforts to promote good health. These deliberate and concerted efforts to
improve overall health will pay dividends for generations to come.
135
I MPROVING ACCESS,
E NSURING Q UALITY

6
• Use the new Diagnostic Services Fund to shorten waiting times for
diagnostic services.
• Implement better ways of managing wait lists.
• Take deliberate steps to measure the quality and performance of Canada’s
health care system and report regularly to Canadians.
• Ensure that the health care system responds to the unique needs of official
language minorities.
• Address the diverse health care needs of men and women, visible minorities,
people with disabilities, and new Canadians.
The Case fHr Change

Canadians want and expect to have access to health care services
when and where they need them. They expect high standards of quality to “It was Einstein who said
be met. They expect the treatments and services they receive to be based
‘insanity is doing things the way
on the best available scientific evidence and the latest knowledge. And
they expect the health care system to diagnose health problems, cure we have always done them and
illnesses and treat injuries, and help improve not only their overall health
but their quality of life as well. Too often, however, those expectations are expecting different results.’
not being met and, as a result, Canadians’ faith in the health care system is
To address the problem of
undermined.
accessibility, we must explore
Providing timely access to quality health care services is a serious new ways of delivering care,
challenge in every province and territory. Consistently, the Commission
heard concerns from Canadians about waiting for diagnostic tests, waiting rather than assuming the solution
for surgeries or waiting to see specialists. In the minds of many Canadians, lies only in continuing expansion
the quality of our health care system should be judged, first and foremost,
by its ability to provide timely access to the care people need. In fact, of hospital based programs.”
quality is about a lot more than access. It includes a number of important H A M I L T O N HSO M E N T A L H E A L T H
factors related to the safety of the treatments and the outcomes that are AND N U T R I T I O N P R O G R A M 20 0 1 .
137
achieved. Understandably, Canadians’ first concern is with access, and that
issue must be dealt with on a priority basis. At the same time, quality will be an increasingly
important issue and one that needs to be addressed on an ongoing basis.
The sections of this chapter outline specific and deliberate actions that should be taken to
reduce waiting times, put objective and transparent processes in place for managing wait lists,
measure the performance of Canada’s health care system and use that information to improve
quality, as well as improve access and quality for minority language communities and meet the
differing health care needs of men and women, visible minorities, people with disabilities and
new Canadians.
By taking action on these issues on an urgent basis, we can restore Canadians’ confidence in
their health care system and, most importantly, we can make sure they get timely access to high
quality health care services.
Reducing Waiting Times and

Managing Wait Lists
Provincial and territorial governments should use the new Diagnostic Services Fund
to improve access to medically necessary diagnostic services.

Provincial and territorial governments should take immediate action to manage wait
lists more effectively by implementing centralized approaches, setting standardized
criteria, and providing clear information to patients on how long they can expect to wait.
Waiting for Health Care

Identifying the Problem
Waiting for health care is a serious concern for Canadians and it has become a preoccupation
for health care professionals, managers, and governments. Studies and public opinion polls have
consistently shown that one of the top concerns of rural and urban Canadians is health care access
(Mendelsohn 2002; Sanmartin et al. 2002; CPRN 2001; Rural Secretariat Research and Analysis
Group 2001). At their August 2002 meeting, Canada’s Premiers acknowledged that access to
health services was the highest priority for all Canadian citizens.
“I go to Emergency when I am
sick; there are no other choices.

Time and time again, the Commission heard that, when it comes to access to specific
diagnostic
Waiting to see a specialistprocedures and some surgical procedures, wait lists (i.e., the number of people
waiting for a particular service) and waiting times (i.e., the average time people are on the wait
is a long-term wait,
list before they receive a service) are too long. Long waiting times are the main, and in many
usually about 6-12cases,months.”
the only reason some Canadians say they would be willing to pay for treatments outside
of the public health care system. Health care providers, regional health authorities and hospitals
R O S S H O W A R D 2001.
are trying to keep pace with growing demands. More surgeries, treatments and tests are being
performed, but demands often outstrip their ability to deliver the necessary services on a timely
basis. As a participant in
138
IMPROVING ACCESS, ENSURING QUALITY
the Commission’s Policy Dialogue on Access at Dalhousie University put

it, long waiting times are not caused by the system performing fewer “I am one of that great cadre
diagnostic and surgical procedures but because medical advances now
allow us to deliver more of these services and to a wider range of people. called ‘elective’ patients. We are
While the concerns of Canadians are clear, the debate over waiting times
not seen as emergencies …
and wait lists is anything but. The debate has become clouded by
contradictory evidence and conflicting claims by health care professionals, I have recently had a hip
managers, health policy experts, and governments at all levels across the
country (Lewis et al. 2000; Barer and Lewis 2000; Shortt 1999). The replacement; I was waiting for
current debate appears to be polarized between two extreme and that replacement for almost two
incompatible positions:
years … the word ‘elective’ is
offensive; it isn’t as though we’re

• Those who look at the way wait lists are managed across the
country and conclude either that it is impossible to say whether going to the store to buy some
there is a problem or that the problem is more perception than
reality; and shrimp versus some liver: we have
• Those who use incomplete information to conclude that the no choice about using the health
problems are so severe that the only solution is to allow parallel care system.”
private facilities in which individuals can use their own funds to
purchase some services and, in their view, “take some pressure off CAROLYN ATTRIDGE. PRESENTATION
AT VICTORIA PUBLIC HEARING.
the public system.”
The Commission rejects both of these positions.
In response to the first view, the problem is not just one of perception. There is evidence to
suggest that there are problems in waiting times for some services but not in others. A
comprehensive examination of the situation in Manitoba, for example, showed that the provincial
system was dealing well with life-saving surgeries such as bypass operations, but not as well with
non-life-threatening elective surgeries (DeCoster et al. 2000).
In response to the second view, those who argue that the public system is no longer able to
manage the situation fail to take into account the progress that is being made in some
jurisdictions. In addition, private facilities may improve waiting times for the select few who can
afford to jump the queue, but may actually make the situation worse for other patients because
much-needed resources are diverted from the public health care system to private facilities.
As individual provinces and territories have struggled to deal with waiting times and wait
lists within their own systems, progress is being made in some areas but more effort needs to be
put into generalizing those efforts across the country (Glynn et al. 2002; Lewis et al. 2000).
Clearly, the progress is not fast enough for Canadians. More can and must be done across the
country to give Canadians what they want and deserve – timely access to the health care services
they need.
Addressing Immediate Priorities – Access to Diagnostic Services

There are three key areas where the health care system needs to solve waiting times and
wait list problems:
• Access to advanced diagnostic technologies such as MRIs (magnetic resonance imaging)
and CT (computed tomography) scanners;
139
COMMISSION ON THE FUTURE OF HEALTH CARE IN CANAD
• Access to specialists (though this varies greatly between specialities, between provinces
and even within provinces); and
• Access to some surgical procedures (e.g., hip and knee replacements) that may not be
life-saving but would improve the patient’s quality of life.
While each of these three areas is important, the Commission believes that immediate and
tangible improvements can be made by addressing access to diagnostic services on a priority
basis. Problems in access to necessary diagnostic services can create bottlenecks in the rest of
the health care system. They also extend waiting times for patients who often must have a
diagnostic test to confirm a diagnosis before surgery or further treatment. By focusing on
diagnostic services as a first priority, provinces and territories can increase their investment in
necessary equipment and staff, and free up resources to be used to address pressing access
problems in other areas. Recommendations on better ways of managing wait lists should also
address a number of issues related to access to surgeries and specialists.
In terms of access to diagnostic technologies, there is no agreed upon definition of the

“right” number of MRIs or other new diagnostic technologies for a particular population.
Nonetheless, as Figure 6.1 shows, Canada has fallen behind other OECD countries in the
integration of this technology into the health care system. There also is a significant variation
among the provinces when it comes to the availability of advanced diagnostic technologies (see
Figure 6.2 and Map 6.1). While there may be many reasons for this under-investment, the most
obvious is that these technologies are incredibly expensive to purchase and require significant
funds to operate on an ongoing basis.
The proposed new Diagnostic Services Fund would provide direct support to provinces and
territories to increase their investment in advanced diagnostic technologies. Funds should be
used not only for purchasing technology but also for training and hiring the necessary staff and
Figure 6.1 25
Selected Imaging CT Scanners MRIs
Technologies
20
(Number per
Million People)
among OECD
Countries, 1999 15
10
0
Germany
Average
Average
United
Sweden
France
United
States
Canada
Kingdom
Australia
OECD
G7
Note: Due to limitations on the data only those countries for which reasonably current inventories exist have been used. Japan has been
excluded from the countries selected due to the disproportionate numbers of imaging technologies in use relative to other OECD
countries but is included in the calculation of OECD and G7 averages. Figures for Canada are 2001 and for Australia 1995.
Source: CCOHTA 2002a,b.
140
Figure 6.2 1.8

Selected Imaging
1.6 CT Scanners MRIs
Technologies
(Number per 1.4
100,000 People),
by Province and 1.2
Canada, 2001
1.0
0.8
0.6
0.4
0.2
0.0
Newfoundland and
Prince Edward
New Brunswick
Saskatchewan
Labrador
Island
Canada
Nova Scotia
Quebec
Ontario
Manitoba
Alberta
British Columbia
Source: CCOHTA 2002a,b.
technicians to operate and maintain the equipment, and interpret the results. The provinces and
territories should work closely with the expanded technology assessment capability of the
Health Council of Canada to ensure that new diagnostic technologies are assessed and integrated
appropriately into the health care system. Steps should also be taken to ensure that diagnostic
technologies are used appropriately (i.e., the tests are warranted given the medical conditions of
patients) and efficiently (i.e., making the maximum use of the equipment). Investments in
diagnostic technology will create some much-needed “breathing space” and give provinces and
territories the opportunity to invest existing resources in reducing waiting times in other
important areas.
Managing Wait Lists

Current Problems with Wait Lists
One of the most serious concerns is not only the length of time some people wait but the
way in which wait lists are managed. In fact, to say wait lists are “managed” is almost a
misnomer. There is no consistent way of dealing with wait lists in particular regions let alone on
a provincial or national basis. This affects the health of people who wait and it seriously
undermines Canadians’ confidence in their health care system.
When individual Canadians are told that they are on a wait list for a particular service, they
probably assume that there is a master list that is managed and co-ordinated based on the
urgency of their need. In reality, that is not what happens.
This is how wait lists are managed in Canada today.
• Most wait lists are managed by individual physicians or individual hospitals (with the
exception of some cardiac surgery lists and cancer care lists).
• There is little co-ordination of those lists between physicians or between hospitals. That
141
means an individual may be on a particular specialist’s list for an appointment but there
142
Map 6.1 Scanners in Canadian Hospitals, 2001
Type of scanner:
Positron emission tomography (PET)
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Magnetic resonance imaging (MRI)

ON
Computed tomography (CT)

Vancouver and area
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¥
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Toronto
and area
Montreal and area
Note: Reported by Hospitals or Health Authorities as of July 15, 2001.

Source: CCOHTA 2001.
may be other specialists who have shorter lists and could provide the service more
quickly. Some people may prefer to consult with particular specialists or to wait for
particular surgeons to perform their surgery. This certainly is their right, but it is a choice
they make and it may mean they have to wait longer.
• There are few rules that govern when and whether a person should be put on a wait list
for a particular service. Individual physicians have almost total discretion as to when a
person is placed on a list. Furthermore, there is no consistency in terms of “when the
clock starts ticking” – whether it is after the first visit to a family physician, the first visit
to a specialist, when the diagnosis is made or when a patient’s name is added to a
particular physician’s or hospital’s wait list (Fyke 2001).
• There is no serious auditing of wait lists to see if individuals are on the list appropriately,
if their condition or circumstances have changed so that they can be removed from the
list, or whether some individuals are on more than one list for the same procedure or
service (Sullivan and Baranek 2002).
In addition to the lack of clear procedures for defining and managing wait lists, there are a
number of factors that influence the length of wait lists and average waiting times. There may
not be a sufficient supply of specialists, surgeons, operating room nurses and technology.
Specialized technology such as MRIs may be in short supply. And people themselves make
choices that affect how long they wait, including decisions to delay or defer treatment for a
variety of reasons.
With all of these factors combined, it perhaps is not a surprise that wait lists are handled in a
somewhat haphazard manner. But the result is that the public is both confused and frustrated.
They do not understand why they wait so long, whether the time they wait is appropriate or too
long, and why something cannot be done to address their concerns. Furthermore, they are not
always told how severe their condition is, whether their health will deteriorate further if they
have to wait, and what options they might have in terms of seeing other specialists or going to
other hospitals.
Actions Underway
Provinces and territories are well aware of these problems and a number of different
initiatives are underway to try to address them. In addition to the Manitoba example cited earlier,
some jurisdictions have good processes in place for managing waiting times for some of the
more serious life-threatening conditions. Centralized registries for life-saving treatments such as
cancer and cardiac care allow the system to prioritize patients according to their need and their
risk (CardiacCareNetwork of Ontario 2001). However, these success stories have been difficult
to transfer to other jurisdictions or to other kinds of services. And there still are instances in
some provinces when individuals have to be transferred outside the country to receive care for
life- threatening conditions. This cannot and should not be allowed to continue.
Some encouraging work has been done by the Western Canada Waiting List Project
(Noseworthy et al. 2002). Established as a partnership among the western provinces, medical
associations, regional health authorities and health research centres, the WCWLP has made
important progress not just in understanding the reality of wait lists in western Canada, but also
in developing tools for physicians to rank urgency and to ensure that wait lists are managed in a
comprehensive, objective and transparent manner. The tools were tested by both physicians and
143
reviewed by focus groups of patients and were found to be effective particularly for assigning
people to wait lists for general surgery, knee and hip replacements, cataract surgery, and
children’s mental health. One limitation of the WCWLP is the fact that it did not address such
life-threatening illnesses as cancer or cardiac care. Work from Manitoba and Ontario suggests
that the greatest effort will be needed in addressing problems related to life-threatening illnesses,
not only because they are the hardest problems to tackle but also because they are the ones that
are most important to Canadians. Nonetheless, the work of the WCWLP is an important example
of how provinces and territories, health authorities and health care providers can work together
to manage waiting times and wait lists in a much more effective manner.
Considering Care Guarantees

One approach for addressing the problem of wait lists is establishing “care guarantees.” This
option was recommended in the Senate Committee’s (2002) recent examination of the Canadian
health care system and the Premier’s Advisory Council on Health in Alberta (Mazankowski
2001). Care guarantees provide patients with a guarantee that they will have access to the
treatment they need within a certain period of time. They have been implemented in several
European countries including the United Kingdom, Sweden and Denmark.
The advantage of care guarantees is the certainty and reassurance they provide to patients.
They also require health care authorities, providers and hospitals to take steps to ensure that the
guarantees can be met. On the other hand, care guarantees should be approached with some
degree of caution.
Currently, reliable methods are not available to determine what the appropriate guarantee
should be and what the likelihood is that the health care system would be able to meet the time
limits set in a guarantee. Care guarantees should rely on an objective assessment of both the
capacity of the system to provide the necessary service or treatment within a certain timeframe
and the urgency of the condition being treated. They cannot simply be pulled out of thin air and
trumpeted to Canadians as a magic bullet solution.
The other major concern is with the difference between life-saving and elective procedures.
Long waiting times for the diagnosis and treatment of life-threatening medical conditions such
as cancer and cardiac care are unacceptable. But the issue is different for elective surgeries or
services that are not life-saving. To begin with, it is difficult to rank elective surgeries by the
level of urgency. For example, is Mr. Smith’s knee replacement more pressing than Ms. Jones’
hip replacement? This is not to say that elective surgeries should be viewed as unimportant or
unnecessary just because the condition they treat is not life threatening. Over time, people’s
health can deteriorate as they wait for elective surgeries. There are important quality of life
“Inuit people are put at higher
issues that can be associated with hip replacements or cataract surgery. Providing these
risk due to waiting times.” surgeries can prevent other medical conditions such as depression in patients whose lives are
negatively affected by their decline in mobility or independence. But provincial and territorial
N U N A V U T M INISTER OF H E A L T H
AND SOCIAL SERVICES. PRESENTATION
health care
AT IQALUIT PUBLIC HEARING.
systems need flexibility in managing these surgeries effectively. That flexibility

could be lost if care guarantees were rigidly applied. It also would be unfortunate to see the
provincial and territorial health care systems handcuffed into care guarantees for elective or non-
life-saving services that could, in practice, mean they would have to reallocate resources away
144
from life-saving surgery or treatment in order to meet the care guarantees for other services.
Putting Co-ordinated Processes in Place

While care guarantees may not be the answer, the issue of waiting times cannot be left on
the back burner. The work of the WCWLP, CardiacCareNetwork, and other projects underway
across the country are important first steps, but it is time to “walk more quickly” with deliberate
steps to manage wait lists and provide objective and clear information for patients waiting for
care.
Specifically, steps should be taken by the provinces and territories, working with regional
health authorities, hospitals, physicians and other health organizations to:
• Implement procedures for managing wait lists in a centralized manner either within
specific regions of a province, in the province or territory as a whole, or between
provinces depending on the particular service involved;
• Implement standardized and objective criteria for assessing patients to ensure that the
time they wait between when they are diagnosed and when they are treated depends only
on the seriousness of their health needs. This work should be done with the full
participation of health care professionals involved in providing the services;
• Provide health professionals with the necessary training to ensure that patients’ needs are
objectively assessed according to the standardized criteria; and
• Provide patients with a clear and understandable assessment of:
–Why a particular service or procedure is being suggested and the options and alternatives that
are available on an interim and longer term basis, including the option of seeing another physician;
– The relative seriousness of their needs for the particular services based on an objective
assessment by health professionals and reflecting the standardized criteria;
– The approximate time they should expect to be on the wait list for a particular service
given the severity of their medical need; and
– Any changes to a patient’s condition or developments in the health care system that could
either lengthen or shorten the wait time.
Wait lists can be managed at different levels, either within a particular region, across a
province or territory, or even on a national basis. The evidence clearly suggests that wait lists for
elective surgeries and a great deal of diagnostic tests are probably best managed by individual
regional health authorities or within a province or territory as a whole. For advanced life-saving
surgeries such as cardiac and cancer treatment – areas where services tend to be concentrated in
major urban centres – wait lists may best be managed on a province-wide basis with some
interprovincial co-operation for provinces that may not offer these advanced services themselves.
There are a small number of life-saving procedures such as pediatric liver transplants, heart
transplants and single and double lung transplants, for example, that are performed so
infrequently and require such a specialized range of personnel and training, that the lists are best
managed on a national basis through provincial and territorial collaboration. Maps 6.2, 6.3 and
6.4 show the concentration of these highly specialized surgeries across the country.
145
146
Map 6.2 Heart Transplant Recipients, under 18 Years of Age, by Province of Treatment, 1996 to 1999
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Heart Transplant Recipients

Under 18 years of age
Transplants = 64
Transplants = 12
Less than 10
None
Source: Canadian Organ Replacement Registry, CIHI 2002.

Map 6.3 Liver Transplant Recipients, under 18 Years of Age, by Province of Treatment, 1996 to
Liver Transplant Recipients

Transplants = 77
Transplants = 52
10 to less than 40
Less than 10
None
1999 147
1999 148
Map 6.4 Single/Double Lung Transplant Recipients, under 18 Years of Age, by Province of Treatment, 1996 to
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Single/Double Lung Transplant Recipients

Transplants = 10
Less than 3
None

Perhaps the most important result from co-ordinated management of wait lists is better
information for patients. With a standardized and objective assessment of a patient’s need for a
particular service (whether it is elective surgery, life-saving surgery or access to advanced
diagnostics), physicians and other health care professionals can provide patients with a
reasonable assessment of how long they can expect to wait for a particular service. This
information and assurance will be a tremendous improvement over the current situation.
As better information, more consistent processes and objective criteria are in place, the
health care system should be able to provide appropriate and realistic targets for patients. When
it comes to life-threatening or potentially life-threatening conditions, Canadians should be
confident that the health care system can tell them:
• How long they will wait for a diagnosis;

• How long they will wait to see a specialist to confirm the diagnosis and plan a course of
treatment;
• How long they will wait before the treatment of their condition begins; and
• How long they will wait for appropriate rehabilitation therapy after treatment.
Canadians also need to understand that immediate service is not always
possible. As consumers, we have come to expect that products and services
should be available when and where we want them. With health care, that “In addition to the safety and
simply is not always possible. There are times when people have to wait
because the system is busy addressing the needs of people with more serious quality of care provided,
health problems. There are times when people have to travel to other centres attention must be paid to the
to get the health care services they need. The important thing is for Canadians
to know that waiting times are being reduced, that people with the most appropriateness of care.
urgent needs do not have to wait, and that wait lists are being managed in a
co-ordinated and objective way based on the urgency of people’s needs. It is time for us to stop the
dangerous, challenge the futile,

Taken together, the recommended actions to manage wait lists should and question the unknown.”
achieve three broad goals – fairness, appropriateness, and certainty. Fairness CANADIAN HEALTHCARE
means that wait times are set on objective criteria based on patients’ needs A S S O C I A T I O N 2001.
rather than by individual providers or hospitals. Appropriateness means that W RITTEN SUBMISSION .
the time people wait is appropriate for their condition. And certainty means
that people will have a clear understanding of how long they can expect to wait and why. In
future, it should be possible to set benchmarks and track progress in meeting those benchmarks
on an ongoing basis.
To make real progress in meeting those goals, it will require: •
The willingness of individual physicians to relinquish their personal management of
individual wait lists and participate instead in the development of objective and
transparent assessment criteria to be applied to all patients;
• The willingness of regional health authorities, hospitals, and provincial and territorial
health departments to provide the infrastructure for central management and co-
ordination of wait lists with the full participation of health professionals and the public;
• The willingness of provincial and territorial governments to work collaboratively in the
management and co-ordination of wait lists for some procedures and services that are
best managed interprovincially;
149
COMMISSION ON THE FUTURE OF HEALTH CARE IN CANADA ¥ FINAL REPORTCOMMISSION ON THE FUTURE OF HEALTH CARE IN CANADA ¥ FINA
• The willingness of the public to participate actively in their own care and to hold the
system accountable for providing services within a reasonable time period; and
• Adequate resources to provide timely access to care.
The Commission urges health care providers, regional health authorities, hospitals and
provincial/territorial governments to get on with the job, and soon. As part of its annual reports,
the Health Council of Canada should track and report on progress in reducing waiting times so
the Canadian public is in a position to judge the performance of their region, their province and
Canada as a whole in comparison with results in other countries.
ImprHving Quality
Working with the provinces and territories, the Health Council of Canada should
establish a national framework for measuring and assessing the quality and safety of
Canada’s health care system, comparing the outcomes with other OECD countries,
and reporting regularly to Canadians.
Assessing Quality in Canada’s Health Care System

What do we mean by quality in the health care system? Simply put, quality health care is
about delivering the best possible care and achieving the best possible outcomes for people
every time they deal with the health care system or use its services. As Saskatchewan’s
Commission on Medicare put it,
Essentially it boils down to doing the best job possible with the resources available. It
means achieving stated goals and targets. It is measurable against accepted and valid
standards. It is incompatible with waste, duplication, and fragmentation. It is about
minimizing underuse, overuse and misuse. It is not about heroic effort or the futile pursuit
of the impossible. It is unlikely to be achieved by a demoralized workforce or inadequately
trained personnel. It does not thrive where there is conflict or lack of consensus on goals
and mission. It is about leadership, goal setting, teamwork, process, measurement,
commitment, incentives and accountability. (Fyke 2001, 44-45)
Improving quality, then, can mean a number of different things. For patients, high quality
health care means that their needs and expectations are being met. For health care providers,
quality health care means their diagnoses are accurate, they are part of a well-functioning
system, and the care they provide is appropriate and effective. For our society as a whole, it
means that the overall health of Canadians improves.
The most important work in providing quality health care for Canadians happens “at the
coal face” – in every interaction people have with health care providers and people working on
the front lines of Canada’s health care system. It is only through the dedicated efforts of these
people that the quality of health care can actually be improved. At the same time, their actions
can be supported by comprehensive actions across the country to measure and assess quality,
identify problem areas and success stories, and give health care providers and administrators the
tools they need to improve health care.
In every province and territory and in every health region, hospital, clinic, health program or
150 facility, efforts have been underway to continually improve Canada’s health care system and
IMPROVING ACCESS, ENSURING QUALITYIMPROVING ACCESS, ENSURING QUALITY
the outcomes it achieves. As outlined in the first chapter of this report, the outcomes achieved in
our health care system are comparable with those in many other industrialized countries around
the world. Yet there also are signs that the quality is not as good as Canadians or health care
providers expect.
Canada lags behind many other countries such as the United Kingdom, the United States and
Australia where national strategies are in place to improve quality and patient safety. Again, to
quote Saskatchewan’s Commission on Medicare (Fyke 2001, 45): “The health care system is
data-rich, and information poor: there is little that tells managers, the public or providers about
the quality of their labours in relation to agreed-upon goals and standards. There are no
benchmarks for either utilization (how many procedures should be done in a population) or
outcomes (what difference should we expect from a service, what is an acceptable failure rate)”.
Similarly, another article notes that “The health care system itself is now being identified as a
major cause of illness, death and added costs because of errors, infections, the adverse effects of
medications, the underuse of effective interventions and the provision
of unnecessary or inappropriate care. For the health care system to aspire

to a safety level of other modern industries (e.g., airlines) there will be a
“The collection and use of
need for: leadership and vision; better data systems and information on
performance; commitment and skills development among providers; and relevant performance indicators
better accountability” (Millar 2001, 79).
will require an organizational
A recent report released by the United States Institute of Medicine
culture that recognizes and
(CQHA 2001) reported that, in the United States, there is a “quality
chasm” between average care (the care we have) and the best quality care rewards continuous quality
(the care we could have). It found that the need to improve quality stems
from a combination of overuse, underuse, and misuse of the health care improvement.”
system. Overuse involves the unnecessary use of particular interventions CANADIAN HEALTHCARE
or treatments such as major surgeries (i.e., coronary bypass or A S S O C I A T I O N 2001.
hysterectomies) or the unnecessary prescription of antibiotics in particular

circumstances. Underuse is characterized by insufficient use of particular
interventions or preventive measures such as low rates of immunization or screening for
particular diseases such as breast or cervical cancer. Misuse is characterized by “failures to
execute clinical care procedures properly” (Berwick 2002, 82).
The Institute acknowledged that challenges of quality in the health care system are “not
because of a failure of goodwill, knowledge, effort or resources devoted to healthcare but
because of fundamental shortcomings in the way healthcare is organized.” One of the architects
of the report, Donald Berwick, suggested that “… we should judge the quality of professional
work, delivery systems, organizations, and policies first and only by the cascade of effects back
to the individual patient and to the relief of suffering, the reduction of disability, and the
maintenance of health” (Berwick 2002, 89).
The study also noted that the United States struggles with insufficient information on the
performance of its health care system, indicating that there is more information on the quality of
the airline or automobile industries than on the quality of health care. These conclusions apply to
Canada as well. Unfortunately, we lack the basic and critical information needed to measure the
results, assess performance, and judge the quality of the health care system. Moreover, current
responsibilities for ensuring quality and safety are widely distributed among different
151
COMMISSION ON THE FUTURE OF HEALTH CARE IN CANADA ¥ FINAL REPORTCOMMISSION ON THE FUTURE OF HEALTH CARE IN CANADA ¥ FINA
players and organizations in the health care system, including professional and regulatory
bodies. These various players in the system do not share a common understanding of the
challenges in improving quality and safety. Nor do they share a common vision for the future.
Setting a Vision for Quality in Health Care

The Commission’s vision for a high quality health care system is one where: •
Patients and their safety are at the heart of health care delivery in Canada;
• Disparities are addressed and there are minimal variations in health outcomes and access
across the country;
• Individuals and organizations involved in the delivery of health care work to
continuously improve the quality of health care services;
• Support is provided to foster a culture of learning rather than a culture of blame and
finger pointing;
• Health care providers and professionals work collaboratively and safely to meet a
consistent, high standard of care;
• Risks to patient safety are reduced as much as possible; and
•
Information and data are collected and used to support quality management and improvements
to the health care system over the long term, with particular emphasis on monitoring and
reducing the number of serious adverse events that affect patients’ safety. Achieving this vision
is primarily the responsibility of the provinces and territories. However, the Health Council of
Canada can and should play an important role in working with provinces, territories, health care
providers, health regions, and Canadians to ensure that this vision is achieved. The work of the
Council should focus on two important areas:
• Establishing consistent approaches for measuring and reporting on quality in Canada’s

health care system; and
• Building on the work underway in provinces, territories, and various organizations to
provide a clear link between information on the performance of the system and actions
being taken to improve quality and safety.
Measuring and Improving Quality

Several major reports on health care across Canada have highlighted the need for better
information about quality in the health care system and recommended the establishment of a
new body to track system performance and outcomes. In Alberta, the Premier’s Advisory
Council on Health recommended the establishment of a permanent, arm’s length Outcomes
Commission. In its words, “Tracking and monitoring outcomes and providing regular reports to
Albertans is an essential way of improving quality in health care” (Mazankowski 2001, 68).
Similarly, Saskatchewan’s Commission on Medicare recommended the creation of a Quality
Council with a mandate to improve the quality of health services in the province (Fyke 2001). In
Quebec, Clair notes that “All countries that have publicly funded systems (Europe and
elsewhere) are moving resolutely towards new strategies designed to provide the incentive to
improve performance and to measure results. We must do the same” (Clair 2001, 130).
Work is underway in provinces and territories to consistently measure performance and to

use that information to improve quality and outcomes. As noted in Chapter 2, the Health Council
152
IMPROVING ACCESS, ENSURING QUALITYIMPROVING ACCESS, ENSURING QUALITY
of Canada can play an important role in supporting the work underway in the provinces,
particularly the work of various quality councils or commissions currently being considered or
established by some provinces.
Specifically, the Health Council of Canada should be responsible for developing a national
quality performance assessment framework. This framework should build on
the intergovernmental work of the Performance Indicators Reporting
Committee (currently reporting to the Deputy Ministers of Health), which has “… the task of improving the
developed comparable indicators pursuant to the First Ministers’ Agreement
on Health of September 2000. It also should incorporate the work currently quality of health care in
underway by the Canadian Institute for Health Information (CIHI) to develop
Canada demands attention
common indicators and report regularly to Canadians on the performance of
Canada’s health care system. Steps should be taken to: from all health care leaders
and agents – governmental

• Work with provinces and territories to identify a comprehensive core
set of indicators to provide better information about the state of the and non-governmental alike.”
health care system and the health of Canadians; R O Y A L C OLLEGE OF PHYSICIANS
• Ensure a consistent approach to data collection and analysis across AND S URGEONS OF CANADA
2001. W RITTEN SUBMISSION .
jurisdictions based on agreed upon performance indicators;
• Assess and monitor health data and evaluate the health status, health
outcomes, quality of service, patient safety, and reporting protocols;
• Widely disseminate information about best practices in achieving high quality and safe
health care in various health care settings;
• Report regularly to the public on progress in improving the performance of the health
care system in the longer term (Chapter 2 provides a summary of the key areas for annual
reports to Canadians); and
• Monitor the relative performance of the Canadian health care system in comparison with
other countries, particularly the OECD.
Linking Performance Measurement with Quality Improvements

Developing sound and consistent measures of the quality of Canada’s health care system is
important work, but to have an impact, it must be linked to effective mechanisms and policy
changes aimed at improving quality and outcomes. To make this link, the Health Council of
Canada should work with provinces, territories and various organizations currently in place to
accredit and monitor quality and safety in Canada’s health care system.
The Canadian Council on Health Services Accreditation (CCHSA) is a national non-

governmental organization. It accredits hospitals, long-term care institutions, rehabilitation
institutes and primary health care organizations. Its mandate ties into virtually all care-related
activities of health care professionals. On a voluntary basis, the CCHSA conducts regular
reviews and assessments in Canada and makes recommendations on areas for improvement.
Because of the importance of linking performance information to the continuing

accreditation of hospitals and other health care facilities, the Health Council of Canada should
work closely with the CCHSA. Performance measures established through the work of the
Council as well as regular information on outcomes would provide an important base of
information for linking outcomes to ongoing accreditation of health care facilities, particularly
in the area of patient safety.
153
The Health Council of Canada should also develop linkages with the National Steering
Committee on Patient Safety and work underway by CIHI and the Canadian Institutes of Health
Research (CIHR) to assess adverse events that affect patient safety. In effect, the Council would
serve as a co-ordinating body, bringing together a network of organizations and initiatives
underway across the country to address issues related to quality and patient safety. As noted
earlier, the Council would provide important comparative information to support the work of
various quality committees and outcomes commissions currently being established in some
provinces.
In summary, the work of the Health Council of Canada is essential to replace today’s patchy
picture of Canada’s health care system with a clear, comprehensive and consistent analysis of
the outcomes the system achieves and the progress that is being made in improving quality. This
information will guide decision makers, identify areas where action is needed, compare
Canada’s outcomes with other countries around the world, and perhaps most importantly,
provide Canadians with solid information about the performance of their health care system.
ImprHving Access fHr

Official Language MinHrities
Governments, regional health authorities, health care providers, hospitals and
community organizations should work together to identify and respond to the needs
of official language minority communities.
Improving Access and Quality for Official Language Minorities

Although access is traditionally looked at in terms of waiting times or distance, it can also
be affected by social and cultural factors such as language, gender, education and wealth. When
people are receiving care in a hospital or another health care program, both their access and the
quality of care they receive may be inhibited by problems in communication, understanding or
acceptance.
The Commission heard from many francophone groups about the impact language has on
access to quality care. For example, in Ottawa, the Commission was asked how an abused child
would be able to communicate his or her situation to a health care professional in a language
other than his or her own (Réseau des services de santé en français de l’Est de l’Ontario 2002).
Similarly, for general health care and especially in emergency situations, inaccurate or partial
communication can result in a failure to access appropriate care (Association canadienne-
française de l’Alberta 2002).
Both the Consultative Committee for French-Speaking Minority Communities (CCFSMC)

and the Fédération des communautés francophones et acadienne du Canada (FCFA) indicate that
quality is closely tied to the ability of health care providers to assist, advise, guide, and educate
patients. A number of studies confirm the importance of language in the effective delivery of
health care services. They conclude that the language barrier:
• Reduces the use of preventive services;

• Increases the amount of time spent in consultations, the number of diagnostic tests
154 ordered, and the probability of confusion in the diagnostic and treatment processes;
• Influences the quality of services where good communication is essential such as mental
health services, social services, physiotherapy, and occupational therapy;
• Reduces the probability of compliance with treatment; and
• Reduces the patient’s satisfaction with the care and services received (Consultative
Committee for French-Speaking Minority Communities 2001).
Access to health care services for official language minorities in Canada varies across the
country and continues to be a problem in spite of the fact that communities, regional health
authorities, institutions and provincial governments are taking steps to ensure that official language
minorities have access to at least a minimum level of service in the language of their choice.
In response to the formidable challenges they face, some of Canada’s francophone

communities, with the assistance of both provincial and federal governments and regional health
authorities, have developed innovative, and often inexpensive, initiatives to obtain and improve
access to quality French language health services. A number of these initiatives clearly
demonstrate that it is possible to deliver quality services even in very small francophone
communities and to develop effective approaches that respond to the needs of communities
(FCFA 2001).
As part of the consultation process, many francophone groups suggested that access to
health care in Canada’s two official languages should be written into the Canada Health Act as
a condition of federal funding. The Commission recognizes the importance of receiving health
care services in a person’s first language, however, making this a national legislated guarantee is
not necessarily the best approach for achieving that objective.
In the Commission’s view, the most effective approach is to concretely support and extend
successful initiatives to improve access to health care services in both official languages. Health
Canada should continue to play an important role in sharing information about the various
initiatives underway across Canada and in providing financial support to organizations, regional
health authorities, institutions, provincial and territorial governments in overcoming language
barriers to access. Regional health authorities – as the primary deliverers of service – should also
take steps to overcome language barriers through staff training, building ties with minority
language organizations and communities, and using technology such as telehealth to provide
services to small minority language communities.
Addressing the Diverse

Health Needs Hf Canadians
Governments, regional health authorities, and health care providers should
continue their efforts to develop programs and services that recognize the different
health care needs of men and women, visible minorities, people with disabilities,
and new Canadians.
Canada has a diverse population and that diversity should be reflected in Canada’s health
care system. Issues related to gender, language, and cultural background have a profound impact
on people’s roles, how they view and use health care services, and how they respond to different
programs and approaches to care (CIHR Institute of Gender and Health 2002). 155
Gender can influence how individuals are treated in the health care system and can
influence their health outcomes. It is well documented that women carry the larger burden for
informal caregiving in our society. This is something that must be taken into account as
provincial and territorial health care systems put a greater emphasis on home care. (Chapter 8
addresses home care and informal caregiving in more detail.) We also know there is a marked
tendency for men to make less use of preventative health care information and they seek help
less frequently for health problems such as mental illnesses. These differences in how men and
women access and use health services need to be addressed in the health care system.
Canadians with physical and mental disabilities have their own unique challenges in
accessing health services. While there has been a great deal of progress in recent years, it
appears to the Commission that this progress is limited by two important factors. First, the
responsiveness of the system to the unique needs of disabled Canadians is often directly related
to the strength of the lobbying efforts of advocacy organizations which can vary from
jurisdiction to jurisdiction. Second, efforts to improve access appear concentrated in urban
areas which can leave disabled Canadians in rural areas doubly isolated. At the same time, the
needs of disabled Canadians can vary significantly from community to community which
requires provincial governments and regional health authorities with an important responsibility
to enhance their efforts to ensure that their residents' access to health services is not impaired by
virtue of their disability.
New Canadians who may have limited fluency in either official language also face
challenges in accessing services in the health care system. They have a tendency to make less
use of primary health care services. This can delay early diagnosis and treatment of illness and
result in a greater use of more expensive diagnostic and specialist services. Nonetheless, the first
contact most new immigrants have with Canada’s social services is through the health care
system. This contact can serve as an important element in their socialization to Canadian society
and in their understanding of the entitlements to health care that come with being a Canadian
citizen.
In St. John’s, Newfoundland, the Commission heard from members of the National
Organization of Immigrant and Visible Minority Women of Canada (2002), the Multicultural
Women’s Organization of Newfoundland and Labrador (2002), and a representative of
Newfoundland and Labrador Health in Pluralistic Societies (2002). They suggested that health
services should be more culturally sensitive, that health promotion materials should be written in
more than the two official languages, and that health care professionals should reflect the
diversity of Canadian society and understand the ethnic and cultural backgrounds of the
populations they serve.
Provincial health systems across the country are increasingly sensitive to these issues and
are working in a number of ways to reduce barriers to access that may exist as a result of
disability, gender, ethnicity, language or culture. At the national level, the creation of an Institute
of Gender and Health as part of the Canadian Institutes of Health Research is an encouraging
development. At the community level – with the support of regional health authorities, health
organizations, provincial and territorial governments – there is a growing emphasis on building
primary health care networks that focus on the needs of immigrant populations and established
ethnic communities.
156
Looking ahead, provincial and territorial health care systems, regional health authorities and
health care institutions should actively involve different ethnic communities and new Canadians
in identifying needs and designing programs to meet those needs. Research on various illnesses,
conditions, treatments, and prevention programs should ensure that gender differences are
included. Multidisciplinary research should address issues specific to gender and ethnicity, and
the impact of these differences on health. Finally, health promotion and prevention programs
should be specifically targeted to the unique needs of men and women, and people with different
language and ethnic backgrounds.
What DHes This Mean fHr Canadians?

It is time to restore Canadians’ confidence in their health care system. And the best way to
do that is by showing real progress on the issues that concern them most – waiting for care and
improving quality. Canadians may be willing to take more time to address some of the other
important issues and recommendations in this report. But they are running short of patience
when it comes to essential steps to improve access and quality in today’s health care system.
The recommendations in this chapter are designed to meet a number of critically important
objectives, including:
• Reinforcing our commitment to provide accessible, safe and high quality health care to
all Canadians;
• Reducing waiting times and taking concrete steps to improve access to diagnostic
services;
• Improving the management and co-ordination of wait lists and ensuring that consistent
and objective criteria are put in place;
• Providing Canadians with better information about how long they can expect to wait for
certain services and treatments;
• Measuring performance in a consistent and comprehensive way, and using that
information to improve the quality of Canada’s health care system;
• Providing Canadians with regular reports on the quality and outcomes of Canada’s health
care system, and how our results compare with other leading countries around the world;
• Improving access to health care for official language minorities in Canada;
• Ensuring that the health care system responds to the different health care needs of
Canadians, including men and women, visible minorities, people with disabilities and
new Canadians.
Transforming these objectives into concrete results depends on the willingness of health
care providers, health authorities, provinces, territories and the federal government to take
action. Canadians have heard the promises before, then been disappointed by the lack of results.
It is time to move beyond mere promises to clear deliverables. Canadians want action to improve
quality and access in their health care system. They deserve nothing less.
157
R URAL AND R EMOTE
C OMMUNITIES

7
• Establish a new Rural and Remote Access Fund to support new
approaches for delivering health care services and improve the health
of people in rural and remote communities.
• Use a portion of the Fund to address the demand for health care
providers in these communities.
• Expand telehealth to improve access to care.
The Case f?r Change

Given its geographic makeup, Canada faces unique challenges in the delivery of health care.
The vastness of the Canadian landscape, combined with the fact that many Canadians live in
isolated and remote communities, makes it difficult to ensure that all our citizens have access to
health care services regardless of where they live.
Canada may, in fact, have a very good health care system with health outcomes that are
generally among the best in the world. But there are growing signs that this is not the reality for
Canadians living in smaller or more isolated communities across the country.
During the Commission’s consultations, Canadians living in rural and remote communities
spoke directly about their serious concerns. They spoke of the need for good health and good
access to health care not only because it is essential to sustain their own quality of life, but also
the quality of life in their communities (CPRN 2001).
People’s choice of whether or not to live in smaller communities is affected by whether or

not they can get reasonable access to health care (Association des régions du Québec 2002). That
view was echoed by rural physicians who said, “geography is a determinant of health” (Society
of Rural Physicians of Canada 2002).
Information on disparities in health confirms that view – geography is, in fact, a determinant
of health. People in rural and remote communities have poorer health status than Canadians who
live in larger centres. Access to health care also is a problem, not only because of distances, but
because these communities struggle to attract and keep nurses, doctors and other health care
providers.
159
Recommendations in other chapters of this report – to expand primary health care, expand
coverage for home care and prescription drugs, or shorten waiting times – will have an impact
on people in smaller communities. But the focus of this chapter is squarely on two pressing
issues: improving health and improving access to health care for people in rural and remote
communities.
Identifying the Issues

Using the Statistics Canada definition of “rural,” Figure 7.1 shows that there are wide
variations in the proportion of rural to urban populations in each of the provinces and territories.
The proportions range from just over 15% in British Columbia and Ontario to 68% in Nunavut.
However, these proportions tell only part of the story. While the percentages in provinces like
Ontario may be small, because of the size of the population, the numbers are actually quite large.
Rural Canada is not a single, homogeneous population. Diversity is a characteristic of Canada and
it applies to smaller communities just as it does to the largest cities. Some rural communities are
relatively close to major urban centres while others are not. Some are located in large agricultural
regions, while others are coastal communities or located in the remotest regions of Canada’s
north. Both the health needs and the way in which they should be addressed vary for different
communities. As with many other issues in health care, there is no “one size fits all” solution.
Figure 7.1 100%

Population Counts
(Thousands) for
Canada, Provinces 80%
and Territories,
and Census
Division by Urban
and Rural, 2001 60%
Census –
40%
100% Data
20%
0% NFLD PEI NS NB QC ON MB SK AB BC YK NWT NU Canada

Urban 296 61 507 368 5,817 9,663 805 629 2,405 3,310 17 22 9 23,908
Rural 217 75 401 362 1,420 1,747 314 350 570 598 12 16 18 6,099
Note: Statistics Canada defines rural population in terms of the rural fringes of census metropolitan areas (CMAs) and census agglomerations
(CAs), as well as populations living in rural areas outside CMAs and CAs. A CMA or CA is an area consisting of one or more adjacent
municipalities situated around a major urban core. To form a CMA, the urban core must have a population of at least 100,000. To form a
CA, the urban core must have a population of at least 10,000. Yukon and the Northwest Territories have high urban percentages because of
the concentration of population in Whitehorse (CA = 21, 405 in 2001) and Yellowknife (CA = 16,541 in 2001).
Source: Statistics Canada 2002b, 2001b.
160
RURAL AND REMOTE COMMUNITIES
While there are clear distinctions between “rural” and “remote” communities, to simplify
the language in this chapter, the terms “rural” or “smaller communities” are occasionally used to
refer to all types of rural and remote communities. Issues specific to these communities also
overlap with Aboriginal health issues (addressed in more detail in Chapter 10) since many
Aboriginal peoples live in smaller communities.
Rural communities may be diverse, but they share some common problems in health status,
in access to health care, and in approaches that have typically been taken in the past to address
those issues.
Disparities in Health
Health indicators have consistently shown that the health status of people living in rural
communities, especially people in northern communities, is not as good as the rest of the
Canadian population.
Statistics Canada and the Canadian Institute for Health Information (CIHI) developed health
indicators for 139 health regions in Canada. They grouped health regions into three categories:
predominantly urban, intermediate and predominantly rural (see Table 7.1). This information
shows that:
• Life expectancy for people in predominantly rural regions is less than the Canadian
• average; Disability rates are higher in smaller communities;
• Rates for accidents, poisoning and violence are also higher in smaller communities; and
• People living in remote northern communities are the least healthy and have the lowest
life and disability-free life expectancies.
Table 7.1
Health Status for Populations in Predominately Urban,
Intermediate and Predominately Rural Health Regions in Canada, 19961
Predominantly Predominately
Indicator of Health Status Urban Intermediate Rural
Life expectancy at birth: years 78.8 77.7 77.0
Infant mortality rate per 1,000 live births 5.1 6.3 7.1
Total mortality: age-standardized rate

per 100,000 people 657.0 704.8 748.3
All circulatory disease-related deaths:

age-standardized rate per 100,000 people 243.4 260.5 269.6
All cancer-related deaths: age-standardized

rate per 100,000 people 181.1 193.0 194.6
Unintentional injury-related deaths:

age-standardized rate per 100,000 people 25.9 34.7 45.4
1 The health regions are grouped according to proportion of total population located in rural and small town (RST) areas in a manner
similar to the OECD classification of rural and urban. Predominately urban health regions contained less than 15% RST population;
intermediate health regions contained 15-50% RST population and predominately rural health regions contained over 50% RST
population. The rates are the average values for the health-region groups. Data are as of 2001.The data also have not been adjusted
to take into account the gender distribution of people in the different regions.
Source: Statistics Canada 2001c.

161
The health of a community also appears to be inversely related to the remoteness of its
location. In Quebec, for example, there is “a trend toward a progressive deterioration in health as
one moves from [the] area bordering urban centres into the very remote hinterland” (Pampalon
1991, 359). The situation is similar in most other provinces and territories. In fact, these
challenges are not unique to Canada. Other countries such as the United States, Australia, and
even relatively small and compact countries like the United Kingdom, have similar challenges
(Gamm et al. 2002; Humphreys et al. 1996; Braden and Beauregard 1994; Fearn 1987).
Disparities in Access to Health Care

Canadians in rural communities often have difficulty accessing primary health care and
keeping health care providers in their communities, let alone accessing diagnostic services and
other more advanced treatments. In some northern communities, the facilities are limited and in
serious need of upgrading.
People in rural communities also have the added burden of paying for the high costs of
travel in order to access the care they need. This often means days or weeks away from family
and social support as well as the added cost of accommodation and meals.
In the 1990s, many provinces took steps to rationalize the delivery and administration of
health care as part of health care reforms. As a result, some services were centralized into larger
centres. Partly because of these changes, provincial and territorial ministries of health and
regional health authorities have used a number of different approaches to improve access
through outreach programs, financial assistance for people who need to travel to access care, and
new delivery approaches like telehealth. These efforts, to greater or lesser degrees, have helped
improve access. But the problem is far from solved. In fact, some would say that there is an
“inverse care law” in operation. People in rural communities have poorer health status and
greater needs for primary health care, yet they are not as well served and have more difficulty
accessing health care services than people in urban centres.
Disparities in Access to Health Care Providers

Problems in access to health services quite often stem from serious shortages in health care
providers in rural communities.
Access to physicians and specialists varies significantly across the country and some
communities do not have access to even the most basic health care services because they lack the
necessary health care providers. In 1993, there was less than one physician per 1,000 people in
rural and small town areas, compared to two or more physicians per 1,000 people in larger urban
centres. The average resident in rural communities and small towns was 10 km from a physician,
compared to less than 2 km for a resident in larger urban centres (Ng et al. 1999).
In northern communities, the problems are stark. About 16,000 people live in the most
northern part of Canada, at 65-69 degrees north latitude (northern parts of Yukon, Northwest
Territories and Nunavut). About two-thirds of them live more than 100 km from a physician.
And no physicians normally live above 70 degrees north latitude to serve the 3,300 people living
there (Ng et al. 1999).
162
Given the shortages of nurses across the country, it is safe to assume

the problems of recruiting and retaining nurses in smaller communities are “…What community wants
serious indeed. According to the Canadian Health Services Research
Foundation, “It’s not just a question of having a lot of people to work in an uncommitted doctor who
the healthcare system; it’s also about making sure healthcare workers are practices there for a few years
well distributed through the provinces and among urban, rural and remote
areas” (CHSRF 2002b, 3). before decamping to a more
desirable locale?…”
The problem of attracting health care providers to rural communities
is exacerbated by competition among individual provinces and territories. CANADIAN FEDERATION
M E D I C A L S T U D E N T S 2001 .
Keeping health care providers in rural areas is an ongoing problem, and OF
territories compete to attract and retain the supply of health care providers
they need.
The problems with the supply of physicians in rural and remote communities demand
solutions. But the experiences of many provinces and territories as well as OECD countries
suggest that short-term solutions aimed at increasing the overall supply of physicians do not
necessarily translate into improvements in their supply in these communities. Provincial and
territorial governments have tried providing incentives to encourage
physicians to move to rural areas through higher pay or other financial

incentives. In other cases, governments have tried to limit where new “The more exposure you have
physicians can practice in order to encourage more of them to work in in training and post-graduate
rural communities.
training programs to rural
Physicians typically object to measures that limit their ability to
choose where they practice. Part of the answer certainly lies in increasing settings … the more likely we
physicians’ exposure to rural settings as part of their education and
are to have people who want
training. With increased exposure to, and experience in, rural settings, the
likelihood of graduating doctors wanting to practice in rural settings to work in rural communities.”
increases (BCMA 2002). Recent efforts by the Society of Rural Physicians
BRITISH COLUMBIA MEDICAL
ASSOCIATION. PRESENTATION AT
of Canada and the College of Family Physicians of Canada to develop VANCOUVER PUBLIC HEARING.
national curricula and guidelines are a step in the right direction. But there
is much more to be done.
Differences in Approaches
Currently, there is no coherent national approach for addressing issues specific to rural
communities. Provinces and territories are developing different ways to address the issues, but
they are doing so in isolation, without enough attention to co-ordination or the overall picture. A
review of current approaches points to the following issues:
• The lack of consensus on what “adequate” access should include – There is no

consensus today on what constitutes adequate access and what services are most
important for people to be able to access. One approach is to identify a basic core of
services for different types of rural communities. This approach would clearly
distinguish between the core services that would be available to people in their own
communities and the services they would have to access from other centres. Key
stakeholders, including health care providers and community members, should be
involved in identifying and agreeing on the core services to be available in each community or region.
163
• The need for effective linkages with larger centres – While some health care services
can be delivered in smaller communities, some form of networked system that links those
communities with urban centres is inevitable. Smaller communities simply cannot
sustain a full range of services. Ontario’s “Rural and Northern Health Care Framework”
(Ontario. Ministry of Health 1997) is an example of linkages between rural facilities,
hospitals in regional centres and tertiary-care institutions in metropolitan areas, but it is
by no means the only model. Similar linkages were proposed by Saskatchewan’s
Commission on Medicare (Fyke 2001). Specialized services will continue to be
concentrated in larger centres, but their linkages to rural communities should be
improved.
• The challenges of serving the smallest and most remote communities – These
communities are the most difficult to serve because they have too few people to sustain
anything but the most basic services, and even that can be difficult. Other countries face
similar challenges and the models they have developed may be worth examining in
Canada. For example, Australia developed a “Healthy Horizons” framework for
improving access and health in small and remote communities (Australia 1999). This and
similar models in other countries should be explored to see if they could be adapted to
suit the unique Canadian context.
• A focus on symptoms rather than causes – With few exceptions, strategies and
programs have focused on how to deliver services and how to recruit and retain more
health care providers. Although lack of access to health services as well as physicians
and nurses are undoubtedly very serious problems, resolving these issues may not be
enough to improve the health status of people in rural communities in a significant way.
Instead, more emphasis needs to be placed on addressing the fundamental causes of the
“rural health deficit.”
• The predominance of “urban” approaches applied to rural communities – Many

health care administrators, planners and providers rely on urban-focused approaches
instead of developing alternative models to suit the unique circumstances of those
communities. These primarily urban models make it difficult, if not impossible, for
smaller communities to catch up to their urban counterparts. There is an increasing
understanding that rural health problems are unlikely to be adequately addressed by
mainstream programs alone (Humphreys et al. 2002). Unique rural health problems
require urgent attention and unique rural conditions need to be taken into account in
addressing those problems. The situation for health care providers is a case in point.
Trends point to increasing specialization in skills and training. This might meet the needs
of “high-tech” and research-intensive medicine in large hospitals in major urban centres,
but the needs are almost the opposite for rural communities. They need a different kind
of “specialist” – namely, well-trained and experienced generalist practitioners who
“specialize” in delivering high quality primary health care in rural communities.
• The lack of research – Policies and strategies for improving health and health care in
smaller communities have not been based on solid evidence or research. Until recently,
Canadian research on rural health issues has been piecemeal in nature and limited to
small-scale projects. To make matters worse, despite the wealth of health-related data at
164
the federal, provincial and territorial levels, most data collected or released are frequently
not presented in a manner that supports meaningful rural health research and analysis
(Pitblado et al. 1999). Furthermore, as with health research in general, there is little
connection between decision makers and researchers. As a result, rural health policies,
strategies, programs and practice have not been as effective as they could have been.
Setting a Clear Visi?n and

Principles
Clearly, there are important challenges to address. The place to start is with a vision where
Canadians residing in rural and remote regions and communities are as healthy as people living
in metropolitan and other urban centres. This vision was echoed by Jose Amaujaq Kusugak at
the Montreal public hearing who said, “I believe that … the success of our Health Care System
as a whole will be judged not by the quality or service available in the best of urban facilities,
but by the equality of service Canada can provide to its remote and northern communities” (Inuit
Tapiriit Kanatami 2002).
This vision should guide all rural health initiatives including policy development, program
planning, clinical practice, research, and health human resources development. It should be
supported by the following principles:
• Rural health initiatives should be designed to provide equity in both access to health care
and in health outcomes.
• No single strategy is appropriate for all communities. Unique approaches are needed to
address the diverse health needs and different circumstances of different communities.
• Both short-term, immediate issues (such as access to nurses and
doctors) and long-term, more fundamental issues (such as
economic and living conditions) must be addressed. “The future is grounded in the
• Health strategies should be focused on outcomes. Different present. A keen appreciation of

approaches can be used as long as the objective is to improve how rural health care is unique
health and access to health care.
is important in determining
• Policies, strategies and programs should be based on evidence and
informed by research. The outcomes of various approaches also possible models that will work
need to be objectively assessed.
and can be sustained.”
• Strategies developed for urban centres may or may not be
S OCIETY R U R A L P HYSICIANS
appropriate for rural communities. Rural communities may need to
OF OF
C A N A D A 2001. W RITTEN SUBMISSION .

adapt urban-based approaches or may have to design their own
strategies to meet their unique needs.
• Community members, federal, provincial and territorial governments, regional health
authorities, health care providers and other stakeholders need to be involved in finding
solutions and taking necessary actions.
A truly national approach is needed to address the serious health challenges in rural health
and to complement local or regional initiatives. Although many of these health issues have
regional or local characteristics, they share common features and common problems – problems
that require a national response. The provinces have constitutional responsibility for
165
administering provincial health care systems and delivering health services to their citizens.
However, the federal government could play a co-ordinating and facilitating role by working
closely with the provinces and territories, as well as other stakeholders. Taken together, the
following cluster of actions recommended in this and other chapters of this report will ensure
that people in rural communities have better access to health care and better health.
Impr?ving Access t? Health Care
Expanding the Supply of Health Care Providers in

Smaller Communities
The Rural and Remote Access Fund should be used to attract and retain health care
providers.

A portion of the Rural and Remote Access Fund should be used to support innovative
ways of expanding rural experiences for physicians, nurses and other health care
providers as part of their education and training.
Improving access in smaller communities is tied directly to their ability to attract and retain
health care providers. The immediate injection of additional funds from the Rural and Remote
Access Fund should be directed to addressing this serious problem. Provinces and territories
should decide which approaches are most appropriate for their communities, including the short-
term option of using financial incentives to attract doctors and nurses to rural and remote
communities.
A more promising solution over the longer term lies in the education and training of health
care providers. As noted by the Association of Canadian Medical Colleges, a number of rural
initiatives are taking place in Canadian medical schools (ACMC 2002). However, more work
needs to be done to expand training opportunities for a range of health care professionals in rural
and remote settings. Collaborative approaches to rural health practice are needed to get the
maximum benefits from the skills of multidisciplinary teams and networks. More flexible use of
health care providers should be encouraged, and training and support should be given to
informal caregivers to support the role they play in rural settings.
Expanding Telehealth Approaches

The Rural and Remote Access Fund should be used to support the expansion of
telehealth approaches.
A number of innovative approaches can be used to improve access in smaller communities.

Telehealth is a prime example. It uses information technologies to link patients and health care
providers to a spectrum of services that can be brought together to provide higher quality care.
166
It offers tremendous possibilities for overcoming the obstacles of distance and improving access
to health care in rural communities (Pong 2002). People in rural and remote locations can be
linked to family physicians, specialists and other health services in major centres. Health care
providers can diagnose, treat and provide consultations at a distance. Patients and health care
providers can have access to information about illnesses and the approach can also be used both
for educating patients and providing professional development for health care providers in more
remote locations. A variety of approaches can be used ranging from tele-triage to tele-education,
and more recently, to tele-homecare. Several provinces have done extensive work on telehealth
initiatives, particularly Newfoundland and Labrador.
Telehealth is particularly promising for northern Canada. The Honourable Edward Picco,
Minister of Health and Social Services in Nunavut, noted that telehealth has the potential to be a
lifesaver in Nunavut (Nunavut 2002). Ensuring access to health care is a daunting challenge
when some people live in communities more than 2,000 km apart. Recognizing the potential
benefits, the Government of Nunavut has signed agreements with the governments of Australia
and Newfoundland and Labrador to share information and new developments in telehealth. In
their view, increased use of telehealth technology will result both in cost savings and in
improved health for territorial residents (Nunavut 2002).
Similarly, conditions in the north have required Yukoners to find innovative ways of
providing effective and accessible health care. Telehealth applications have been used to
facilitate increased mental health services, professional and continuing education, and family
doctor visits. Most communities in the Yukon are a five- to six-hour drive away from
Whitehorse and many are in locations that often are inaccessible by road or plane, especially in
bad weather. There are instances where Yukon residents must rely on out-of-territory hospitals
for specialized services. The cost of a single flight can be more than $10,000. Consequently, the
costs of the Yukon medical travel plan have increased by 26% over the last five years (Yukon 2002).
The situation in the Northwest Territories is similar. People in the Northwest Territories
face serious health issues including high rates of certain illnesses combined with a number of
social factors that affect health. These challenges are exacerbated by the fact that health care
services are stretched thin and access is seriously limited by the interplay of geographical
expanse and limited health human resources and health care facilities. As a result, the
government spends 6.5% of its budget for health and social services on transportation (NWT 2002).
With better evidence and evaluation, more effective choices can be made about the best use
of telehealth technologies in specific settings. Actual evidence of the benefits of telehealth is
minimal (Roine et al. 2001) and one study (Whitten et al. 2002, 1437) concluded that “there is
presently no persuasive evidence about whether telemedicine represents a cost-effective means
of delivering health care.” This is not to suggest that telehealth initiatives should not proceed.
Rather, it points to a need for increased attention and effort in the evaluation of telehealth
applications.
Because of the potential for telehealth to improve access to health care, the Rural and
Remote Access Fund should be used to expand telehealth applications. Funds should be used to
support both the necessary equipment within smaller communities as well as the necessary
education, training and support to allow these technologies to be used and managed effectively.
167
Early experience in the provinces is pointing to the immense value of telelearning and
continuing education using information and communication technologies. Individual
investments in telehealth should reflect the needs in individual communities and ensure that:
• The necessary policies are in place for licensing health care providers to deliver health
services at a distance (in particular, cross-jurisdictionally);
• Privacy and security issues for patients have been adequately addressed;
• Training and support is available to facilitate effective and efficient use of telehealth
applications; and
• The impact of telehealth applications on health outcomes in rural and remote
communities is assessed.
Implementation of telehealth is hampered by the fact that many smaller communities do not
have high-speed connections to the Internet. These connections depend on having access to
technology known as basic broadband infrastructure. According to a recent report by the OECD
(2001c), Canada ranks second in terms of overall broadband access, behind Korea, but ahead of
Sweden and the United States. Despite this relatively high ranking, the National Broadband Task
Force estimates that there are approximately 5,000 communities (79% of all Canadian
communities) that fall into the “harder-to-serve” category. In their view, “the most revolutionary
aspect of broadband is its potential to reduce … distance and time as cost factors – in economic
activity and in providing public services” (Canada. Industry Canada 2001, 3). The Task Force
recommended that broadband facilities and services be extended to all Canadian communities by
2004, with priority given to First Nations, Inuit, rural, and remote communities.
Priorities for future expansion of Canada’s broadband infrastructure should take central
account of how telehealth care can improve access to health care in rural and remote
communities across the country.
Impr?ving Health
The Rural and Remote Access Fund should be used to support innovative ways of
delivering health care services to smaller communities and to improve the health of
people in those communities.
In the past, innovative approaches have been funded primarily through pilot projects. The
problem with this approach is that projects tend to be limited in both size and scope. Full-scale
demonstration projects, supported by the Rural and Remote Access Fund, would allow provinces
and territories to test not only innovative approaches to delivery of health care services and
initiatives but also to explore the underlying causes of health problems in smaller communities.
Our experience in addressing a full range of factors and conditions that affect people’s health at
the community or regional level has been limited. As a result, the relationship between health
determinants, health behaviours and health status is largely unknown (Roussos and Fawcett
2000). Lower educational attainment, higher unemployment and poorer access to health care
undoubtedly have an impact on the health status of people in smaller communities, but the
specific impact of these factors has not been studied in a comprehensive way. Similarly, the
168
impact of living in smaller communities on health behaviours and health status needs much more
study. It is even less clear how adverse conditions in rural and remote communities can be
ameliorated or reversed.
Multi-faceted approaches to strengthen social capital, enhance community resilience, build a
viable economic base, and foster positive health behaviours are also limited. But there are some
good models to follow such as the Canadian Heart Health Initiative, the Healthy Community
Movement, and Better Beginnings Better Futures. These approaches take a broader approach,
not just focusing on a particular illness but also including a number of factors that affect
people’s health.
The population health demonstration projects envisioned in this report should be much larger
in scale than previous pilot projects and involve different partners in different sectors of the
economy and society in those communities. The objective is to find the best approaches to
strengthen community resiliency, social capital and local capacity, improve healthy behaviours
and lifestyles, and improve the overall health status of people in rural and remote communities.
The Rural and Remote Access Fund should support provinces, territories, communities and health
authorities in developing and implementing a variety of models and approaches. For the Fund to
be successful, a process must be in place to monitor, evaluate and disseminate the results of these
demonstration projects, and, in particular, to highlight best practices and enable Canadian
communities to learn from each other’s experiences. Funding should be based on demonstrated
needs in communities, the use of innovative approaches to address those needs, and the potential
of demonstration projects to result in overall improvements in the health of people in smaller
communities across the country.

For people living in rural and remote communities, it means that some of their most
pressing health needs will be addressed. It means that deliberate, decisive and immediate action
can be taken to address severe shortages in health care providers in many smaller communities.
It means the potential of new approaches like telehealth to literally bring health care to the
doorstep of people in rural and remote communities can be realized. And over the longer term, it
means the disparities between the health status of people in smaller communities and the rest of
the Canadian population can be appreciably reduced.
169
H OME CARE: THE N EXT
E SSENTIAL S ERVICE

8
• Use the proposed new Home Care Transfer to establish a national
platform for home care services.
• Revise the Canada Health Act to include coverage for home care services
in priority areas.
• Improve the quality of care and support available to people with mental
illnesses by including home mental health case management and
intervention services as part of the Canada Health Act .
• Expand the Canada Health Act to include coverage for post-acute home
care including medication management and rehabilitation services.
• Provide Canada Health Act coverage for palliative home care services to
support people in their last six months of life.
• Introduce a new program to provide ongoing support for informal
caregivers.
The Case f?r Change

Home care is one of the fastest growing components of the health care system. Services that
used to be provided exclusively in hospitals, doctors’ offices, clinics, or long-term care facilities
now can be provided in people’s homes. Home care services now include a wide range of
treatments from follow-up visits to check on how well a person is recovering after surgery, to
regular visits to seniors to monitor their health or, in some cases, even complex treatments such
as dialysis or intravenous therapies. The advantages are obvious. People get to stay in their own
homes with the assurance that someone will be there to monitor their health. For some people,
especially seniors or people with disabilities, it means they can maintain their independence. The
costs are generally lower than keeping people in hospital. Based on a major Canadian project
known as the National Evaluation of the Cost-Effectiveness of Home Care (Hollander and
Chappell 2002), there is growing evidence that investing in home care can save money while
improving care and the quality of life for people who would otherwise be hospitalized or
institutionalized in long-term care facilities.
171
Although home care is not currently considered a medically necessary service under the
Canada Health Act, provinces and territories recognize its value and have taken steps to expand
home care under provincial and territorial health care plans. But there are wide variations across
the country in terms of what types of home care services are covered and how much individuals
pay to cover a portion of the costs.
Because home care has become a partial substitute for care that was previously provided
primarily in hospitals or by physicians, and because of the value of effective home care services
both to individuals and the health care system, a strong case can be made for taking the first step
in 35 years to expand coverage under the Canada Health Act . As outlined in Chapter 2, the
Commission recommends that the definition of what is covered under the Canada Health Act
should immediately be expanded to include medically necessary home care as well as diagnostic
services (discussed in greater detail in Chapter 6).
This important step reflects the views expressed by many Canadians as part of the
Commission’s consultations. The Commission repeatedly heard that our definition of “medically
necessary” should not be confined to hospital and physician services. The definition should be
based on need, not where the service is provided or who provides the service.
Because of the significant costs that would be involved in including all home care services
under the Canada Health Act , priorities should be placed on the most pressing needs. There is
little doubt that effective home care support is vitally important to people with mental illnesses,
to people who have just been released from hospital, and to those who are in their last months of
life. These three areas – mental health, post-acute care, and palliative care – should be the first
three home care services to be included under a revised Canada Health Act.
The Commission also heard consistently about the important role family, friends and other
informal caregivers play in looking after people who have chronic illnesses or disabilities,
ongoing mental health problems, or who face months of rehabilitation time at home. The
pressures on these caregivers are significant and should be recognized. A new national program
should be established through Employment Insurance to provide direct support to informal
caregivers and allow them to spend the necessary time caring for their family members.
Taken together, these recommendations would have a tremendous impact on Canadians

from coast to coast to coast. For thousands of people with mental illnesses, it gives assurance
that they will be able to live full and productive lives in their community with the ongoing
support they need when they need it. For people recuperating from surgeries at home, for
example, it means adequate home care services will be available. For those who are facing the
end of their lives, it means home care support will be there to help them and their families. And
for family members in each of these situations, it means they will have direct support and the
time they need to help provide care. It also means that current provincial and territorial resources
dedicated to home care services in these three priority areas would be freed up to provide
additional home care services for people with physical disabilities and chronic illnesses.
172
HOME CARE: THE NEXT ESSENTIAL SERVICE
H?me Care in Canada

Variations across the Country
Everyone seems to know intuitively what home care is; yet there is no single definition of
what home care means. At a minimum, it is a term used for an array of services that allow
individuals who suffer some mental or physical incapacity to live at home and receive the care
they need. Quite often, the effect of this is to prevent, delay or substitute home care for hospital
or long-term residential care. Home care support generally includes:
• Professional services such as nursing, physiotherapy, occupational therapy, and speech

therapy;
• Personal care including assistance with the activities of daily living, such as bathing,
toileting, transferring and grooming;
• Home making and home support to assist with the activities of daily living, such as
cleaning, doing laundry and meal preparation.
Hollander and Walker (1998) note that differences in home care relate primarily to three
different functions:
• Maintenance or prevention – helping people with health problems remain at home and
preventing institutionalization;
• Long-term care substitution – meeting the needs of people at home who would otherwise
be institutionalized; and
• Acute care substitution – allowing people to be treated at home rather than having to
remain in, or enter, acute care facilities.
Since the 1970s, provinces and territories have established and funded home care programs.
For a variety of reasons, including different regional needs and priorities, variations in provincial
and territorial budgets, and the evolution of local health care programs, it is not surprising that
there are significant variations across the country, not only between provinces and territories, but
also within them. Despite these challenges, some general comparisons can be made in terms of
the range of home care services, difference in eligibility requirements, and funding for home
care.
Home Care Services

All provinces and territories offer some assessment and case management as part of home
care services. However, the similarity ends there. For home nursing care, some provinces
provide extensive coverage while others limit home nursing care to a monthly dollar amount,
hourly limits or the equivalent cost of institutional care. For home medical supplies, some
provinces and territories provide supplies for a limited time or for acute home care only, and
some base their decisions on means testing. For home rehabilitation services, some provinces
and territories offer full programs while others offer none at all.
173
Eligibility for Home Care Services

There also are differences in eligibility requirements. As a result, people living in one
province may be eligible for certain services while people in other provinces with similar
circumstances are not.
With the exception of British Columbia, where eligibility can require 12 months of
residency, general eligibility requirements for home care across the country include: •
three months residency
• a health insurance card
• a health or medical need for care
• a suitable home for care (safe, with adequate family, social, or community support)
• a physician referral (in some provinces and territories).
Within these general eligibility requirements, some provinces and territories provide
complete coverage for certain services while others provide more limited home care services
according to acuity of illness, financial means, dollar limits or other criteria.
Funding for Home Care

Currently, home care services are funded through a combination of provincial and territorial
funds, federal funds, private insurance, and payments by individual Canadians (see Figure 8.1).
In some provinces, means testing is used to determine access to home care services.
In terms of the percentage of provincial and territorial budgets spent on health care, there also
are wide variations across the country. New Brunswick, for example, spends close to 10% of its
total health care budget on home care compared with less than 2% in Nunavut (see Figure 8.2).
On average, provinces and territories spend between 4 and 5% of their health
Figure 8.1
Percentage
Distribution of Private Provincial
Home Care Sector Government
Expenditures, 23% 76%
by Source of
Finance, 2000/01 Federal
Government
Direct
1%
Note: Private sector home care expenditures were estimated by Health Canada based on results of Statistics Canada surveys as well as the
input from private providers of home care services. Estimates of home care paid by private insurers was not available and is therefore not
included.
Source: Health Canada 2001d; CIHI 2001d.
174
Figure 8.2 12
Provincial-
Territorial Home 10
Care Expenditures
as a Percentage of 8
Total Provincial-
Territorial Health
6
Expenditures,
2000/01
4
0
and Labrador
Quebec
Manitoba
New Brunswick
Saskatchewan
Yukon Territory
Newfoundland
Prince Edward
Island
Ontario
Alberta
Northwest
Territories
Nunavut
Canada
Nova Scotia
British Columbia
Source: Health Canada 2001d.
Figure 8.3 $30,000 $3,000

Hospital Expenditures
Provincial-
$25,000 Home Care Expenditures $2,500
Territorial
Home Care Expenditures

Hospital Expenditures
Hospital and $20,000 $2,000

Home Care
Expenditures $15,000 $1,500
($Millions),
1980/81 to $10,000 $1,000
2000/01
$5,000 $500
$- $-
1980/81
1982/83
1984/85
1986/87
1988/89
1990/91
1992/93
1994/95
1996/97
1998/99
2000/01
Source: Health Canada 2001d.
budgets on home care. Between 1980/81 and 2000/01, the average annual rate of growth for
home care expenditures by provincial and territorial governments was 14% compared to 6.2%
for hospitals and 7.1% for all provincial-territorial health expenditures (see Figure 8.3).
Looking Ahead
Looking ahead, there is every reason to assume that the demand for home care services will
increase. That demand will be driven by a number of factors including: •
New advances in treatments, medications and technology that make it increasingly
possible for people to be treated at home rather than in hospital or in other institutions;
175
• New primary health care models that enable teams and networks of health care providers
to manage and monitor people’s health at home and in their communities;
• A growing elderly population that wants access to home care;
• Increasing pressures on informal caregivers;
• Continuing trends for early discharge from hospital;
• The overall cost-effectiveness of home care;
• Improvement in the quality of life resulting from home care;
• Accelerated healing times; and
•
Ethical considerations around providing specific care in certain settings.
Given these trends, it is important to address current disparities in
home care services across the country. The extent of regional variations in
home care has some Canadians wondering if they should move to areas
“We need to make decisions
with better programs in their later years of life so they will have access to
even beyond the cost – that is, the services they need. When differences in health care coverage and
services across the country have this effect on Canadians, it suggests
[on] the value added of being something must be done. Disparities across the country also mean that
many people have significant home care needs that currently go unmet.
able to remain at home,
Finally, provincial and territorial spending on home care will continue to
for instance.” grow as this becomes an increasingly important component of the
continuum of care provided for Canadians. For these reasons, the first
A SSOCIATION QUƒBECOISE
DES PHARMACIENS PROPRIƒTAIRES

critical steps should be taken to integrate home care into the publicly
D U Q UƒBEC . P RESENTATION AT
funded health care system and include priority home care services under a
Q UƒBEC C I T Y P U B L I C H E A R I N G .
revised Canada Health Act.
Making H?me Care the Next

Essential Service
The proposed new Home Care Transfer should be used to support expansion of the
Canada Health Act to include medically necessary home care services in the following
areas:
• Home mental health case management and intervention services should
immediately be included in the scope of medically necessary services covered
under the Canada Health Act.
• Home care services for post-acute patients, including coverage for medication
management and rehabilitation services, should be included under the Canada
Health Act.
• Palliative home care services to support people in their last six months of life
should also be included under the Canada Health Act.
176
Defining and Funding a National Platform

of Home Care Services
Canadians have said that home care services are too important to be excluded from the
definition of insured health services under the Canada Health Act . While it is not financially
feasible to include all home care services under the Canada Health Act at this time, the first step
is to establish a national platform of services that would be available to Canadians in all parts of
the country under the same terms and conditions.
A national platform for home care services would, in effect, set a “floor” of services that
must be available across the country. Establishing a national platform for home care services
does not preclude provinces, territories or regions from adding to the basic services to meet the
needs and priorities of their communities. In fact, the additional support for home care provided
through the proposed new Home Care Transfer should free up resources that should be used to
improve and expand existing home care benefits for people with chronic and long-term health
problems and disabilities. Over time, as fiscal resources permit, more home care services could
be brought under the Canada Health Act umbrella.

In terms of the costs of expanding coverage for home care services, the Commission relied
on the work of several consultants (Hirdes et al. 2002) to estimate the costs involved in including
the three priority areas under the Canada Health Act – home mental health services, post-acute
home care, and palliative home care. The consultants’ findings and the approach they took in
preparing an estimate are included in Appendix G.
Based on their analysis, the estimated costs (excluding perscription
“We need a national home care
drugs) would be as follows:
plan that entrenches home
Home mental health case management
support within the foundations
and intervention $568.1 million
Post-acute medical care $117.7 million of our system in Canada so that
Post-acute rehabilitation $204.6 million [we] can move freely about
Palliative home care $ 89.3 million
Canada without having to worry
Total $979.7 million
about whether any one region
As noted in Chapter 2, the proposed Home Care Transfer would
might exclude our presence
provide $1 billion to kick-start expanded coverage for home care services
in the three priority areas on the condition that provinces and territories simply by not having a home
provide home care services consistent with the national platform. After an
initial two-year period, the Home Care Transfer should be rolled into the support program.”
long-term Canada Health Transfer. This would ensure that ongoing, stable HOME SUPPORT ACTION GROUP
OF V I C T O R I A . P RESENTATION AT
funding is available to support continuing integration of home care services VICTORIA PUBLIC HEARING.
as an essential component of the health care system.
177
Home Mental Health Case Management

and Interventions
Mental health has often been described as one of the “orphan children” of medicare. The
Commission consistently heard that it is time to deal with this issue and bring mental health into
the mainstream of public health care. The reality is that mental health care has changed and it is
now largely a home- and community-based service with only a small number of people needing
hospital or institutional care and even then, only for shorter periods of time. The Commission’s
recommendation reflects this reality and takes the long overdue step of ensuring that mental
health home care services are included as medically necessary services under the Canada Health
Act and available to Canadians across the country.
Significant changes in how mental health services are provided date back to the early 1960s.
Emmett Hall’s Royal Commission on Health Services (1964, Vol. 1, 21) reported that “[o]f
all the problems presented before the Commission, that which reflects the greatest public
concern, apart from the financing of health services generally, is mental illness…” The Hall
“You sir, and the Commission,
Commission recommended that mental health care should be integrated into the hospital
are my last hope forsystem
reform by
in adding psychiatric wards and wings to hospitals, replacing larger, segregated
mental asylums. Mental illness was to be given the same status as physical illness in terms
the mental health system.”
of the organization and provision of services.
CLAUDETTE GRIEB. PRESENTATION
AT TORONTO PUBLIC HEARING.
At the time that Hall reported, a trend to move mental health patients from asylums to
hospitals and from hospitals to the community was underway. Hall’s recommendations reflected
this trend. In reference to children with mental illnesses, Hall (1964, Vol. 1, 24) wrote that “the
majority [of them should] not be segregated in institutions but remain at home, in the
community.”
Over the next few decades, de-institutionalization became more widespread. According to
the Canadian Mental Health Association (2001, 8), in the 1960s and 1970s, “budgetary
considerations and new medications combined with a new vision of ‘community psychiatry’ …
led to the deinstitutionalization of large numbers of patients with serious mental illness.” The
goal at the time was short-term outpatient treatment or a brief stay in a general hospital in order
to “normalize” mental illness and make it an “illness like any other.”
Despite these early recommendations and changes in society, mental health care remains
one of the least integrated aspects of health care. By the mid-1970s, it became clear that the
process of de-institutionalization was flawed. As the Canadian Mental Health Association
(2001, 8) described it, “For many former hospital residents the new system meant either
abandonment, demonstrated by the increasing numbers of homeless mentally ill people; ‘trans-
institutionalization’: living in grim institution-like conditions such as those found in the large
psychiatric boarding homes; or a return to family who suddenly had to cope with an enormous
burden of care with very little support. In addition, fears and prejudices about mental illness, in
part responsible for the long history of segregation in institutions, compounded the problems in
the community. These attitudes increase the barriers to access to community life in areas such as
employment, education and housing.”
178
Recent history has shown that the trend to treating people with mental
illnesses in their own communities rather than in institutions has not been
accompanied by sufficient resources. Many mental health patients were “People with mental illness are
discharged with insufficient resources and networks to support their ability
to live at home. Often, to be eligible for home care, a person had to have a excluded from home care and
physical disability or difficulties with activities of daily living. These
requirements preclude many people with mental illnesses from accessing home support services – unlike
necessary home care interventions and support. According to the Canadian people with physical illnesses or
Mental Health Association (2001), one of the main lessons to be learned
from this failed experiment is that clinical services must be in place in the disabilities – and these would
community before hospital beds are closed.
make an enormous difference
to their health.”
In the case of mental illnesses, home care is not simply an alternative
CANADIAN MENTAL HEALTH
to institutionalization. Treating people effectively in the community rather A S S O C I A T I O N , N EWFOUNDLAND AND
than in institutions or hospitals requires home care, particularly in order to LABRADOR DIVISION. PRESENTATION
ensure that people with mental illnesses continue to take their medications AT ST. JOHN’S PUBLIC HEARING.
appropriately and do not need repeated re-admissions.

In addition to improving care and support for people with mental illnesses, providing case
management and interventions when needed is also a cost-effective approach. It not only
precludes the need for people to stay in institutions but it also prevents the high costs of
continuous re-admission to hospitals or other facilities. In many cases, a home care client may
have a brief episode of unmanageable behaviour in the home and institutionalization will occur
immediately. By focusing home mental health care on people who generally live well in the
community, but who may have occasional problems, recurrent institutionalization can be
prevented or minimized, and very large savings to the system can be realized (Hollander and
Chappell 2002).
Two types of home care services should be available for people with mental health
problems. The first is case management, in which a case manager would work directly with the
individual and with other health care providers and community agencies to monitor the
individual’s health and make sure the appropriate supports are in place. This would ensure both
continuity and co-ordination of care. The second is home intervention to assist and support
clients when they have an occasional acute period of disruptive behaviour that poses a threat to
themselves or to others and could trigger unnecessary hospitalization.
As the average age of Canada’s population increases, the number of people with dementia
and Alzheimer’s disease is expected to increase. Currently, people with these illnesses remain in
their own homes as long as possible, but the burden of care on their family is enormous. With
case management support, family members and the individuals involved would have the support
they need in terms of assessing changing needs, providing the necessary care, and planning for a
time when these individuals may no longer be able to remain in their own homes.
179
Post-acute Home Care

Changes in health care delivery have resulted in shorter hospital stays and more services
being delivered at home rather than in hospital. Advances in technology and new prescription
drugs (Cregan 1999) and hospital policy (RNAO 1997) often mean people need to spend less
time in hospital. New surgical techniques mean that people face shorter recuperation times and
are more able to return to their own homes to convalesce. “In addition, research on aging
suggests that improved health status of seniors has had an impact on decreasing the number of
hospitalization days by two-thirds since 1970” (CIHR Institute of Aging 2002) (see Figures 8.4
and 8.5).
Figure 8.4 13,500

Inpatient/Acute
Care Admissions, 13,000
Age Standardized
(Number per 12,500
100,000 People),
Canada, 12,000
11,500
1994 to 1999
11,000
10,500
10,000
1994
1995
1996
1997
1998
1999
Note: Figures are comprised of the average of provincial standardized rates of admission.
Source: CIHI 2002c.
Figure 8.5 11.8

Inpatient/
11.6
Acute Care
Hospitalizations: 11.4
Average Length
of Stay, Aged 11.2
65+, Canada,
1994 to 1999 11.0
10.8
10.6
10.4
1994
1995
1996
1997
1998
1999
Note: Figures are comprised of provincial average length of stay data.

Source: CIHI 2002c.
180
While there are some clear advantages to early discharge for many
patients, early discharge from hospital is not always beneficial. Some “We want a national system for
patients who are discharged early are unable to perform the normal
activities of daily living, have complex medical needs that require ongoing home care. We have examples
professional attention, or have considerable medication requirements. In throughout the country that show
these cases, discharging people early from hospital without adequate
resources simply shifts the burden for care from hospitals to patients and that some of our older people
their families. Furthermore, discharging patients – especially when they
are elderly – without adequate assessment of their post-acute care needs have to be hospitalized when
can considerably increase the risk of re-admission (Afilalo 2001). they could be cared for at home
for much less money. And for this

There is good reason to believe that home care has picked up where
hospitals left off. It is commonly held that hospitals have decreased we recommend a national system
inpatient days because of the “belief that significant public sector cost well financed by the federal
savings may be realized by redirecting care away from institutions and
towards the community” (Coyte 2000, 7). This is not unique to Canada. A government, the provinces
British study reports that “Pressure on hospital beds, the increasing age of
and the territories.”
the population, and high costs associated with acute hospital care have
fuelled the search for alternatives to inpatient hospital care” (Richards A SSEMBLƒE DES AINƒES ET AINƒS
FRANCOPHONES DU CANADA.
P RESENTATION AT WINNIPEG
et al. 1998, 1797). Home care services have become a less costly substitute PUBLIC HEARING.
for many services that were previously provided in hospitals.
The current trends for early release from hospital are expected to
continue and new advances in technology and prescription drugs are likely to make it possible to
provide more services safely in the home. Because these home care services substitute for
services that previously would have been covered in hospital, it makes sense that they should be
covered under the Canada Health Act, even though they are provided at home. Post-acute home
care services are generally a cost-effective alternative to delivering these same services in
hospital. Providing coverage under the Canada Health Act would support the current trend to
increasing care at home and ensure that post-acute home care is available on the same terms and
conditions across the country.
Coverage for post-acute home care should include case management, health professional
services, and medication management. Post-acute home care should be provided for a maximum
of 14 days following discharge from acute care or for a maximum of 28 days if rehabilitation is
needed for the specific condition (Appendix G).
Palliative Home Care

Palliative care is currently provided in hospitals, long-term care facilities and hospices, as
well as through home care. When it is provided in a hospital, palliative care is fully publicly
covered as a medically necessary service under the current Canada Health Act. When it is
provided at home, only some health care services and prescription drugs are covered depending
on each provincial, territorial, or regional program.
According to the Canadian Hospice Palliative Care Association (2001), few provinces have
designated palliative care as a core home care service with a specific budget. The Association
181
notes that “Resources required to provide good care in the community,

“My personal experience with either in a person’s home or in a specialized residential hospice, have not
been made available, even when access to hospital beds has been reduced.”
end-of-life care took place in There are considerable disparities in access to palliative care across the
1997 when my 7-year-old son country. These services have been developed on an ad hoc basis and are
limited by the financial capability of communities and charitable
Matthew was dying of cancer.… organizations. Consequently, many Canadians do not have access to
palliative care. Some estimates suggest that only 5% of Canadians have
During the final stages of his
access to hospice palliative care. These services are primarily provided for
disease, Matthew received people with cancer. Canadians who live in remote and rural communities,
and individuals with disabilities also have limited access to hospice
excellent multi-disciplinary palliative care (Canadian Hospice Palliative Care Association 2001).
care.… I had assumed that this
same level of care was available Disparities in access to palliative care were highlighted by a Senate
Subcommittee chaired by Senator Sharon Carstairs, Minister with Special
to all people of all ages who need
Responsibility for Palliative Care, its report entitled Quality End-of-Life
end-of-life care in Newfoundland
Care: The Right of Every Canadian (Senate 2000). The report suggests
and Labrador. I now know this is that access to palliative care is often based on “the luck of the draw” rather
than a basic entitlement of Canadians. As one provincial presenter
far from accurate … make suggested, “[Palliative] home care is variable, fragmented, and financed
certain that the delivery of end- through different mechanisms. There are few consultation teams available
for home or long-term care situations and minimal community hospice
of-life care becomes a truly services to provide visiting volunteers, day programs, and respite for
families. The delivery system … is too rigid for the 24-hours a day care
universal service available to all
required by terminally ill people at home.” Senator Carstairs and her
individuals with a need.” Subcommittee have highlighted a number of important concerns related to
palliative care. The work currently underway on developing a national
HONNA JAMES-HODDER.
strategy for end-of-life care will undoubtedly provide valuable assistance
P RESENTATION AT
ST. JOHN’S PUBLIC HEARING.

to governments as they seek to go beyond the national platform
recommended in this report.
Problems with lack of access to palliative home care are likely to

“My three year old son was increase in future as Canada’s population ages. A 1997 Angus Reid poll
found that approximately 80% of Canadians prefer to die at home (CACC
diagnosed with cancer. When 2001). The percentage of hospital deaths peaked in 1994 at 80.5% and, by
1997, it had dropped to 75.3% in a steady trend-line (Wilson et al. 2001).
I faced decisions about his Notwithstanding this trend, the Canadian Association for Community Care
treatment, palliative care was not reports that home-based palliative care is “often not possible because of
the lack of home-based palliative care services” and that “only about 10%
available at that time in home of Canadians have access to palliative care services.”
and it is not available today.”
HOSPICE PALLIATIVE CARE More compelling than this growth in demand, however, is the
A SSOCIATION OF P EI. P R E S E N T A T I O N suggestion that there is a right to die with dignity, and that this includes the
AT C HARLOTTETOWN P UBLIC H EARING . right to die at home (Hospice Palliative Care Association of Prince Edward
Island 2002). As the Seniors Resource Centre of Newfoundland and
Labrador (2002) told the Commission, “Seniors do not wish to end their
182 days in institutions.” Instead, they would prefer to be in the comfort of
their homes, surrounded by familiar faces and a comforting environment.

One of the objectives of helping people die with dignity is to reduce pain as “… the federal government
much as possible and to maintain the highest possible level of functioning
[should] immediately assess the
(CACC 2001). While these objectives can be met both at home and in
institutions, the home is often the best place to maintain the highest level of need for home care and
functioning.
pharmacare for the dying …
Including palliative home care as an essential service for Canadians can [and] … implement income
be justified on many different grounds, not the least of which is our social
obligation to people during their dying days. It is a highly emotional time and job protection for family
and a compassionate society must ensure that people have the care and
support they need to spend their remaining time at home, if that is their members who are caring
choice. And, as pointed out in the final report of the National Evaluation of for the dying.”
the Cost-Effectiveness of Home Care (Hollander and Chappell 2002, xi)
palliative care at home “should result in fewer trips to the hospital and CANADIAN PALLIATIVE CARE
A S S O C I A T I O N . P RESENTATION AT
OTTAWA PUBLIC HEARING.

save money.”
Some limits around the time frame for palliative care are necessary.
Depending on patients’ particular condition, they may live for long periods
of time in spite of the fact that they have a terminal illness and are
“The focus should be on allowing
receiving no other treatments to attempt to cure the illness. People can have
living wills and “do not resuscitate” orders precluding heroic measures for people to die with dignity and to
many years prior to their death. Therefore, eligibility to receive palliative
home care should be limited to individuals who have a prognosis of death recognize that death is normal
within six months. People would be eligible for palliative home care based
and has a special place.”
on a referral from their physician. The types of palliative home care
services should include pain and symptom relief, case management, professional A SSOCIATION QUƒBECOISE DES SOINS
PALLIATIFS. P RESENTATION AT Q UƒBEC
CITY PUBLIC HEARING.
services, medication management, and counselling when needed. Respite

care should also be provided when appropriate.
Impr?ving Supp?rt f?r

Inf?rmal Caregivers
Human Resources Development Canada, in conjunction with Health Canada should
be directed to develop proposals to provide direct support to informal caregivers to
allow them to spend time away from work to provide necessary home care assistance
at critical times.
Recognizing the Role of Informal Caregivers

Quite simply, home care could not exist in Canada without the support of social networks
and informal caregivers. By informal caregivers, we mean the family members and friends who
provide support on an unpaid basis (Hollander and Chappell 2002).
While there are varying estimates of how much home care support is provided by informal
caregivers, all estimates are high. The Ontario Coalition of Senior Citizens’ Organizations
(2002), for example, estimates that 85 to 90% of home care is provided by family and friends. 183
Similarly, the Family Caregivers Association of Nova Scotia (2002) estimates that 80% of care
needs of Canada’s elderly are addressed by informal caregivers. Informal caregivers play a
critically important role in providing ongoing care, support, and advocacy for people with
physical disabilities. In terms of the numbers of informal caregivers, the Canadian Association
for Community Care reports that currently there are three million informal caregivers in Canada
ranging from teenagers to seniors (CACC 2001).
In addition to informal caregivers, there also is an abundance of volunteers who devote

hours of service caring for people who are ill. The Health Charities Council of Canada (2002)
estimated that, in 1997, 93 million hours of formal volunteering were provided in Canada, on top
of over 2 billion hours of informal caregiving. The combined value of these services was
estimated at between $20 and $30 billion.
Informal caregivers play an essential role in the delivery of home care services and in the
health and care of their families and friends. Many informal caregivers are more than happy to
provide care and support to their loved ones, but the reality is that caregiving is becoming an
increasing burden on many in our society, especially women. A recent study suggests that
caregivers experiencing the strain of caregiving have 63% higher mortality rates (Schultz and
Beach 1999).
The Commission heard repeated concerns about the burden of informal caregiving and the
impact it has on the lives of many Canadians. A representative of the Assemblée des aînées et
aînés francophones du Canada (2002) at the public hearing in Winnipeg told the Commission
that his mother took care of his grandmother for 24 years and that his sister left a religious order
to take care of their mother – all with no compensation. Many presenters expressed the view that
family members should not be forced to care for the ill (Fédération des infirmières et infirmiers
du Québec 2002; Laurentian University, School of Nursing 2002) and expressed concern about
the particular burden that home care places on women (Pauktuutit-Inuit Women’s Association
2002; Prince Edward Island Nurses Union 2002). The Association québecoise de défense des
droits des personnes retraitées et préretraitées (2002) suggested that social policies should be
established to give relatives incentives to keep their loved ones at home, and to make it easier for
them to do so. In St. John’s, the Commission was reminded that an aging population will require
more publicly funded health care due to the fact that there will be fewer and fewer younger
family members to take care of those who are aging (Seniors Resource Centre of Newfoundland
and Labrador 2002).
To acknowledge the important role of informal caregivers, various forms of support are
possible from direct remuneration to tax breaks, job protection, caregiver leave, and respite. In
the Commission’s view, informal caregivers should be able to take time from their jobs to
provide the necessary care at home. The most direct way of providing this support would be
through Employment Insurance benefits. People should be granted time off for informal
caregiving at home for family members and loved ones at critical times. While the specific
eligibility criteria should be developed by the federal government, it should be possible to
introduce this new benefit within the resources that are currently available in the Employment
Insurance program.
184
Taking the Next Steps

Extending the revised Canada Health Act to include coverage for home care services as
defined earlier in the chapter is a critical first step. But to gain the most benefits from home care
services, they need to be fully integrated with the continuum of care provided in the health care
system. In effect, home care should not be seen as a distinct category of care but as a key part of
the health care system.
A number of issues need to be addressed by provinces and territories on an ongoing basis in
order to integrate home care more fully into the continuum of care.
Adequate and Appropriate Health Human Resources

As home care services continue to expand, there will be growing demands for trained home
care providers. Case managers will become increasingly important in co-ordinating care with a
team of health care providers and other sectors of the health care system including hospitals,
long-term care facilities, and hospices. For post-acute home care, for example, the case manager
should be someone involved in patient discharge who assesses the needs of the patient,
determines if post-acute home care is appropriate, and determines the length of time and the
services to be provided. For palliative home care, the case manager should be someone who co-
ordinates services for patients in conjunction with physicians, family members, and other
agencies. In home mental health intervention, the case manager should be a professional with
training in the mental health field who can quickly assess the emergency needs of a client or
family in crisis and dispatch the necessary home intervention team to handle the situation.
Continuity and Co-ordination of Health Care

Studies suggest that efficiency can be improved if there are effective linkages between home
care and other aspects of the health care system. A 2001 Health Transition Fund report
demonstrated that, by bridging the gap between hospital and community care with a nurse
discharge co-ordinator, readmission to hospital can be reduced considerably (Afilalo 2001).
Several reports and studies point to the importance of good discharge planning and effective
home care programs. A study on home-based intervention for people with congestive heart
failure showed a reduction in hospital re-admissions and improvements in survival (Stewart and
Horowitz 2002). Similarly, a study on elderly patients found that if there is appropriate screening
of elderly patients in emergency departments and appropriate referrals are made before the
patients are discharged, a seamless delivery system of health care can be provided. In addition,
the study showed that “[a] home care visit resulting from a referral may be all that is needed for
the maintenance of a patient’s condition. To improve the quality and continuity of patient care,
home care screening should be integrated into the routine discharge Emergency Department
activities” (Castro et al. 1998, 127). Another study recommended that all emergency
departments adapt the use of a high risk assessment tool for the clinical nurse to use to screen for
patients that will benefit from the work of the discharge co-ordinator (Afilalo 2001). Hollander
and Chappell (2002) also reported that, with stable home care arrangements (i.e., clients who
remain at the same level for six months or more), the costs of care are about 50% less than
facility care. However, when home care clients change their type of care, the cost is only 10 to
30% less than the costs of facility and extended care.
185
Continuity of care is also critically important for patients. For home care to be as effective
as possible, ongoing communication is necessary to prevent the revolving door effect of patients
transferring back and forth between levels and types of care. This kind of revolving process can
offset the savings gained through home care. It also has costly effects, especially in the case of
the elderly who often suffer from relatively minor ailments that could easily be treated at home
at a lesser cost than in hospital.
The need to integrate home care with the overall continuum of care is well recognized by
provincial and territorial Premiers. At their January 2002 meeting, the Premiers agreed to a
series of initiatives to foster the integration of home care into a seamless continuum of care and
to establish common practices across the country. Among their objectives, the Premiers agreed
to: •
Explore options to provide support and assistance to families and other caregivers who
care for people in the home;
• Identify approaches to facilitate broader adoption of technology including telehealth
technologies for use in home and community settings;
• Support collaboration between home and community care and housing providers to
develop innovative and affordable supportive living and other facility arrangements;
• Examine approaches that will improve the continuity of care for home care clients by
enhancing co-ordination and linkages between home care providers and other health care
providers (in acute care, primary care and long-term care sectors); and
Collaborate
• on identifying common data elements across provinces and territories that would
promote consistent classification of home care clients, allow for comparisons of home and
community care services and outcomes, lead to better research and evidence- based decision
making, and provide better linkages to other settings and levels of care. In terms of moving
ahead with concrete actions to improve integration and continuity of care, several suggestions
have been made to improve the infrastructure in home care, by the Canadian Home Care
Association (2001), the Canadian Association for Community Care and the Canadian Home Care
Association (2001), Hollander and Walker (1998), as well as in background work done for the
Annual Premiers’ Conference in the Fall of 2002. The suggestions include establishing:
• A single point of access to home care and residential services;

• Co-ordinated assessment and placement at the system level to ensure that there is an
appropriate determination of a client’s needs, and development of a care plan to address
those needs;
• Formal linkages among primary care physicians, acute care hospitals, housing options,
long-term care facilities and the case management function in the home care sector;
• Co-ordinated information systems to support these linkages;
• A consistent client classification system that allows for the comparison of clients across
service delivery components, by level of care;
• Policies that foster the most cost-effective delivery of services through co-ordinated,
ongoing, system-level case management – whatever the site of service – and that provide
stability for clients, families and service providers; and
• Planning processes that include home and community care organizations and
representatives as participants at both the health care system level and in local or
186 regional health authority networks.
Integration with Primary Health Care

Because of the central importance of primary health care in providing comprehensive care,
linkages between primary health care teams and networks and home care are essential. In several
provinces, telephone information lines are available 24 hours a day, 7 days a week to provide
immediate access to health information and advice. These services should have clear links to
home care services. Primary health care teams and networks can also serve an important role in
identifying people who need expanded home care services in order to maintain their health. New
developments in electronic health care records outlined in Chapter 3 would also provide an
essential link between home care and primary health care, and allow providers to share
important information and track the health of their patients on an ongoing basis.
Expanding Home Care

The Commission’s recommendations would expand home care in three priority areas –
home mental health case management and intervention, post-acute home care and home
palliative care – and also provide a significant benefit to informal caregivers. The largest
component of current provincial and territorial home care budgets goes to support home care for
people with chronic health problems or physical disabilities. As noted earlier, while the Home
Care Transfer is not specifically targeted at these needs, the introduction of caregiver support
should provide a significant benefit for family members caring for people with chronic illnesses
and physical disabilities. The new Transfer should also free up a substantial amount of funds in
current home care budgets. Provinces and territories should immediately be able to use those
freed up resources to expand services and address the pressing home care needs of people with
chronic conditions and physical disabilities. In the future, as resources permit, expanded home
care services focused on meeting the needs of people with chronic illnesses and physical
disabilities could be included under the Canada Health Act . It is the Commission’s hope that
these further steps will be pursued by all governments as soon as resources permit.

Making certain aspects of home care an insured service under the revised Canada Health
Act is a clear sign that Canada’s health care system is evolving to meet the changing reality of
health care delivery in Canada.
More specifically, as a result of these recommendations:
• All Canadians from coast to coast to coast will have access to essential home mental
health case management and interventions, post-acute home care services, and palliative
home care services;
• Particularly in the case of mental health, trained professionals will be available to
intervene with temporary behaviour or other problems and help people with mental
health problems cope with their illnesses on an ongoing basis;
• Essential home care support will be available for people with dementia and Alzheimer’s
disease to help them and their families cope with the situation and make decisions about
the best options for care;
• People who are dying and who prefer to die in their own homes will get the care they
need to be able to die with dignity; 187
• People who are released early from hospital will receive the necessary treatments and
support at home, including support for rehabilitation; and
• For the first time, the invaluable role of informal caregivers will be recognized and
supported, and people will be able to take the time they need from work to provide care
for their loved ones at home.
This is a vitally important step for Canadians. It means home care will be increasingly
integrated with the rest of Canada’s health care system. And it means Canadians will be able to
maintain their health, recuperate and recover, or spend their dying days in their own homes with
the care and support they need.
188
PRESCRIPTION D RUGS

9
• Take the first steps to better integrate prescription drugs into Canada’s
health care system.
• Use the new Catastrophic Drug Transfer to offset the cost of provincial
and territorial drug plans and reduce disparities in coverage across the
country.
• Establish a new National Drug Agency to control costs, evaluate new and
existing drugs, and ensure quality, safety, and cost-effectiveness of all
prescription drugs.
• Establish a national formulary of prescription drugs to provide
consistency across the country, ensure objective assessments of drugs,
and contain costs.
• Develop a new medication management program for chronic and some
life-threatening illnesses as an integral part of primary health care.
• Review aspects of Canadian patent law.
The Case fHr Change

When medicare was first introduced, prescription drugs played a limited role in the health
care system and in the day-to-day lives of the vast majority of Canadians. Today, they are a fact
of life for many Canadians. Prescription drugs provide relief from many of our regular aches and
pains. They also protect children from illnesses, cure diseases that once were a death sentence,
and help manage the chronic health conditions of thousands of Canadians. Prescription drugs
have also replaced the need for some intensive surgeries and have helped to reduce recovery
times, often allowing people to recover at home rather than in hospitals. In fact, they have
fundamentally changed the face of health care in Canada.
Looking ahead, there is every reason to believe that we have only seen the tip of the iceberg
when it comes to the potential for new prescription drugs. In the future, we can expect continued
increases in both the supply of, and demand for, drugs, driven by the advent of new genetic
189
technologies and the ability to detect and prevent many genetic diseases (Miller et al. 2002). As
we learn more about our genetic make-up and genetic factors that cause certain diseases, we may
be able to develop and prescribe medications that will prevent many congenital diseases.
The current and potential benefits of prescription drugs are undeniable. But the benefits will
only be fully realized if prescription drugs are integrated into the system in a way that ensures
they are appropriately prescribed and utilized and that the costs can be managed.
As the following sections of this chapter indicate, rising costs are an increasing worry, both
for provinces and territories and for individual Canadians. There are also disparities in coverage
across the country. The process for evaluating and approving new prescription drugs is time-
consuming and each province and territory has its own approach for deciding which prescription
drugs are covered under its insurance plan. In spite of considerable efforts by provinces and
territories, costs are increasing and taking up an increasing share of health care budgets across
the country. Furthermore, prescription drugs continue to be on the sidelines of Canada’s health
care system rather than integrated, as they should be, with primary health care and with other
aspects of the health care system.
Given the expanding role of prescription drugs in Canada’s health care system, a strong
case can be made that prescription drugs are just as medically necessary as hospital or physician
services (National Forum on Health 1997). However, the immediate integration of all
prescription drugs into a revised Canada Health Act has significant implications, not the least of
which would be substantial costs. Therefore, the goal should be to move in a gradual but
deliberate and dedicated way to integrate prescription drugs more fully into the continuum of
care. Over time, these proposals will raise the floor for prescription drug coverage across Canada
and lay the groundwork for the ultimate objective of bringing prescription drugs under the
Canada Health Act .
Two critical issues must be addressed. The first is improving access and ensuring that
financial barriers do not prevent Canadians from accessing the prescription drugs they need.
Currently, there are disparities in coverage across the country and these disparities could worsen
as costs for prescription drugs increase. The second issue is continuing to improve the quality,
safety and cost-effectiveness of prescription drugs.
To address those issues, five essential steps must be taken:

• A new Catastrophic Drug Transfer – As mentioned in Chapter 2, provinces and
territories would receive additional funds through this new federal transfer to help cover
the high costs of prescription drug plans and protect their residents against the potentially
“catastrophic” impact of high cost drugs. This provides a clear incentive for provinces
and territories to expand their coverage and reduce disparities across the country.
• A new National Drug Agency – One new prescription drug comes onto the market in
Canada every four to five days. In the future, that pace will accelerate. New research on
genetic testing and biotechnology will undoubtedly bring a host of complex and difficult
issues. Canada must have a comprehensive, streamlined, and effective process in place
for addressing these issues and ensuring the safety, quality and cost-effectiveness of all
new drugs before they are approved for use in Canada. But just as important, processes
should be in place for reviewing drugs on an ongoing basis, monitoring their use and
outcomes across the country, and sharing high quality, timely information, and analysis
190
PRESCRIPTION DRUGS
with provinces and territories, health care providers, researchers, and Canadians. A new
independent National Drug Agency would perform these functions on behalf of all
governments and all Canadians.
• A national formulary for prescription drugs – Currently, each province and territory
has its own list of prescription drugs that are covered under its drug insurance plan. A
national formulary, developed by the National Drug Agency in conjunction with the
provinces and territories, would provide consistent coverage, objective assessments, and
help contain costs.
• A new medication management program linked to primary health care – Primary

health care reform is an essential component of our vision for the future of Canada’s
health care system. Linking medication management with primary health care would
ensure that the effectiveness of prescription drugs can be monitored by teams and
networks of health care providers working with individual patients on an ongoing basis.
• Patent review – Aspects of Canada’s patent laws should be reviewed in order to improve
access to generic drugs and contain costs.
Provinces and territories are well aware of both the enormous potential and the growing costs
of prescription drugs. Individually and collectively, they have taken steps to try to manage costs
within their own jurisdictions and to explore the most effective solutions. However, given the
national scope of the issues and the substantial costs involved, this is a clear case where there is
more to be gained by working together rather than proceeding on many separate tracks. The five
key steps proposed in this chapter provide an opportunity for provinces and territories to work with
the federal government to improve access to essential prescription drugs, contain costs, protect
safety and quality, link pharmaceutical information networks and ensure that, as Canadians, we get
the best health outcomes for our rapidly growing investment in prescription drugs.
A SnapshHt Hf PrescriptiHn Drugs

in Canada
Prescription drugs play an increasingly important role in Canada’s health care system. The
following sections highlight the expanding role of prescription drugs, disparities in access and
coverage across Canada, and the increasing cost of prescription drugs in provincial and
territorial health care budgets.
The Expanding Role of Prescription Drugs “Evidence strongly suggests that

To put the role that prescription drugs play in our health care drugs are money well spent.
system in context, consider these facts:
Yet considerable evidence also
• 300 million prescriptions are filled in Canada each year,
amounting to about 10 prescriptions for each man, woman or points to significant waste,
child;
and inappropriate prescribing
• As shown in Table 9.1, Canadian family spends an average of
close to $1,210 a year on prescription drugs. This is a lot of and use.”
money but a small proportion of Canadians, especially people CANADIAN PHARMACISTS
with chronic illnesses and some elderly people, spend A S S O C I A T I O N 2001.
considerably more. W RITTEN SUBMISSION .
191
Table 9.1
Utilization of Prescriptions, 2001
Average family size 3.0

Prescriptions per person 10.1
Prescriptions per family 30.3
Average prescription price $39.92
Consumption per family/year $1,209.58
Source: IMS HEALTH Canada et al. 2002.
Prescription drugs play an important role in two key areas:

• Treatment of life-threatening, chronic and common illnesses –
Scientists and drug companies continue to develop new prescription
“When I was diagnosed at the drugs that either cure or delay the progress of deadly illnesses. These
so-called “miracle drugs” save lives and provide substantial benefits to
age of two, life-expectancy individual Canadians, but the costs can be very high. While the price of
[for Cystic Fibrosis] was six years. the drugs may come down over time, the fact that they are widely used
means that the overall costs continue to be substantial and drive up
When I graduated from the overall drug budgets.
college of law at the age of
Some drugs help treat chronic conditions such as asthma, high
thirty-one, life expectancy was blood pressure, coronary heart problems, diabetes, and mental
illnesses. People with these chronic illnesses are required to take
thirty-two years. During those
prescription drugs regularly over extended periods of time, sometimes
intervening years the disease for their entire lives. The cost of these medications is generally less
than the cost of new miracle drugs. However, because they are taken
did not change; what did change over a longer period of time and by a large number of people, they
was the discovery of new
make up a significant proportion of heath spending. The role of
prescription drugs in managing chronic illnesses will increase as our
treatments for Canadians … society ages (Morgan and Hurley 2002b). Furthermore, we are now
starting to see new, high-cost (and controversial) preventative
Unfortunately universal access medications that may delay the onset of debilitating diseases. An
is no longer the case … new example is Interferon Beta 1b for people with multiple sclerosis. The
regular use of this drug was estimated to cost $16,685 per person per
drugs may or may not be year (Brown et al. 2000), but its effectiveness remains a matter of
some debate.
covered in different provinces …
We need a uniform drug
coverage with universal access for Not surprisingly, the most common prescription drugs mirror the
most common illnesses in the population. Information from Quebec
all Canadians.”
shows that more than half of all the prescription medications consumed
C H R I S M A C L E O D . P RESENTATION AT in that province in 2000 were from only six classes of medicines (see
TORONTO PUBLIC HEARING. Table 9.2), corresponding to some of the most common illnesses in the
population – heart disease, gastric and duodenal ulcers, mental illness,
and arthritis (Montmarquette 2001).
192
PRESCRIPTION DRUGS
Table 9.2
Increase in Spending for Six Categories of Pharmaceuticals in the Quebec Drug
Insurance Program, 1997 to 2000
Growth
Cost ($Millions) 1997 to 2000
Categories 1997 1998 1999 2000 (%)
Lipid reducing agents 105.7 131.0 158.4 189.6 79.3
Anti-hypertensives 111.9 135.2 161.7 193.5 73.0
Anti-inflammatories
(analgesics) 60.0 61.3 71.4 119.0 98.3
Psychotropic 69.6 93.7 123.0 150.0 115.4
Gastrointestinal 89.6 108.1 129.7 150.6 68.0
Anti-infectives 82.1 97.9 111.0 120.8 47.2
Subtotal 518.9 627.2 755.2 923.5 78.0
Total drug costs 1,119.4 1,292.8 1,498.4 1,772.2 58.3
Proportion spent on
six categories (%) 46.4 48.5 50.4 52.1
Source: Quebec, MSSS 2001.
• Substitution for other medical interventions – Prescription drugs are increasingly used
as a substitution for other treatments and medical interventions, including surgery. For
example, new medications for treating peptic ulcers mean that surgeries for ulcers have
virtually disappeared in the past 15 years (HC 2001g). Certain drugs allow people to be
released more quickly from hospital so they can return to their own homes and families
rather than staying in hospital. This saves on the cost of hospital stays but results in
increased costs for drugs and home care services. Unfortunately, the data are simply not
available to allow us to put a dollar figure on these “substitution” costs and to accurately
assess how much we are saving in hospital costs by spending more on prescription drugs.
One of the most dramatic changes has occurred in the field of mental health. Prior to the
advent of psychotropic drugs in the 1960s, many individuals with untreatable mental
illnesses were hospitalized repeatedly or even indefinitely. Today, these same mental
illnesses can often be controlled with prescription drugs, allowing many people to lead full
and satisfying lives without recurring hospitalization, particularly if they have adequate
support available in their homes and communities.
As the role of prescription drugs in the health care system expands, a number of concerns
have been identified.
• The cost of prescription drugs is increasing. Recent data from the United States indicate
that the average price of a new speciality drug is two and a half times higher than the
price of similar, older medications (NIHCM Foundation 2002).
193
• While new drugs can make a profound difference, some new prescription drugs are not
significantly more effective than older, less expensive drugs in terms of improving
survival rates, quality of life of users or patient safety (Garattini and Bertele 2002).
• Existing medications often are put to new use and this increases both the price and the
consumption of those drugs. A study in the United States demonstrated that finding new
uses for existing medications, with only slight modifications in their ingredients, resulted
in a 75% increase in the price of the medications (NIHCM Foundation 2002).
• Prescription drugs are not always used appropriately. In a submission to the

Commission, the Canadian Pharmacists Association suggested that “One significant cost
driver rarely discussed is the unquantifiable cost to the system of inappropriate drug use.
… We know how much we spend … [b]ut we do not know how much we are wasting”
(Canadian Pharmacists Association 2002,1). They estimate that the cost of underuse,
misuse and overuse could range from $2 to $9 billion a year.
• As more people are treated with drug therapies either in hospital or at home, errors in the
prescription and administration of drugs have increased and, in the United States, they
are the sixth leading cause of death (Lazarou et al. 1998). Errors that could have been
prevented with better information systems and better integration of prescription drug care
with the rest of the health care system have been estimated to cost about $10.9 billion a
year (Kidney and MacKinnon 2001).
Access to Drugs and Drug Coverage

Disparities among the Provinces and Territo
Canada has a fragmented system of drug coverage across the country (Grégoire et al. 2001).
To a very large extent, people’s income, the kind of job they have, and where they live
determine what type of access they have to prescription drugs.
There is considerable variation among provincial plans in terms of who is covered, for what
drugs, and what kinds of co-payments or deductibles are required (see Figure 9.1). Provincial
plans vary between those that cover a wider range of prescription drugs for a targeted group of
people (e.g., seniors and social assistance recipients) and those that provide benefits for a
broader range of people but cover a narrower range of drugs and have high co-payments and
deductibles in order to limit utilization. There is significantly less coverage for prescription
drugs in Atlantic Canada compared to the rest of the country. And provinces with a larger
industrialized base tend to have more generous employer-sponsored drug insurance programs
while smaller, less industrialized provinces are less likely to have private insurance that covers
expenses that are not picked up by the public plan.
Not surprisingly, given the variability in provincial plans, there is extremely limited
interprovincial portability of provincial drug plan benefits. When people move from one province
to another, they generally lose their drug coverage and have to wait for three months to be eligible
in their new province (Applied Management et al. 2000b). In effect, the lack of portability in
prescription drug plans can be a barrier to mobility across the country.
194
PRESCRIPTION DRUGS
Figure 9.1 Provincial government Privately insured Private out-of-pocket Other government
Coverage of
Prescription
Drug
Expenditures,
by Source of
Finance, 1999
Note: Data not available for Prince Edward Island, Yukon, Northwest Territories or Nunavut.
Source: CIHI 2002a; Canada, Senate 2002a.
Private and Public Coverage

Canada has a mix of private and public coverage for prescription drugs. The majority of
drug costs are covered through employer-sponsored private group insurance plans. Provincial
and territorial plans subsidize the cost of prescription drugs for their residents, particularly social
assistance recipients and seniors. The federal government provides drug coverage for registered
First Nations and eligible Inuit through the Non-Insured Health Benefits Program (NIHB) for
drug needs that are not covered by provincial and territorial plans. It also provides prescription
drug coverage for members of the Armed Forces and eligible veterans (Applied Management et
al. 2000a). This combination of private and public plans determines who has access to
prescription drugs, under what conditions, and how much they pay.
Data from the Canadian Institute for Health Information (CIHI 2002a) indicates that in
1999: • insurance plans covered approximately 34% ($3.4 billion) of prescription drug
Private
costs;
• Individual Canadians paid 22% ($2.3 billion) of prescription drug costs out of their own
pockets;
• Public insurance plans covered approximately 44% ($4.4 billion) of prescription drug
costs; and
• The relative share of private spending (56%) versus public spending (44%) has changed
little since 1985.
The mix of public and private coverage results in all but a small minority of Canadians
having some form of coverage for prescription drugs. However, there are significant disparities
in coverage across the country and these disparities could well become worse as provinces and
territories face rising costs for prescription drugs.
195
The Cost of Prescription Drugs

In 1980, $1.3 billion was spent on prescription drugs in Canada, about 5.8% of total
spending on health care in the country (see Figure 9.2). By 2001, the percentage had doubled to
12% and the total amount of money spent on prescription drugs had climbed dramatically to
$12.3 billion (see Figure 9.3).
There is every reason to believe that the use of prescription drugs will become even more
widespread in the future and that costs will continue to increase. Given this reality, provinces
and territories will face serious challenges in trying to manage costs on the one hand and ensure
reasonable access to medically necessary drugs on the other. Their choices are limited. They can:
restrict coverage to a narrower range of drugs; increase deductibles and co-payments; reduce
spending in other areas of the health care budget; or find other ways to raise the necessary
revenues to pay for increasing drug costs. The first two options – limiting coverage or increasing
deductibles – would have a negative impact on a sizeable minority of Canadians that rely on
public insurance plans (Applied Management et al. 2000b).
A better option is for provinces and territories to work together to address these issues from
a common perspective. By working together, they can:
• Ensure that all Canadians have equitable access to medically necessary prescription
drugs regardless of where they live or their personal circumstances;
• Ensure the quality and safety of new and existing drugs;
• Manage and contain costs.
Figure 9.2
All Other Prescription Drug
Prescription Health Expenditures
Drug Expenditures Expenditures 5.8%
as a Proportion of 94.2% ($21 ($1.3 billion)
billion)
Total Health
Expenditures, 1980
Source: CIHI 2002a; CIHI 2001e.
196
PRESCRIPTION DRUGS
Figure 9.3 All Other Prescription Drug

Prescription Drug Health Expenditures
Expenditures as a Expenditures 12%
Proportion of 88% ($90.2 ($12.3 billion)
billion)
Total Health
Expenditures, 2001
Source: CIHI 2002a; CIHI 2001e.
Establishing a New CatastrHphic

Drug Transfer
The proposed new Catastrophic Drug Transfer should be used to reduce disparities in
coverage across the country by covering a portion of the rapidly growing costs of
provincial and territorial drug plans.
Canadians with very high prescription drug needs are expected to shoulder a considerable
financial burden simply because they were born with a serious illness or are struck by an illness
at some point during their lives. In some provinces, programs are in place to provide assistance
to cover an individual’s or a family’s drug costs if they exceed a high deductible. In other
provinces, this assistance is not available. Based on what we know about Canadians’ values,
people’s access to necessary prescription drugs should not be determined by where they live.
Through the Catastrophic Drug Transfer, the federal government
would provide targeted funding to cover a portion of provincial

and territorial drug insurance costs. This is how the new transfer “… drug therapy has to produce
would work.
definite improvements in
• The federal government would reimburse 50% of the costs
of provincial and territorial drug insurance plans above a patients’ quality of life, be
threshold of $1,500 per person per year (i.e., the point at accessible, be used cost
which drug expenses for an individual would be considered
“catastrophic”). This threshold is roughly equivalent to the effectively and do no harm.”
deductibles in many of the provinces’ drug plans and would CANADIAN PHARMACISTS
cause the least amount of disruption to existing drug A S S O C I A T I O N 2001.
insurance plans. W RITTEN SUBMISSION .
197
• With the additional funds provided through the Transfer, provinces and territories would
be expected to expand access to prescription drugs within their own drug insurance plans
by reducing their deductibles or co-payments, or by extending coverage to people who
are not now included under their plans.
• The federal Catastrophic Drug Transfer would be based on conditions and reporting
requirements jointly agreed to by the federal government and individual provincial and
territorial governments.
In order to estimate the potential costs of the Catastrophic Drug Transfer, the Commission
asked the Manitoba Centre for Health Policy (MCHP 2002) to provide a detailed analysis of drug
costs for the province of Manitoba in recent years. The Manitoba database, which is widely
considered to be the most comprehensive database of its kind in Canada, was then used by the
Commission to estimate the potential cost of the Catastrophic Drug Transfer on a national basis.
An essential first step was selecting an appropriate threshold for catastrophic coverage. The
threshold should be low enough to ensure that real changes are made in the way prescription
drugs are covered and integrated into the health care system. On the other hand, if the threshold
were too low, the costs would be prohibitively high for the federal government. Taking these
considerations into account, a threshold of $1,500 was selected, as noted above.
Based on a threshold of $1,500, the Manitoba data showed that for 2000/01: •
There were 39,878 Manitobans with drug costs in excess of $1,500 a year;
• These people had 2,049,855 prescriptions at an average cost of $54.53 each;
• The average cost of prescriptions for Manitobans that year was $35.08, indicating that
people with high drug needs also needed drugs that are more expensive than the average;
The total
• cost to the Manitoba Pharmacare plan for these individuals was approximately $112
million or 44% of the total cost ($256 million) of the public plan (MCHP 2002). A number of
factors and assumptions were considered in order to extrapolate the Manitoba data to the rest of
the country. Manitoba’s formulary is reasonably generous relative to other provinces and
territories. The size of the prescription drug market in Manitoba relative to the rest of the country
was included in the calculations. An assumption was made that people in other parts of the
country with high total drug costs would also pay, on average, more per prescription than people
with lower drug costs. And finally, a 15% margin of error was included to account for different
patterns of drug use, access and demographics.
Based on these assumptions, the cost of the Transfer could range from $749.1 million to
$1.01 billion. To be fiscally prudent, the Commission has chosen to use the higher figure for the
Catastrophic Drug Transfer. Using the Manitoba example, of the total costs noted above, the
province spent approximately $52 million to provide coverage for people, minus the $1,500
threshold. The Catastrophic Drug Transfer would have covered 50% of these costs, giving
Manitoba an additional $26 million to put toward increasing access to prescription drugs.
In addition to providing incentives for provincial and territorial governments to expand

access to prescription drugs, the new Catastrophic Drug Transfer would have a number of
additional benefits. It would be an important first step in integrating prescription drugs into
Canada’s health care system because it would allow important information to be collected on
how drugs are utilized on a national scale. Perhaps most important to Canadians, the new
Catastrophic Drug Transfer would reduce disparities across the country and ensure that,
regardless of where people live, they would be protected from the high cost of prescription drugs.
198
PRESCRIPTION DRUGS
Establishing a NatiHnal
Drug Agency
A new National Drug Agency should be established to evaluate and approve new
prescription drugs, provide ongoing evaluation of existing drugs, negotiate and
contain drug prices, and provide comprehensive, objective and accurate information
to health care providers and to the public.
Identifying Problems with the Current Approach

The current system for approving new drugs for use in Canada and deciding which
prescription drugs are covered in each of the provinces and territories is cumbersome, complex,
and time-consuming. Health ministers across the country have acknowledged this problem and,
at their September 2002 meeting, agreed to establish a single, common drug review process to
streamline drug assessment and decisions about listing drugs on provincial insurance plans.
Furthermore, provinces and territories share a common concern about their inability to contain
increasing costs or to influence the price of prescription drugs.
The following sections highlight problems with the current processes for addressing the
costs of prescription drugs and ensuring their quality and safety.
Addressing the Cost of Drugs
The price of prescription drugs is addressed primarily through the Patented Medicine Prices
Review Board (PMPRB), created by the federal government in 1987. At the time the Board was
established, Canadian prices for patent drugs were second only to the United States and there
was a fear that prices would go even higher as a result of new patent protection
laws that extended protection for brand name drugs to 20 years. Since “There should be a national
1987, Canadian prices for patented drugs have dropped in comparison to
median prices in other countries and now are less than in the United States strategy to deal with public
(which has the highest prices among OECD countries), Switzerland, the
expectations and about what
United Kingdom and Germany, but higher than in France, Italy and Sweden
(PMPRB 2002). In the case of generic drugs, the federal government does is and is not covered –
not regulate their prices and the price of generic drugs in Canada is “well
above the median foreign prices today” (Critchley 2002, 5). and there should be a ban on
advertising.… There should be
further study of the apparent

Provinces and territories are concerned with the rising costs of
prescription drugs and have taken steps individually and collectively to try over-prescription of
to contain costs. The specific approaches range from careful approval of
all new drugs to be covered in each province (establishing a “formulary of pharmaceuticals.”
approved drugs”) to the Reference Drug Program in British Columbia. S T A N D I N G C OMMITTEE ON SOCIAL
Some provinces have generic drug substitution policies that either permit P R O G R A M S . P RESENTATION AT
YELLOWKNIFE PUBLIC HEARING.
or require pharmacists to substitute a therapeutically equivalent generic

drug for a higher cost brand name product when filling prescriptions. Some have experimented
with risk-sharing arrangements with drug companies to limit total expenditures on a new drug
and one province used price freezes in order to contain costs.
199
Individual actions by provinces and territories have had limited success. What is clear is that
no single province or territory or the federal government acting alone can hope to control drug
costs within its respective part of the health care system. The issues are national in scope and the
problems are similar in every part of the country. This is a clear case where the best solution lies
in a national approach where provinces, territories and the federal government can share their
expertise, streamline processes, and pool their collective influence in addressing drug prices. A
National Drug Agency would provide the most effective vehicle for provinces and territories to
work together on national strategies for containing drug costs.
Evaluating the Effectiveness of New Drugs

Decisions on whether or not new drugs are safe for use in Canada currently are made by
Health Canada. The approval process was developed 40 years ago in the aftermath of the
thalidomide tragedy. During the 1990s, several studies highlighted weaknesses in the approval
of pharmaceutical products before they are allowed on the market (Krever 1997; Gagnon 1992;
“It is important Hlynka that the 1991). system Those studies recommended steps to improve the methods and rules for
prescription drug approvals. The Gagnon Report, for example, recommended the creation of an
of drug approvalindependentbe expedited.drug evaluation agency linked to a network of centres of excellence in universities
There should also across

be post thedrug country. In 1992, a group appointed by the federal and provincial deputy ministers
of Health also recommended the creation of a national agency, independent of Health Canada
approval – because and otherthere may governmental agencies, to undertake the evaluation of new technologies, evaluate
prescription drugs that were already on the market, and bring together similar data from other
be long-term countries
side effects.” (Federal-Provincial Task Force 1992). Provincial and territorial ministers came to a
similar
S OCIƒTƒ CANADIENNE DE LA conclusion at their meeting in January 2002. And various experts have continued to call
SCLƒROSE EN PLAQUES for. Health
P R E S E N T ACanada
TION to create an independent agency to evaluate and approve prescription drugs
A T M O N T R E A L P (Rawson
U B L I C H E A R 2002).
ING.
Why does the Canadian system of pharmaceutical evaluation need to be reformed? •

The current process has been in place for many years and has resisted frequent
attempts to modernize it – Since the Canadian system was introduced, the key objective
was to ensure the safety of drugs before they are approved for use in Canada. The focus
is on assessing the risks and benefits of a new prescription drug before it reaches the
market based on clinical trials and manufacturing guidelines. This approach is fine in and
of itself, but it does not address the fact that problems with new drugs may not be evident
until after thousands or even millions of prescriptions have been filled. Furthermore, the
process does not compare the efficiency of new prescription drugs to existing drugs on
the market or to other therapeutic approaches that could be used. Yet this is critically
important information for policymakers and health care providers to guide their decisions
on including prescription drugs in insurance plans or in choosing the most effective
medication or treatment.
200
PRESCRIPTION DRUGS
• Despite much effort by Health Canada, there are significant delays in the drug
approval process – Canada’s drug approval process is one of the longest among OECD
countries. The median time for drug approvals in Canada in 1995 was 650 days
compared to Australia at 562 days, the United States at 464 days, Sweden at 444 days,
and the United Kingdom at 439 days. The approval time in Canada fell to 490 days in
1997 but, by 2000, it was back up to 650 days (Rawson 2000). Longer approval times are
often attributed to the lack of resources dedicated to delicate and technical work by
Health Canada to ensure that the risk of error is virtually non-existent.
It is important to note that, in spite of the lengthy review process, Canadians are not
deprived of access to potentially life-saving medications. Health Canada has introduced a
process for “fast-tracking” the approval of drugs intended for treating serious, life-
threatening or severely debilitating illnesses or conditions. As of November 1, 2002, the
target for screening and review of these drugs is 215 days (HC 2002b). Additionally,
Health Canada has a process in place for granting special access to non-approved or
experimental drug products and therapies in cases of life-threatening illness where other
conventional therapies have failed or where no comparable drug is approved for use in
Canada (HC 2002c).
With a growing number of new prescription drug discoveries, the pressures on the
existing process will only increase. Furthermore, genomics and biotechnology are
bringing more and more advances to the forefront. Each of these new developments will
not only have to be evaluated from a clinical perspective but also will be subject to
intense ethical and political debate over the appropriate and inappropriate use of
reproductive technologies, genetic testing and cloning.
• The role of pharmaceutical companies in the evaluation process needs to be

addressed – Pharmaceutical companies complain about bottlenecks in the federal
government’s regulatory process. They argue that the current process curbs
innovation and delays not only the introduction of new patent medicines but also the
eventual introduction of generic drugs. Their frustration is heightened by the fact
that pharmaceutical companies currently cover 82% of the costs of the evaluation
process for drugs aimed at the Canadian market. Not surprisingly, if they are paying
the majority of the costs, they want a quicker process in place. Some have suggested
that a more direct link should be established between their payment for evaluations
and the performance of the evaluation system. The problem is that this would create
an inevitable “conflict of interest” for the agency doing the evaluation in that their
budgets would be determined by their ability to meet the expectations of
pharmaceutical companies for timely drug approvals. Recent controversies in the
United States over the relationship between the Food and Drug Administration and
the pharmaceutical industry indicate that even a system with strong safeguards can sometimes be seen to be too close t
Roles, Responsibilities and Funding of the National Drug Agency

All of these issues can and should be addressed through the proposed new National Drug
Agency. The Agency would be established as a federal agency with federal regulatory powers,
operate independently from Health Canada, and report directly to Parliament. It should build on
201
the expertise currently in place in the federal government and the provinces as well as university-
based centres of excellence such as the proposed Centre for Innovation on Pharmaceutical
Policy outlined in Chapter 3.
The National Drug Agency should be responsible for:
• Negotiating, analyzing and monitoring drug pricing by both brand name and generic
drug manufacturers and providing information about drug pricing in Canada and abroad;
• Efficiently reviewing clinical research and approving new drugs and vaccines for use in
Canada and collaborating with similar agencies in other industrialized countries;
• Engaging in pharmaco-surveillance and assessing outcomes;
• Providing pharmaco-economic evaluations of drugs already on the market;
• Developing an early warning system to deal with expensive new drugs, including the
products of advanced genetic technologies;
• Establishing and managing a common national drug formulary to ensure that decisions
on including or excluding particular drugs are based on the best available clinical,
pharmacological and economic evidence;
• Collecting and disseminating information related to prescribing practices and the
utilization of prescription drugs in Canada as part of an effort to improve the overall
process of clinical and economic evaluation;
• Ongoing monitoring and review of industry practice related to patent protection
legislation;
• Disseminating objective and reliable knowledge and information to health professionals
and the public;
• Developing the guidelines and purchasing vaccines for a new national immunization
strategy (outlined in Chapter 5).
One of the critical roles of the National Drug Agency involves negotiating and monitoring
drug prices. The Agency would be responsible for leading negotiations with pharmaceutical
companies and handling bulk purchase agreements in an effort to ensure that the price of
prescription drugs can be contained. Its role in scrutinizing drug prices would apply to both
brand name and generic drugs as well as vaccines and some over-the-counter medications.
Withthat
“We are concerned changes
some in the international marketplace for drugs, the National Drug Agency will need
to develop new methods for evaluating drug prices and reporting to governments and to
pharmaceutical companiesInformation on the price of drugs and the possible relationship of those prices to
Canadians.
patent protection will inform and help guide Canada’s international efforts to ensure that
spend more of their budgets on
pharmaceutical prices are not allowed to grow unchecked.
marketing than on research
and development. This makes
us wonder if the drugs we are

Another important role of the National Drug Agency is to
getting are really the best for communicate evidence-based information and guidance to both health
us, or simply the ones with professionals and to patients, using various media including the Internet.
This relates directly to recommendations earlier in this report on
the best ad campaign.” introducing electronic health records and establishing a comprehensive
EDMONTON HIGHLANDS HEALTH
source of electronic health information. There is no doubt that the public
C A R E A C T I O N G R O U P 2002.
W RITTEN SUBMISSION . wants more information about drugs and their effectiveness. Rather than
202 leave this to pharmaceutical companies, the National Drug Agency could
PRESCRIPTION DRUGS
meet this need by providing balanced, objective information in an accessible manner. This is a
much better approach than direct-to-consumer advertising in place in the United States. This type
of advertising is a major business in the United States and it has been shown to affect patients’
requests for drugs. Studies suggest that since restrictions on direct-to-consumer advertising in the
United States were relaxed in 1997, nearly $3 billion have been spent each year on advertising
drugs to American consumers (Morgan and Hurley 2002a). The federal government should
continue to prohibit direct-to-consumer advertising of prescription drugs in Canada. The role of
informing Canadians is better served by the National Drug Agency acting in the public interest.
The new agency should include the price control functions of the Patented Medicine Prices
Review Board, but be expanded beyond patented drugs to include generic prescription drugs as
well in order to ensure that the price of all prescription drugs is fair to consumers. It also should
include all the perscription drug analysis, surveillance, approval and pharmaco-surveillance
functions currently undertaken by Health Canada. Rather than creating a huge new bureaucracy,
the Agency should work with a network of experts and centres of excellence across the country.
This approach has achieved impressive results in Australia where expert committees oversaw the
approval process, the registration of new drugs on the national formulary, and post-market
clinical and economic evaluations (Birkett et al. 2001).
In terms of funding for the National Drug Agency, the current budgets of the federal bodies
to be integrated into the Agency should be sufficient to ensure its viability, considering the
economies of scale that can be achieved. The Agency would continue to receive funding from
the pharmaceutical industry for drug approvals, but the Commission strongly believes that the
industry’s contribution should not be directly tied to paying for any particular service. In effect,
a “firewall” must be established between the industry’s financial contribution and the Agency’s
work. Very stringent guidelines for pharmaceutical industry contributions should be in place to
ensure the Agency’s independence from the industry it regulates.
Benefits of a National Drug Agency

A National Drug Agency would provide a number of important benefits.
• Decisions about adding prescription drugs to public insurance plans would be guided by
consistent principles. These include: ensuring that prescription drugs provide real
benefits; they are safe; they are used efficiently; and that there are measurable clinical
and economic advantages in choosing one drug over another. It also would ensure that
health professionals and patients have objective and understandable information to guide
their choices about treatments and drugs.
• The drug evaluation and approval process would be streamlined. This is particularly
important as the demand for evaluations grows as a result of new discoveries and
developments. A National Drug Agency would also be able to collaborate with other
similar agencies in industrialized countries to streamline the evaluation process and share
information on the evaluation of new and existing drugs.
• Assessments of new drugs would address a number of factors in addition to clinical

safety. Clinical concerns – such as the physiological effect of the medicine, the comfort it
provides to patients, its side effects, potential interactions with other medicines and so on
– need to be addressed. But economic concerns also are important, especially the relative
cost of the medicine compared to other medicines and even with other therapeutic
203
approaches.
• The cost and use of prescription drugs could be contained by systematically evaluating
new and existing prescription drugs and sharing that information broadly within the
health care system. Lessons learned about the use of particular drugs in real situations
could also be fed back into the process of approval, evaluation and dissemination and
assist in the development of guidelines for use of prescription drugs. In the final analysis,
drugs should be approved for use and coverage in the health care system solely on the
basis of their effectiveness or efficiency, not simply because they are new or because
pharmaceutical companies have invested a lot in their development.
• Combining the approval, evaluation and dissemination functions into a single National
Drug Agency would provide for significantly better use of both people and dollars. It
also means that resources could be used not only to review and approve new drugs, but
also to evaluate drugs that are already on the market and to disseminate information more
widely than has been possible in the past.
• The process would not only speed up the review and approval of new prescription drugs
but also streamline the introduction of generic drugs.
• A National Drug Agency would provide governments more leverage with
pharmaceutical companies in order to try to constrain the ever-increasing cost of drugs.
In relation to other countries, Canada has never been a major player in the international
pharmaceutical trade and our ability to influence or contain prices for prescription drugs
is severely limited. This situation is made even worse by the fact that there currently is
no national mechanism in place for dealing with the approval of drugs or their use
“Surely there must be a way …
across Canada. A National Drug Agency would combine the forces of the provinces,
territories and the federal government and increase our ability to influence the policies
for us to be able to purchase
of major pharmaceutical companies. As noted in Chapter 11, Canada should work with
drugs in a collective wayother
rathercountries to contain costs on an international basis.
than in thirteen different ways.”

C ONGRESS OF U N I O N R ETIREES OF
C A N A D A . P RESENTATION
Traditionally, assessments of the efficiency of a particular drug have been left in the hands
AT
OTTAWA PUBLIC HEARING.

of individual physicians. For example, many Canadian parents have received prescriptions for
antibiotics for the treatment of common ear infections for their children. To make a decision on
the best course of action, their doctor had to consider the age of the child, the number of
recurrences of the infection, the advantage of certain dosages or drugs over others and also, in
more extreme cases, the advantages of surgery. The doctor may choose to prescribe painkillers
or antibiotics depending on the child’s condition. But he or she might also have had to consider
whether the parents could afford the prescription and whether they had coverage under provincial
or employer plans.
Relying on physicians to make these complex assessments may have been an effective
strategy in the past, but given the scope of new medications on the market today and anticipated
in the future, relying on physicians alone to make these decisions is no longer appropriate or
realistic. Consider these facts.
• According to Health Canada’s drug product database there were almost 22,000 drug
products available on the market in Canada in 1999 for human use. Of these drug
products, approximately 5,200 are prescription drugs, excluding biologic drug products
204
PRESCRIPTION DRUGS
and those drugs considered controlled substances (PMPRB 2000). In 2001, 82 new
patented drug products were introduced, an average of 1 new product every 4.5 days
(PMPRB 2002). This is a dramatic increase over 1996 when only 21 new products were
introduced, an average of 1 every 17 days (PMPRB 1997).
• Certain side effects associated with new medications are so rare or only occur in
combination with other medications that they are not discovered in the clinical trials and
do not become apparent until the medications have been widely prescribed in the general
population.
• The increasing number and use of prescription drugs multiplies the risk of potentially
dangerous drug interactions.
On top of these concerns, patients increasingly want to play an active role in decisions about
their own treatments. It is difficult for physicians to be the only or the primary source of
information on prescription drugs. Physicians also deal with individual patients on a case-by-
case basis and may not necessarily consider the option of providing a less expensive but equally
effective medication unless they have reliable guidelines in place.
It is important, then, to ensure that physicians, patients, insurers and governments have
access to understandable and sophisticated information on the economic effects of particular
drugs and prescribing practices. This information, provided by the National Drug Agency, would allow:
• Clinicians to make decisions in the best interest of their patients (to prescribe the most
appropriate medicine, taking into account the available knowledge, on the one hand, and
the medical history of the patient, on the other);
• Patients to participate in decisions in an informed way or at least to understand the
benefits and risks associated with the medicine that is prescribed;
• Pharmacists to be able to understand the rationale for the prescription and to advise
patients accordingly;
• Administrators of insurance plans or managers of public drug plans to be assured that the
best possible choices are made among a range of equivalent medicines.
Establishing a NatiHnal FHrmulary

Working collaboratively with the provinces and territories, the National Drug Agency
should create a national prescription drug formulary based on a transparent and
accountable evaluation and priority-setting process.
Currently, each province and territory maintains a “formulary” of approved drugs – a list of
drugs it covers as part of its drug insurance plan. Private insurers in each province or territory
often base their coverage on the formulary of approved drugs in each jurisdiction. Because of the
impact of decisions to list drugs on the formulary, pharmaceutical companies and various
interest groups often lobby provincial and territorial governments to ensure that certain drugs are
included on their respective drug formularies.
Aside from the resulting patchwork of coverage across the country (with different provinces
covering different prescription drugs) there are two other significant problems with this
205
approach. First, it means that individual provinces and territories are faced with powerful
lobbying activities from the pharmaceutical industry and other interest groups to have “their
drug” placed on the formulary. This can result in some drugs being included on formularies for
reasons other than their effectiveness. Decisions made in one province can also have a ripple
effect and increase pressure on other provinces to make similar decisions. Second, it limits the
ability of each government to negotiate price and volume discounts with manufacturers because
no single province has a large enough market share to influence the price.
A national formulary of approved drugs would:

• Be based on a transparent and accountable evaluation and priority-setting process
including rigorous pharmaco-economic evaluations;
• Give the National Drug Agency more power to negotiate prices with pharmaceutical
companies on behalf of the provinces and territories; and,
• Establish a national list of prescription drugs to be covered in Canada in order to reduce
both the disparities across the country and the pressures faced by individual provinces
and territories to cover new prescription drugs.
Developing and maintaining a national drug formulary should be a key responsibility of the
proposed new National Drug Agency. The Agency would be responsible for evaluating drugs
and negotiating a national formulary with the provinces and territories on an ongoing basis.
Integrating PrescriptiHn Drugs

intH the Health Care System
A new program on medication management should be established to assist Canadians
with chronic and some life-threatening illnesses. The program should be integrated
with primary health care approaches across the country.

The National Drug Agency should develop standards for the collection and
dissemination of prescription drug data on drug utilization and outcomes.
Medication Management and Primary Health Care

With a national formulary in place, the next important step is to link medication
management to primary health care. Guidelines should be established to move in stages to a
more comprehensive medication management program within five years.
The objective of a medication management program is to make a clear link between
individuals’ use of prescription drugs and primary health care. As noted earlier in this report,
primary health care is a vital component of our vision for Canada’s health care system.
Integration of prescription drugs with primary health care can best be accomplished as part of a
“health management approach” in which individuals’ health is monitored by a team or network
of health care providers working with the individuals themselves. For people with chronic health
care conditions such as diabetes, for example, it means that they would have access to a range of
206
PRESCRIPTION DRUGS
health care providers such as physicians, nurses, dieticians, pharmacists,

and counsellors working together to monitor and help them manage their “This [costs/benefits of
health. Part of that management would be the effective use of prescription
drugs and other medications. alternatives, in a medication
It also means that pharmacists can play an increasingly important role strategy] would permit health
as part of the primary health care team, working with patients to ensure professionals, and particularly
they are using medications appropriately and providing information to
both physicians and patients about the effectiveness and appropriateness pharmacists, to promote the
of certain drugs for certain conditions. This expanded role would allow
proper use of medication
pharmacists to consult with physicians and patients, monitor patients’ use
of drugs and provide better information and communication on more effectively.”
prescription drugs. In the future, there may also be a role for pharmacists
A SSOCIATION QUƒBECOISE DES
PHARMACIENS PROPRIƒTAIRES
who are not engaged in the retail sale of prescription drugs to prescribe DU Q UƒBEC . P RESENTATION AT
certain drugs under specific, limited conditions. Q UƒBEC C I T Y P U B L I C H E A R I N G .
Under current drug insurance plans, evidence suggests that costs have
a direct impact on whether or not people comply with their prescriptions. For example, people
may stop taking both essential and non-essential medications when they are faced with onerous
co-payments, deductibles or co-insurance (Adams et al. 2001; Tamblyn et al. 2001; Soumerai et
al. 1993). People with lower incomes are most affected by these out-of-pocket charges
(Kozyrskyj et al. 2001). If people refuse to take necessary drugs because of the costs, it affects
not only the individuals involved but also their families, their communities, and the overall
health of the population. It also can increase costs in the longer term. For certain conditions,
such as the treatment of mental illness or the management of chronic health conditions, a failure
to take or to keep taking medications can have serious negative consequences, including
repeated hospitalization. Through a medication management program, people would be linked to
a primary health care team and the likelihood of inappropriate or incomplete use of prescription
drugs would be reduced.
The proposed medication management program should be based on rigorous standards and
protocols. In the first instance, it should cover chronic conditions such as arthritis, diabetes and
mental illness, and life-threatening conditions such as cardiovascular disease and cancer.
Consideration should also be given to providing coverage for elderly people because of the
serious consequences to their health if they do not take their medications because of the costs.
Over time, the medication management program could be expanded to include pre- and post-
surgical drug therapies as part of a more global approach to primary health care.
How would this type of medication management drug program work?

• The federal government would expand the Catastrophic Drug Transfer to include the
medication management program.
• The expanded transfer would reimburse provinces and territories for the cost of drugs
used in a prescription management program provided that the drugs are on a national
formulary and proven to be effective in treating a particular illness, disease or condition.
• Disease management protocols would be in place and would guide decisions about the
prescriptions a patient receives.
• Incentives would be introduced to ensure access to essential prescription drugs and the
selection of cost-effective products while, at the same time, providing some flexibility 207
for both prescribers and patients.
Collecting and Sharing Information

Another important step is to link information on prescription drugs with primary health care
and ongoing health research. National standards should be set for collecting data on drug
utilization and outcomes while preserving personal privacy. The data should be “linkable” to
existing health research databases and made available for use in policy-related research,
particularly focusing on drugs that are available in the marketplace. Steps should also be taken to
ensure that the information can be integrated with electronic patient records and electronic
prescribing tools. As outlined in Chapter 3, electronic health records are an important way of
tracking health information and ensuring that complete and accurate information is available to
health care providers and individual Canadians. This is particularly important in prescription
management programs where electronic health records would allow members of a primary
health care team to monitor and assess the effectiveness and outcomes of prescription drugs for
individual patients.
Developing comparable and comprehensive information is essential for a number of

purposes. It would provide a base of information to use in national evaluations of the safety of
new and existing prescription drugs. It would provide information to health authorities,
provinces and territories to guide their decisions on the best “basket” of drugs to be covered. It
also would give health care providers and individual patients access to the best available
evidence on certain drugs and guide their choices of the right medication for the patient’s
particular health needs.
Reviewing Aspects Hf
Patent PrHtectiHn
The federal government should immediately review the pharmaceutical industry
practices related to patent protection, specifically, the practices of evergreening and
the notice of compliance regulations. This review should ensure that there is an
appropriate balance between the protection of intellectual property and the need to
contain costs and provide Canadians with improved access to non-patented
prescription drugs.
Like other manufactured goods, new prescription drugs are protected by patents. In the case
of prescription drugs, current patent laws guarantee exclusive access to the Canadian market for
20 years. This extensive protection for new prescription drugs remains a matter of considerable
debate despite the fact that it has become the international norm. On the one hand, it protects the
intellectual property of pharmaceutical companies and helps offset the considerable investment
they make in researching and developing new drugs. On the other hand, it delays the
introduction of lower cost generic drugs.
During the Commission’s public hearings, many people pointed to extensive patent
protection as one of the reasons why drug costs are high. In fact, as noted earlier, patented
medicines are cheaper on average in Canada than in other jurisdictions, particularly the United
States, although recent reports suggest that this cost advantage is shrinking (PMPRB 2002).
208
PRESCRIPTION DRUGS
While some may suggest that Canadian drug patent legislation is a key obstacle to controlling
drug prices, in fact, Canadian legislation is in line with international standards. Furthermore,
there is no empirical evidence to suggest that Canada’s patent protection laws are responsible for
increasing drug prices.
A particular concern with current pharmaceutical industry practice is the process of

“evergreening,” where manufacturers of brand name drugs make variations to existing drugs in
order to extend their patent coverage. This delays the ability of generic manufacturers to develop
cheaper products for the marketplace and it is a questionable outcome of Canada’s patent law.
Furthermore, regulations under the patent law require generic drug manufacturers to demonstrate
that their product is not infringing on a patent held by another drug manufacturer rather than
putting the onus on the patent drug manufacturer to show that their patent has been infringed –
what is referred to as the notice of compliance regulations. Suggestions have been made that this
leads to “pre-emptory” lawsuits from patented drug manufacturers as a way of delaying the
approval of generic drugs. Clearly, if this is the case, the practice is not in the public interest. The
federal government should review this issue, determine what constitutes a legitimate extension of
patent protection, and also consider ways of streamlining the approval of generic drugs (see
Figure 9.4).
Looking ahead, there will be a number of important challenges for Canada’s patent laws to
address. One of the most controversial issues relates to gene patenting. Canada’s current patent
law does not specifically prevent patenting of human genes, DNA sequences and cell lines. This
issue has sparked considerable debate not only in Canada but also around the world (Ontario
2002). Canada’s Premiers addressed this issue in January 2002. They expressed concerns about
the need for the right protections and safeguards to be in place and agreed to work together on a
co-ordinated framework. The Premiers called for federal action to review these issues as well as
the implications for the Patent Act. The Commission supports the Premiers’ view that the federal
government should review the current provisions of the patent law in relation to the issue of
patenting of genes and DNA.
Figure 9.4
Manufacturers’ Patented Non-patented (brand name) Generic
Sales ($Billions)
of Patented and
Non-Patented
Drugs, 1990 to
2001
Source: PMPRB 2002.
209
What DHes This Mean fHr Canadians?

Prescription drugs play a growing and essential role in Canada’s health care system and the
health of Canadians. They are a vital component of the health care system and that reality should
be reflected in how we fund, cover and ensure access to quality, safe and cost-effective
prescription drugs.
With the recommendations in this chapter, disparities across the country in coverage for the
high cost of prescription drugs will be reduced and eventually eliminated. That means Canadians
can move from one part of the country to the next and know that they will receive similar
coverage. It also means that coverage against the catastrophic costs of prescription drugs will not
depend on where people live or their incomes. With this essential step in place, further action
can be taken to integrate prescription drugs with the care people get through primary health care
approaches across the country. For an increasing number of Canadians with chronic illnesses
and health conditions, this will be a welcome addition and an important step in ensuring they get
the best outcomes from their prescription drugs.
Finally, Canadians can be assured that the safety and quality of the drugs they use will be
safeguarded by a new National Drug Agency. And through the combined efforts of the Agency
and provinces and territories, important steps can be taken to ensure that we get the best
outcomes for our substantial and growing investment in prescription drugs.
210
A NEW APPROACH TO
ABORIGINAL HEALTH

10
• Consolidate Aboriginal health funding from all sources and use the
funds to support the creation of Aboriginal Health Partnerships to
manage and organize health services for Aboriginal peoples and promote
Aboriginal health.
• Establish a clear structure and mandate for Aboriginal Health
Partnerships to use the funding to address the specific health needs of
their populations, improve access to all levels of health care services,
recruit new Aboriginal health care providers, and increase training for
non-Aboriginal health care providers.
• Ensure ongoing input from Aboriginal peoples into the direction and
design of health care services in their communities.
The Case f r Change

The future of Canada’s health care system must reflect the values, needs and expectations of
all Canadians, including Canada’s Aboriginal peoples. The poor health status of Canada’s
Aboriginal peoples is a well-known fact and a serious concern not only to Aboriginal peoples
but also to all Canadians. The situation is simply unacceptable and must be addressed.
Aboriginal health issues have been studied in greater detail by other commissions and
committees, including the Royal Commission on Aboriginal Peoples (RCAP). In spite of these
various studies and a number of initiatives underway in every province and territory, the fact
remains that there are deep and continuing disparities between Aboriginal and non-Aboriginal
Canadians both in their overall health and in their ability to access health care services. The
reasons for this are complex and relate to a number of different factors, many of which have less
to do with health and more to do with social conditions.
To understand the various issues and to hear directly from Aboriginal peoples, the
Commission worked with the National Aboriginal Health Organization (NAHO 2002) to host a
national forum on Aboriginal health issues. People from First Nations, Metis, Inuit and urban
Aboriginal communities came together to share their success stories, their challenges, and their
211
views on the future of health care.
From these discussions and consultations, it is clear that a new approach is needed – one
that tackles the root causes of health problems for Aboriginal peoples, cuts across administrative
and jurisdictional barriers, and focuses squarely on improving the health of Aboriginal peoples.
Specifically, actions must be taken to:
• Consolidate fragmented funding for Aboriginal health to take the best advantage of the
total potential funds available in order to improve health and health care for Aboriginal
peoples;
• Create new models to co-ordinate and deliver health care services and ensure that
Aboriginal health care needs are addressed;
• Adapt health programs and services to the cultural, social, economic and political
circumstances unique to different Aboriginal groups; and
• Give Aboriginal peoples a direct voice in how health care services are designed and
delivered.
Addressing the Ab riginal

“Disc nnect”
In fundamental terms, there is a “disconnect” between Aboriginal peoples and the rest of
Canadian society, particularly when it comes to sharing many of the benefits of Canada’s health
care system. There are at least five underlying reasons for this disconnect:
• Competing constitutional assumptions
• Fragmented funding for health services
• Inadequate access to health care services
• Poorer health outcomes
• Different cultural and political influences
Constitutional Assumptions
There are conflicting views about constitutional responsibilities for Aboriginal health care
and the result is a confusing mix of federal, provincial and territorial programs and services as
well as services provided directly by some Aboriginal communities.
The Canadian government is responsible for funding and organizing services for some
groups of Aboriginal peoples, primarily those First Nations and Inuit people living on reserves.
According to the federal government, however, there is no constitutional obligation or treaty that
requires the Canadian government to offer health programs or services to Aboriginal peoples. As
a result, the federal government limits its responsibility to being the “payer of last resort.” A
1974 ministerial policy statement describes federal responsibility for Aboriginal health issues as
voluntary, aimed at ensuring “the availability of services by providing it directly where normal
services [were] not available and giving financial assistance to indigent Indians to pay for
necessary services when the assistance [was] not otherwise provided” (Canada. Health and
Welfare 1974). This continues to be the position of the federal government.
Aboriginal peoples do not share the federal government’s view. They link federal health
programs to statutory or treaty obligations or, more broadly, to the trustee role of the federal
government (AFN 2002; Ahenakew and Sanderson 2001; APNQL 1999). This understanding was
212 most clearly and comprehensively put forward in the final report of the RCAP in the mid-1990s.
A NEW APPROACH TO ABORIGINAL HEALTH
For many years now, a process has been underway for transferring
certain responsibilities for managing and delivering health services, “… there are federal and
especially community health and primary health care services, from Health
Canada to Aboriginal communities (see Table 10.1). As of 2001, 82% of provincial jurisdictional issues
eligible First Nations and Inuit communities have, or are in the process of, and we are the shuttle in the
transferring responsibility, with 46% having signed transfer agreements
(FNIHB 2001). The communities that have assumed responsibility for badminton game back and forth.”
health services have had the opportunity “to test their own capacity to NA HO 2002. D IALOGUE ON
manage programs and eliminate cultural and linguistic barriers in the ABORIGINAL HEALTH: SHARING OUR
delivery of health care services” (Favel-King 1993). This transfer of C HALLENGES AND OUR SUCCESSES.
control is sometimes seen as an intermediate step toward self-government (Read 1995).
Table 10.1
First Nations and Inuit Health – Transfer Payment – 2001/02
2001/02
Main Estimates
Contributions for integrated Indian and Inuit community-based health care services $ 291,493,000
Payment to Indian bands, associations or groups for the control and provision of
health services $ 161,349,000
Contribution to support pilot projects to assess options for transferring the
Non-Insured Health Benefits Program to First Nations and Inuit control $ 24,000,000
Contributions to Indian bands, Indian and Inuit associations or groups or local
governments and the territorial governments for non-insured health services $ 83,761,000
Payments to the Aboriginal Health Institute/Centre for the Advancement of
Aboriginal Peoples’ Health $ 7,500,000
Contributions for First Nations and Inuit health promotion and prevention
projects and for developmental projects to support First Nations and Inuit
control of health services $ 29,037,000
Contributions to universities, colleges and other organizations to increase the
participation of Indian and Inuit students in academic programs leading to
professional health careers $ 2,992,000
Contributions to the Government of Newfoundland toward the cost of
health care delivery to Indian and Inuit communities $ 583,000
Contributions to Indian and Inuit associations or groups for consultations on
Indian and Inuit health $ 979,000
Contributions on behalf of, or to, Indians or Inuit toward the cost of construction,
extension or renovation of hospitals and other health care delivery facilities and
institutions as well as of hospital and health care equipment $ 1,413,000
Contributions toward the Aboriginal Head Start On-Reserve Program $ 22,500,000
Total contributions $ 625,607,000
Source: Canada. Treasury Board Secretariat 2002.
213
The transfer of health and health care responsibilities to Aboriginal communities is an

important objective. However, it also is a cause for concern. Some fear that the end result will be
federal government withdrawal from its historical commitment to protect the health of
Aboriginal peoples (Waldram et al. 1995; Weaver 1986). Others criticize the policy for failing to
consider emerging needs (O’Neil 1995).
The Auditor General of Canada (2000) has repeatedly questioned the appropriateness of
transferring responsibilities to Aboriginal communities because they are not directly accountable
to Parliament for how the funds are used and there are no requirements in place to assess
whether the organizations receiving the funds are able to manage them appropriately. Other
concerns relate to the fact that funding can be transferred, but it is difficult to transfer knowledge
and experience in addressing a variety of health care issues “on the ground.” It will take time for
communities to develop experience and networks of contacts to solve specific health problems.
Because of this, the success of the transfer of responsibility will depend, in part, on whether
communities can be supported long enough so that they can build the necessary experience and
networks of contacts and supports.
Health Canada indicated to the Auditor General of Canada (2000) that while the transfer
initiative allows First Nations and Inuit to take charge of community-based services, its aim is
not to modify the general approach to health problems. And because the transfer policy is
directed primarily at residents of reserve-based communities, it does not provide solutions for
problems faced by urban Aboriginals, even though their numbers are growing and their health
problems are more evident. In fact, in 1996, at least 5 out of 10 Aboriginals lived in urban
communities.
Not surprisingly, Aboriginal representatives in Canada do not speak with a single voice on
the issue of the transfer of responsibility for health care. The diversity of interests, needs and
capacities among Aboriginal communities and organizations leads to different views of how the
delivery of Aboriginal health services should be organized. The Commission heard calls for
greater federal, provincial and territorial collaboration with Aboriginal communities. Conversely,
there also were calls for the provinces to stay out of delivery of services since it was the federal
government’s responsibility to deal with these issues on a one-to-one basis with Aboriginal
peoples. The one common thread was a consistent call for more active participation of Aboriginal
peoples, communities and organizations in deciding what services are delivered and how.
Funding for Health Services

Given the complexities of constitutional and governance issues, it comes as no surprise that
funding for health services for Aboriginal peoples is equally complex.
Federal funding supports three types of health programs and initiatives (see Table 10.2): •
Public or community health programs;
• National initiatives that are directed at health and health-related issues such as the
Aboriginal Diabetes Initiative and the National Native Alcohol and Drug Abuse
Program. These initiatives vary according to where they are delivered and the
characteristics of the population they are intended to serve; and,
• Individual funding that provides support for prescription drugs, dental and vision care,
and transporting patients to and from specific health care services.
214
Table 10.2
Program Coverage for Different Aboriginal Populations in Canada, 1999/2000
First All Aboriginal

Nations Peoples (On/Off
Inuit in Inuit (On/Off Inuit (On/Off Reserve + Status,
First Nations on Reserve Settlement/Community Reserve) Settlement) Metis Non-status)
Addiction
National Native Alcohol and Drug Abuse Program
– Residential Treatment Program X X X X
National Native Alcohol and Drug Abuse Program
– Community-based Program X
Solvent Abuse Program X X X X
Tobacco Control Strategy X X
Children
Aboriginal “Head Start” X
Canada Prenatal Nutrition Program X X
FAS/FAE Initiative (Foetal Alcohol Syndrome) X X
Chronic Disease
Aboriginal Diabetes Initiatives – Care, Treatment, Lifestyle Support X (+ Community north of 60) X
Aboriginal Diabetes Initiatives – Primary Prevention and Promotion X X X X X X
Communicable Disease
Communicable Disease Control X (+ Individuals living on reserve)
HIV/AIDS Strategy X X (Inuit in Labrador)
X (Northern
Tuberculosis Elimination Strategy X Quebec & Labrador)
Community Health Services
Brighter Futures (Mental Health, Child Development, Healthy Babies,
Injury Prevention, Parenting Skills) X X
Building Healthy Community (Mental Crisis Intervention) X X
Community Health Prevention and Promotion (Maternal, Child
Health, School Health, Adolescent Health, Adult Health, Elder Health) X X
X (Services may be provided X (Services may be
to non-First Nations provided to non-First
clients where these Nations clients where these
Community Health Primary Care services are not otherwise services are not otherwise
(Emergency Care, Non-urgent Care) readily available) readily available)
Community Nutrition
Dental/Oral Health Strategy (National School of Dental X
Therapy, Oral Health Promotion and Prevention) (+ Innu people) X
First Nations and Inuit Home X (+ First Nations
and Community Care Program community north of 60) X
Capacity Development
Health Careers (Bursaries and Scholarship, Community-based Activities) X X X X X X
Non-insured Health Benefits
(Dental Health, Medical Transportation, Drugs, Medical Supplies
and Equipment, Vision Care, Mental Health) X X (+ Recognized Innu) X X (Recognized Inuit)
Source: Health Canada 2001c.
215
As of March 2001, the total amount of federal funding for health under direct First
Nations and Inuit control amounted to $588.6 million, with 31% of that ($182.5 million)
covered by transfer agreements (FNIHB 2001) (see Figures 10.1, 10.2 and 10.3). A large
proportion of that funding goes to individuals through the Non-Insured Health Benefits
(NIHB) program. This program functions like an insurance plan rather than as part of an
integrated health care system for Aboriginal peoples. The Auditor General of Canada (1997)
has commented that the current scheme encourages both patients and providers to “over-
consume” care. Mechanisms are in place to control administration and assess compliance,
but there are no mechanisms to encourage more effective care or to change the behaviour of
either patients or providers. Prevention programs or health education, for example, are not a
part of this program.
Figure 10.1
NIHB Annual $17,744
Expenditures by $22,797
Benefit ($Millions),
1991/92 $36,675 $104,531
Medical transportation
Phamaceuticals
Dental
Other services
Premiums
Vision care
$84,427 $104,415
Source: Health Canada 2001h.
Figure 10.2
NIHB Annual $30,094 $17,242
Expenditures by
Benefit ($Millions), $27,307 $150,019
1995/96 Medical transportation
Phamaceuticals
Dental
Other services
Premiums
Vision care
$123,303 $157,297

216
Figure 10.3
NIHB Annual $19,748
$17,779
Expenditures by
Benefit ($Millions), $16,775
$182,851
2000/01 Medical transportation
Phamaceuticals
Dental
$109,852 Other services
Premiums
Vision care
$228,861
In addition to federal programs, Aboriginal peoples most often rely on hospital and medical
care available in their home province and benefit from these services in the same way as other
residents. However, the federal government does not compensate provinces for providing health
services to Aboriginal peoples except under some specific local agreements. The costs of these
services are not specifically accounted for, but recent estimates suggest they could be as high as
80% of the average health care costs of the population of a province. Information from
Saskatchewan suggests that combined federal and provincial per capita health expenditures for
First Nations people in that province are almost double the provincial average. This is consistent
with findings from the Manitoba Centre for Health Policy’s in-depth inquiry done in partnership
with the Manitoba First Nations (Martens et al. 2002).
For a number of reasons, the current funding situation is confusing and unsatisfactory. •
Not all Aboriginal peoples have equal access to programs and services offered by the
federal government. Benefits vary according to where people live (i.e., on or off reserve),
how they are identified (e.g., First Nations, Inuit or Metis) and their legal status as treaty
or non-treaty. This leads to growing dissatisfaction among Aboriginal peoples who are
not eligible for federal programs.
• The fact that certain federal programs appear to be more generous than similar provincial
programs is often an irritant to neighbouring non-Aboriginal communities. They view
the differences in access to federal and provincial programs as a breach of equity.
• Funding for Aboriginal health services is scattered among federal, provincial and
territorial governments, and Aboriginal organizations. This makes it difficult to
co-ordinate and get the maximum benefit for the amount of funding available. Studies
suggest that the problem is not the level of funding for health care services but rather the
fragmentation of funding, which in turn leads to poorly co-ordinated programs and
services. As the Manitoba Centre for Health Policy suggests:
217
R[egistered] F[irst] N[ations] people make high use of health care services. They average
one more visit per year to a physician than other Manitobans. They also average twice the
hospitalization rate and 1.7 times the total days in hospital. So the system appears to be
responding to the needs of those in poorer health, which is good news. The bad news is
that poorer health is not likely due to a lack of health care services; more health care
doesn’t appear to be the answer (Martens et al. 2002).
Health Status
The general health status of Aboriginal peoples is better today than it was 50 or even 10
years ago primarily because of noticeable improvements in living conditions and continued
investments in disease prevention and public health. Access to running water and housing
conditions on reserves also have improved considerably over the past 10 years (INAC 2002).
Yet the disparities with other Canadians remain. In 2000, the gap between life expectancy of
registered First Nations people and other Canadians was estimated at 7.4 years for men and 5.2
years for women (INAC 2002) (see Figure 10.4). Life expectancy for other Aboriginal groups
has not been rigorously measured on a national basis but suggestions are that the situation is
likely comparable, if not worse, for other Aboriginal populations, especially those living in the
three territories (see Figure 10.5).
The Aboriginal population is younger, on average, than the rest of the Canadian population.
In 1996, the difference was about 10 years. Compared to the general population, the proportion
of Aboriginal children under five years of age (for every 1,000 women of childbearing age) was
70% greater for Aboriginal peoples (Statistics Canada 1998). Canada’s Aboriginal population is
also growing at a rate of 3% per year, more than double the Canadian rate.
Studies show that young Aboriginals are more often exposed to problems such as alcohol
abuse and drug addiction than other Canadians of the same age. Combined with pervasive
poverty, persistent racism, and a legacy of colonialism, Aboriginal peoples have been caught in a
cycle that has been perpetuated across generations.
Figure 10.4 85
Life Expectancy at
Birth, Registered
Indian Population, 80
2000
75
70
65
60
Registered Indians Total Canadian Registered Indians Total Canadian
Population Population
Male Female
Source: Canada, INAC 2000.
218
Figure 10.5
Life Expectancy
90
at Birth, Aboriginal
Peoples and 80
Canadian 70
Population, 1991 60
50
40
30
20
10
0
Male Female Male Female Male Female Male Female
Registered Indian Inuit MŽtis and Non-Status Canada
Figure 10.6 1,800

0-29 30-59 60+
Population 1,600
Projections for 1,400
the Aboriginal
Population 1,200
1,000
in Canada,
by Age Group, 800
(Thousands), 600
2001 to 2016
400
200
0
2001 2006 2011 2016
There also is a sizeable group of young Aboriginal people who now are entering adult life
(see Figure 10.6). These young people not only need an acceptable standard of living,
employment, a good education and adequate housing, but also support in addressing health
problems they may have experienced as children or adolescents.
Throughout the Commission’s public hearings, numerous Aboriginal representatives

expressed serious concerns about the persistent disparities in health status experienced by
Canada’s Aboriginal peoples. They emphasized indicators such as the high diabetes rate (see
Figure 10.7), growing rates of HIV infection, cardiac problems (Southern Chiefs Organization
and Assembly of Manitoba Chiefs 2002), and high disability rates – especially mental
disabilities (BC Aboriginal Network on Disability Society 2002). They also highlighted the lack
of a holistic strategy that recognized traditional approaches, as well as the lack of sufficient
resources to deal with these problems (AFN 2002).
219
Figure 10.7
25%
Incidence of
Diabetes among Canada First Nations
First Nations and
Canada, by Age 20%
Group, 1991
15%
10%
5%
0%
15-19 20-24 25-29 30-39 40-49 50-59 60+
Source: Canada, INAC 2002.
Access to Health Services

In the past 10 years, Aboriginal peoples’ access to health services has improved markedly,
especially access to hospital care and prescription drugs. But more needs to be done to close the
gap between access for Aboriginal peoples and the general population.
One of the important issues affecting access for Aboriginal peoples, and for all Canadians,
is the supply and distribution of health care providers. During the Aboriginal health forum co-
hosted by NAHO, the Commission heard consistently from participants about the challenges in
recruiting and retaining Aboriginal health care providers in their communities. This is true for
First Nations, Inuit, Metis, and urban Aboriginal groups. In 1997/98, there were almost 2,000
qualified Aboriginal health care workers in Canada, including 800 nurses and 67 doctors. This
makes up less than 1% of the health care providers in Canada, far lower than the proportion of
Aboriginal peoples to the general population (FNIHB 1999).
Efforts to expand the number of Aboriginal health care providers through training and
partnerships are essential. In addition, more needs to be done to provide appropriate training for
non-Aboriginal health care providers so they are in a better position to meet the health needs of
Aboriginal communities. This requires a concerted effort to recruit health care providers from
Aboriginal communities and to expand training initiatives for non-Aboriginal health care
providers. The Eskasoni Health Centre in Cape Breton, where physicians from Dalhousie
University Medical School are brought into Mi’kmaq communities to deliver services, has
shown that positive results can be achieved when non-Aboriginal health care providers have
opportunities to work in Aboriginal communities and learn their particular needs and culture.
Examples like this and other programs across the country need to be significantly expanded.
In recent years, a number of positive initiatives have been taken to address some of the
determinants of health for Aboriginal peoples rather than simply treating illnesses. These
initiatives have been based on a partnership between Aboriginal communities and various levels
of government. These partnerships are necessary in order to break down the barriers between
different policy sectors (APNQL 2000; AHABC 1999), whether they are as a result of federal,
220
provincial or local jurisdiction. The key is to break down the “silos” that
currently exist between health policy and other social policy areas such as “A population health approach
education, housing or social services. In the Eskasoni case, the
most closely reflects an Aboriginal
development of a remarkable primary health care model was hampered
time and again by legal and administrative obstacles associated with view of health and may best
jurisdiction, in particular, the designation of some funding as “health”
funding and some as “social services” funding (Hampton 2001). serve to support policy changes,
legislative and policy reform

This theme of breaking down silos and integrating services was
repeated by governments, by Aboriginal leaders, and by health policy between all levels of government
experts at the Commission’s public hearings, in meetings with various in collaboration with Aboriginal
organizations, and during the expert roundtables held across the country.
In many respects, providing integrated services means setting aside a governments provided an
priori assumptions about who should be responsible for organizing and
delivering services for Aboriginal peoples. Some remain convinced that Aboriginal view of health
the effective resolution of Aboriginal health problems will be achieved is maintained.”
through a combination of more individual control over their own health
M ÉTIS N A T I O N A L C O U N C I L 20 0 2 .
and more effective self-government at the collective level (NAHO 2001;

First Nations Chiefs’ Health Committee 2000). However, given the overlapping responsibilities
and the complexity of the health issues involved, better results could be achieved by sharing
responsibilities rather than jealously guarding jurisdiction.
At the NAHO forum (2002) and during public hearings, the Commission also heard that
delivering health care services in a culturally sensitive way was very important, particularly for
non-Aboriginal health care providers. The Canadian Public Health Association (2001, 6)
emphasized the same point. In their view, “Only by designing programs that respect the cultures
of the nation’s people and communities and by celebrating Canada’s diversity, can health
professionals help improve the health of vulnerable populations and reduce the demands on the
health system as a whole.”
Cultural and Political Diversity “Inuit have their own ideas on

Aboriginal peoples have strong and diverse cultures. In the case of
how to improve their health.
First Nations, for example, there are more than 600 different communities
that fall under approximately 50 culturally and linguistically distinct Innuqatigittarniq – the health
groups dispersed across Canada. The values and customs of these diverse
groups must be respected and reflected in both the design and the delivery interconnection of mind, body,
of health care services. There also are a large number of political entities spirit and environment – is one of
that represent different Aboriginal populations at different levels,
including local Band Councils, regional Tribal Councils, provincial the lamps or qulliqs lighting the
organizations, national organizations, as well as organizations
representing Aboriginal women and urban Aboriginals. way for Inuit health reform.
Qaujamajatuqangit –
Both the cultural diversity and the diversity of political organizations Inuit traditional knowledge –
must be reflected in whatever approaches are used to improve access and
health for Aboriginal peoples. Given this diversity, it may be best to is another such qulliq.”
emphasize regional or local solutions that can be more focused on specific Q I K I Q T A N I I N U I T A S S O C I A T I O N 20 0 2 .
communities or community needs rather than searching for broad W RITTEN SUBMISSION .
221
solutions that are unlikely to address the unique needs of different communities across the
country. Local and regional approaches may also be more effective in attracting more Aboriginal
peoples to various health care professions and in recruiting non-Aboriginal providers to work in
Aboriginal communities.
The N rthern Territ ries Issue

The existence of three vast territories in Canada’s north – Yukon, Northwest Territories and
Nunavut – deserves special attention in developing health policy for Aboriginal peoples. Twenty
percent of the population in the Yukon, half of the population in the Northwest Territories and
85% of the population of Nunavut are Aboriginal, each with different proportions of First
Nations, Inuit and Metis (see Table 10.3).
The territories also have unique constitutional arrangements that are different from the 10
provinces. The Parliament of Canada determines their governance structure and the nature and
extent of the jurisdiction that can be exercised locally by the territories. Parliament also provides
for the essential financial needs of the territorial governments. In general, the territorial
governments have responsibilities for delivering health care services that are comparable to the
provinces. Federal funding is provided under the Canada Health Act under the same conditions
and principles (Brown 2000). The notable exception is the Yukon self-government agreement
that was concluded in 1994. The agreement states that the Yukon is responsible for “…
provision of health care and services to citizens of the First Nation, excluding regulation and
licensing of facility-based services outside the settlement land of the First Nation” (Canada.
Department of Justice 1994).
During a large part of the territories’ history, federal authorities directly managed and
delivered services in hospitals, clinics and other health centres. At the beginning of the 1980s,
the federal government began to transfer responsibility for health care services to the territorial
governments. Responsibility for health care services was transferred to the Northwest Territories
Table 10.3
Federal Transfers to Territorial Governments
Fiscal Arrangement (Revenue Sources)

Demography 2001/02
Territorial Canada % of Estimated Territorial
Total Aboriginal Formula Health and Revenues Coming
Population Population Financing Social Transfer from Transfer Payments
Northwest 40,900 47.7% $510,000,000 $55,000,000 57%
Territories
Nunavut 28,200 85.0% $611,000,000 $31,000,000 84%
Yukon 29,900 20.1% $346,000,000 $33,000,000 70%
Note: Aboriginal Population figures are based on Statistics Canada 1996 Census Data.
Source: Canada. Department of Finance Canada 2002b.
222
in 1988. But as the transfer of responsibility only targeted services that were usually insured by
the provinces, the NIHB program and some other national health programs were excluded. A
comparable agreement was reached with the Yukon in 1997.
In 1988, the federal government entered into an agreement with the government of the
Northwest Territories for the administration of health services including the NIHB program.
When Nunavut was created in April 1999, the agreement was transferred to the Government of
Nunavut as well. Both governments receive annual funding for the ongoing administration of
NIHB. Program criteria, eligibility, and rates are set by the federal government and the
government must have written approval from the Minister of Health for contracts in excess of
$50,000. The situation is a bit different for the Yukon because the management of NIHB has
been transferred to Aboriginal communities rather than to the Yukon government.
Sparse populations and chronic shortages of resources have required each territorial
government to concentrate on providing as wide a range of primary health care services as
possible, although even this is often a significant challenge. A large proportion of hospital and
advanced diagnostic needs are met through service arrangements with various provinces.
In Nunavut and the Northwest Territories, access to health services is available to all
residents regardless of their membership in one or another ethnic community. Paradoxically, the
only rules that exclude people from access to services are those established by the federal
government for the NIHB program for First Nations and Inuit.
Without idealizing the situation, the northern territories have been able to strike a balance
between preserving the traditional way of life for different groups and communities and moving
ahead with social policies that reflect common values for all residents. In effect, they have
established a collective citizenship that emphasizes social solidarity for all groups and cultures
but, at the same time, respects the cultural and ethnic differences of their populations. This
model should serve as an example for the rest of Canada.
Against this backdrop of issues and “disconnects” affecting Aboriginal peoples across
Canada and the unique challenges of people in the north, the following recommendations
propose fundamentally new funding and institutional arrangements for addressing those issues
and – perhaps most importantly – improving the health of Aboriginal peoples.
An Inn vative S luti n

Current funding for Aboriginal health services provided by the federal, provincial
and territorial governments and Aboriginal organizations should be pooled into single
consolidated budgets in each province and territory to be used to integrate Aboriginal
health care services, improve access, and provide adequate, stable and predictable
funding.

The consolidated budgets should be used to fund new Aboriginal Health Partnerships
that would be responsible for developing policies, providing services and improving
the health of Aboriginal peoples. These partnerships could take many forms and
should reflect the needs, characteristics and circumstances of the population served. 223
A Partnership Approach to Health

Currently, there are three main options for financing, organizing and delivering health care
services to Aboriginal peoples:
• The status quo in which Health Canada would continue to negotiate individual
arrangements with communities for the transfer of funds and responsibility for delivering
health care services;
• The approach recommended by the Royal Commission on Aboriginal Peoples that would
tie the delivery of health services to larger objectives of expanding Aboriginal self-
government models across the country (RCAP 1996); and
• A more recent approach suggesting that Aboriginal health services should be integrated
into provincial health care systems and become the responsibility of provincial
governments (Richards 2002).
Needless to say, there are supporters and critics for each of these approaches. Transferring
responsibility from Health Canada to Aboriginal communities has been successful in some
respects, but it fails to deal adequately with problems of accountability, transparency and capacity
building within Aboriginal communities. The self-government approach requires a number of
immensely complex and divisive constitutional issues to be resolved by governments and
Aboriginal peoples or the courts. Transferring responsibility to the provinces ignores the
constitutional responsibility of the federal government and would require funds already
transferred to Aboriginal communities to be shifted to the provinces. It also provides no guarantee
that Aboriginal peoples would have a voice in how services are organized and delivered.
Because of the difficulties with each of these approaches, a new and innovative solution is
proposed. It takes the existing resources provided by governments and Aboriginal organizations
and pools them into consolidated funds that can be used to improve health and health care for
Aboriginal peoples. And it proposes new Aboriginal Health Partnerships to take responsibility
for organizing, co-ordinating and ensuring that the health needs of Aboriginal peoples are met.
The approach cuts across all existing administrative and political lines and puts the focus
squarely on health care. It is both a practical and a principled approach that reflects the values
expressed so often to the Commission by both Aboriginal and non-Aboriginal individuals and
“… one of the essential
organizations. It relies on an understanding of specific Aboriginal environments and
ingredients in creating effective all their varied dimensions. It also may produce results that can be applied in
communities in
other communities and other settings across the country. Various approaches for delivering
Aboriginal healthprimary
systemshealth
is a care in different settings could use the approach suggested here as a model. And
the option certainly would be open for partnerships to involve both Aboriginal and
multi-jurisdictional approach to peoples.
non-Aboriginal
health service reform.”
NATIONAL ABORIGINAL HEALTH
O R G A N I Z A T I O N 2001.
WRITTEN SUBMISSION.
In short, this approach:

• Encompasses the positive elements of the transfer initiatives already underway in terms
of ensuring that services are designed and delivered in a way that reflects the needs of
different Aboriginal communities;
• Ensures that the various agreements and arrangements that have been negotiated over the
years are taken into account;
224
• Reflects the fact that the political and constitutional status of Canada’s Aboriginal
peoples is constantly evolving. Rather than trying to pre-judge the direction of those
changes, the approach is flexible enough to accommodate this evolution and the
development of different models of self-government in the future;
• Involves both orders of government and Aboriginal organizations in real and meaningful
partnerships with proper accountability arrangements;
• Is equitable in that it would work for a variety of Aboriginal communities regardless of
their location, community, status or health needs;
• Recognizes the essential role Aboriginal peoples must play in defining and implementing
programs to meet the needs of their populations.
Frameworks and Funding

The first step is to establish a framework agreement among the federal, provincial and
territorial governments and Aboriginal organizations on how funds would be consolidated in
particular provinces and territories. These framework agreements would set out the basic
conditions for consolidating and allocating funds for Aboriginal health services.
While it might be tempting to think in terms of a single national framework, given the
diversity of cultures, languages, needs and circumstances across the country, a national model
likely is unworkable. Instead, framework agreements should be negotiated on a provincial or
territorial basis. This would provide the flexibility necessary to accommodate innovative
approaches in various provinces and territories. It would not preclude framework agreements
that involve more than one province or territory, particularly in cases where reserves cross
provincial boundaries, members of particular communities move back and forth across
provincial borders, or where there are enough similarities among Aboriginal groups in different
provinces to make a common framework appropriate.
The negotiation of these framework agreements should involve both orders of government
that contribute to the consolidated budget as well as those Aboriginal organizations (mostly at
the Band or local level) within a province or territory that currently (or in the future) control
some portion of funds designated for health services. Again, given the diverse ways in which
transfer agreements have been negotiated across the country, in all likelihood the representation
around the negotiating table would differ dramatically across the country.
While there undoubtedly will be variations, all framework agreements should:

• Describe the terms by which each of the funding partners agrees to contribute to the
consolidation of funds;
• Ensure that each order of government remains accountable to its own legislative body;
• Ensure that each participating Aboriginal organization remains accountable to its own
membership;
• Describe the terms and conditions under which any funding partner may withdraw from
the agreement and from a particular Aboriginal Health Partnership;
• Reflect an understanding that the consolidated funds remain, in effect, “latent” until such
time as individual Aboriginal Health Partnerships are formed in specific communities
and with specific mandates that would allow them to draw from the consolidated funds.
The current arrangements for the funding and delivery of services would remain in place
until Aboriginal Health Partnerships have been established.
225
In terms of funding, the combination of federal, provincial and territorial funding, along
with funding transferred to Aboriginal organizations, provides a stable and substantial base of
funding to support Aboriginal health care programs and services. As noted earlier, a substantial
amount of funding has been transferred to certain First Nations and Inuit communities. The
current fragmented approach does not allow either Aboriginal peoples or governments to get the
maximum benefit from the amount of money that is being spent. Nor does it allow policymakers
to use the available resources in a co-ordinated way as a lever for change in either health
behaviours or health services. A consolidated fund would address these concerns and also allow
all Aboriginal peoples to benefit regardless of their status, location or health needs.
The provincial and territorial framework agreements would provide a consolidated budget
on an annual basis. The consolidated funds would be drawn on a per capita basis to fund specific
Aboriginal Health Partnerships that serve particular populations, communities or regions within
a province or territory. The funds would only be transferred to Partnerships once they had
detailed plans in place and could demonstrate their ability to co-ordinate and deliver services
according to their plans. Until Partnerships are in place, the funds would remain under the
control of the government or Aboriginal organization that currently holds them.
Creating Aboriginal Health Partnerships

Aboriginal Health Partnerships could be organized in many different ways. The key is that
they must reflect the needs and circumstances of the communities and people they serve. In the
words of a participant in the Aboriginal forum, “what works is a community-centred approach,
not a cookie-cutter approach, not a policy created in distant lands and applied to us” (NAHO
2002). In some cases, communities where self-government structures are in place could play an
important role in the control and management of health programs. This is especially true in self-
governing communities that serve a specific population and area and where it is possible to
mobilize resources in a systematic and stable way. On the other hand, urban Aboriginal peoples
might be better served by teams or networks of health care providers. One example of this
approach is the Indian Health Service in the United States that now operates integrated health
centres in urban areas (Indian Health Service 2001; Kunitz 1996).
Aboriginal Health Partnerships should reflect the positive features of some of the most
successful initiatives underway in different parts of the country including the Eskasoni program
in Nova Scotia, the Northern Health Strategy in Saskatchewan, the Pangnirtung Health Centre in
Nunavut, and the Anishnawbe project in Toronto. These features include:
• Restructuring health care services around prevention and primary health care in order to
use the nearest available resources to meet the needs of Aboriginal peoples;
• Integrating programs and resources to address both the social policy and the health
policy dimensions of illness and overall health;
• Using a networking approach to provide a continuum of services, especially for services
and care that are not available in the community;
• Providing stable funding that is consistent with both health and social objectives; and
• Developing health and social management capacities in communities.
226
A number of common principles should underlie how Aboriginal Health Partnerships would
operate.
• Partnerships should take a holistic approach to health – Partnerships should look
beyond more narrow health issues and consider broader conditions that help build
capacity and good health in individuals and communities, such as nutrition, housing,
education, employment and so on. The Partnerships should be used to break down the
barriers between social policies and health policies in order to address the underlying
causes of Aboriginal health problems. They should address not only local needs and
conditions but also common issues that affect Aboriginal peoples across the country.
Provinces and territories that manage basic activities, programs and health resources
should be actively involved.
• Services must be adapted to the realities of the Aboriginal communities –

Approaches that adapt health services to the social and cultural realities of different
Aboriginal communities are providing the best results. Obviously, social and cultural
barriers can impede the delivery of health care services and lead to incomplete and
impersonal care. If programs and services are adapted to local circumstances, it is not
only easier to identify individuals’ health care needs but also to achieve objectives that
go beyond the immediate health problem to the social conditions that can promote better
health. This adaptation can be achieved by involving Aboriginal peoples directly in
defining the services that are needed and how they are to be organized and delivered. The
process should reflect the values rooted in the political and cultural traditions of different
Aboriginal peoples.
• Partnerships should reflect the specific needs of the communities they serve – There
is no single model that is appropriate, given the diverse needs of Aboriginal
communities. Partnerships should be organized and managed in a way that meets the
specific needs and diverse circumstances of Aboriginal peoples and the various
communities involved. This could mean Partnerships could be arranged on a regional,
community or local basis, depending on the needs and preferences of Aboriginal peoples.
How Partnerships Would Work

The following key elements describe how Aboriginal Health Partnerships would operate: •
Per capita funding would be provided from the consolidated budgets in each province,
territory or region based on the number of Aboriginal peoples who sign up to be served
by the Partnership as well as interested non-Aboriginal peoples who may choose to be
served by the Partnership;
• The Partnerships would operate on a “fundholder” model where the Partnership would be
responsible for organizing, purchasing and delivering health care services that could
range from establishing primary health care networks to more integrated organizations
responsible for managing a larger range of services;
• Aboriginal Health Partnerships would be responsible for adapting health care services to
the cultural and social circumstances of Aboriginal peoples by:
– Designing and organizing health care services taking into account the special social,
cultural, linguistic and economic circumstances of the population being served;
227
– Improving access to primary, acute and advanced diagnostic care for Aboriginal
peoples; and
– Recruiting and expanding opportunities for health care providers from Aboriginal
communities and increasing training initiatives for non-Aboriginal health care
providers to prepare them to deliver services to Aboriginal patients within and outside
their communities.
• The Partnership should be responsible and accountable for the funds it receives and how
those funds are used for Aboriginal health and health-related services. The Partnership
should be established as a not-for-profit community corporation with a Board of
Directors comprised of representatives of the funders (primarily Aboriginal organizations
with direct control over funds designated for the provision of health services along with
federal, provincial and territorial governments), and other individuals involved in
establishing the Partnership (e.g., key organizers, users and health care providers).
Leadership and Accountability Structures

The proposed leadership and accountability structures for Aboriginal Health Partnerships
are a new approach for Canada. The responsibilities envisioned for members of the Board of
Directors for the Partnerships go beyond any current models in place in Canada’s health care
system today. Establishing the Partnership as a fundholding organization able to purchase or
contract for services from regional health authorities, hospitals or other health organizations also
is new for Canada, although it has some parallels with the responsibilities of regional health
authorities in some provinces.
Clear conditions must be in place to address and to clarify the responsibility and
accountability for the Aboriginal Health Partnership. They should include:
• An explicit mandate for the Partnership;
• Up-to-date information on performance indicators; and
• The capacity to make decisions based on the best available evidence.
Structures would have to be in place to allow the Partnership to discuss options, exchange
ideas, and also to produce financial accounts that are public and open to all those involved.
Given the fact that this is a new concept both for governments and for Aboriginal peoples, it
likely will take some time before a significant number of these Partnerships are in place across the
country. This is a reasonable approach and it allows time to experiment with different approaches
and to assess their impact. In the meantime, provinces, territories, the federal government and
Aboriginal leaders and communities should work together to explore this approach and to
continue to expand and improve health programs and services for Aboriginal peoples.
Possible Scenarios for Aboriginal Health Partnerships

The above discussion points out some of the essential features that would need to be in
place for Aboriginal Health Partnerships to operate. But what would these Partnerships look like
and what kinds of things would they do? The following scenarios describe how an Aboriginal
Health Partnership could work in both an urban setting and in an Aboriginal community.
228
Three different models could act as starting points for consideration:

• A regional partnership model targeting all individuals who want to benefit from
integrated and culturally appropriate health services in a given area;
• A community initiative model for individual or a small number of communities that
share historical, linguistic and cultural characteristics; and
• A local partnership model based on teams of health care providers and other concerned
advocates with services targeted primarily to urban Aboriginal peoples.
The three examples in the following boxes are meant to serve as illustrations only. The way
a Partnership would actually work may well vary from all three examples. If there are a number
of Partnerships in a province, for example, the province may want to set up a provincial
framework for specialized hospital and diagnostic services, at the same time allowing for
considerable variations in the way primary health care services are delivered. Partnerships with
an initial mandate for a particular range of services could expand over time as their capacity for
co-ordinating and integrating services grows. This would provide a smoother transition where
the role and responsibilities of the Partnerships could evolve or be phased in on a pre-determined
but flexible schedule rather than having them take over responsibility for a broad range of
services all at once.
A Regional Aboriginal Health Partnership

A regional Aboriginal Health Partnership could mirror regional health authorities that currently exist in
many provinces. A number of different Aboriginal communities in one region of a province could work
together to decide what health care services were needed and how they should be accessed or delivered.
The communities would establish a Board of Directors for the Partnership including representatives of
the communities being served, the federal, provincial and territorial governments, and the Aboriginal
organizations involved. The Aboriginal Health Partnership might choose to maintain responsibility for
public and population health initiatives and the delivery of primary health care services within some or all
the communities involved. The particular mix of services in any community would depend on the size of
the community and the ability of the Partnership to provide the necessary resources in terms of both
health care providers and financial support. The Partnership may choose to work with existing regional
health authorities to draw up service agreements for the delivery of diagnostic and acute care or other
health care services. These service agreements would ensure that services delivered by the health
authorities are appropriate and adapted to the cultures of the communities. In effect, the Partnership
would “buy” health care services on behalf of its members and would be able to negotiate the conditions
for the delivery of those services.
229
A Community-based Aboriginal Health Partnership

A community-based Aboriginal Health Partnership could be implemented by either a single Aboriginal
community or by a small number of communities working together. The population of these communities
would have to be large enough to sustain the services being delivered. The members of the Board of
Directors would include representatives of the Band Council(s), the federal government, the provincial or
territorial government, and several people from the Aboriginal community. The Partnership would
receive a pool of funds from the Band Council, the federal and provincial or territorial governments based
on the number of people in the community and would be responsible for making decisions about how
those funds were used. It would operate independently of the political structures in place in the
community and be responsible specifically for health and health-related issues. The Partnership could
design and deliver a range of public health, primary health care and social services that are specifically
aimed at the needs of its community members. The services would be delivered in a manner consistent
with the cultural traditions of the community. The Partnership could also contract with a nearby regional
health authority to provide hospital and advanced diagnostic services.
An Urban Aboriginal Health Partnership

An urban Aboriginal Health Partnership could be organized by a group of health care providers and
Aboriginal peoples who are frustrated with the fragmented array of services in a particular city and see
the value in bringing these services together in a more co-ordinated and culturally sensitive way. The
Partnership would be led by a Board of Directors including representatives of the provincial, territorial
and federal governments, Aboriginal and non-Aboriginal organizations, and some health providers
associated with the new approach. Once the Partnership is in place, Aboriginal peoples in the city would
be able to “sign up” to receive their primary health care services from the Health Partnership. The
Partnership would receive funding for every person who signs up for the Partnership’s services. It would
use these funds to provide or purchase primary health care and other health care services. It could enter
into contractual arrangements with its local health authority or hospital board to provide acute and
advanced diagnostic services. And it could develop a network of linkages with social service agencies and
schools so it is able to address issues related to poverty, housing and education.
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What D es This Mean f r Canadians?

The recommendations in this chapter are focused primarily on the needs of Aboriginal
peoples and on ensuring that concerted efforts are made to address the serious and continuing
disparities between their health and the health of non-Aboriginal peoples. New ideas and
innovative solutions are proposed – ones that will challenge Aboriginal community members,
their leaders, and provincial, territorial and federal governments to set aside funding issues, set
aside past practices and political disagreements, and focus instead on a single overriding goal –
improving the health of Aboriginal peoples.
For non-Aboriginal Canadians, this means that deliberate action will be taken to improve
the health of Aboriginal peoples. They, too, want to see progress. They want their Aboriginal
neighbours and friends to enjoy the same health status and the same benefits of the public health
care system as the vast majority of Canadians.
The challenge of moving forward will be in the hands of Aboriginal leaders and the federal,
provincial and territorial governments. It will take the trust and willingness of all parties to seize
the ideas and recommendations in this chapter, take action, and improve the health of Aboriginal
peoples, especially the health of their children and their hope for the future.
231
H EALTH CARE AND
G LOBALIZATION

11
• Take clear and immediate steps to protect Canada’s health care system
from possible challenges under international law and trade agreements
and to build alliances within the international community.
• Play a leadership role in international efforts to improve health and
strengthen health care systems in developing countries.
• Reduce our reliance on the recruitment of health care professionals from
developing countries.
The Case fDr Change

Mention the word “globalization” and most people think immediately of the growing
interconnectedness of economies, increased mobility of people and capital, the rise of huge
multinational companies, international trade agreements, and the use of information technology
to establish immediate market links around the world. But in fact, globalization is about much
more than economics. Globalization has political, social and cultural consequences that affect
almost every aspect of our society.
Though there is no standard definition of globalization, most commentators agree that it

results in the increased flow and exchange of:
• Goods and services through direct trade between nations;
• Capital, including investment by foreign-based companies or individuals;
• Labour, including the ability of people to seek employment across international borders;
and
• Information, using the Internet and other communications technology to transmit and
share information.
It is important to understand how health care fits within this international global context.
Concerns have been expressed that international trade agreements could have an impact on our
health care system and future reforms that could be made. Others take the opposite view and say
that Canada’s health care system is protected from the impact of trade agreements. There are no
definitive answers to this debate, but it is clear that Canada can and must take whatever steps are
233
necessary to preserve the future of Canada’s health care system and protect it from the potential
impact of international trade agreements and laws. Canada also has an opportunity to take an
international leadership role in sharing its expertise and helping developing countries improve
their health care systems and the health of their people.
GlDbalizatiDn and
Its Impact Dn Canada
The key characteristic of globalization is the speed of economic and political changes rather
than the direction of those changes (Helliwell 2000). In fact, trade liberalization, deregulation
and consolidation of multinational corporations have been underway for most of the 20th century.
While some argue that the world is not any more globalized now than it was in the era when
colonial powers used their vast empires to create unprecedented international flows of goods and
people, the difference now is the pace of change. Global communications networks have made
capital increasingly mobile and, with the relatively low cost of transportation, goods and
services can be produced and shipped around the globe faster, cheaper and in greater quantities.
As the speed of these changes has increased, so have the intensity of the debates by those
who see globalization as a positive trend or a serious threat. On the one hand, globalization blurs
the borders between countries, people, and ideas. Communications technology reduces the
significance of location and distance. People can communicate instantaneously, buy goods and
services, or get the latest ideas and information from almost anywhere in the world. International
trading rules are becoming more uniform. And people are more aware of what is happening in
other parts of the world and the impact our actions and policies have on other people around the
globe.
Globalization has also been a divisive force. While it has broken down many of the barriers
between countries, there also are signs of increased nationalism, ethnic strife, protectionism, and
resistance to trade liberalization. On the other hand, countries that once were able to restrict their
citizens’ access to information or to influences outside their borders find themselves increasingly
unable to control the flow of information across borders via the Internet. As a result,
globalization may provoke some countries to “build walls” in order to protect economic,
political, and social space that is perceived to be under threat (Turenne-Sjolander 1996). In
addition, those who see the negative aspects of globalization express concerns about the
potential loss of sovereignty and point to studies that show increasing disparities between people
in highly developed and industrialized countries, and those in the very poorest developing
countries (UNDP 2002).
With these growing tensions, it is not surprising that international institutions charged with
creating and extending international trade increasingly find themselves at the centre of heated
debates over international and domestic politics. The World Bank, the World Trade
Organization, and the International Monetary Fund have become the focus of intense political
debate and conflict as people search for ways to ensure their ultimate accountability to the
governments that created them.
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HEALTH CARE AND GLOBALIZATION
Paradoxically, both the proponents and the critics of globalization see the same end point –
a borderless world where capital, labour, goods and services, ideas and information flow
unimpeded by national boundaries or domestic policy preferences. Depending on the perspective
people take, this can be viewed either as a positive sign of the world coming together or as a
serious threat to the independence and autonomy of individual nations.
The fact that we are moving to a more globalized world is not to suggest that national
borders are irrelevant. National borders still shape our political communities, our political
preferences, and our economic behaviour in very important ways (McCallum 1995). Whatever
impact globalization has had, it should not be assumed that borders no longer matter and that the
formal and informal networks that traditionally operated within individual nations no longer
serve to hold those states together. For example, even though there is a great deal of trade
between provinces and the United States (e.g., between Ontario and the American Midwest or
between British Columbia and the Pacific Northwest), the political, economic and cultural
linkages that bind the country together on an east-west basis remain strong and continue to
define us as a nation. Further, smaller national and regional economies do not appear to be less
viable than before globalization and continue to rank well in terms of general economic
measures (e.g., GDP per capita), as well as measures of welfare and citizen satisfaction. This
suggests that globalization is not necessarily a threat to the independence of smaller economies
(Helliwell 2000).
The issue, then, is not necessarily whether globalization is good or bad for Canada. Canada
is, and will continue to be, a trading nation with strong international connections. Instead, the
focus should be on the steps that can and should be taken to ensure that the increasing economic
interdependence of countries like ours does not compromise our ability to make our own
decisions about political, economic and social policies, including health care. In the past, our
relative size, especially in relation to the United States, has meant that Canada has been a “rule-
taker” (i.e., a country that accepts the rules set down by more powerful countries) rather than a
“rule-maker” (i.e., a country that acts with other like-minded countries to set the rules). But as
the number of countries that are parties to international agreements grows and international trade
organizations struggle to balance social policy interests of their members with the commitment
to open up markets to trade, Canada is well placed to work with other like-minded countries to
ensure that international agreements protect our social policies while not depriving us of the
benefits of increased trade.
Health Care and International Trade Agreements

Concerns about the potential impact of globalization on Canada’s health care system have
focused, for the most part, on the perceived potential of international trade agreements to limit
the policy choices federal, provincial and territorial governments can make in relation to the
health care system. In almost every one of the Commission’s public hearings as well as the
regional roundtables, concerns were expressed by experts and citizens alike that Canada’s health
care system should be protected from the impact of international trade agreements. The focus is
235
primarily on the North American Free Trade Agreement and agreements negotiated under the
auspices of the World Trade Organization.
Since the 1980s in particular, significant efforts have been made to liberalize international
trade through a variety of bilateral and multilateral trade agreements. These agreements began as
an effort to reduce tariffs and other barriers to trade but have expanded to include trade in
services and the international protection of intellectual property.
Canada is involved in a number of international trade agreements, including the following: •

The North American Free Trade Agreement (NAFTA) grew out of a bilateral agreement
with the United States in the late 1980s that was subsequently expanded to a continental
trade agreement that includes Mexico.
• The World Trade Organization (WTO) Agreement on Tariffs and Trade is the successor
to the General Agreement on Tariffs and Trade (GATT) and is the general agreement
concerning trade in goods administered by the WTO. The WTO was created in 1995 and
provides an institutional framework for a number of international trade agreements.
• The General Agreement on Trade in Services (GATS) came into effect with the creation
of the WTO.
• The Agreement Respecting Trade-Related Aspects of Intellectual Property Rights
(TRIPS) was negotiated under the auspices of the WTO and will be one of the key focal
points of the current round of WTO negotiations.
The intent of these international trade agreements is to reduce barriers in trade of both goods
and services across international boundaries. They are explicitly designed to limit the ability of
governments to adopt policies that would make access to international markets inappropriately
difficult. Each agreement requires the countries involved to submit their policies to binding trade
dispute mechanisms. If one country that is a party to an agreement feels that another member
country is unfairly restricting access to their own markets or engaging in practices that give their
own goods and services an unfair advantage in international markets, they can refer their
concerns to a trade dispute panel whose decision is binding.
The various international agreements have several important common features. They all
typically include a commitment to national treatment. This means the governments involved
agree to treat foreign goods, services or investments on the same terms as they treat their own
national providers of the same goods, services or investments. Under NAFTA, for example,
Canada must provide the same treatment to foreign investors “in like circumstances” as it does
to domestic investors. Similar provisions are also included in GATS (Lexchin et al. 2002).
Each of the agreements has particular exceptions and “reservations.” Under NAFTA,
“social services established or maintained for a public purpose” are exempted from the terms of
the agreement. Successive Canadian governments have argued that this reservation protects the
public health care system from the full force of NAFTA’s provisions and means that services
that existed prior to the agreement are protected. However, there is no clear definition of what
constitutes a “social service” or what determines whether a service is established for a “public
purpose” (CCPA 2002, 8; Johnson 2002). Similarly, many of Canada’s obligations under the
GATS apply only to those services or sectors that are explicitly made subject to the agreement.
To date, Canada has chosen not to make hospital services and a whole array of health services
subject to the GATS or to open them to foreign private investment or delivery by foreign-based
companies.
236
The complexity of the various agreements is staggering. It is no surprise, then, that there are
sometimes heated debates and disagreements among experts and even governments about what
the agreements mean and what their potential impact could be.
People who support increased trade liberalization and economic interdependence insist that
Canada’s social policy is protected from any potential negative impact through safeguards in
international trade agreements. With health care, they argue that the agreements not only protect
the existing public health care system but also allow provinces and territories to expand it as they
see fit. On the other hand, those who are skeptical about economic integration fear that the
agreements may not have successfully carved off Canada’s social policies and that public
services may eventually be subject to the rules of international trade. Some fear that the
agreements will require governments to open up the delivery of health care services to private
for-profit delivery by foreign health care companies.
The evidence on both sides of the debate is contestable and often based on interpretations
about what the agreements “might,” “could,” or were “intended to” mean. What is most
frustrating is that the agreements can easily be read in a number of ways. There are only a
limited number of legal decisions on the agreements and those decisions are often contradictory
and open to many different interpretations. In terms of NAFTA, the situation is even more
complicated because the decisions of its dispute resolution panels are not binding on each other.
A decision by one panel at one point in time on one particular issue does not bind another panel
to accept that interpretation of the agreement (Epps and Flood 2002).
Another concern with NAFTA is that, unlike other trade agreements under the World Trade
Organization, there is no ongoing process for amending NAFTA. It is, to some degree, a
“locked” agreement that would require all three governments to agree simultaneously to
“unlock” it (Johnson 2002). The result is that Canada is left in a position where it can only assert
its particular interpretation of the agreement (especially related to how comprehensively the
social services reservation should be interpreted) and trust that its interpretation will prevail in
dispute settlement processes. Ouellet (2002) has also argued that there is a risk that subsequent
WTO agreements may contain provisions that run counter to some provisions of NAFTA.
In spite of the fact that there has been no formal declaration on what is or what is not
protected by the reservation under NAFTA, there is strong consensus that the existing single-
payer monopoly of Canada’s health care system is not subject to a challenge under NAFTA
(CCPA 2002; Epps and Flood 2002; Johnson 2002). It is less clear what would happen if one or
more provinces or territories or the federal government decided to make significant changes in
the insurance or delivery of health care services. While NAFTA appears to protect the current
health care system, there is some uncertainty around the question of whether it protects future
changes that could be made in the health care system (Epps and Flood 2002). It would depend
on what kind of reforms a particular government introduced and whether those reforms meant
that the health care system would still meet the requirements of “social services provided for a
public purpose.” Research done for the Commission argues that if, for example, governments
were to include some expanded level of pharmaceutical insurance, incorporate some range of
home care services under the Canada Health Act , or allow private for-profit organizations to
deliver health care services, then international trade agreements could come into play.
237
A related issue is the obligation of signatories to international agreements to provide

compensation to foreign investors if they put policies in place that are deemed to “expropriate”
the investment of foreign companies. If, for example, a government were to decide that all home
care services should be publicly delivered, it could be subject to claims for compensation from
foreign-based companies that delivered home care services or from insurers who sell private
insurance for home care services. Similarly, if a government decided to expand public coverage
for prescription drugs in such a way that excluded private insurers from the market, there may
also be claims for compensation.
In health care, claims for compensation are theoretically possible. It is not necessarily clear
that compensation would have to be paid to foreign investors; it depends on how health reforms
are framed and implemented (Johnson 2002). In reality, there are very few foreign-based
companies directly involved in delivering health care services in Canada. Services like home
care are delivered mostly by relatively small, private companies owned and based in Canada.
And most private insurers in Canada are domestic firms. Rather than conclude, then, that Canada
is hemmed in to the current system and cannot change, the more reasonable conclusion is that if
we want to expand the range of services in the public system, it is better to do it now while there
still is very little foreign presence in health care in Canada and the potential costs of
compensation are low.
One significant caution involves opening up delivery of medical services to for-profit

entities, hospitals or specialized clinics. Some have described this as a “one-way valve” that,
once opened, may not be able to be closed (CCPA 2002). It is possible that, once foreign-based
for-profit hospitals are allowed to operate, it would be very difficult to reverse course and
subsequently preclude those hospitals from operating even if their services were of poorer
quality, their costs were high, or their presence no longer reflected the policy goals of
Canadians. Another concern relates to large corporate entities, especially those in the United
States, choosing to expand into the Canadian market. NAFTA would make it virtually
impossible to exclude these foreign companies on the basis of their nationality alone. Once there
is a significant foreign presence engaged in for-profit delivery of health care services, any
attempt to restrict its access to the market in the future may result in relatively high
compensation claims. It also is possible, but not certain, that opening the door to foreign
for-profit health care delivery in one province could force other provinces and territories to make similar provisions.
All of these issues and potential “what if ” situations continue to be the subject of
considerable debate in Canada. But the reality is that there are no clear and definitive answers to
the question of what international trade agreements mean for Canada’s health care system.
Trade in Health Care

Most Canadians probably do not think of health care as something that is traded
internationally. The vast majority of health care services are provided by local health care
professionals and delivered primarily in local communities. When patients in a city like
Kamloops or a town like Baie Comeau are referred to a specialist, they may need to travel to
Vancouver or Québec City, but they rarely are referred to specialists in other countries.
In a few cases, health care services are purchased from other countries, most frequently the
United States. In these cases, the services are very specialized and are not available in Canada. If
238 Canadians become ill or are injured while travelling in other countries, they may receive
treatments that are partially reimbursed by their health care system. In these cases, neither the
service nor the service provider crosses a border; instead, the patient goes to where the service is
available. Consequently, this is not typically considered trade in the way it is generally
understood, although some suggest that it should still be considered as trade in health care
services (Vellinga 2001).
As technology and advances in specialized kinds of medical treatment become more

widespread, trade in health care services will become more common. The use of advanced
diagnostic testing technologies, satellite communication, telehealth, and the Internet may make it
possible, and perhaps even desirable, for a patient in Kamloops or Baie Comeau to get the advice
and expertise of highly regarded specialists in San Diego or Helsinki. Similarly, patients in
Tennessee or Alaska might receive consultations from leading pediatric care specialists at
Toronto’s Hospital for Sick Children. In fact, there already are examples of physicians being
able to assist in surgeries through satellite transmissions linking a doctor in one country with a
surgery being performed in another country. In these cases, neither the patient nor the health care
provider crosses a border but the service does. This kind of trade in health care services may be
minuscule today, but it will become increasingly common in the future. Governments need to
come to grips with how this technology gets integrated into their respective health care systems,
how it is paid for, and how the services are provided (Vellinga 2001).
Aside from trading expertise in health care, health care is a product-intensive service.
Everything from bandages, intravenous bags and hospital beds to computer software and
advanced diagnostic equipment are goods that are manufactured in one location and shipped to
another, often across borders. In these cases, the goods are treated like any other commodity that
is traded and is subject to a growing array of international trade agreements.
Prescription drugs are the single most important set of health care “goods” that is traded
across international borders. As noted earlier in this report, prescription drugs are a growing
component of the health care system. The pharmaceutical industry is also increasingly
dominated by a relatively small number of large trans-national corporations with research and
development facilities around the world. Their investment in research and development can be
shifted relatively quickly from one place to another.
While drug research, development and manufacturing are important components of the
economies in several provinces, primarily Quebec and Ontario, in fact, Canada has never been a
major player in the international prescription drug trade. Canada has traditionally been a net
importer of prescription drugs; however, Canada’s balance of trade in pharmaceuticals is getting
worse. Canada is becoming less self-sufficient when it comes to pharmaceutical production and
estimates are that the trade deficit could grow to $7.7 billion by 2005 and $11.4 billion by 2010
compared with a deficit of $4.7 billion in 2001 and $1.8 billion in 1997 (Reichert and Windover
2002). As Canada becomes more reliant on drugs developed and manufactured abroad, the
benefits of research and development are increasingly occurring outside of Canada. This also
means that federal, provincial and territorial governments have less leverage with
pharmaceutical companies when it comes to constraining the ever-increasing costs of
prescription drugs.
In the future, the National Drug Agency recommended in this report will work with similar
agencies in other countries to streamline the process for approving new drugs and sharing
information on the pharmaco-economic impact of new and existing drugs. The approval time for 239
new drugs and the process for introducing generic drugs could be shortened by a deliberate
effort to take advantage of the wealth of international information on pharmaceutical testing and
evaluation. Canada also has an opportunity to work with other countries and use their collective
leverage with trans-national pharmaceutical companies to control the costs of prescription drugs
and ensure that the approved drugs are both effective and economical.
Health as a Canadian Foreign Policy Priority

Numerous individuals and organizations made submissions to the Commission addressing
the issue of globalization and health care. Despite this concern and the fact that Canada is a
signatory to an array of international agreements to promote access to health care as a
fundamental right (Blouin et al. 2002), health policy has been focused on what happens in our
own country. Moreover, the broader area of international health promotion is very much an
afterthought in Canada’s foreign policy.
This may be changing. In November 2001, the Canadian International Development Agency
(CIDA) launched an Action Plan on Health and Nutrition. The plan recognizes that promoting
better health in developing countries is as important for Canada as improving health at home. As
noted on CIDA’s Web site, “In a world where communicable diseases know no borders, where
tensions and strife in one region can send tremors of unease around the globe, investing in global
health helps to ensure Canadians’ own health and security.”
In an increasingly interconnected world, Canada cannot isolate itself from health issues in
other countries. The increased mobility of people across the globe means that health problems
that at one time would have remained relatively isolated in one part of the world now can spread
faster and more widely (WHO 1997). The spread of drug-resistant strains of tuberculosis, HIV,
and the West Nile Virus all point to the reality that health care challenges in one region of the
world can quickly become a global problem. Indeed, these issues go beyond being health
problems and can become matters of international and domestic security. For example, the social
and economic devastation caused by the HIV/AIDS crisis in southern Africa can threaten the
stability of developing democracies in the region and provide a breeding ground for political
extremism, civil wars, ethnic conflicts, and even genocide. To believe that such events would not
affect Canada and other nations is to fail to recognize how much the world has changed in the
past few decades.
Despite the concerns Canadians might have about our own health care system, international
experts suggest that Canada’s approach to publicly provided health care is a model for other
countries. As we move ahead with new directions for governing, funding and organizing
Canada’s health care system, we have an opportunity to ensure that access to health care is not
only part of our own domestic policy but also a prime objective of our foreign policy as well.
Canada’s membership in the United Nations, the World Health Organization and the Pan-
American Health Organization, combined with our reputation on the international stage, give us
the opportunity to take a more prominent role in making health and health care an international
priority. This will require us to move from merely talking about health as a human right to taking
more concrete action to assist in improving the health of people beyond Canada’s borders (Blouin
et al. 2002). Working with the World Health Organization to strengthen and renew the
International Health Regulations on monitoring and containing communicable diseases would, for
example, be an important first step in reinforcing Canada’s commitment to international health.
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Within this global context, Canada has an opportunity not only to protect and preserve its
health care system from any potential impact of international trade agreements but also to play a
more prominent role in improving health and health care around the world.
Preserving Canada’s Health System in

RelatiDn tD InternatiDnal Agreements
Federal and provincial governments should prevent potential challenges to Canada’s
health care system by:
• Ensuring that any future reforms they implement are protected under the
definition of “public services” included in international law or trade agreements
to which Canada is party;
• Reinforcing Canada’s position that the right to regulate health care policy should
not be subject to claims for compensation from foreign-based companies.

The federal government should build alliances with other countries, especially with
members of the World Trade Organization, to ensure that future international trade
agreements, agreements on intellectual property, and labour standards make explicit
allowance for both maintaining and expanding publicly insured, financed and
delivered health care.
Preventing Challenges under International Agreements

There is an increasingly complex set of rules and agreements regarding international trade
of goods and services. As a trading nation, Canada has a stake in ensuring that those rules not
only promote international trade but also protect the right of all countries to make independent
policy choices.
As noted earlier, there are ongoing debates about whether and to what extent international
trade agreements have an impact on Canada’s health care system. Some feel the potential threats
of international agreements are serious while others think there is no need to be concerned about
the potential constraints international trade agreements could impose on Canada’s freedom to
make its own policy decisions in health care. In the face of that uncertainty, the solution does not
lie in sitting back and waiting for the outcomes of potential challenges under the various trade
agreements but in taking a proactive approach to ensure that Canada can continue to make
whatever policy decisions it sees fit to maintain and enhance our health care system, independent
of any international trade agreements.
Governments should ensure that any proposed health care reforms continue to be consistent
with the reservations under NAFTA (CCPA 2002; Johnson 2002; Ouellet 2002). This means
provinces, territories and the federal government need to make it clear to our trading partners
that Canada’s health care system will continue to be designed, financed, and organized in a way
that reflects Canadians’ values. It does not mean that Canada is unwilling to participate in
international trading regimes but that social policy such as health care is, in effect, “off limits”
and remains the prerogative of federal, provincial, and territorial governments.
241
If there are disagreements about the potential meaning or impact of particular clauses or
provisions in international trade agreements, governments in Canada, especially the federal
government, have an obligation to state clearly and often their view on how those clauses should
be interpreted by any adjudicating body. They also should reinforce Canada’s position that
reform of the Canadian health care system is not subject to claims for compensation from
foreign-based companies under either NAFTA or the GATS. One important way of ensuring that
reforms such as integrating prescription drugs or home care services continue to fall within the
reservations set out in NAFTA is to ensure that they conform to the criteria for “public services”
as defined in international law. To meet the requirements of this definition, public services
should:
• Be universally accessible on the basis of need rather than the ability to pay;
• Have a clear public purpose and objective;
• Be financed out of public revenues; and
• Adopt standard procurement procedures that are intended to protect the public interest
where private services are contracted.
Building Alliances with Other Countries

Canada is certainly not alone in wanting to preserve and protect its ability to set its own
public policies independent of international trade agreements. Many countries have similar
concerns. Organizations responsible for overseeing the process of trade liberalization, including
the WTO, are coming under increasing internal and external pressure to ensure that the ability of
individual governments to set their own health and social policies are not unduly constrained by
international trade agreements.
In the most recent round of WTO negotiations, the most important result was the
“heightened concern expressed … with social issues and … the ability of countries to address
social problems” (Johnson 2002, 32). The so-called “Doha Declaration” that opened this round
of negotiations made it quite clear that the TRIPS agreement “can and should be interpreted in a
manner supportive of WTO members’ right to protect public health and, in particular, to
promote access to medicines for all” (WTO 2001, 1). Canada was a strong supporter of the Doha
Declaration.
Many countries share Canada’s concern about the potential for trade agreements to unduly
constrain future policy options and want to ensure that efforts to liberalize trade do not override
social policy objectives. It is clear from the latest round of negotiations that, at least for now,
there is international agreement that countries must have significant room to adopt social
policies, including health care policies that build the “social capital” of their societies in
meaningful and productive ways.
Looking ahead, the best way for Canada to address the impact of globalization and
international trade agreements, and achieve real and meaningful change is to build alliances with
other countries and work within the current system of negotiations. Within the WTO, Canada
should take a clear and unambiguous position that access to affordable, quality health care
should not be compromised for short-term economic gain. Every country should retain the right
to design and organize its health care system in the interests of its own citizens. International
trade agreements should not penalize countries, especially those in the developing world, for
protecting and promoting their own domestic approaches to delivering health care services.
242
Canadians believe that access to health care is a fundamental human right. The extension of that
belief is that all countries should have the freedom to provide access on terms that are acceptable
to their citizens.
By building alliances with the member countries of the WTO or other international
organizations that highlight significant international health issues (e.g., the World Health
Organization), Canada can not only preserve its right to make its own health policy decisions but
also pursue international health policy directions that result in improved health for people around
the world.
ImprDving Health in
DevelDping CDuntries
The federal government should play a more active leadership role in international
efforts to assist developing nations in strengthening their health care systems through
foreign aid and development programs. Particular emphasis should be placed on
training health care providers and on public health initiatives.

Provincial, territorial and federal governments and health organizations should
reduce their reliance on recruiting health care professionals from developing
countries.
Playing an International Leadership Role

As noted earlier, Canada’s health care system is not immune to international developments.
Outbreaks of diseases can quickly spread around the globe. The health workforce is becoming an
international resource as all countries seek the best ways of attracting and keeping an adequate
supply of nurses, doctors and other health care providers. Advances in technology, new
discoveries in cures and treatments, and new ways in organizing and delivering health care
services are no longer isolated to any one country. News travels fast in health care, as in most
other areas of our society and economy.
In addition, Canada has a number of international obligations as a result of its participation

in international health covenants and agreements such as the United Nations’ Universal
Declaration of Human Rights. Furthermore, Canada is well regarded on the international stage. It
is time for Canada to use both its positive relationship with developing countries and its
considerable expertise in health care to help improve health and health care around the world.
That will involve strengthening Canada’s role in foreign aid programs to assist in training much-
needed health care providers for developing countries and in promoting public health initiatives
designed to prevent the spread of illnesses such as polio, HIV/AIDS, and other communicable
diseases.
Building Health Care Systems in Developing Countries

As noted in the chapter on Canada’s health care providers, every province in Canada has a
history of recruiting health care professionals from other countries, especially from developing
countries. Some provinces depend quite heavily on international health care graduates to fill the 243
gap in their own health workforce.
Individuals from developing countries have the right to emigrate and to choose Canada as
their destination. For centuries, people have sought refuge from political turmoil, religious or
ethnic persecution and poverty by immigrating to more prosperous countries that offer greater
personal security and opportunity. In no way would we want to curtail the right of any
individuals to seek a better life for themselves or their families. And the effective integration of
these international medical graduates and other health professionals needs to be part of Canada’s
overall health human resource strategies.
But recruiting health care providers from developing countries raises important ethical
concerns. Canada’s problems in recruiting and retaining health care providers pale in comparison
to shortages and distribution problems in developing countries (Mehmet 2002; Zurn et al. 2002).
Given the limited resources of these countries, their investment in training health care
professionals is proportionately far greater than the investment Canadians make in training their
own health care professionals. Educated, professional people in developing nations also support
political stability, economic development and the protection of human rights. When middle-class
professionals are lured away by promises of greater economic opportunities abroad, they take
“Reliance on medical school
with them their potential to contribute to the stability and progress of the nation they leave
behind.
graduates from other countries is,
in the long-term, not an
acceptable solution. As a relative

As a member of the international community, Canada has an ethical
rich country, Canada should take responsibility to ensure that it does not attempt to solve its shortages of
health care professionals on the backs of less powerful, less wealthy and
responsibility for training an less developed nations. Provinces, territories and health regions should
adequate number of doctors to review their policies on recruiting health care professionals from
developing countries and reduce their dependence on international
meet domestic needs.” graduates. Canada should also work with other countries to assist
developing countries in strengthening their own health care systems –
C A N A D I A N F EDERATION OF
M E D I C A L S T U D E N T S 2001.
especially in the areas of public health and health information – so that
expensively trained health care providers will want to stay in their own
countries’ health care systems.
Sharing Information with Other Countries

Part and parcel of globalization is the growing interconnectedness of a world in which
information flows across borders at an ever-increasing pace. This provides tremendous potential
to learn from the experiences of other countries not only in important areas of health policy but
also in relation to the latest medical advances. The challenge is to work collaboratively with
other countries to ensure that health information is reliable, accessible and accurate, and also can
be shared among countries to support citizens, health care providers, managers, researchers and
policymakers. The federal government can play a leadership role in working with other countries
to develop clear guidelines for sharing information across international borders.
Many countries are facing the same challenges as our health care system in terms of
providing timely access to comprehensive and accurate health information. The investments in,
and co-ordination of, Canada’s health infostructure recommended earlier in this report can put
Canada in a strong position to take the lead in developing an international global network of
244
health information. This type of network would contribute significantly to our global health
knowledge base, help facilitate international co-operation and information sharing, support
developing countries with limited health information capacity, and help support improved health
and health care outcomes over the longer term. By working with other members of the World
Health Organization and the Pan-American Health Organization, Canada has a unique
opportunity to shape not only how reliable and accessible information gets disseminated but also
how this information is connected across jurisdictions.
The same technology can be used to share specific medical expertise among health care
professionals around the world. Canadian physicians, for example, would be able to consult with
colleagues anywhere in the world. They also would be able to provide information, advice and
diagnoses to physicians in other parts of the world, especially in developing countries. By
establishing a global health information network, Canadian health care professionals could work
closely with colleagues in developing nations, allowing them to provide better care to their own
citizens and encouraging them to stay in their own countries.
At the same time, the Commission understands that sharing information across international
boundaries must respect and protect the privacy of individual patients. For that reason,
appropriate international safeguards will need to be developed and implemented.
Establishing a global information network will be not be an easy task or something that can
be accomplished in the near future. The challenges involved in extending health technology and
information to the developing world are immense. Currently, less than 1% of global research and
development is spent on technological innovations aimed specifically at poorer nations. New
technology and health care innovations are, to put it bluntly, simply beyond the financial reach of
much of the world’s population (Donald 1999). It is naïve to believe that our own technological
advances will simply “trickle down” to developing nations over time. Unless strategies are
developed to ensure that developing nations can gain better access to information and health
technology, there is a risk that this technology could exacerbate the divide between the developed
and the developing world. Therefore, strategies to expand technology and health information need
to be backed up with the same degree of global support that developed nations currently give to
the range of international trade agreements that govern international trade relations.
What DDes This Mean fDr Canadians?

There is no doubt that globalization will continue to have an impact on all aspects of our
economy, society and culture, not only in Canada but in all countries around the world. Most
often, the focus for Canadians is on our own problems – how do we sustain Canada’s health
system, improve access or attract enough health care providers to meet our needs. But Canada’s
health care system is not immune from changes around the world. As a country, we have a
tremendous opportunity to lead the world in sharing health care expertise and helping to improve
the health and health care of people in developing countries.
It is not possible to say with any certainty what impact international trade agreements could
have on future changes in our health care system. The best approach in the face of this
uncertainty is, in some ways, to hope for the best, prepare for the worst, and work with other
countries to ensure that trade agreements clearly respect the diversity and relative sovereignty of
245
every country to make choices about its own social policies, including health care. In terms of
future changes to Canada’s health care system, the objective must be to ensure that international
agreements do not constrain our ability to introduce new options and new approaches to health
care in Canada.
With these recommendations, Canadians can be assured that:

• Steps will be taken here in Canada and on the world stage to preserve and protect
Canada’s publicly funded health care system against any potential challenges under
international trade agreements.
• Canada will work with other countries, especially those in the World Trade Organization,
to ensure that when it comes to important social policy areas such as health care, all
countries have the right to chart their own course independent of international trade
agreements.
• Health care will become an important part of Canada’s foreign policy and reflect our
collective responsibilities for improving health and health care in developing countries.
246
CONCLUSION
In completing this report, I am acutely aware that the support of Canadians for their public
health care system is conditional. It is given in exchange for a commitment that their
governments will ensure that high quality care is there for them when they need it. If Canadians
come to believe that their governments will not honour their part of the bargain, they will look
elsewhere for answers. And the grave risk we will face is pressure for access to private, parallel
services – one set of services for the well off, another for those who are not. Canadians do not
want this type of system.
The changes I am proposing are intended to strengthen and modernize medicare, and place
it on a more sustainable footing for the future. They are based on a vision of medicare as a
national endeavour, where governments work together to ensure timely access to quality health
care services as a right of citizenship, not a privilege. And they are designed to achieve a more
effectively integrated and a more accountable world-class system that helps to make Canadians
the healthiest people in the world.
The reform agenda is an ambitious one, but at a time when one of our most cherished
national programs is at a crossroads, Canadians expect no less. The future of this report and of
our health care system is now in the hands of Canadians. In the coming months, the choices we
make, or the consequences of those we fail to make, will decide medicare’s future. I believe
Canadians are prepared to embark on the journey together and build on the proud legacy they
have inherited. The next step – taking action to implement the recommendations – is where the
most important, and perhaps the toughest, work begins. I have no doubt that Canadians and their
governments are up to the challenge.
The 47 recommendations I have made in this report, and the timetable for their
implementation, are outlined below.
Recommend tions
RECOMMENDATION 1:
A new Canadian Health Covenant should be established as a common declaration of
Canadians’ and their governments’ commitment to a universally accessible, publicly funded
health care system. To this end, First Ministers should meet at the earliest opportunity to agree
on this Covenant.
247
RECOMMENDATION 2:
A Health Council of Canada should be established by the provincial, territorial and federal
governments to facilitate co-operation and provide national leadership in achieving the best
health outcomes in the world. The Health Council should be built on the existing infrastructure
of the Canadian Institute for Health Information (CIHI) and the Canadian Coordinating Office
for Health Technology Assessment (CCOHTA).
RECOMMENDATION 3:
On an initial basis, the Health Council of Canada should:
• Establish common indicators and measure the performance of the health care system;
• Establish benchmarks, collect information and report publicly on efforts to improve
quality, access and outcomes in the health care system;
• Coordinate existing activities in health technology assessment and conduct independent
evaluations of technologies, including their impact on rural and remote delivery and the
patterns of practice for various health care providers.
RECOMMENDATION 4:
In the longer term, the Health Council of Canada should provide ongoing advice and co-
ordination in transforming primary health care, developing national strategies for Canada’s
health workforce, and resolving disputes under a modernized Canada Health Act .
RECOMMENDATION 5:
The Canada Health Act should be modernized and strengthened by:
• Confirming the principles of public administration, universality and accessibility,
updating the principles of portability and comprehensiveness, and establishing a new
principle of accountability;
• Expanding insured health services beyond hospital and physician services to immediately
include targeted home care services followed by prescription drugs in the longer term;
• Clarifying coverage in terms of diagnostic services;
• Including an effective dispute resolution process;
• Establishing a dedicated health transfer directly connected to the principles and
conditions of the Canada Health Act .
RECOMMENDATION 6:
To provide adequate funding, a new dedicated cash-only Canada Health Transfer should be
established by the federal government. To provide long-term stability and predictability, the
Transfer should include an escalator that is set in advance for five year periods.
RECOMMENDATION 7:
On a short-term basis, the federal government should provide targeted funding for the next
two years to establish:
248
CONCLUSION
• a new Rural and Remote Access Fund

• a new Diagnostic Services Fund
• a Primary Health Care Transfer
• a Home Care Transfer
• a Catastrophic Drug Transfer
RECOMMENDATION 8:
A personal electronic health record for each Canadian that builds upon the work currently
underway in provinces and territories.
RECOMMENDATION 9:
Canada Health Infoway should continue to take the lead on this initiative and be responsible
for developing a pan-Canadian electronic health record framework built upon provincial
systems, including ensuring the interoperability of current electronic health information systems
and addressing issues such as security standards and harmonizing privacy policies.
RECOMMENDATION 10:
Individual Canadians should have ownership over their personal health information, ready
access to their personal health records, clear protection of the privacy of their health records, and
better access to comprehensive and credible information about health, health care and the health
system.
RECOMMENDATION 11:
Amendments should be made to the Criminal Code of Canada to protect Canadians’ privacy
and to explicitly prevent the abuse or misuse of personal health information, with violations in
this area considered a criminal offense.
RECOMMENDATION 12:
Canada Health Infoway should support health literacy by developing and maintaining an
electronic health information base to link Canadians to health information that is properly
researched, trustworthy and credible as well as support more widespread efforts to promote good
health.
RECOMMENDATION 13:
The Health Council of Canada should take action to streamline technology assessment in
Canada, increase the effectiveness, efficiency and scope of technology assessment, and enhance
the use of this assessment in guiding decisions.
RECOMMENDATION 14:
Steps should be taken to bridge current knowledge gaps in applied policy areas, including
rural and remote health, health human resources, health promotion, and pharmaceutical policy.
249
RECOMMENDATION 15:
A portion of the proposed Rural and Remote Access Fund, the Diagnostic Services Fund,
the Primary Health Care Transfer, and the Home Care Transfer should be used to improve the
supply and distribution of health care providers, encourage changes to their scopes and patterns
of practice, and ensure that the best use is made of the mix of skills of different health care
providers.
RECOMMENDATION 16:
The Health Council of Canada should systematically collect, analyze and regularly report on
relevant and necessary information about the Canadian health workforce, including critical
issues related to the recruitment, distribution, and remuneration of health care providers.
RECOMMENDATION 17:
The Health Council of Canada should review existing education and training programs and
provide recommendations to the provinces and territories on more integrated education
programs for preparing health care providers, particularly for primary health care settings.
RECOMMENDATION 18:
The Health Council of Canada should develop a comprehensive plan for addressing issues
related to the supply, distribution, education and training, remuneration, skills and patterns of
practice for Canada’s health workforce.
RECOMMENDATION 19:
The proposed Primary Health Care Transfer should be used to “fast-track” primary health
care implementation. Funding should be conditional on provinces and territories moving ahead
with primary health care reflecting four essential building blocks – continuity of care, early
detection and action, better information on needs and outcomes, and new and stronger incentives
to achieve transformation.
RECOMMENDATION 20:
The Health Council of Canada should sponsor a National Summit on Primary Health Care
within two years to mobilize concerted action across the country, assess early results, and
identify actions that must be taken to remove obstacles to primary health care implementation.
RECOMMENDATION 21:
The Health Council of Canada should play a leadership role in following up on the
outcomes of the Summit, measuring and tracking progress, sharing information and comparing
Canada’s results to leading countries around the world, and reporting to Canadians on the
progress of implementing primary health care in Canada.
RECOMMENDATION 22:
Prevention of illness and injury, and promotion of good health should be strengthened with
the initial objective of making Canada a world leader in reducing tobacco use and obesity.
250
CONCLUSION
RECOMMENDATION 23:
All governments should adopt and implement the strategy developed by the Federal,
Provincial and Territorial Ministers Responsible for Sport, Recreation and Fitness to improve
physical activity in Canada.
RECOMMENDATION 24:
A national immunization strategy should be developed to ensure that all children are
immunized against serious illnesses and Canada is well prepared to address potential problems
from new and emerging infectious diseases.
RECOMMENDATION 25:
Provincial and territorial governments should use the new Diagnostic Services Fund to
improve access to medically necessary diagnostic services.
RECOMMENDATION 26:
Provincial and territorial governments should take immediate action to manage wait lists
more effectively by implementing centralized approaches, setting standardized criteria, and
providing clear information to patients on how long they can expect to wait.
RECOMMENDATION 27:
Working with the provinces and territories, the Health Council of Canada should establish a
national framework for measuring and assessing the quality and safety of Canada’s health care
system, comparing the outcomes with other OECD countries, and reporting regularly to
Canadians.
RECOMMENDATION 28:
Governments, regional health authorities, health care providers, hospitals and community
organizations should work together to identify and respond to the needs of official language
minority communities.
RECOMMENDATION 29:
Governments, regional health authorities, and health care providers should continue their
efforts to develop programs and services that recognize the different health care needs of men
and women, visible minorities, people with disabilities, and new Canadians.
RECOMMENDATION 30:
The Rural and Remote Access Fund should be used to attract and retain health care
providers.
RECOMMENDATION 31:
A portion of the Rural and Remote Access Fund should be used to support innovative ways
of expanding rural experiences for physicians, nurses and other health care providers as part of
their education and training.
251
RECOMMENDATION 32:
The Rural and Remote Access Fund should be used to support the expansion of telehealth
approaches.
RECOMMENDATION 33:
The Rural and Remote Access Fund should be used to support innovative ways of
delivering health care services to smaller communities and to improve the health of people in
those communities.
RECOMMENDATION 34:
The proposed new Home Care Transfer should be used to support expansion of the Canada
Health Act to include medically necessary home care services in the following areas:
• Home mental health case management and intervention services should immediately be
included in the scope of medically necessary services covered under the Canada Health
Act.
• Home care services for post-acute patients, including coverage for medication
management and rehabilitation services, should be included under the Canada Health
Act.
• Palliative home care services to support people in their last six months of life should also
be included under the Canada Health Act .
RECOMMENDATION 35:
Human Resources Development Canada, in conjunction with Health Canada should be
directed to develop proposals to provide direct support to informal caregivers to allow them to
spend time away from work to provide necessary home care assistance at critical times.
RECOMMENDATION 36:
The proposed new Catastrophic Drug Transfer should be used to reduce disparities in
coverage across the country by covering a portion of the rapidly growing costs of provincial and
territorial drug plans.
RECOMMENDATION 37:
A new National Drug Agency should be established to evaluate and approve new
prescription drugs, provide ongoing evaluation of existing drugs, negotiate and contain drug
prices, and provide comprehensive, objective and accurate information to health care providers
and to the public.
RECOMMENDATION 38:
Working collaboratively with the provinces and territories, the National Drug Agency
should create a national prescription drug formulary based on a transparent and accountable
evaluation and priority-setting process.
252
CONCLUSION
RECOMMENDATION 39:
A new program on medication management should be established to assist Canadians with
chronic and some life-threatening illnesses. The program should be integrated with primary
health care approaches across the country.
RECOMMENDATION 40:
The National Drug Agency should develop standards for the collection and dissemination of
prescription drug data on drug utilization and outcomes.
RECOMMENDATION 41:
The federal government should immediately review the pharmaceutical industry practices
related to patent protection, specifically, the practices of evergreening and the notice of
compliance regulations. This review should ensure that there is an appropriate balance between
the protection of intellectual property and the need to contain costs and provide Canadians with
improved access to non-patented prescription drugs.
RECOMMENDATION 42:
Current funding for Aboriginal health services provided by the federal, provincial and
territorial governments and Aboriginal organizations should be pooled into single consolidated
budgets in each province and territory to be used to integrate Aboriginal health care services,
improve access, and provide adequate, stable and predictable funding.
RECOMMENDATION 43:
The consolidated budgets should be used to fund new Aboriginal Health Partnerships that
would be responsible for developing policies, providing services and improving the health of
Aboriginal peoples. These partnerships could take many forms and should reflect the needs,
characteristics and circumstances of the population served.
RECOMMENDATION 44:
Federal and provincial governments should prevent potential challenges to Canada’s health
care system by:
• Ensuring that any future reforms they implement are protected under the definition of
“public services” included in international law or trade agreements to which Canada is
party;
• Reinforcing Canada’s position that the right to regulate health care policy should not be
subject to claims for compensation from foreign-based companies.
RECOMMENDATION 45:
The federal government should build alliances with other countries, especially with
members of the World Trade Organization, to ensure that future international trade agreements,
agreements on intellectual property, and labour standards make explicit allowance for both
maintaining and expanding publicly insured, financed and delivered health care.
253
RECOMMENDATION 46:
The federal government should play a more active leadership role in international efforts to
assist developing nations in strengthening their health care systems through foreign aid and
development programs. Particular emphasis should be placed on training health care providers
and on public health initiatives.
RECOMMENDATION 47:
Provincial, territorial and federal governments and health organizations should reduce their
reliance on recruiting health care professionals from developing countries.
Proposed Timelines for the

Implement tion of the Recommend tions
The vision implicit in this report will not be achieved overnight. However, the immediate
priorities must be to strengthen medicare’s legislative and institutional foundations, to stabilize
funding, and to address the critical concerns that are eroding Canadians’ confidence in the
system.
At the conclusion of this section, I propose timelines to help guide sequencing and
implementation of the Commission’s 47 recommendations.
254
Policy Area Early 2003 2003/04 2004/05 2005/06 2010 2011 to 2020
Modernized Canada
First Ministers Health Act (CHA)
Meeting and the passed by
adoption of the Parliament; Canada Health Federal-provincial-territorial
Canadian Health Health Council of Transfer with re-negotiation of Canada Health
Governance Covenant Canada established escalator takes effect Transfer escalator every five years
Privacy guarantees Health Council’s

placed in Criminal reports on
Code; Infoway’s
Health Council begins progress; Health Council All provincial
work on Canadian develops user-friendly and territorial
performance Institutes of health information for health records
Development of indicators, data Health Research Canadians; moved to
electronic health collection and establishes first first fully functional electronic form
Information records technology Centres for electronic health with full
and Research continues assessment Innovation records established interoperability
Streamline process
for recognition of
international medical
graduates;
new personnel and
new incentives to
meet distribution Health Council of Health Council makes
problems under Canada develops recommendations on
Rural and Remote long-term plan reforms to training of
Access Fund and for health human health professionals
Health Care Diagnostic Services resources and to the reform of
Providers Fund planning scopes of practice
$500 million in National Drug Agency

new federal launches national Ongoing work
funding for immunization strategy; by Health
CONCLUSION
primary health Health Council Council to

$1 billion in new care initiatives; reports to Canadians facilitate Full realization
federal funding for National Summit on progress on development of of integrated
Primary primary health on Primary primary health care primary health primary health
Health Care initiatives Health Care initiatives care care
255
256
Policy Area Early 2003 2003/04 2004/05 2005/06 2010 2011 to 2020
Health Council of Health Council regularly reports to
Canada releases governments and Canadians on
$1.5 billion Federal funding for new diagnostic comprehensive set of access, quality and safety, and
Diagnostic equipment and personnel; performance and quality provides recommendations for
Access and Services Fund centralized management of wait lists indicators for health improvements to be undertaken by
Quality created undertaken by provincial governments system governments
Health Council of Canada regularly
$1.5 billion Federal funding for new initiatives on reports on the health of Canadians
Rural and improving rural and remote access Expansion of telehealth in rural and remote areas and
Remote including supply, distribution and mix of and related initiatives makes recommendations for
Rural and Access Fund health professionals and the expansion of through new Canada improvements to be undertaken by
Remote created telehealth Health Transfer governments
Priority home care Further

services included in expansion of Full integration of
New program new CHA; home care home and
to support $1 billion in new services to be continuing care
informal federal funding for Expansion of provincial home care programs included in services into the
Home Care caregivers home care initiatives through new federal funds the CHA CHA
Establishment
Establishment of of Medication
National Drug Management Full integration of
Agency; Drug Insurance prescription drugs
Federal government $1 billion per year Program linked at all levels of care
Prescription review of Catastrophic Drug Development of to primary and coverage under
Drugs drug patent legislation Transfer takes effect National Drug Formulary health care the CHA
Intergovernmental Expansion of
negotiations with Establishment of Aboriginal Majority of
Aboriginal consolidated funds Health Aboriginal health
organizations on the available to fund Partnerships services delivered
Aboriginal creation of new Aboriginal First Aboriginal Health across the through Health
Health consolidated funds Health Partnerships Partnerships operating country Partnerships
Establishment of “health” as a foreign policy goal;

Clear steps to protect health care alliance building with other nations to ensure that international trade agreements
system from challenge under trade protect the sovereignty of nations to protect social policy priorities;
agreements; review practice of expanded efforts to assist the development of health care systems in the developing
recruitment of health professionals world, including expanding public health initiatives and ensuring access to health care
Globalization from developing countries technology
appendice
257
A
S UBMISSIONS
During its Fact Finding phase from June to December 2001, the Commission issued a call
for submissions, and in its ongoing efforts to remain transparent, posted the responses it received
electronically on its Web site. The Commission received further submissions during the
consultation phase of its mandate.
The following is a list of formal submissions received by the Commission up to September

13, 2002. Attributed to the original author, these submissions were prepared expressly for the
Commission.
Beyond official submissions to the Commission, individuals and organizations also
brought to the Commission’s attention hundreds of briefs and policy documents. A statistical
overview of the volume of calls to the Commission’s toll-free information line, e-mails and
correspondence is provided at the end of this appendix.
Submi ion from Organization

Aboriginal Nurses Association of Canada Assemblée des aînées et aînés francophones
Aîné.e.s en Marche/Go Ahead Seniors Inc. du Canada
Alberta Association of Registered Nurses Assemblée des premières nations du Québec
Alberta Catholic Health Corporation et du Labrador et la Commission de la santé
Alberta College of Social Workers et des services sociaux
Association canadienne-française
Alberta Consortium for Health Promotion de l’Alberta
Research and Education
Association canadienne-française
Alberta Federation of Labour de l’Ontario
Alberta Medical Association Association coopérative d’économie
Alberta Mental Health Board familiale de Québec
Alberta New Democratic Party Association des arthritiques de Québec
Alberta Society of Friends of Medicare Association des médecins de CLSC
Alberta Union of Provincial Employees du Québec
Alliance for Access to Medical Information Association des spécialistes en médecine
Alliance of Seniors to Protect Canada’s interne du Québec
Social Programs
Association médicale du Québec
Association of Canadian Academic
Alternatives North
Healthcare Organizations
Amgen Canada Inc. 259
Association of Canadian Medical Colleges British Columbia Psychological Association

(November 2001) Bromley Road Baptist Church Social Impact
Association of Canadian Medical Colleges and Community Awareness Group
(May 2002)
Association of Chinese Canadian Calgary Meals on Wheels
Professionals (BC)
Canada’s Research-Based Pharmaceutical
Association of Integrative Medicine of Companies (Rx&D)
Prince Edward Island
Canadian Alliance of Community Health
Association of International Physicians Centre Associations
& Surgeons of Ontario
Canadian Anesthesiologists’ Society and
Association of Local Public Health Agencies the Association of Canadian University
Association of Massage Therapists and Departments of Anesthesiology Canadian
Wholistic Practitioners Association for Community Care and
Association of Midwives of Newfoundland Canadian Home Care Association Canadian
and Labrador Association for Parish Nursing Ministry
Association of Newfoundland Psychologists
Association of Nurses of Prince Edward Canadian Association for Proximal
Island Stabilization of Cerebral Palsy Children
Association of Ontario Health Centres Canadian Association of Advanced Practice
Association of Public Service Alliance Nurses
Retirees Canadian Association of Allied Health
Association of Workers’ Compensation Programs
Boards of Canada Canadian Association of Chain Drug Stores
Association québécoise des soins palliatifs Canadian Association of Emergency
Atlantic Institute for Marketing Studies Physicians
Atlantic Seniors Health Promotion Network Canadian Association of General Surgeons
Au Cœur de l’Être (CAGS)
Canadian Association of Healthcare
Aventis Pasteur Limited
Auxiliaries
Canadian Association of Internes and
Bay of Quinte Conference/United Church Residents
of Canada
Canadian Association of Midwives
Baycrest Centre for Geriatric Care Canadian Association of Occupational
BC Coalition of People with Disabilities Therapists
BC Freedom of Information and Privacy
Canadian Association of Optometrists
Association
Canadian Association of Pathologists
B.C. Government and Service Employees’ Canadian Association of Provincial Cancer
Union Agencies
B.C. Retired Teachers’ Association
Canadian Association of Psychosocial
Bernard Betel Centre for Creative Living
Oncology
BIOTECanada
Canadian Association of Public Health
Birches Family Advisory Council Dentistry
Breastfeeding Committee for Canada Canadian Association of Radiologists
British Columbia Medical Association
Canadian Association of
British Columbia Old Age Pensioners
Radiopharmaceutical Scientists
Organization
260 Canadian Association of Retired Teachers
SUBMISSIONS • APPENDIX A
Canadian Association of the Deaf Canadian Health Record Association,

Canadian Association of University Teachers Canadian College of Health Record
Administrators
Canadian Association on Gerontology/
Association canadienne de gérontologie Canadian Healthcare Association
Canadian Auto Workers (CAW-Canada) Canadian Home Care Association
Canadian Auto Workers Local 222 Oshawa Canadian Hospice Palliative Care
and Retired Workers Chapter Association
Canadian Blood Services Canadian Institute of Actuaries

Canadian Institute of Child Health
Canadian Cancer Advocacy Network
Canadian Institutes of Health Research
Canadian Cancer Society Canadian Institutes of Health Research,
Canadian Cardiovascular Society Institute of Aging
Canadian Chamber of Commerce/
Chambre de Commerce du Canada Canadian Institutes of Health Research,
Institute of Gender and Health
Canadian Chiropractic Association and the
Canadian Memorial Chiropractic College Canadian Labour Congress
Canadian Coalition Against Insurance Fraud Canadian Life and Health Insurance
Canadian Cochrane Network and Centre/ Association Inc.
The Cochrane Collaboration Canadian Medical Association/Association
médicale canadienne (October 2001)
Canadian College of Health Service
Canadian Medical Association/Association
Executives
médicale canadienne (June 2002) Canadian
Canadian College of Health Service Medical Protective Association Canadian
Executives – Bluenose Chapter Mental Health Association Canadian
Canadian Congress of Neurological Sciences Mental Health Association –
Canadian Co-operative Association and
Le Conseil Canadien de la Coopération Newfoundland and Labrador Division
Canadian Council for Public-Private Canadian Midwifery Regulators Consortium
Partnerships Canadian National Institute for the Blind
Canadian Naturopathic Association
Canadian Council of Chief Executives Canadian Nurses Association
Canadian Council of Churches’ Ecumenical
Health Care Network and Kairos: Canadian
Canadian Ophthalmological Society
Ecumenical Justice Initiatives, Kitchener
(December 2001)
consultation
Canadian Ophthalmological Society
Canadian Council on Health Services (June 2002)
Accreditation
Canadian Orthopaedic Association
Canadian Council on Integrated Healthcare
Canadian Orthoptic Society
Canadian Council on Social Development
Canadian Dental Association Canadian Paediatric Society
Canadian Pensioners Concerned
Canadian Dental Hygienists Association (Ontario Division)
Canadian Drug Manufacturers Association
Canadian Pharmacists Association
Canadian Federation of Medical Students
Canadian Physiotherapy Association
Canadian Federation of Nurses Unions
Canadian Population Health Initiative,
Canadian Federation of University Women
Canadian Geriatrics Society Canadian Institute for Health Information
Canadian Psychoanalytic Society
Canadian Health Coalition Canadian Psychological Association
Canadian Health Libraries Association Canadian Public Health Association/ 261
Association canadienne de santé publique
Canadian Public Health Laboratory Forum Coalition of Physicians for Social Justice
Canadian Rheumatology Association Coalition to Save Social Programs
Canadian Society of Addiction Medicine
College of Family Physicians of Canada/
Canadian Society of Nuclear Medicine
Collège des médecins de famille
Canadian Society of Telehealth
du Canada
College of Health Disciplines, University
Canadian Task Force on Preventative
of British Columbia
Health Care
College of Medical Laboratory
Canadian Teachers’ Federation/Fédération
Technologists of Ontario
canadienne des enseignantes et des
enseignants College of Physicians and Surgeons
of Ontario
Canadian Union of Public Employees
Canadian Union of Public Employees College of Registered Nurses of Manitoba
Ontario Division College of Traditional Chinese Medicine
Practitioners and Acupuncturists of British
Canadian Union of Public Employees Columbia
Prince Edward Island
Collège québécois des médecins de famille
Canadian University Departments of
Communications, Energy and Paperworkers
Anaesthesia
Union of Canada
Canadian Women’s Health Network
Cancer Advocacy Coalition of Canada Community Social Planning Council
CardiacCareNetwork of Ontario of Toronto
Concerned Friends of Ontario Citizens
Care Watch Toronto in Long Term Care Facilities
CARP-Canada’s Association for the Confederation of Canadian Unions
Fifty-Plus Conférence religieuse canadienne –
Catholic Health Association of Canada région du Québec
Catholic Health Association of Manitoba
Congress of Union Retirees of Canada/
Catholic Health Association of Ontario
Association des syndicalistes retraités
Catholic Women’s League of Canada
du Canada
Catholic Women’s League of Canada,
Ontario Provincial Council Conseil du patronat du Québec
Conseil du travail d’Edmundston et région
Centrale des syndicats démocratiques Consumers’ Association of Canada
Centrale des syndicats du Québec Council of Canadians, Coquitlam Chapter
Centretown, Carlington, Somerset West and Council of Canadians Nelson Chapter,
Sandy Hill Community Health Centres, Health Committee
Ottawa
Council of Canadians with Disabilities
Children and Youth Home Care Network Council of Senior Citizens’ Organizations
Chinese Canadian National Council of British Columbia
Chinese Medicine and Acupuncture
Cummings Jewish Centre for Seniors
Association of Canada
CUPE Saskatchewan and the CUPE Health
Chronic Disease Prevention Alliance Care Council
of Canada
Church in Society Committee Dakota Ojibway Tribal Council des
Citizens for Choice in Health Care premières nations du Québec et du
Coalition for Active Living Labrador
Coalition for Primary Health Care
Deep River and District Hospital
Coalition of National Voluntary
262 Diagnostic Imaging and Therapy
Organizations
Systems Council
Drug Trading Company Limited Government of Newfoundland and Labrador,

Durham Haliburton Kawartha and Department of Health and Community
Pine Ridge District Health Council Services
Durham Paramedic Association Greater Ottawa Chamber of Commerce
Durham Region Health Coalition Green Shield Canada
Grey Bruce Huron Perth District Health
Council
East Thompson/North Shuswap Community
Health Advisory Committee Group of IX Seniors Organizations in
Nova Scotia
Ecumenical Health Care Network
Edmonton Highlands Health Care Action
Group Halifax Faith Groups
Edmonton McClung and Edmonton Hamilton HSO Mental Health & Nutrition
Meadowlark NDP Provincial Program
Constituency Associations Health Action Lobby (HEAL)
Eli Lilly Canada Inc. Health and Community Services,
St. John’s Region
Emergency Medical Services Chiefs
of Canada Health Association of BC
Emergency Nurses Association of Ontario Health Care Coordination Initiative
English Speaking Catholic Council (Canadian Forces, Correctional Service
Extendicare (Canada) Inc. Canada, Royal Canadian Mounted Police,
and Veterans Affairs Canada)
Health Care Leaders Association of BC
Faith Partners Health Charities Council of Canada Health
Family Caregivers Association of Sciences Council at the University of
Nova Scotia Alberta
Family Council of Northwoodcare
Heart and Stroke Foundation of Canada
Incorporated
Home Support Action Group and
Federal/Provincial/Territorial Dental
Directors Working Group Dr. Kari Krogh
Hospital Employees’ Union
Federal Superannuates National Association
Fédération de l’Âge d’Or du Québec
Fédération des associations étudiantes du Injured Workers Consultants Community
campus de l’Université de Montréal Legal Clinic (Toronto)
Fédération des Associations Étudiantes Institute for Aboriginal Health, Division
of First Nations Health Careers Institute
en Médecine du Québec
of Public Service of Canada and
Fédération des communautés francophones
Yukon Employees Union of the Public
et acadienne du Canada
Service Alliance of Canada
Fédération des infirmières et infirmiers
Insurance Bureau of Canada/Le Bureau
du Québec
d’assurance du Canada
Fédération des parents francophones
International Association of Fire Fighters
de Terre-Neuve et du Labrador
International Society for Augmentative and
Fédération Franco-TéNOise
Alternative Communication-Canada IWK
Federation of Saskatchewan Indian Nations Health Centre
Gerontological Nurses Association (Ontario) Joint Provincial Nursing Committee

GlaxoSmithKline Inc. of Ontario 263
KAIROS, Canadian Ecumenical Justice New Brunswick Common Front for Social
Initiatives Justice
Kids First Parent Association of Canada New Brunswick Council of Hospital Unions
Kingston and the Islands Federal Liberal New Brunswick Council of Nursing Home
Association (Policy Committee) Unions
Kingston Health Coalition New Brunswick Federation of Union
Retirees
Learning Disabilities Association of New Brunswick Healthcare Association
New Brunswick (NBHA)
Lethbridge Raging Grannies New Brunswick Nurses Union
Liberal Party of Alberta New Democratic Party of Canada
New Green Alliance
Medical Reform Group Newfoundland & Labrador Centre for Health
Information and EDS Canada Newfoundland
Medtronic of Canada, Ltd.
and Labrador Federation
Métis National Council
of Labour
Montfort Hospital
Newfoundland and Labrador Health Boards
Moose Jaw-Thunder Creek District Association
Health Board
Newfoundland and Labrador Nurses’ Union
Mount Zion Lutheran Church, Edmonton Newfoundland and Labrador Palliative Care
Mountain View Women’s Institute Association
Movement for Canadian Literacy
Multicultural Women’s Organizations of Norfolk General Hospital
Norms and Narratives Research Group,
Newfoundland and Labrador, National Social Sciences and Humanities Research
Organization of Immigrant and Visible Council
Minority Women of Canada and
Northwest Territories Registered Nurses
Newfoundland and Labrador Health in
Association
Pluralistic Societies
Nova Scotia Advisory Council on the Status
Multiple Sclerosis Society of Canada
of Women
Nova Scotia Citizens’ Health Care Network
National Aboriginal Health Organization Nova Scotia College of Chiropractors
National Citizenship and Immigration Law
Section, Canadian Bar Association Nova Scotia Government & General
Employees Union
National Coalition for Vision Health
Nova Scotia League for Equal Opportunities
National Council of Women of Canada
Nova Scotia Provincial Health Council
National Defence Headquarters
Nurses Association of New Brunswick
National ME/FM Action Network of Canada
National Pensioners and Senior Citizens
Federation (August 2001) Occupational and Environmental Medical
Association of Canada
National Pensioners and Senior Citizens
Older Adult Centres’ Association of Ontario
Federation (March 2002)
Older Women’s Network (Hamilton and
National Union of Public and General District Chapter)
Employees
Older Women’s Network (Ontario) Inc.
Native Women’s Association of Canada
Ontario Association of Medical Laboratories
Nelson and Area Health Council Ontario Association of Non-Profit Homes
264 New Brunswick Catholic Health Association and Services for Seniors
Ontario Association of Optometrists Public Health Nursing Leaders Council

Ontario Association of Social Workers and of British Columbia
the Social Work Doctors’ Colloquium Public Service Alliance of Canada
Ontario Brain Injury Association
Ontario College of Family Physicians Qikiqtani Inuit Association
Ontario Consultants on Religious Tolerance Quality End-of-Life Care Coalition
Ontario Federation of Labour
Ontario Health Coalition Redberry Lake NDP Association
Ontario Hospital Association Region of Peel, Health Department
Ontario Long Term Care Association Regional Health Authorities of Manitoba
Ontario Medical Association, Section on Registered Nurses Association of Ontario
Emergency Medicine Registered Psychiatric Nurses Association
of Saskatchewan
Ontario Metis Aboriginal Association
Ontario Nurses’ Association Registry of Marriage and Family Therapists
Ontario Provincial Forum of Mental Health in Canada
Implementation Task Force Chairs Regroupement des intervenantes et
Ontario Psychological Association intervenants francophones en santé et en
Ontario Psychological Association – services sociaux de l’Ontario
Section on Independent Practice Réseau québécois pour la santé du sein
Ontario Society (Coalition) of Senior Retired Teachers of Ontario
Citizens’ Organizations
Riverdale Seniors’ Council
Ontario Teachers Insurance Plan Roman Catholic Archdiocese of Halifax
Ontario Women’s Health Council Royal College of Physicians and Surgeons
of Canada (October 2001)
Ordre des pharmaciens du Québec
Ottawa Health Coalition Royal College of Physicians and Surgeons
of Canada (June 2002)
Ottawa Hospital, Spiritual Care Advisory
Committee Running to Daylight Foundation –
The Ben Globerman Memorial Rural
Health Connection Committee
Paramedic Association of Canada
Parkinson Society Canada
Safe Kids Canada and the Centre for Health
Pensioners and Senior Citizens/
Information and Promotion
50+ Federation
Sal’i’shan Institute
Prairie Hope Ministries Inc.
Salvation Army
Prairie Women’s Health Centre
of Excellence Saskatchewan Academic Health Sciences
Network
Premier’s Council on the Status of Disabled
Persons, New Brunswick Saskatchewan Action Committee,
Status of Women
Prince Albert Citizen’s Agenda Committee
Prince Edward Island Teachers Federation Saskatchewan Government and General
ProBed Medical Technologies Inc. Employees’ Union-Health Sector
Saskatchewan Population Health and
Project Genesis Evaluation Research Unit, Inc.
Province of Nova Scotia Saskatchewan Psychological Association
Saskatchewan Union of Nurses
Provincial and Territorial Ministers
Responsible for Physical Activity, Saskatchewan Voice of People With
Disabilities 265
Recreation and Sport
Saskatoon & District Chamber of Commerce Townshippers’ Association

Health Opportunities Committee Saskatoon Transitional Council of the College of
Council on Aging, Informal Caregiver Centre Osteopathic Manual Practitioners of Ontario
Saskatoon Health Oasis Ukrainian Women’s Association of Canada

Schizophrenia Society of Canada
Union of Nova Scotia Municipalities
Seniors’ Action and Liaison Team
(Edmonton) United Church of Canada
United Church of Canada, Hamilton
Senior Link Conference
Senior Peoples’ Resources in North Toronto United Steelworkers of America
Inc. (SPRINT)
United Steelworkers of America Local 1005
Seniors Network BC
United Way of Greater Toronto
Seniors’ University Group, Inc.,
University College of the Cariboo
University of Regina
University Health Network
Service Alliance of Canada
(September 2001)
Service Employees International
Union Canada University Health Network (June 2002)
University of British Columbia
Services de Counselling de Hearst,
School of Nursing
Kapuskasing et Smooth Rock Falls
SMARTRISK
Valley Caregivers Support Group,
Social Policy Research Unit,
Rural Nova Scotia
Vancouver-Quadra Constituency
Society of Obstetricians and Gynaecologists
of Canada Victoria Coalition for Health Care Reform
Victorian Order of Nurses
Society of Rural Physicians of Canada
Squamish and District Labour Committee
St. Boniface General Hospital Watson Wyatt Canada
St. Christopher House We Care for Tantramar Health Services
Committee
St. John’s Nursing Home Board
Western Arctic Aboriginal Head Start Council
St. Joseph’s Care Group, Marycrest
Western Cities Medical Health Officers
Home for the Aged
Whitehorse General Hospital
St. Michael’s Hospital
Steelworkers Organization of Active Retirees William M. Mercer Limited
Strait Richmond Community Health Board Winnipeg Presbytery, The United Church
of Canada
WoodGreen Community Centre of Toronto
Table de concertation en santé de l’Ontario
T-Fact Canada Corp. Ltd.
Yee Hong Centre for Geriatric Care
Thames Valley District Health Council
YMCA Canada
Toronto Dental Coalition
York Support Services Network
Toronto Health Coalition & Friends
of Medicare Toronto YouthCO AIDS Society
Toronto Public Health Yukon Federation of Labour, Whitehorse
General Hospital Local of the
Toronto Rehabilitation Institute
Professional Institute of the Public
Toronto School of Traditional Chinese Service of Canada
266
Medicine
Yukon Medical Association
Toronto & York Region Labour Council
YWCA of Canada
Submi ion from

Individual Canadian
Abell, Dr. Margaret E.; Abell, Clarke, Stephen
Dr. Nicholas A.; Abell, Dr. W. Robert Clarkson, Darrell
Alter, Dr. Robin Cleveland, Dr. Eric
Conrick, Rev. Gail
Andermann, Anne
Corley, Judy
Anderson, Richard Corney, Brenda D.
Arnott, Roy; Arnott, Barbara; Arnott, Crispo, Dr. John
Joanne; Arnott, Mac; Arnott, David;
Arnott, Jenna
Daniel, Alice J.
Baltzan, Dr. M.A
Dascavich, William
Barnes, Keith E.
Davie, Brenda
Basnyat, Dr. S.
Davitt, W. Shawn
Bass, Peter Day, Dr. Brian
Denman, Harold
Bazett, Michael
Desjardins, L.L.
Becker, Dr. Henry A.
Desjardins, Louis
Bennett, Carolyn, MP
Bennett, Meagan Dickson, Jim
Disher, Sandi
Bertoia, Frank
Dobson, Joy
Dolesch, Steve
Bigham, Bruce
Bizon, Norman J. Blair,
Stephen G. Boddy,
Victoria Boissonnault,
Bruce A. Bonham, Eaton, R. Mike
Gerald Braun, Jolene
Emerson, Dr. Brian P.
Erban, Joseph; Dworkind, Dr. Michael
Evans, Robert G.
Brett, Todd
Bryde, John
Fahey, Marilyn
Byrne, Dr. Joseph M.
Fewster, Jean
Finley, Sandra
Calderhead, Vincent
Finn, Jean-Guy
Campbell, Elaine; Doran, Cheryl;
Enman, Anna Fitzgerald, Dr. G. William N.
Campigotto, Mary Jane Flood, John M.
Caro, Dr. Denis H. J. Ford, Dr. Denys K.
Frank, Dr. John
Castonguay, Claude (Ex-ministre de la santé
Fulton, Lorna
du Québec)
Champagne, Philippe
Chance, Graham W. Gagliardi, Jack
Chatee, Selwyn Galbraith, Denise
Church-Labrick, Conrad Garic, Bojan
267
Gibson, Maggie Kumanan, Mekalai

Godbout, Jean Kurisko, Dr. Lee
Griew, Dr. Stephen Kwan, Klotz
Gurin, David Labaty, Christine
Gventer, Matthew Lack, J.
Hack, Arshad LaMarre, Joshua
Hajaly, Robert Lamarsh, John D. and Snider, Earle
Haliburton, Mary-Sue Leadston, Thomas
Halkett, Murray Lee, Ed
Hann, Crystal Leonard, Shaina
Hardy-Joel, Rhonda Leung, Rebecca K.
Lichtman, J.
Harris Burgess, Dr. Joanne
Heath, Olga Lipka, Miguel Angel
Hempel, Lina Loiselle, Aurora
Lynch, Tim
Henry, Régis
Henshaw, Daniel Lytton, Hugh
Heshka, Jean; Heshka, William
Hill, Percy MacDonald, Dr. M. H.
Hlady, Vibeke Mackey, Dr. Paul
Hoare, Christopher MacLean, Michael; Jasper, Grace and
Holmberg, Dale the students of Social Work and Aging
Course, Faculty of Social Work,
Holzman, Linda
Howard, Ross
Maher, E.J.
Hubbert, Anne
Malloy, M. L.
Hudson, Dr. John Edward
Mandzyk, Kim
Mark, Inky, MP
Johnson, Bonny
Mason, S.
Johnson, Peter
Mayer, Teresa
Jones, Ernest
Mccorquodale, Ross
Jordan, Joe, MP
McDaniels, Eugene
Jordon, Jim
McGregor, Maurice
Jost, Phil A.
McGurrin, Helen
Joyal-Painchaud, Monique
McInnes, Dawn
Milligan, Verna
Kastelic, Kathryn
Mitchell, Andrew
Kelly, Dr. Francis B.
Moisse, Jim
Kelly, Wayne
Monahan, Kevin
Knowles, Caroline
Morgan, Gerry
Kochalyk, Kim I.
Kochan, Maria H. Morrison, Bob; Morrison, Denise
Kreasul, Robert G. Mosher, Cindy
Kristensen-Rawluk, Joan Moulton, Carlyn
268
Neilson, John Smith, David E. and St. Denis, Daniel

Nelson, Vernon E. Sneddon, Bill
Souch, Arlene
Oancia, Tammy Speck, Brandi
O’Connor, Denise Speer, David
O’Hagan, Mary Spilchen, Marg
Olsen, John Staples, Brian
Stogre, Fr. Michael
Stolte, Juanita
Palmer, Patrick
Palmer, Selwyn
Papish, Dr. Roy O.
Telegdi, Andrew, MP
Parrish, Carolyn, MP
Thériault, Gérard
Patrick, Donald R.
Thompson, Brian
Peters, Melissa
Throness, Laurie
Pittman, Michael
Trudel, Paul
Pniauskas, Sandi
Pond, Morgan
Popple, Jeff Tuck, Dennis G.
Tucker, Robert
Turner, Carolyn
Pratt, Camellia C.
Pratt, David, MP Verburg, Geb
Prytulak, Dr. Walter
Vynckier, Cynthia
Randall, Patricia L. (Caputo) Waldner, Dianna

Rawluk, Tanya Warrick, Dr. Paddy
Renwick, Jeff Watson, Ellen; Watson, Brad
Richardson, C. H. Westfall, Andrea
Ritcey, Gerald C. White, Norma
Roddick, Paul M. Whitfield, Kyle
Williams, Lloyd R.
Ross, Bob
Wilson, E. Donald
Ross, Margaret M.; MacLean, Michael J.; Wirsig, Claus
Fisher, Rory Wiseman, Herb
Rourke, Dorothy Wolf, Shelly
Roy, Carole Wong, Alfred
Russell, Dr. Robert
Sarmiento, Linda Zur, Andrew

Scriver, Dr. Charles R.
Shaw, Mavis
Shaw, Otalene
Shewan, Mary Doris
Simpson, Eva; Simpson, John
Sloan, Gillian
269
Other Input to the Commi ion

In addition to formal submissions, the Commission also received informal submissions from
individual Canadians, health care stakeholders and advocacy groups in the form of abstracts,
e-mails, correspondence and calls to its toll-free public information line:
Type of Correspondence* Total

Mail correspondence 6,736
E-mail correspondence 4,421
1-800 calls 2,927
Total Correspondence 14,084
* As of September 13, 2002
270
CONSULTATIONS
CitizensW Dialogue Sessions

B
The Commission partnered with the Canadian Policy Research Networks, a not-for-profit
policy think-tank, to organize 12 regional one-day “deliberative dialogue” sessions across the
country. Each session brought together some 40 randomly selected Canadians. At the outset of
the process, participants completed a questionnaire probing their perceptions of the challenges
confronting Canada’s health care system and their preferred solutions for addressing them. They
were subsequently provided with a workbook outlining four scenarios for revitalizing the health
care system that included arguments for and against each scenario. (An analysis of historical
public opinion research data indicated that each of the scenarios enjoyed a relatively high level
of public support – despite the seemingly irreconcilable values-base implicit among them. The
purpose of the “deliberative dialogue” sessions was to oblige Canadians to make difficult
choices between the competing scenarios.)
Working with professional facilitators, participants spent the balance of the day discussing
the four scenarios and their likely consequences. At the end of the day, participants were asked
to complete a second questionnaire to assess whether their initial perceptions had changed and if
so, why. The results of the 12 sessions were analyzed and common themes and directions noted.
A national public opinion survey was then undertaken to assess whether the results of the
“deliberative dialogue” process would be validated. The four scenarios were:
• More public investment – The first scenario was to add more resources (such as doctors,
nurses, and equipment) to deal with medicare’s current problems by increasing public
spending, either through a tax increase or by re-allocating funds from other government
programs.
• Share the costs and responsibilities – The second scenario was to add more resources
to deal with current problems not by increasing public spending but through a system of
user co-payments for health care services that would provide an incentive for people not
to over-use the system as well as needed funds.
• Increase private choice – The third scenario was to give Canadians increased choice in
accessing private providers for health care services. Side-by-side with the public system,
Canadians also could access health care services from a private sector provider (either
for-profit or not-for profit) and pay for it from their own resources or private insurance.
271
• Reorganize service delivery – The fourth scenario was to reorganize service delivery in
order to provide more integrated care, realize efficiencies and expand coverage. Under
this scenario, each Canadian would sign up with a health care provider network that
would work as a team to provide more co-ordinated, cost-effective services and
improved access to care.
Date Location
January 19, 2002 Montreal
January 20, 2002 Montreal (French)
February 2, 2002 Vancouver
February 9, 2002 Halifax
February 9, 2002 Thunder Bay
February 10, 2002 Halifax
February 16, 2002 Calgary
February 16, 2002 Bathurst (French)
February 23, 2002 Regina
February 23, 2002 Québec City (French)
March 2, 2002 Toronto
March 2, 2002 Ottawa
CPAC Televised Forums

In order to raise awareness of the challenges confronting the health care system and to
encourage informed discussion during the public consultations, the Commission initiated a
number of public education activities, including a series of nationally televised Policy Forums
delivered in partnership with Canada’s Public Affairs Channel (CPAC). This nationally televised
six-part series featured health policy experts representing different points of view engaging in a
moderated discussion of key health care issues. Each program was followed by an open-line
call- in that allowed interested Canadians to question the participants.
Topics included:
• Values: What do Canadians want from their health care system?
• Sustainability: Can we afford Medicare?
• Leadership: Who should call the shots in Canada’s health care system?
• Access: What health care rights should Canadians have?
• Principles: The Canada Health Act: Lightning rod or beacon?
• Innovation: Can innovation save Canadian health care?
January 24, 2002

Values: What do Canadians want from their health care system?
Crête, Jean
Professeur titulaire, Département de science politique, Université Laval
Graves, Frank
President, EKOS Research Associates
Mendelsohn, Matthew
Professor, Department of Political Studies, Queen’s University
272
CONSULTATIONS • APPENDIX B
January 31, 2002

Sustainability: Can we afford Medicare?
Evans, Robert G.
Professor, Department of Economics, University of British Columbia
Haddad, Henry (Dr.)
Former President, Canadian Medical Association
Lee-Crowley, Brian
President, Atlantic Institute for Market Studies
February 7, 2002
Leadership: Who should call the shots in Canada’s health care system?
Lomas, Jonathon
Executive Director, Canadian Health Services Research Foundation
Maslove, Allan
Professor, School of Public Administration, Carleton University
Paquet, Gilles
Senior Fellow at the Centre of Governance, University of Ottawa
February 14, 2002

Access: What health care rights should Canadians have?
Sinclair, Douglas (Dr.)
President, Canadian Association of Emergency Physicians
Wong-Rieger, Durhane
President, Anemia Institute
Wootton, John (Dr.)
Editor, Canadian Journal of Rural Medicine
February 21, 2002

Principles: The Canada Health Act: Lightning rod or beacon?
Flood, Colleen
Associate Professor, Faculty of Law, University of Toronto
Orovan, William (Dr.)
Chair of the Provincial Working Group on Financing of Academic Health Science Centres
Prémont, Marie-Claude
Associate Professor, Faculty of Law, McGill University
February 28, 2002

Innovation: Can innovation save Canadian health care?
Armstrong, Pat
Professor, Department of Sociology, York University
Poston, Jeff
Executive Director, Canadian Pharmacists Association
Rachlis, Michael (Dr.)
Health Policy Analyst
273
Open Public Hearings

In order to benefit from the input and counsel of individual Canadians and health care
stakeholder and advocacy groups, the Commission organized 21 days of public hearings across
the country. To facilitate access by those in remote communities, participants had the option of
presenting their submissions by telephone. To ensure breadth of perspective and balanced
participation, notices were placed in newspapers across the country inviting interested
individuals and groups to come forward and to submit a one-page abstract of their proposed
submission. At the end of each session, the Commission opened the floor to individuals who
wished to comment on the proceedings or provide additional input. Participants had the option
of addressing the Commission in either official language, and in Nunavut, special arrangements
were made to allow presentations in Inuktitut. The Canadian Public Affairs Channel (CPAC)
broadcast all sessions in both official languages.
Regina – March 4, 2002

Organization Presentations Citizen Presentations
Canadian Association of Retired Teachers Adair, Carol
Canadian Taxpayers Federation Bryden, John
Citizens Concerned About Free Trade Bury, John
Congress of Union Retirees of Canada Finley, Sandra
Council of Canadians Gill, Carmen
Divisions scolaires francophones Holmberg, Dale
Kerr, Mildred
Fédération des communautés francophones et acadienne
Lavergne, Jocelyne
du Canada
Silver, William
Federation of Saskatchewan Indian Nations Storrie, Kathleen
Government of Saskatchewan – Hon. Lorne Calvert, Premier Taylor, Allan
Government of Saskatchewan – Thériault, Luc
Hon. John Nilson, Minister of Health
Prince Albert Health District
Zerr, Deborah
Saskatchewan Action Committee, Status of Women
Saskatchewan Community Health Cooperative Federation
Saskatchewan Federation of Labour
Saskatchewan Medical Association
Saskatchewan Palliative Care Association
Saskatchewan Voice of People with Disabilities
Saskatoon and District Chamber of Commerce
Survivors of Suicide, Regina Chapter
Winnipeg – March 6, 2002

Assemblée des aînées et aînés francophones du Canada Cooper, Austin
Assembly of Manitoba Chiefs Currie Waldie, Mark
274 Canadian Centre for Policy Alternatives de Jardin, Alan
Canadian Union of Public Employees – DeWiele, Lorraine (Dr.)

Manitoba Regional Office Ducharme, Theresa
Catholic Health Association of Manitoba Hiebert, Eduard
Frontier Centre Hryciw, Nancy
Government of Manitoba – Hutchings, Douglas
Hon. Gary Doer, Premier Johnson, Paul
Government of Manitoba – Peterson, Gary
Hon. Dave Chomiak, Minister of Health Shapiro, Evelyn
Government of Manitoba – Shtatleman, Barry
Somerville, Irvine
Hon. Greg Selinger, Minister of Finance
Somerville, Sandra
Manitoba Association of Optometrists
Vieno, Marlene
Manitoba Centre for Health Policy
Yuin, Joseph
Manitoba Chiropractors Association
Manitoba Psychological Society
Manitoba Retirees
Redvers Chamber of Commerce Health
Task Force
Société franco-manitobaine
Southern Chiefs Organization
University of Manitoba – College of Nursing
Winnipeg Regional Health Authority
Vancouver – March 12, 2002

BC Coalition of People with Disabilities Balabanov, Olive
Baxter, David
BC Nurses Union
British Columbia Medical Association Blais, Lois M.
Cambie Surgery Centre Cocks Hayward, Jane
Canadian Association of Provincial Cancer Agencies Eagle, Ron
Canadian Coalition Against Insurance Fraud Hlady, Vibeke
College of Traditional Chinese Medicine Practitioners and William M. Mercer Ltd
Acupuncturists of British Columbia Jordan, Jim
Fédération des francophones de la Colombie-Britannique Koch, Thomas (Dr.)
First National Chiefs’ Health Committee Prouten, Bill
Fraser Institute Rattew, Keith Sobol,
Isaac (Dr.) Winters,
Government of British Columbia – Ministry of Health Services
Ronald Wong,
– Provincial Health Services Authority
Alfred Zeller, Allan
Health Association of British Columbia L.
Info-Lynk Consulting
New Democratic Party of Canada – Alexa McDonough
University of British Columbia – Centre for Health Services
and Policy Research
275
Victoria – March 14, 2002

BC Aboriginal Network on Disability Society Aikman, Chris
Attridge, Carolyn
BC Government and Service Employees’ Union
Bevis, Fred
Canadian Cooperative Association –
BC Region Brandt, Katherine
Canadian Naturopathic Association Buna, Michael (Dr.)
Government of British Columbia – Cooper, Glenn
Hon. Sindi Hawkins, Dowman, Greg
Minister of Health Planning Duncan, Peter (Dr.)
Home Support Action Group of Victoria Galasso, Pascuale (Dr.)
Hayashi, Allen (Dr.)
Multiple Sclerosis Society Mackey, Paul (Dr.)
New Democratic Party of British Columbia – Joy McPhail Martin, Victoria
Pender Island Health Clinic Mattson, Debra
Seniors on Guard for Medicare Neubauer, Joanne
Newbigging, Barbara
University of Victoria – School of Nursing Scott, Donald
Victoria Coalition for Health Reform
Victoria Hospice Society
Starcher, Dana
Thompson, Patrick
Vantreight, Ian
Québec City – March 25, 2002

Organization Presentations Citizen Presentation
Association coopérative d’économie familiale du Québec Price, Shelley
Association des arthritiques du Québec
Association des médecins de CLSC du Québec
Association des optométristes du Québec
Association des régions du Québec
Association des résidences pour retraités du Québec
Association médicale du Québec (AMQ)
Association québecoise de défense des droits des personnes
retraitées et préretraitées
Association québecoise de soins palliatifs
Association québecoise des pharmaciens propriétaires
Centrale des syndicats démocratiques
Conférence religieuse canadienne région du Québec
Conseil du patronat du Québec
English Speaking Catholic Council
Fédération des infirmières et infirmiers du Québec
Federation of Québec Medical Student Societies (FQMSS)
276
First Nations of Quebec and Labrador Health and Social

Services Commission
Fraser Institute
Frosst Health Care Foundation
Liberal Party of Quebec – Hon. Jean Charest
Merck Frosst Canada Ltd.
Montreal Economic Institute (MEI)
Réseau québecois pour la santé du sein
Townshippers Association
VisualMed Clinical Systems Inc.
Montreal – March 26, 2002

Association des spécialistes en médecine interne du Québec Alexan, Nadia
Association québecoise de gérontologie Banik, Upen
Canadian Association for Retired People Donnelly, Brenda
Forget, Claude E.
Centrale des syndicats du Québec
Hushley, Del
Chambre de commerce du Québec Hussain, Jalaluddin
Coalition des médecins pour la justice sociale
Coalition pour le maintien dans la communauté
Coalition solidarité santé
Collège des médecins du Québec
Collège québecois des médecins de famille
Confédération des organismes de personnes handicapées
du Québec
Confédération des syndicats nationaux
Conseil provincial pour la protection des malades
Cummings Jewish Centre for Seniors
Fédération des médecins omnipraticiens du Québec
Fédération des médecins spécialistes du Québec
Fédération des travailleurs et travailleuses du Québec
Fédération québecoise des sociétés Alzheimer
Force jeunesse
Inuit Tapiriit Kanatami
McGill University – Faculty of Law
McGill University – Faculty of Medicine
McGill University – Faculty of Medicine, Centre for Medical
Education
Patients’ Committee of the McGill University Health Care
Project Genesis
Société canadienne de la sclérose en plaques du Québec
Société canadienne de l’hémophilie – section Québec
Société canadienne de médecine nucléaire
277
Toronto – April 2, 2002

Association canadienne-française de l’Ontario Babb, Clement
Canada 25 Chovaz McKinnon, Cathy
Canadian Council on Integrated Health Care Crispo, John
Canadian Institutes of Health Research Greenlea, Carol
Canadian Snowbird Association Grieb, Claudette
Chiefs of Ontario Horsfall, Clive
Horsfall, Susan
Consumers’ Association of Canada
Krehm, William
Government of Ontario – Hon. Tony Clement, MacLeod, Chris
Minister of Health and Long Term Care Marsden, Anne
Liberal Party of Ontario – Dalton McGuinty Meade, Ethel
New Democratic Party of Ontario – Howard Hampton
Ontario Dialogue on Health Care
Oh, John
Ontario Health Coalition
Rae, John
Ontario Hospital Association Reinsborough, Arleen
Ontario Medical Association Reinsborough, John
Registered Nurses Association of Ontario Taylor, Marcia
Rotary Club of Toronto – Don Valley Young, Gilbert
Toronto Health Coalition
Ottawa – April 4, 2002

Assembly of First Nations Bond, Daryn
Canada’s Research-Based Pharmaceutical Companies Bowes, Denise
Canadian Drug Manufacturers Association Diegel, Martin
Diegel, Wendy
Canadian Health Care Association
Duffey, Romney B.
Canadian Health Coalition Evans, Allayne
Canadian Hospice Palliative Care Association Hubbert, Anne
Canadian Labour Congress King, Phillip
Canadian Medical Association
Canadian Nurses Association Miller, Allison
Canadian Public Health Association O’Kelly, Fionuala
Priestman, Kathleen
Congress of Union Retirees
Roy, Carole
Health Charities Council of Canada
Insurance Bureau of Canada Smith, Ralph
National Council of Women Sniderman, Allan
Snipper, Jon
Ottawa Health Coalition
Steeves, Valerie
Réseau des services de santé en français de l’Est de l’Ontario Walker, John
Royal College of Physicians and Surgeons of Canada Yeo, Michael
278
Iqaluit – April 8, 2002

Organization Citizen Presentations
Presentations Government of Nunavut
Cooper, Rosemary
Hon. Edward Picco, Minister of Health and Social Services Ell, Monica
Nunavut Tunngavik Incorporated
Galia, Rosario Ann
Pauktuutit – Inuit Women’s Association of Canada Idlout, Lori
Qikiqtani Inuit Association
Okalik, Eegesiak
Wilman, Mary
Sudbury – April 11, 2002

Cambrian College Pre-Health Group 24 Blanco, Jose
Canadian Association of Chain Drug Stores Bond, Fred
Canadian Psychological Association Bucholtz, Elaine
Group Health Centre Sault Ste-Marie Butcher, Marilyn
Fritz, Elaine
Laurentian University – School of Nursing
Ontario Association of Speech Language Pathologists and Glass, Karen
Audiologists Hoop, Annette
Ontario Coalition (Society) of Senior Citizens’ Organizations Lounsbury, Hubert
Ontario College of Family Physicians Murray, J. Scott
Ontario District Health Councils Nash, Chris
Ontario Metis Aboriginal Association Rebellaton, Nancy
Service de Counselling de Hearst-Kapuskasing-Smooth Rock Roellchen-Pfohl, Paul
Society of Rural Physicians of Canada Salamon, Steven A. J.
Skierszkan, Karl
Sudbury and District Board of Health Soule, Clarence
Sudbury and District Labour Council
United Steelworkers of America
St. John’s – April 15, 2002

Association of Registered Nurses of Newfoundland and Burke, Cynthia
Labrador Day, Judith (R.N.)
Canadian Mental Health Association, Newfoundland and Eaton, Geoff
Labrador Division
Heath, Olga
Canadian Treatment Action Council (CTAC)
Hicks, Philip
Council of Canadians Janes-Hodder, Honna
Dieticians of Newfoundland and Labrador Mayo, Tom
Fédération des parents francophones
Patey, Paul
Government of Newfoundland and Labrador – Hon. Gerald
Piller, Janine
Smith, Minister of Health and Community Services
Pittman, Michael
Labrador Inuit Health Commission (LIHC) Walsh, Dale
Labrador West District Labour Council
Warrick, Paddy (Dr.)
Memorial University of Newfoundland – Faculty of Medicine
279
Multicultural Women’s Organization of Newfoundland and

Labrador
New Democratic Party of Newfoundland and Labrador –
Jack Harris
Newfoundland and Labrador Association of Public
and Private Employees
Newfoundland and Labrador Health Boards Association
Newfoundland and Labrador Health in Pluralistic Societies
Newfoundland and Labrador Medical Association
Newfoundland and Labrador Nurses Union
Newfoundland and Labrador Public Health Association

Seniors Resource Centre of Newfoundland and Labrador
Social Sciences and Humanities Research Council of Canada
(SSHRC) – Norms and Narratives Research Group
Halifax – April 17, 2002

Atlantic Institute for Market Studies Antoft, Kell
Canadian Auto Workers Cameron, Alex
Canadian Cardiovascular Society and the Canadian Council of Coyle, Stephen
Cardiovascular Nurses Hack, Arshad
Canadian Federation of Independent Business Hann, Crystal
Canadian Pediatric Society Jost, Phil A.
Eskasoni Health Centre Kelly, Debbie
Family Care Givers Association of Klassen, Gerald (Dr.)
Nova Scotia MacLellan, Mary Ruth
Fédération acadienne de la Nouvelle-Écosse MacMaster, Edward
Government of Nova Scotia – Matheson, Brian
Hon. Jamie Muir, Minister of Health O’Brien, Pearl
Group of IX Seniors Organization in
Nova Scotia Smith, Cheryl
Taylor, Anna
National Coalition for Vision Health
Thorn, Ian
New Democratic Party of Nova Scotia – Darrell Dexter
Nova Scotia Association of Health Organizations Walker, Mary-Ann
White, Cliff
Nova Scotia Government and General Employees Union
Young, Robert
Nova Scotia Nurses Union
Paramedic Association of Canada
280
Charlottetown – April 18, 2002

Abegwit First Nations Bingham, Ken
Broderick, Leo
Association of Nurses of Prince Edward Island
Deacon, Donald
Canadian Association of Internes and Residents (CAIR)
Canadian Association of Public Dentistry Foley, Michael
Canadian Union of Public Employees of PEI Kumanan, Mekalai
Lewis, Donna
Federal Superannuates National Association
McInnis, Charlene
Government of Prince Edward Island – Hon. Pat Binns, Premier Perry, Edith
Government of Prince Edward Island – Salonius, Peter
Hon. Jamie Ballem, Minister of Health and Social Services Toombs, Wilna
Hospice Palliative Care Association of PEI
Medical Society of Prince Edward Island
New Democratic Party of Prince Edward Island – Herb Dickieson
PEI Advisory Council on the Status of Women
PEI Health Coalition
PEI Licensed Nursing Assistants Association
PEI Nurses’ Union
PEI Regional Health Boards
PEI Union of Public Sector Employees
Société Saint-Thomas-d’Aquin
University of Prince Edward Island – School of Nursing
Fredericton – April 19, 2002

Canadian Association of Blue Cross Plans – Atlantic Region Adams, Cynthia
Canadian Association of General Surgeons Anderson, Richard
Anderson, Vivienne
Community & Hospital Infection Control Association of Corbett, Bradley
Canada (CHICA Canada) Dickinson, Randy
Corporation Hospitalière Beauséjour Grasse, Daniel J.
Government of New Brunswick – Hon. Bernard Lord, Premier LeBlanc, Gilles
Government of New Brunswick – Linkletter, Dorothy
Hon. Elvy Robichaud, Minister of Health and Wellness Low, Jacqueline
Mouvement acadien des Communautés en santé Mantz, Eileen
du Nouveau-Brunswick
New Brunswick Association of Nursing Homes Inc.
Neilson, John
New Brunswick Council of Nursing Home Unions
Paynter, Martha
New Brunswick Health Coalition Renner, Serena
New Brunswick Healthcare Association Schofield, Aurel
New Brunswick Physiotherapy Association Smallwood, Shirley
New Democratic Party of New Brunswick – Elizabeth Weir
Nurses Association of New Brunswick
281
Premier’s Health Quality Council

Régie régionale Beauséjour
Wilmot United Church
Wilhelm, Linda
Calgary – April 30, 2002

Alberta Federation of Labour Aizenman, Rebecca
Ames, Davena
Alberta Medical Association
Association canadienne-française de l’Alberta Bang, Karen Marybelle
Calgary Chamber of Commerce Bankes, Hugh J.
Chambers, Steven
Calgary Health Region
Corney, Brenda
Canadian Association of Emergency Physicians
Canadian Association of Radiologists Daniel, Alice
Canadian Geriatrics Society Dean, Kiri
Canadian Mental Health Association Hasham, Salim
Government of Alberta – Hon. Gary Mar, Hatcher, Mary
Minister of Health and Wellness
Hunt, Lee
Métis National Council MacDonald, M. H.
Premier’s Advisory Council on Health – Maher, E. J.
Rt. Hon. Don Mazankowski McCaig, Bud
Morrison, Bob
United Nurses of Alberta
Murray, Christopher
YMCA Parker, John
Ramjeeawon, Jack
Smith, Beverly
Swanson, Harold
Temple, Walley J.
Wilson, E. Donald
Whitehorse – May 2, 2002

Acquired Brain Injury for Community Living Brookless, Carole
Association Franco-Yukonnaise Larke, Bryce (Dr.)
Millard, Ron
Calgary Health Region – Division of Gynecology
Council of Yukon First Nations and Yukon First Nations
Health and Social Commission
First Nations Health Program Committee
Government of the Yukon – Hon. Pat Duncan, Premier
Government of the Yukon – Hon. Sue Edelman,
Minister of Health and Social Services
Government of the Yukon – Hon. Cynthia Tucker,
282
Minister of Education, Policy Liaison
New Democratic Party of the Yukon – Ken Boulton

Whitehorse General Hospital
Yukon Anti-Poverty Coalition
Yukon Association for Community Living
Yukon Coronary Health Improvement Project (CHIP)
Yukon Federation of Labour
Yukon Medical Association
Yukon Registered Nurses Association
Yukon Wholistic Health Network
Edmonton – May 14, 2002

Alberta Association of Registered Nurses Beliveau, Christine
Cameron, Brenda
Alliance jeunesse-famille de l’Alberta
Daly, Bill
Association of Canadian Academic Healthcare Organizations
Canadian Public Health Laboratory Forum Janz, Heidi
Capital Health Authority Langridge, Lise
Laughton, David
Chronic Disease Prevention Alliance of Canada
Lutes, Lynette
Citizens for Choice on Health Care
McPherson, Gary
College of Physicians and Surgeons of Alberta Melnychuk, Stella
Communication, Energy, and Paperworkers Union Milligan, Verna
Edmonton Health Care Study Circle Mills, Bob
First Nations Treaties 6, 7, and 8
Friends of Medicare Newman, Trudy
Liberal Party of Alberta – Kevin Taft Rahn, James
New Democratic Party of Alberta – Raj Pannu Rogers, Robert Dale
Senior Action and Liaison Team (SALT) Wilson, Donna (Dr.)
Wilson, Margaret
Seniors Community Health Council
Wright, Robert
Society of Obstetricians and Gynecologists of Canada
University of Alberta – Parkland Institute
Yellowknife – May 16, 2002

Alternatives North Bourne, Joyce
Wasicuna, Bob
Canadian College of Health Services Executives
Canadian Public Health Association
Dene Nation
Fédération Franco-TéNoise
Government of First Nations
Government of the Northwest Territories –
Hon. Stephen Kakfwi, Premier
283
Government of the Northwest Territories – Hon. J. Michael

Miltenberger, Minister of Health and Social Services
Legislative Assembly of the Northwest Territories –
Standing Committee on Social Programs
Midwives Association of Northwest Territories and Nunavut
Northern Territories Federation of Labour
Northern Territories Medical Association
Northwest Territories Council of Persons with Disabilities
Northwest Territories Registered Nurses Association
Status of Women Council
Tree of Peace Friendship Centre
Western Arctic Aboriginal Head Start Council
Yellowknife Association of Concerned Citizens for Seniors
Ottawa – May 28, 2002

Aboriginal Nurses Association Blair, Stephen
Association of Ontario Health Centres Cazabon, Benoit
Hughes, Joan
Canadian Chamber of Commerce
Canadian Chiropractors Association and Canadian Memorial Pearson, Wendy
Chiropractic College Skinner, Christopher
Canadian College of Health Service Executives Weinman, Kyla
Canadian Council on Social Development Williams, Colin J.
Wilson, Laura
Canadian Federation of Nurses Unions
Canadian Institute for Health Information
Canadian Institutes of Health Research – Institute of Aging
Canadian Life and Health Insurance Association
Canadian Medical Forum
Canadian Mental Health Association
Commission of Official Languages
Conference Board of Canada
Ecumenical Health Care Network

Health Action Lobby
Heart and Stroke Foundation of Canada
Montfort Hospital
National Aboriginal Health Organization
Native Women’s Association of Canada
Ottawa Health Coalition
Sickle Cell Parents’ Support Group
United Steelworkers of America
284
Toronto – May 30, 2002

Arthritis Society of Canada Arnott, Barbara
Association for Health Care Philanthropy of Canada Arnott, Roy
Association of Municipalities of Ontario Barnard, Peter
BIOTECanada Brideaux, Philip
Buchanan, Lembi
Canadian Union of Public Employees – Ontario Division
Conchelos, Mary
College of Physicians and Surgeons of Ontario
Corrigan, Joan
Committee on Monetary and Economic Reform Dubois-Taylor, Lynette
Ontario Joint Provincial Nursing Committee Hassard, Murray
Ontario Long Term Care Association Hawkins, Miranda
Knox, Sarah
Ontario Nurses’ Association
Ontario Women’s Health Council
Professional Association of Internes and Residents of Ontario Noble, Martha
Six Nations of the Grand River Pniauskas, Sandi
Rantucci, Melanie
Tommy Douglas Research Institute
Vandenbroucke,
York University Margaret
West, Pamela
Toronto – May 31, 2002

Association of Canadian Medical Colleges Ania, Fernando
Bulley, Chris
Canadian Association of Midwives
Canadian Association of Retired Persons (CARP) Clark, Paul
Canadian Auto Workers Union Hunt, Margo
Canadian Cancer Society Joseph, Leela
Canadian Council of Chief Executives Mak, Adriaan
Canadian Diabetes Association Rae, Bob
Centre for Addiction and Mental Health Riley, Helen
Coalition for Primary Health Care Rubin, Murray
Employer Committee on Health Care in Ontario Smitherman, George
Medical Reform Group Thompson, Brian
van Oostveen, Jon
National Union of Public and General Employees van Oostveen, Judy
St. Michael’s Hospital Wirsig, Claus A.
Toronto Public Health Wu, Mary
University of Toronto – Faculty of Nursing
Young, Terrence
285
Expert Workshops
In 9 of the 21 communities in which the Commission held public hearings, expert
workshops were organized the day following the hearings. At these sessions, participants were
asked to assist the Commission in interpreting the results of both the local Citizens’ Dialogue
session as well as the previous day’s public hearings. Participants were also asked to provide
advice on the issues of sustainability, access, governance, accountability and quality.
March 5, 2002, Regina, Saskatchewan

Participants:
Blau, June, Saskatchewan Registered Nurses Association
Burka-Charles, Marcy, Saskatchewan Population Health and Evaluation Research Centre
Butler-Jones, David (Dr.), Chief Medical Officer of Health
Dosman, James, Community Action Group for Economic Development and Health Research
Gelhorn, Donald (Dr.), College of Family Physicians of Canada
Greyeyes, Doris, Federation of Saskatchewan Indian Nations
Kendel, Dennis (Dr.), College of Physicians and Surgeons of Saskatchewan
Labonte, Ron, Saskatchewan Population Health and Evaluation Research Centre University
of Saskatchewan
Leis, Anne, Fédération des communautés francophones et acadienne du Canada
Longmoore, Rosalee, Saskatchewan Union of Nurses
Nelson, Dave, Canadian Mental Health Organization (Saskatchewan Division)
Norheim, Wes, Congress of Union Retirees of Saskatchewan
Sanderson, Sol, Federation of Saskatchewan Indian Nations
Simard, Louise, Saskatchewan Association of Health Organizations
Smillie, Christine, Canadian Diabetes Association Saskatchewan
Thompson, Laurie, Health Services Utilization and Research Commission
Whetstone, Arthur, Saskatchewan Chamber of Commerce
Yeates, Glenda, Saskatchewan Health
March 7, 2002,Winnipeg, Manitoba

Participants:
Chernomas, Robert, Department of Economics, University of Manitoba
Colon, Bailey, Assembly of Manitoba Chiefs
Corby, Linda, Dieticians of Canada
Donner, Lissa, Consultant
Frankel, Sid, Social Planning Council of Winnipeg
Grant, Karen, Women’s Health Clinic Winnipeg
Hildahl, Wayne, Pan-Am Clinic
Howard, Jennifer, Policy Management Secretariat, Government of Manitoba
286
Hudson, Peter, Canadian Centre for Policy Alternatives, Manitoba Office

Johannson, Joan, Kairos, Canadian Ecumenical Justice Initiative
Johnston, Shirley, Manitoba Society of Seniors
Metge, Colleen J., Faculty of Pharmacy, University of Manitoba
Postl, Brian, Winnipeg Regional Health Authority
Roos, Noralou, Manitoba Centre for Health Policy, University of Manitoba
March 13, 2002, Vancouver, British Columbia

Participants:
Bruce, Ted, Vancouver Coastal Health Authority
Cohen, Marcy, BC Hospital Employees Union
Day, Brian, Cambie Surgery Centre
Gee, Linda, BC Ministry of Health and Long-Term Planning
Gilbert, John, College of Health Disciplines, University of British Columbia
Gutray, Bev, Canadian Mental Health Association, BC Region
Horvat, Dan, BC Ministry of Health Planning
Jones, Joyce, Seniors Network of BC
Lantz, Bonnie, Registered Nurses Association of BC
Nakagawa, Bob, Simon Fraser Health Region
Odegard, Larry, Health Association of BC
Thompson, Patrick, Council of Senior Citizens Organizations
Van Ginkel, Anita, Council of Canadians (Coquitlam Chapter)
Wang, Caroline (Dr.), Vancouver Medical Association
March 27, 2002, Montreal, Quebec

Participants:
Adam, Daniel, Association des hôpitaux du Québec
Aucoin, Leonard
Boucher, Denise, Confédération des syndicats nationaux
Brunet, Paul, Conseil provincial pour la protection des malades
Contandriopoulos, André-Pierre, Faculté de médecine, Université de Montréal
Desmeules, Marc, Faculté de médecine, Université Laval
Forget, Claude
Lamarche, Paul, Faculté de médecine, Université de Montréal
Maioni, Antonia, Institute for Canadian Studies, McGill University
Marchand, Louise, Chambre de Commerce du Québec
McGregor, Maurice, Royal Victoria Hospital
Millette, Yves, Association canadienne des compagnies d’assurances de personnes
Nadeau, Emilien, Association des Régions du Québec
Péladeau, Pierrot, Institut de recherches cliniques de Montréal
Valois, Marie, Ordre des infirmières et infirmiers du Québec
Veilleux Gerard, Power Communications
287
Vinay, Patrick, Université de Montréal
April 3, 2002, Toronto, Ontario

Participants:
Anderson, Geoff, Health and Policy Management and Evaluation, University of Toronto
Bonnett, Chris, Canadian Council on Integrated Health Care
Closson, Tom, University Health Network, Toronto General Hospital
Edelson, Miriam, Ontario Public Service Employees Union Grinspun,
Doris, Registered Nurses Association of Ontario
Gutkin, Cal (Dr.), College of Family Physicians of Canada
Heber, Alexandra, Medical Reform Group
Kaegi, Gerda
Kerbel, Carole, Toronto District Health Council
Lankin, Frances, United Way of Greater Toronto
Mallon, Ruth, Ontario Pharmacists Association
Moulton, Carlyn, THiiNC
Orovan, William, Ontario Hospital Association
Orsini, Steve, Ontario Hospital Association
Scott, Fran, Toronto Public Health
Yalnyzan, Armine, Canadian Centre for Policy Alternatives
April 5, 2002, Ottawa, Ontario

Participants:
Auffrey, Lucille, Canadian Nurses Association
Brimacombe, Glenn, Association of Canadian Academic Healthcare Organizations
Brown, Robert, Canadian Institute of Actuaries
Hackney, Christy, Intergovernmental Policy Unit, Ontario Ministry of Health and
Long-Term Care
Heidemann, Elma, Canadian Council on Health Services Accreditation
Jamieson, Shelley, Extendicare
Lomas, Jonathan, Canadian Health Services Research Foundation
Marrett, Penny, Health Charities Council of Canada
McBane, Michael, Canadian Health Coalition
Millar, John, Canadian Institutes of Health Research
Savoie, Gerald, Montfort Hospital
Service, John, Canadian Psychological Association
Sholzberg-Gray, Sharon, Canadian Healthcare Association
Tholl, William (Dr.), Canadian Medical Association
Wiggins, Cindy, Canadian Labour Congress
April 16, 2002, St. John’s, Newfoundland

Participants:
Anderson, Theresa, Labrador West District Labour Council
Butler, Roger, Family Practice Unit, Memorial University of Newfoundland
288 Dawe, Joan, Newfoundland and Labrador Department of Health and Community Services
Elliott, Pamela, St. John’s Health CARE Corporation

Fitzgerald, Brenda, Health and Community Services St. John’s Region
Kay, Michael, Newfoundland and Labrador Physiotherapy Association
Legge, Wanda, Newfoundland and Labrador Department of Health and Community Services
Murray, Michael, SSHRC Norms and Narratives Research Group, Memorial University
of Newfoundland
Orchard, Carole, School of Nursing, Memorial University of Newfoundland
O’Reilly, Steve, Newfoundland and Labrador Centre for Health Information
Peters, Sharon, Faculty of Medicine, Memorial University of Newfoundland
Priddle, Margo, Canadian Pharmacists Association
Robbins, Carl, Telehealth and Education Technology Resource Agency Health Sciences
Centre, Memorial University of Newfoundland
Rowe, Penny, Community Services of Newfoundland and Labrador
Woodward, Peter, Woodward Group of Companies
April 18, 2002, Halifax, Nova Scotia

Participants:
Arseneau, Catherine, Health Care Human Resource Sector Council
Batt, Sharon, Centre for Excellence in Women’s Health
Chisholm, Robert, Canadian Union of Public Employees
Clarke, James (Dr.), Physician
Deacon, Colin
Elliot, Janice, Public Policy Forum
Keefe, Janice, Graduate Course in Policy, Family Studies and Gerontology,
Mount Saint Vincent University
MacDonald, Noni, Faculty of Medicine, Dalhousie University
Malcom, John, Cape Breton District Health Authority
Tomblin Murphy, Gail, School of Nursing, Dalhousie University
Ward, Tom, Nova Scotia Department of Health
May 15, 2002, Edmonton,Alberta

Participants:
Ballermann, Elisabeth, Health Sciences Association of Alberta
Collette, Denis, University of Alberta
Fast, Yvonne, Canadian Union of Public Employees
Fredrickson, Pat, Canadian Practical Nurses Association
Gardiner, George, Council of Canadians
McPherson, Alec, Biomira
Meggison, Doug, Health Sciences Association of Alberta
Noseworthy, Tom, Faculty of Medicine, University of Calgary
Raina, Kim, Centre for Health Promotion Studies, University of Alberta
Shaskin, Igor, Pharmacists Association of Alberta
Shiell, Alan, Department of Community Health Services, University of Calgary 289
Spence, Matthew, Alberta Heritage Foundation for Medical Research

Temple, Walley, Tom Baker Cancer Centre
Tyrrell, Lorne, Faculty of Medicine and Dentistry, University of Alberta
Weatherill, Sheila, Capital Health Authority
Zussman, David, Public Policy Forum
Regional Forums
In order to facilitate the process of synthesizing the various inputs obtained through the
12 Citizens’ Dialogue sessions, the 21 days of public hearings and the 9 Expert Workshops, the
Commission organized 3 Regional Forums. These Forums were designed to enable the
Commission to further engage the expert community in its deliberations and also to gauge the
extent to which consensus existed across regions on the broad directions for renewing the health
care system.
June 4, 2002, Halifax, Nova Scotia

Participants:
Brideau, Nicole, Nurses Association of New Brunswick
Clarke, Rick, Nova Scotia Federation of Labour
Dickinson, Randy, Premier’s Council on the Status of Disabled Persons
Fitzgerald, Brenda, Health and Community Services, St. John’s Region
Hughes, Mary, Hospice Palliative Care Association of PEI
Lee-Crowley, Brian, Atlantic Institute for Market Studies
Losier, Barbara, Mouvement acadien des Communautés en santé du Nouveau-Brunswick
Lucas Jeffries, Marian, New Brunswick Health Coalition
MacDonald, Noni, Faculty of Medicine, Dalhousie University
Murray, Michael, Community Health, Memorial University of Newfoundland
Simpson, Bob, New Brunswick Healthcare Association
June 11, 2002, Saskatoon, Saskatchewan

Participants:
Bruce, Ted, Vancouver Coastal Health Authority
Carrière, Alain, Nunatta Environmental Services Inc.
Chernomas, Robert, Department of Economics, University of Manitoba
Clarke, Rick, Nova Scotia Federation of Labour
Cohen, Marcy, British Columbia Employees Union
Corriveau, André, Health and Social Services, Government of the Northwest Territories
Donner, Lissa, Consultant
Horvat, Dan, Primary Care and Rural Programs, Ministry of Health Planning,
Government of British Columbia
Leis, Anne, Fédération des communautés francophones et acadienne du Canada
Mirwald, Rita, Cameco
290 Nakagawa, Bob, Simon Fraser Health Authority
Pasquali, Paula, Health and Social Services, Government of Saskatchewan

Postl, Brian, Winnipeg Regional Health Authority
Simard, Louise, Saskatchewan Association of Health Organizations
Smith, Heather, United Nurses of Alberta
Thompson Laurence, Health Services Utilization and Research Commission
Weatherill, Sheila, Capital Health (Edmonton)
June 20, 2002, Toronto, Ontario

Participants:
Basrur, Sheela, Toronto Public Health
Connors, Kathleen, Canadian Federation of Nurses Unions
Herbert, Carol, University of Western Ontario
Jamieson, Shelly, Extendicare Canada Inc
Lozon, Jeff, St. Michael’s Hospital
Martin, Murray, Hamilton Health Science Corp
Moulton, Carlyn, THiiNC
Murray, David, Group Health Centres
Orsini, Steve, Ontario Health Association
Sholzberg-Gray, Sharon, Canadian Healthcare Association
Tholl, William (Dr.), Canadian Medical Association
Wiggins, Cindy, Canadian Labour Congress
Partnered Dialogue Sessions

To broaden public awareness of key issues in the health care system and to engage the
expert and academic communities in its deliberations, the Commission partnered with
universities across the country to organize a series of televised, on-campus policy dialogue
sessions. Each session featured a panel of health care experts who discussed possible solutions to
key health care challenges. The topics discussed and policy options considered were based on
nine issue/survey papers developed for the Commission by the Canadian Health Services
Research Foundation. The topics included:
1. Home Care in Canada*

2. Pharmacare in Canada*
3. Access to Health Care in Canada
4. Sustainability of Canada’s Health Care System
5. Consumer Choice Within a Publicly Funded System
6. The Canada Health Act
7. Globalization and Canada’s Health Care System
8. Medically Necessary Care: What Is It, and Who Decides?*
9. Human Resources in Canada’s Health Care System
* Held in both English and French.
291
Home Care in Canada, Access to Health Care in Canada,

May 16, 2002 June 3, 2002
University of Windsor, Windsor, Ontario Dalhousie University, Halifax, Nova Scotia
Moderator: Moderator:
Wong-Rieger, Durhane, Anemia Institute Goldbloom, Richard, Dalhousie University
Participants: Participants:
Derbyshire, Carol, Hospice of Windsor Jurgens, Tannis (Dr.), Dalhousie University
Hearn, Ambrose, Victorian Order of Nurses Kam Tat Cheung, Cedric, Chinese Medicine
Henningsen, Nadine, and Acupuncture Association of Canada
Canadian Homecare Association Kenny, Nuala (Dr.), Dalhousie University
Hernandez, Cheri Ann, King, Russell (Dr.), Former New Brunswick
University of Windsor Minister of Health
Parent, Karen, Queen’s University Sinclair, Douglas (Dr.), Queen Elizabeth II
Wittenberg, Jean-Victor (Dr.), Health Sciences Centre
Hospital for Sick Children
The Canada Health Act, Consumer Choice Within a

June 10, 2002 Publicly Funded System,
University of Saskatchewan, June 17, 2002
Saskatoon, Saskatchewan
University of Alberta, Edmonton, Alberta
Moderator:
Moderator:
Wallin, Pamela,
Pamela Wallin Productions Inc Caulfield, Timothy, University of Alberta
Barrett, Peter (Dr.), Deber, Raisa, University of Toronto Graham,
Canadian Medical Association Wendy (Dr.), Primary Care Reform Jacobs,
Philip (Dr.), University of Alberta Olhauser,
Bégin, Monique, Hon., Former Federal
Larry (Dr.),
Minister of Health, University of Ottawa
Harrison, Liz, University of Saskatchewan College of Physicians and Surgeons
MacKinnon, Janice, Former Finance Shiell, Robert,
Minister of Saskatchewan Canadian Prostate Cancer Network
Orovan, Bill (Dr.), Smith, Donna Lynn, University of Alberta
Ontario Medical Association
Smadu, Marlene,
University of Saskatchewan
292
Pharmacare in Canada, Pharmacare in Canada,

September 5, 2002 September 9, 2002
Queen’s University, Kingston, Ontario McGill University, Montreal, Quebec
Banting, Keith, Queen’s University Maioni, Antonia, McGill Institute
Participants: for the Study of Canada
Blackburn, Jim, Association of Faculties Participants:
of Pharmacy of Canada Boucher, Laurier, Canadian Association
Daniels, Mark, Canadian Life and Health of Social Workers
Insurance Association Chauvette, Lucie, Réseau québécois d’action
Ferguson, Bryan, Applied Management pour la santé des femmes
Morrice, Denis, The Arthritis Society Lamothe, Lise, Université de Montréal
Sinclair, Duncan, Queen’s University Lelorier, Jacques (Dr.),
Willison, Don, McMaster University Université de Montréal
Millette, Yves, Canadian Life and Health
Insurance Association (Quebec Affairs)
Tamblyn, Robyn, McGill University
Medically Necessary Care: Sustainability of Canada’s

What Is It, and Who Decides? Health Care System,
September 10, 2002
September 11, 2002
Université de Montréal, Montreal, Quebec Toronto General Hospital,
Toronto, Ontario
Moderator:
Moderator:
Molinari, Patrick, Université de Montréal
Graham, Wendy (Dr.), Primary Care Reform
Participants:
Participants:
Audet-Lapointe, Pierre (Dr.),
Fondation québecoise du cancer Aberman, Arnie (Dr.), University of Toronto
Barrett, Brendon (Dr.), Memorial University
Barre, Paul (Dr.), Royal Victoria Hospital
of Newfoundland
Caty, Anne, Patient
Goodhand, Peter, President, Medec
Page, David, Canadian Hemophilia Society
MacKinnon, David, President,
Tessier, Dominique (Dr.),
Ontario Hospital Association
College of Family Physicians of Canada
Weinstock, Daniel, Université de Montréal Sher, Graham (Dr.),
President, Canadian Blood Services
Sutcliffe, Simon (Dr.),
Executive Director, BC Cancer Agency
293
Human Resources in Canada’s Medically Necessary Care:

Health Care System, What Is It, and Who Decides?
September 12, 2002 September 17, 2002
Memorial University, University of Manatoba,

St. John’s, Newfoundland Winnipeg, Manitoba
Davis, Elizabeth Finlay, Mary Lou
Busing, Nick (Dr.), University of Ottawa Chernomas, Robert, University of Manitoba
Clarke, James (Dr.), Canadian Association
Davidson, Janet,
of Internes and Residents
Toronto East General Hospital
Moore-Orr, Robin, Memorial University Harvey, Dexter, University of Manitoba
of Newfoundland Patel, Sunil (Dr.), Rural General Physician
O’Brien-Pallas, Linda-Lee, Roos, Noralou, Director, Manitoba Centre
University of Toronto for Health Policy
Webb, Maggie, Labrador Inuit Association
Sirna, Josie, Thalassemia Foundation
Globalization and Canada’s Home Care in Canada,

Health Care System, September 23, 2002
September 19, 2002 Pavillion Jeanne de
University of British Valois, Moncton, New
Columbia, Vancouver, British Brunswick Moderator:
Columbia Moderator:
McKee-Allain, Isabelle,
Université de Moncton
Gilbert, John
Evans, Robert G., Baker, Cynthia, Université de Moncton
University of British Columbia Guérette Daigle, Lise, New Brunswick
Health (soins infirmiers et services aux
Harris, Susan,
patients à la Régie régionale Beauséjour)
Kaufman, Terry,
Labonte, Ronald,
CLSC Notre-Dame-de-Grâce
University of Saskatchewan
LeBlanc, Jeannette, Université de Moncton
Morrow, Marina, BC Centre of Excellence
Lirette, Willie, l’Association des aînées et
for Women’s Health
aînés francophones du N.-B.
Sinclair, Scott, Canadian Centre for
Policy Alternatives Schofield, Aurel (Dr.),
College of Family Physicians
Spiegel, Jerry,
294
Issue Survey Papers

To enable Canadians to express their views on specific issues affecting the health care
system, the Commission partnered with the Canadian Health Services Research Foundation to
develop a series of nine issue/survey papers. Each of the 10-page papers followed an identical
format:
• a brief overview of the issue;

• the enumeration of three policy alternatives and their respective strengths and
weaknesses; and
• a series of survey questions that allowed interested individuals or groups to express their
views and preferences on the alternatives.
The issue/survey papers were available through the Commission’s toll-free information line
and were posted on the Commission’s Web site where they could be completed on-line.
Release Date Title Participation*

May 15, 2002 Homecare in Canada 2,545 Completed
May 15, 2002 Pharmacare in Canada 1,524 Completed
May 15, 2002 Access to Healthcare in Canada 1,594 Completed
June 10,2002 Sustainability of Canada’s Healthcare System 1,730 Completed
June 10, 2002 Consumer Choice in Canada’s Healthcare System 1,197 Completed
June 10, 2002 The Canada Health Act 1,012 Completed
July 10, 2002 Medically Necessary: What Is It, and Who Decides? 1,201 Completed
July 10, 2002 Health Human Resources in Canada’s Healthcare 1,143 Completed
System Globalization and Canada’s Healthcare System
July 10, 2002 1,487 Completed
* Participation numbers as of September 13, 2002.
Consultation Workbook
The Shape the Future of Health Care Workbook presented four perspectives for addressing
the issue of medicare’s sustainability, and outlined the pros and cons of each. The workbook was
an important component of the consultation program because it gave the Commission insight
into the “values” that Canadians want to see expressed in medicare’s policies and programs. The
four perspectives included:
• More public investment;
• More co-payments and cost sharing;
• Increased private choice; and
• Reorganized service delivery.
Release Date Title Participation

March 7, 2002 On-line version Initiated 20,439
Completed 13,109
March 7, 2002 Paper base Completed 1,083 295
Site Visits and Meetings with

National Organizations and
National Caucuses
To facilitate input by interested individuals and organizations, and to broaden the reach of
its public awareness efforts, the Commission provided health care stakeholder and advocacy
groups with information packages to share with their membership, and Parliamentarians with
materials to share with their constituents. Over the course of its mandate, the Commission met
directly with many of these groups and with the national caucuses of all federal political parties,
with the exception of the Bloc Québecois. The Commissioner also conducted a series of site
visits. These meetings included:
Site Visits
Visits were made to the following sites:
Aboriginal Head Start Program, Manitoba Centre for Health Policy and
Ndilo, Northwest Territories Evaluation, Winnipeg, Manitoba
Cambie Surgical Centre, Mid-Main Community Health Centre,
Vancouver, British Columbia Vancouver, British Columbia
CardiacCareNetwork of Ontario, Pangnirtung Community Health Centre,
Toronto, Ontario Pangnirtung, Nunavut
CLSC Suzor Côté, Victoriaville, Quebec South Riverdale Community Health Centre,
Evangeline Community Health Centre, Toronto, Ontario
Wellington, Prince Edward Island St. Göran’s Hospital, Stockholm, Sweden
First Nations Health Program, St. Michael’s Hospital, Toronto, Ontario
Whitehorse, Yukon Telemedicine Centre, Health Science
Complex, Memorial University,
GENOME Atlantic, Halifax, Nova Scotia
Group Health Centre, St. John’s, Newfoundland
Sault Ste. Marie, Ontario Toronto Rehab Cardiac Rehabilitation
Hôpital Européen Georges Pompidou, Program, Toronto, Ontario
Paris, France University Health Network, Toronto Western
Iqaluit Hospital, Iqaluit, Nunavut Hospital, Toronto, Ontario
Liljeholmens Community Clinic, Whitehorse General Hospital,
Stockholm, Sweden Whitehorse, Yukon
London Health Sciences Centre,
London, Ontario
Meetings
Assembly of First Nations Canadian Blood Services
Association of Canadian Academic Canadian College of Health Service
Healthcare Organizations Executives
Association of Canadian Medical Colleges Canadian Council for Public-Private
C. D. Howe Institute Health Seminar Partnerships
Canadian Alliance Party Caucus Canadian Drug Manufacturers Association
Canadian Federation of Independent
Canadian Association of Retired Persons
296 Business
Canadian Health Coalition National Forum on Health

Canadian Health Services Research Native Women’s Association of Canada
Foundation New Democratic Party Caucus
Canadian Healthcare Association Northern Health Strategy Working Group,
Canadian Home Care Association Saskatchewan
Canadian Institute for Health Information Ontario Home Health Care Providers
Canadian Institutes of Health Research Ontario Long Term Care Association
Canadian Labour Congress Ontario Medical Association
Organisation for Economic Co-operation
Canadian Medical Association and Development
Canadian Medical Forum
Canadian Mental Health Association Pan-American Health Organization, Dr.
George O. A. Alleyne (Washington, DC)
Canadian Nurses Association
Pollara Research
Canadian Palliative Care Association
Premier’s Advisory Council on Health,
Alberta
Canadian Policy Research Networks
Privacy Commissioner, George Radwanski
Canadian Population Health Initiative
Progressive Conservative Party Caucus
Public Policy Forum
Capital Health Authority, Edmonton Public Service Alliance of Canada
Coalition of National Voluntary Registered Nurses Association of Ontario
Organizations Royal College of Physicians and Surgeons
of Canada
Saskatchewan Academic Health Sciences
Congress of Aboriginal Peoples
Network
Council of Canadians Saskatoon District Health
Dalhousie Medical Research Foundation Senator Hillary Rodham Clinton (NY),
Department of Health (London, UK) (Washington, DC)
Extendicare (Canada) Inc.
Special Assistant to the President for Health
Federal/Provincial/Territorial Ministers
Policy, Anne Phelps (Washington, DC)
Responsible for Sport, Recreation
Standing Senate Committee on Social
and Fitness Affairs, Science and Technology Task
Federation of Saskatchewan Indian Nations Force on Health Research and
Foundation for Integrated Medicine Economic Development, Saskatchewan
(London, UK) THiiNC Health Inc.
Frosst Health Care Foundation United Way of Greater Toronto
Health Services Restructuring Commission University Health Network (Toronto)
of Ontario University Hospital Network (Toronto)
World Bank, Chris Lovelace
Inuit Tapiriit Kanatai
(Washington, DC)
(Inuit Tapirisat of Canada)
Liberal Party Caucus
Medical Reform Group
Métis National Council
Ministère délégué à la santé (Paris, France)
Ministry of Health and Social Affairs
(Sweden) 297
Speeches and Presentations

In addition, the Commissioner has formally addressed a number of stakeholder and other
groups across the country and elsewhere, including:
Canadian Federation of Nurses Unions Corpus Christi College, Oxford University

(June 1, 2001, Edmonton, Alberta) (November 26, 2001, Oxford, UK)
Institute for Research on Public Policy Ontario Hospital Association
(June 11, 2001, Montreal, Quebec) (February 13, 2002, Toronto, Ontario)
Canadian Medical Association Canadian College of Health Service
(August 14, 2001, Québec, Quebec) Executives (February 14, 2002, Toronto,
Ontario)
Canadian Chamber of Commerce
(September 17, 2001, Winnipeg, Manitoba) McGill University Health Care Conference
London Health Sciences Centre (February 15, 2002, Montreal, Quebec)
(September 28, 2001, London, Ontario) School of Advanced International Studies
Ditchley Foundation (September 28, 2001, (SAIS), Johns Hopkins University –
Cambridge, Ontario) roundtable discussion (February 25, 2002,
Washington, DC)
National Association of Canadian Clubs
(September 29, 2001, School of Advanced International Studies
Saskatoon, Saskatchewan) (SAIS), Johns Hopkins University
(February 26, 2002, Washington, DC)
Queen’s University (October 12, 2001,
Kingston, Ontario) Standing Committee on Health
(House of Commons)
Conference Board of Canada
(February 28, 2002, Ottawa, Ontario)
(October 18, 2001, Ottawa, Ontario)
University of British Columbia Research
Carleton University Awareness (March 11, 2002,
(October 18, 2001, Ottawa, Ontario) Vancouver, British Columbia) University
Business Council on National Issues of British Columbia – Public
(October 19, 2001, Toronto, Ontario)
Forum on Health Care (March 13, 2002,
Vancouver, British Columbia)
(October 23, 2001,
Simon Fraser University (March 13, 2002,
Saskatoon, Saskatchewan)
Vancouver, British Columbia)
McGill University – Faculty of Management
(October 25, 2001,
(March 27, 2002, Montreal, Quebec)
Vancouver, British Colombia)
Truro Chamber of Commerce
National Health Policy and Research
(April 16, 2002, Truro, Nova Scotia)
Conference (November 5, 2001,
Association of Universities and Canadian
Saskatoon, Saskatchewan)
Colleges (April 17, 2002,
Conference of the Organisation for Economic
Halifax, Nova Scotia)
Co-operation and Development (OECD)
(November 6, 2001, Association of Medical Colleges of Canada
Ottawa, Ontario) (April 28, 2002, Calgary, Alberta)
Faculty of Applied Health Sciences, Healthcare Philanthropy Canada
University of Waterloo (November 20, (April 29, 2002, Banff, Alberta)
2001, Waterloo, Ontario) Townhall Meeting
Frosst Health Care Foundation (May 1, 2002, Whitehorse, Yukon)
(November 21, 2001, Toronto, Ontario)
298
Canadian Pharmacists Association Canadian Medical Association Annual

(May 13, 2002, Winnipeg, Manitoba) Meeting (August 20, 2002,
Canadian Health Economics Research Saint John, New Brunswick)
Association Conference Canada Seminar – Harvard University
(May 23, 2002, Halifax, Nova Scotia) (October 16, 2002, Boston, MA)
Health Care Panel – Yale University
Canadian Health and Life Insurance
Association (May 29, 2002, (October 17, 2002, New Haven, CT)
Montreal, Quebec) Health Care Panel – New School University
Canadian Labour Congress (June 11, 2002, (October 18, 2002, New York City, NY)
Vancouver, British Columbia) Memorial University of Newfoundland
Canadian Nurses Association (June 25, 2002, (October 23, 2002,
Toronto, Ontario) St. John’s, Newfoundland)
National Aboriginal Achievement Awards Commonwealth Fund (October 24, 2002,
(July 10, 2002, Ottawa, Ontario Washington, DC)
299
THE EXTERNAL RESEARCH
PROGRAM
C
The Commission’s external research program consists of a number of different but
interrelated components, which are outlined more fully below. The program was designed to
solicit not only critical analysis of the existing body of knowledge around health care in Canada
and elsewhere, but also to fill in gaps in that knowledge and to provide the Commission with
new insights into how best to confront the challenges facing Canada’s health care system.
Discussion apers
A total of 40 discussion papers were commissioned from scholars, policy analysts, and
experts from across the country and internationally. These papers were focused on specific
questions relating to the following four key research themes articulated by the Commission in
the Spring of 2001 and outlined in the Interim Report in early 2002:
a) Canadian values and democratic institutions

b) The sustainability of the health care system
c) Identifying and overcoming barriers to change
d) Strengthening collaboration within the health system
All the discussion papers were subject to a peer review process undertaken on behalf of the
Commission by the Institute of Health Services and Policy Research (IHSPR) of the Canadian
Institutes of Health Research (CIHR). The Commission would like to thank Morris Barer, Donna
Shields-Poe, Diane Watson and Rob Courchaine of the IHSPR for their assistance in
administering the peer-review process. The final versions of the papers were issued, in both
official languages, on the Commission’s Web site.
The list of papers is as follows:

• Julia Abelson and John Eyles (McMaster University) Public Participation and Citizen
Governance in the Canadian Health System;
• Pat Armstrong (York University) and Hugh Armstrong (Carleton University) Planning
for Care: Approaches to Health Human Resources Policy and Planning;
• Gerard W. Boychuk (University of Waterloo) The Changing Political and Economic
Environment of Health Care in Canada;
• André Braën (University of Ottawa) Health and the Distribution of Powers in Canada;
• Timothy Caulfield (University of Alberta) How Do Current Common Law Principles 301
Impede or Facilitate Change?;

• François Champagne (University of Montreal) The Ability to Manage Change in Health

Care Organizations;
• Clémence Dallaire and Sonia Normand (Laval University) Changes and a Few Paradoxes:
Some Thoughts on Health System Personnel;
• Raisa Deber (University of Toronto) Delivering Health Care Services: Public, Not-for-
Profit, or Private?;
• Jean-Louis Denis (University of Montreal) Governance and Management of Change in
Canada’s Health System;
• Harley D. Dickinson (University of Saskatchewan) How Can the Public Be Meaningfully
Involved in Developing and Maintaining an Overall Vision for the Health Care System
Consistent with Its Values and Principles?;
• Robert G. Evans (University of British Columbia) Raising the Money: Options,
Consequences, and Objectives for Financing Health Care in Canada;
• Katherine Fierlbeck (Dalhousie University) Paying to Play? Government Financing and
Health Care Agenda Setting;
• Colleen M. Flood and Sujit Choudhry (University of Toronto) Strengthening the
Foundation: Modernizing the Canada Health Act;
• Anita J. Gagnon (McGill University) Responsiveness of the Canadian Health Care
System Towards Newcomers;
• Sholom Glouberman and Brenda Zimmerman (Baycrest Centre for Geriatric Care,
Toronto) Complicated and Complex Systems: What Would Successful Reform of
Medicare Look Like?;
• Donna Greschner (University of Saskatchewan) How Will the Charter of Rights and
Freedoms and Evolving Jurisprudence Affect Health Care Costs?;
• Michel Grignon, Valérie Paris, Dominique Polton, in collaboration with Agnès
Couffinhal and Bertrand Pierrard (CREDES, Paris, France) Influence of Physician
Payment Methods on the Efficiency of the Health Care System;
• Seamus Hogan and Sarah Hogan (University of Canterbury, New Zealand) How Will the
Ageing of the Population Affect Health Care Needs and Costs in the Foreseeable Future?;
• Louis M. Imbeau, Kina Chenard and Adriana Dudas (Laval University) The Conditions
for a Sustainable Public Health System in Canada;
• Martha Jackman (University of Ottawa) The Implications of Section 7 of the Charter for
Health Care Spending in Canada;
• Jon R. Johnson (Goodmans, Toronto) How Will International Trade Agreements Affect
Canadian Health Care?;
• John N. Lavis (McMaster University) Political Elites and Their Influence on Health-
Care Reform in Canada;
• Howard Leeson (University of Regina) Constitutional Jurisdiction Over Health and
Health Care Services in Canada;
• Pascale Lehoux (University of Montreal) Could New Regulatory Mechanisms Be
Designed after a Critical Assessment of the Value of Health Innovations?;
• Antonia Maioni (McGill University) Roles and Responsibilities in Health Care Policy;
302
THE EXTERNAL RESEARCH PROGRAM • APPENDIX C
• Theodore R. Marmor (Yale University), Kieke G. H. Okma (Queen’s University and

Ministry of Health, Welfare and Sport, the Netherlands) and Stephen R. Latham (Yale
University) National Values, Institutions and Health Policies: What Do They Imply for
Medicare Reform?;
• Ian McKillop (Wilfrid Laurier University) Financial Rules as a Catalyst for Change in
the Canadian Health Care System;
• Steve Morgan (University of British Columbia) and Jeremiah Hurley (McMaster
University) Influences on the “Health Care Technology Cost-Driver”;
• Richard Ouellet (Laval University) The Effects of International Trade Agreements on
Canadian Health Measures: Options for Canada with a View to the Upcoming Trade
Negotiations;
• Réjean Pelletier (Laval University) Intergovernmental Cooperation Mechanisms;
• Jayne Renee Pivik (University of Ottawa) Practical Strategies for Facilitating
Meaningful Citizen Involvement in Health Planning;
• Marie-Claude Prémont (McGill University) The Canada Health Act and the Future of
Health Care Systems in Canada;
• Cynthia Ramsay (Elm Consulting, Vancouver) A Framework for Determining the Extent
of Public Financing of Programs and Services;
• Candace Johnson Redden (Brock University) Health Care Politics and the
Intergovernmental Framework in Canada;
• Jean-Luc Migué (Fraser Institute) Funding and Production of Health Services: Outlook
and Potential Solutions;
• François Rocher and Miriam Smith (Carleton University) Federalism and Health Care:
The Impact of Political-Institutional Dynamics on the Canadian Health Care System;
• Melissa Rode (independent scholar) and Michael Rushton (University of Regina)
Options for Raising Revenue for Health Care;
• Alan Shiell (University of Calgary) and Gavin Mooney (Curtin University of
Technology, Perth, Australia) A Framework for Determining the Extent of Public
Financing of Programs and Services;
• Stephen Tomblin (Memorial University) Creating a More Democratic Health System:
A Critical Review of Constraints and a New Approach to Health Restructuring;
• Gail Tomblin-Murphy (Dalhousie University) and Linda O’Brien-Pallas (University of
Toronto) How Do Health Human Resources Policies and Practices Inhibit Change?
A Plan for the Future.
Research rojects
In those areas where it was felt that the Commission’s deliberations would benefit from
more in-depth analysis of key issues and challenges facing the system, the Commission designed
three major research initiatives. The terms of reference for each of these projects were designed
with the assistance of outside experts who provided input on the key research questions that
would be the focus of these projects (these roundtables are noted in the Interim Report).
303
In the Fall of 2001, the Commission posted three “Request for Proposals” calling on
research teams from across the country to design projects that would answer the questions posed
in the RFPs. A panel consisting of senior Commission staff, academics and a representative of
the Federal Department of Public Works and Government Services evaluated the proposals
submitted. The applications were judged on the basis of the suitability of the research team, the
credentials of the individual team members and, most importantly, the scholarly merit of the
proposed research plan.
The work for these projects was begun in late 2001 and completed in the summer of 2002.
Each of these projects consisted of a different set of research products (e.g., background research
papers, comprehensive literature reviews, annotated bibliographies, expert interviews and
roundtables), but each team was required to summarize its work in a detailed Final Report that
was posted, in both languages, on the Commission’s Web site. Copies of the other research
products will form part of the official archive of the Commission. However in the interim those
other research products are available on request from the principal investigators listed below
(subject to any conditions they may specify).
The three research project teams are:

Fiscal
a) Federalism and Health
• Principal Investigator: Harvey Lazar, Director, Institute of Intergovernmental
Relations, Queen’s University, Kingston, Ontario K7L 3N6
• Investigators: Keith Banting (Queen’s University); Robin Boadway (Queen’s
University); David Cameron (University of Toronto); Jennifer McCrea-Logie
(University of Toronto); France St. Hillaire (Institute for Research on Public Policy,
Montreal); Jean-François Tremblay (Queen’s University)
b) Globalization and Health

• Principal Investigator: Bruce Campbell, Executive Director, Canadian Centre for
Policy Alternatives, 410-75 Albert St., Ottawa, Ontario K1P 5E7
• Investigators: Chantal Blouin (North-South Institute, Ottawa); John Foster (North-
South Institute, Ottawa); Ronald Labonte (Universities of Saskatchewan and Regina);
Joel Lexchin (York University); Matthew Sanger (Canadian Centre for Policy
Alternatives, Ottawa); Steven Shrybman (Sack, Goldblatt and Mitchell, Ottawa); Scott
Sinclair (Canadian Centre for Policy Alternatives, Ottawa)
c) Health Human Resources

• Principal Investigator: Cathy Fooks, Director, Health Network, Canadian Policy
Research Networks, Suite 600, 250 Albert Street, Ottawa, Ontario, K1P 6M1
• Investigators: Katya Duvalko (University of Toronto); Patricia Barenak (University of
Toronto); Lise Lamothe (University of Montreal); Kent Rondeau (University of Alberta)
Citizens’ Dialogue roject

In conjunction with the Canadian Policy Research Networks (CPRN) and Viewpoint
Learning, the Commission undertook a unique process of engaging citizens across the country in
a structured dialogue concerning both options for health care reform and the trade-offs involved
in making particular choices for future health policy initiatives. Using a methodology originally
304
developed by Viewpoint and scenarios developed in conjunction with the Commission that
reflected the different types of reform proposals most often put forward for public debate,
CPRN held 12 day-long dialogue sessions across the country involving cross-sections of the
Canadian public.
The objective of these dialogues was to gain insight into the values of Canadians with
regard to the health care system and to understand what trade-offs Canadians would find most
acceptable in any set of reforms to the system. The results of these dialogues were then
compared with a national public opinion survey (conducted by EKOS Research Associates) in
order to test whether the views expressed in the dialogues were consistent with those held more
generally in the population.
In preparation for the dialogue sessions and the analysis of those results, the Commission
also asked a leading public opinion scholar to conduct a comprehensive analysis of past public
opinion surveys concerning Canadians’ attitudes toward the health care system.
Both the historical public opinion analysis and the results of the Citizens’ Dialogue process
were made available, in both official languages, on the Commission Web site. These two
documents are:
a) Matthew Mendelsohn (Queen’s University). Canadians’ Thoughts on Their Health Care
System: Preserving the Canadian Model Through Innovation.
b) Judith Maxwell, Karen Jackson, Barbara Legowski (CPRN), Steven Rosell and Daniel
Yankelovich (Viewpoint Learning), in association with Pierre-Gerlier Forest and Larissa
Lozowchuk (Commission on the Future of Health Care in Canada). Report on Citizens’
Dialogue on the Future of Health Care in Canada.
Expert and Research Roundtables

During the course of its fact-finding and research phases, the Commission asked four
institutions to host roundtables on key issues on which the Commission felt that a sustained
dialogue with noted experts would be particularly informative for its own deliberations.
In all these instances the material prepared for the roundtable by participants remains the
property of the host institution. At least two of those institutions, the Collège des Économistes
de la Santé in Paris and the C. D. Howe Institute in Toronto, have indicated their intention to
publish at least some of the material presented. Those wishing to learn more about the presenters
or the presentations are encouraged to contact the host institutions for each of the roundtables
indicated below.
Expert Roundtable on Public-Private Partnerships

Held on November 27, 2001, by the London School of Hygiene and Tropical Medicine in
London, UK
Participants:
• Roy J. Romanow, Commissioner, Commission on the Future of Health Care in Canada
• Nick Black, Professor of Health Services Research, London School of Hygiene and
Tropical Medicine (Organizer)
• Greg Marchildon, Executive Director, Commission on the Future of Health Care in
Canada 305
• Pierre-Gerlier Forest, Director of Research, Commission on the Future of Health Care in

Canada
• Steve Dewar, Acting Director of Health Policy, King’s Fund
• Carol Popper, Professor of Economics, University of Bristol
• Simon Stevens, Managing Director of Healthcare Services Division, Nestor plc
• Steve Davies, Senior Research Fellow, University of Wales (Cardiff)
• Declan Gaffney, Greater London Authority
• Jon Susses, Associate Director, Office of Health Economics, London
Research Roundtable on Co-Payments and Related Policy Options
Held on November 29, 2001, by the Collège des Économistes de la Santé in Paris, France
Participants:
• Gérard de Pouvourville, Président, Collège des Économistes de la Santé (Organizer)
Canada
Canada
• Ian McLean, Plenipotentiary Minister, Canadian Embassy
• Stefan Felder, University of Magdebourg, Germany
• Marc Jegers, Free University of Brussels, Belgium
• Livio Grattini, Institute Mario Negri, Milan, Italy
• Jakob Kjellberg Christensen, Danish Institute for Health Services Research, Denmark
• Ulf Persson, University of Lund, Sweden
• Guillem Lopez I Casanovas, University Pompeu Fabra, Barcelona, Spain
• Agnès Couffinhal, CREDES, Paris, France
• Valérie Paris, CREDES, Paris, France
Expert Roundtable on Health System Cost-Drivers
Held on February 25, 2002, by the School of Advanced International Studies at Johns
Hopkins University in Washington, DC.
Participants:
• Charles Doran, Director of the Center for Canadian Studies, School of Advanced
International Studies, Johns Hopkins University (Organizer)
Canada
• Pierre-Gerlier Forest, Director of Research, Commission on the Future of Health Care
in Canada
• Tom McIntosh, Research Coordinator, Commission on the Future of Health Care
in Canada
• Henry J. Aaron, Senior Fellow, Brookings Institution, Washington, DC
• Howard Palley, Chair, Health Specialization, School of Social Work, University of
Maryland
306
• Donald M. Steinwachs, Chair, Health Policy and Management, Bloomberg School of

Public Health, Johns Hopkins University
• Pauline Vaillancourt-Rosenau, School of Public Health, University of Texas Colleen
• M. Grogan, School of Social Service Administration, University of Chicago
• Tamara Woroby, Center for Canadian Studies, School of Advanced International Studies,
Johns Hopkins University
• Chris Gray, graduate student, Center for Canadian Studies, School of Advanced
International Studies, Johns Hopkins University
Research Roundtable on Financing Options for Health Care

Held on May 24, 2002, by the C. D. Howe Institute in Toronto, Ontario
Participants:
• Jack M. Mintz, President and CEO, C.D. Howe Institute, Toronto, Ontario (Organizer)
Canada
Canada
• Tom McIntosh, Research Coordinator, Commission on the Future of Health Care in
Canada
• William B. P. Robson, Vice-President and Director of Research, C. D. Howe Institute,
Toronto, Ontario
• Jean-Luc Migué, Senior Fellow, Fraser Institute
• Shay Aba, Policy Analyst, C. D. Howe Institute, Toronto, Ontario
• Åke Blomqvist, University of Western Ontario
• Michanne Haynes, Institute for International Business, University of Toronto
• David Laidler, University of Western Ontario
• John Richards, Simon Fraser University
• Mark Mullins, Economic Consultant
• Allison O’Brien, Institute of Public Economics, University of Alberta
• Paul Boothe, Institute of Public Economics, University of Alberta
• Mark Stabile, Department of Economics, University of Toronto
• Grant Reuber, G. L. Reuber and Associates, Inc., Toronto, Ontario
• Finn Poschmann, Senior Policy Analyst, C. D. Howe Institute, Toronto, Ontario
• Robert D. Brown, FCA
307
Mapping Canada’s
Health Care System
The Commission contracted the Canadian Institute for Health Information (CIHI) to produce a
number of maps detailing different aspects of Canada’s health care system. These maps included
such things as the distribution of health providers across the country and the location of
sophisticated diagnostic technology. The majority of the maps, however, focused on “performance
indicators” such as years of disability-free life expectancy, the prevalence of ambulatory care
sensitive conditions, the prevalence of particular health conditions such as asthma, and other health
determinants such as income, unemployment, physical activity and smoking rates.
These maps played an important role in the deliberations of the Commission as it worked to
understand the regional differences in both the health status of Canadians and the performance
of the provincial and territorial health systems. Some of these maps have been reproduced
throughout this report.
The Commission would like to thank the staff of CIHI for their hard work in producing
these maps, particularly Jennifer Zelmer and Indra Pulcins, who were responsible for overseeing
the mapping project (and acted as a liaison with Statistics Canada, which produced some of the
data for the maps).
308
COMMISSION STAFF
D
This report would not have been possible without the hard work and dedication of all
those who worked for the Commission. I would like to specifically thank Greg Marchildon,
Executive Director and Lead Drafter, as well as:
Cécile Allard , Director, Corporate Support Services

Michel Amar , Director, Communications and Consultation
Jennifer Bayne, Director, Knowledge Management
Lillian Bayne , Associate Executive Director to February 2002, and Special Advisor,
Stakeholder and Expert Relations from February 2002
Laurie Best, Manager, Communications to October 2001
Nicole Bilodeau , Correspondence and Records Management Clerk
Carlo Binda, Manager, Intergovernmental Relations
Audrey Bufton, Manager, Correspondence to June 2002
Chantelle Calder, Executive Assistant to Research Director
Carolynne Chateigner , Administrative Support to October 2001
Pauline Duperreault, Manager, Records Management and Correspondence
Louise Durocher, Office Manager, Ottawa
Pierre-Gerlier Forest , Co-Director, Research to February 2002
and Director, Research from February 2002
Peggy Garritty, Writer, December 2001, July 2002
Nadia Gilbert, Research and Policy Analyst
Phil Gordon, Liaison/Outreach Officer
Lynn Gray, Financial Manager
Claude-Jean Harel, Web Site Communications Editor
Bob Harvey, Manager, Information Services to May 2002
Nancy Johnson, Administrative Support to May 2002
Meghan Jones, Travel Logistics and Claims Clerk
Céline Kidder, Client Services and Reception
Louise Lang-Levesque , Executive Assistant to Executive Director to June 2002
Gordon Lawson, Research and Policy Analyst
Steven Lewis, Co-Director, Research to February 2002 309
Larissa Lozowchuk, Research and Policy Analyst

Marie-Josée Maisonneuve, Client Services and Reception
Geneviève Martin, Research and Policy Analyst
Sinead McGartland, Assistant, Communications
Tom McIntosh, Research Coordinator
Robert McMurtry, Special Advisor
Larissa McWhinney, Research and Policy Analyst
Mindy Meckelborg, Correspondence Clerk
Andrew Noseworthy, Director, Intergovernmental Relations to February 2002
and Acting Executive Director from February 2002
Kevin O’Fee, Research and Policy Analyst
Angela Pedley, Executive Assistant to the Commissioner
Beryl Radcliffe , Contracts and Records Management
Nathalie Roy, Research and Policy Analyst
Nathan Schalm, Research Support
Julie Schneiderman, Events Planning and Communications
Louise Séguin-Guénette, Coordinator, Publications
Cheryl Seneschen, Administrative Support to November 2001
Jayne Simms-Dalmotas, Associate Director, Communications and Consultation
Cristina Ugolini, Research and Policy Analyst
Nicole Viau-Cheney, Director, Administration to July 2001
Fulai Wang, Information Services Support
Chad Watson, Administrative Support
310
E
STATISTICAL H ISTORY OF
H EALTH EXPENDITURES
AND TRANSFERS IN
CANADA, 1968 TO 2002
The tables on the following pages commence with the fiscal year 1968/69 because of the
lack of consistent and reliable data respecting public expenditures for health in years prior to this
date. Blank spaces within columns represent where data were unavailable for that year or
judged to be unreliable. The data selected are those determined to be the most consistent and
reliable based upon official sources.
All data pertaining to federal transfer payments have either been provided directly by the
Department of Finance Canada or are derived from departmental source material (see technical
notes). Figures related to the allocation of cash transfers for the period 1968/69 to 1976/77 (the
combined value of transfers made under the Hospital Insurance and Diagnostic Services Act and
under the Medical Care Act and including the cash value of tax abatements made to the Province
of Quebec in lieu of Hospital Insurance) appear as provided by the Department of Finance
Canada. Similarly, federal transfers made during the period 1977/78 to 1995/96 through
Established Programs Financing (EPF) and their distribution either in cash or tax points, and in
terms of the notional allocation for health, also appear in the form in which the figures were
supplied to the Commission on the Future of Health Care in Canada by the Department of
Finance Canada. For the period 1996/97 to 2005/06 (CHST), only the total transfer value and
the total cash and tax point calculations for the CHST were provided by the Department of
Finance. For the purposes of Appendix E, the calculation of notional allocations for “health”
from the CHST are made by the Commission on the Future of Health Care in Canada (see
technical notes for details).
311
312
Appendix E.1: Public Health Expenditures and Federal Transfers for Major Social Programs Including Notional Allocations for Health (Current Dollars Unless Otherwise Specified):
1968/69 to 2001/02 and Projections Beyond
A B C D E F G H I J K L M N
Health Transfer Regime

Fiscal Year
Total Public and Private
Health Expenditures
Total Public and Private Health
Expenditures (Constant 1997
Dollars)
Total Public Sector Health
Expenditures
Expenditures (Constant 1997
Dollars)
Total Provincial-Territorial Health
Expenditures
Provincial-Territorial Expenditures
for Hospital and Physician
Services
Combined Federal and Provincial-
Territorial Health Expenditures
Cash Component of Major Social
Transfers
Tax Point Component of Major
Social Transfers
Health Component Federal Tax
Point Transfers for EPF
(1977/78 to 1995/96) and CHST
Total Major Social Transfers

Health Component Total Federal
Transfers for HIDSA and Medicare
(1968/69 to 1976/77), EPF
(1977/78 to 1995/96) and CHST
Health Component Federal Cash
Transfers for HIDSA and
Medicare(1968/69 to 1976/77),
EPF (1977/78 to 1995/96)
and CHST
Total Federal Direct Health

Expenditures
($Millions)
Hospital 1968/69 4,911.9 .. .. .. 2,515.2 .. .. .. .. 831.1 .. 831.1 831.1 ..

Insurance and 1969/70 5,505.3 .. .. .. 3,255.8 .. .. .. .. 1,100.0 .. 1,100.0 1,100.0 ..
Diagnostic 1970/71 6,253.8 .. .. .. 4,144.6 .. .. .. .. 1,468.3 .. 1,468.3 1,468.3 ..
Services Act 1971/72 7,118.7 .. .. .. 4,752.6 .. .. .. .. 1,792.0 .. 1,792.0 1,792.0 ..
(1957) and
1972/73 7,787.7 .. .. .. 5,326.1 .. .. .. .. 1,984.7 .. 1,984.7 1,984.7 ..
The Medical
Care Act
1973/74 8,699.4 .. .. .. 5,902.7 .. .. .. .. 2,168.3 .. 2,168.3 2,168.3 ..
(1966) 1974/75 10,223.9 .. .. .. 7,177.6 5,770.7 363.0 7,540.5 .. 2,624.7 .. 2,624.7 2,624.7 ..
1975/76 12,200.6 39,695.6 9,301.4 29,730.5 8,742.2 6,985.0 410.0 9,152.2 .. 3,168.2 .. 3,168.2 3,168.2 ..
1976/77 14,051.0 40,778.2 10,818.5 30,619.6 9,883.7 7,974.9 449.6 10,333.3 .. 3,728.0 .. 3,728.0 3,728.0 ..
1977/78 15,451.2 41,621.0 11,845.8 30,924.8 11,317.0 8,431.1 483.8 11,800.8 8,201.1 5,462.4 2,738.7 4,673.0 2,814.0 1,858.9
Established 1978/79 17,108.4 42,953.6 13,042.1 31,718.6 12,589.1 9,285.5 486.2 13,075.3 9,304.4 6,202.4 3,102.0 5,345.0 3,239.0 2,105.5
Programs 1979/80 19,170.1 44,216.2 14,552.7 32,281.8 14,066.4 10,183.8 521.7 14,588.1 10,591.5 7,027.9 3,563.6 6,094.0 3,675.0 2,418.8
Financing 1980/81 22,308.7 46,703.1 16,852.1 33,922.0 16,372.0 11,863.9 602.2 16,974.2 12,022.5 7,853.8 4,168.7 6,863.0 4,033.0 2,829.5
(EPF) (1977) 1981/82 26,289.1 48,863.8 19,955.0 35,583.2 19,419.6 13,965.6 722.9 20,142.4 13,620.4 8,880.1 4,740.2 7,726.0 4,508.0 3,217.5
1982/83 30,771.7 51,224.7 23,459.4 37,548.5 22,866.0 16,489.1 898.8 23,764.8 15,632.6 10,270.9 5,361.6 8,682.0 5,043.0 3,639.3
1983/84 34,053.9 53,220.1 26,095.3 39,539.8 25,061.3 18,032.4 1,027.0 26,088.2 17,251.6 11,771.7 5,479.8 9,590.0 5,861.0 3,719.5
1984/85 36,759.2 55,162.3 27,973.0 40,845.2 26,642.8 19,125.6 1,132.5 27,775.3 18,540.8 12,569.6 5,971.3 10,379.0 6,326.0 4,053.1
1985/86 39,858.5 57,583.8 30,111.7 42,460.9 28,727.5 20,456.5 1,166.1 29,893.6 19,971.1 13,434.7 6,536.3 11,171.0 6,735.0 4,436.6
1986/87 43,350.0 60,372.6 32,541.3 44,467.1 31,097.5 22,446.2 1,292.4 32,389.8 21,231.0 14,018.3 7,212.6 11,905.0 7,010.0 4,895.7
1987/88 46,821.3 62,085.0 35,087.8 45,932.7 33,401.6 24,261.8 1,368.9 34,770.5 22,548.1 14,436.8 8,111.3 12,590.0 7,085.0 5,505.6
1988/89 50,982.6 64,754.1 38,187.2 48,164.4 36,595.0 26,160.8 1,574.2 38,169.1 24,010.8 15,111.7 8,899.1 13,315.0 7,274.0 6,040.3
1989/90 56,115.6 67,668.6 41,931.3 50,197.5 40,225.9 28,543.2 1,724.6 41,950.5 25,669.3 15,891.9 9,777.4 14,179.0 7,542.0 6,636.5
1990/91 61,047.0 69,863.6 45,469.9 51,639.3 43,194.7 30,438.9 2,053.6 45,248.3 26,462.5 16,384.5 10,078.0 14,411.0 7,571.0 6,840.5
1991/92 66,246.2 72,591.6 49,351.4 53,796.2 47,085.6 33,268.8 2,130.2 49,215.8 27,423.6 17,409.4 10,014.2 14,701.0 7,904.0 6,797.2
1992/93 69,764.8 74,119.0 51,666.3 54,686.3 48,659.2 33,811.8 2,224.2 50,883.4 28,300.4 18,396.4 9,904.0 14,919.0 8,197.0 6,722.5
1993/94 71,514.1 74,736.7 51,952.7 54,297.8 48,430.4 33,713.5 2,300.6 50,731.0 28,991.4 18,810.3 10,181.1 15,131.0 8,221.0 6,910.5
1994/95 73,138.4 75,284.2 52,668.7 54,189.8 49,042.5 33,463.7 2,593.7 51,636.1 29,369.9 18,719.0 10,650.9 15,302.0 8,073.0 7,229.4
1995/96 74,063.2 75,488.8 52,783.4 53,694.3 48,827.3 32,875.8 2,692.4 51,519.7 29,882.4 18,476.4 11,406.0 15,697.0 7,955.0 7,741.9
1996/97 74,689.3 75,604.5 52,807.1 53,409.3 49,070.3 33,028.8 2,578.5 51,648.8 26,900.0 14,741.8 12,158.2 14,592.0 6,339.1 8,253.0
Canada Health 1997/98 78,326.1 78,326.1 55,004.8 55,004.8 51,394.7 34,399.8 2,942.8 54,337.5 25,838.8 12,500.0 13,338.8 14,429.4 5,375.0 9,054.4
and Social 1998/99 83,516.8 82,355.1 59,065.7 58,438.2 55,004.5 36,754.0 3,090.5 58,095.0 26,841.3 12,500.0 14,341.3 15,109.9 5,375.0 9,734.9
Transfer 1999/00 89,546.6 87,240.2 63,372.2 62,221.2 59,104.5 37,911.4 3,451.8 62,556.3 30,068.2 14,500.0 15,568.2 16,802.7 6,235.0 10,567.7
(CHST)
2000/01 95,881.3 91,098.2 69,037.7 65,980.4 64,466.8 41,246.2 3,732.9 68,199.7 31,912.5 15,500.0 16,412.5 18,375.8 7,235.0 11,140.8
(1996)
2001/02 102,511.9 96,013.6 74,465.0 70,468.5 69,301.6 43,482.1 3,737.1 73,038.7 34,400.5 18,300.0 16,100.5 19,068.0 8,139.0 10,929.0
2002/03 106,714.9 .. .. .. 72,558.8 45,525.8 .. .. 35,663.6 19,100.0 16,564.0 19,398.6 8,155.0 11,243.6
2003/04 110,983.5 .. .. .. 76,186.7 47,802.0 .. .. 37,000.0 19,800.0 17,200.0 20,088.4 8,413.0 11,675.4
Projections 2004/05 116,754.6 .. .. .. 80,072.2 50,239.9 .. .. 38,300.0 20,400.0 17,900.0 20,821.5 8,671.0 12,150.5
2005/06 122,709.1 .. .. .. 84,075.8 52,751.9 .. .. 39,800.0 21,000.0 18,800.0 21,576.4 8,815.0 12,761.4
Appendix E.2: Percentage Share and Rate of Change in Public Health Expenditures and Major Social Transfers Including Notional Allocation for Health: 1968/69 to 2001/02 and Projections Beyond
A B C D E F G H I J K L M N O P Q R S T
Total Federal Health Transfers as a

Proportion of Provincial-Territorial
Expenditures for Hospital and
Physician Services
Tax Point Component of Major

Social Transfers
Federal Health Cash Transfers as a
Proportion of Total Provincial-
Federal Tax Point Transfers as a
Federal Health Cash Transfers as a
Proportion of Provincial-Territorial
Expenditures for Hospital and
Physician Services
Federal Tax Point Transfers as a
Territorial Health Expenditures for
Hospital and Physician Services
Provincial-Territorial Health
Expenditures as a Proportion of
Provincial-Territorial Program Spending
Total Health Expenditures as a
Proportion of GDP
Total Public Health Expenditures
as a Proportion of GDP
Total Federal Direct Health

Expenditures
Cash Component of Major
Social Transfers
Total Public and Private Health

Expenditures (Constant 1997 Dollars)
Provincial-Territorial Expenditures for
Hospital and Physician Services
Combined Federal and Provincial-
Total Major Social Transfers
Total Federal Health Transfers as a
Total Provincial-Territorial Health

Expenditures
Health Transfer Regime

Fiscal Year
Total Public and Private
Health Expenditures
Expenditures
Expenditures
(Constant 1997 Dollars)
(%)
Hospital 1968/69 13.6% .. .. .. 14.3% .. .. .. .. .. .. 33.0% 33.0% .. .. .. .. .. 6.5% ..

Insurance 1969/7 12.1% .. .. .. 29.4% .. .. .. .. 32.4% .. 33.8% 33.8% .. .. .. .. .. 6.6% ..
and 1970/71 13.6% .. .. .. 27.3% .. .. .. .. 33.5% .. 35.4% 35.4% .. .. .. .. .. 7.0% 4.9%
Diagnostic 1971/72 13.8% .. .. .. 14.7% .. .. .. .. 22.0% .. 37.7% 37.7% .. .. .. .. .. 7.2% 5.3%
Services Act
1972/73 9.4% .. .. .. 12.1% .. .. .. .. 10.8% .. 37.3% 37.3% .. .. .. .. .. 7.1% 5.3%
(1957) and
The Medical
1973/74 11.7% .. .. .. 10.8% .. .. .. .. 9.2% .. 36.7% 36.7% .. .. .. .. .. 6.8% 5.0%
Care Act 1974/75 17.5% .. .. .. 21.6% .. .. .. .. 21.0% .. 36.6% 36.6% .. 45.5% 45.5% .. 28.3% 6.7% 5.0%
(1966) 1975/76 19.3% .. .. .. 21.8% 21.0% 13.0% 21.4% .. 20.7% .. 36.2% 36.2% .. 45.4% 45.4% .. 28.4% 7.1% 5.4%
1976/77 15.2% 2.7% 16.3% 3.0% 13.1% 14.2% 9.6% 12.9% .. 17.7% .. 37.7% 37.7% .. 46.7% 46.7% .. 28.8% 7.1% 5.4%
1977/78 10.0% 2.1% 9.5% 1.0% 14.5% 5.7% 7.6% 14.2% .. 46.5% .. 41.3% 24.9% 16.4% 55.4% 33.4% 22.0% 28.0% 7.0% 5.4%
Established
1978/79 10.7% 3.2% 10.1% 2.6% 11.2% 10.1% 0.5% 10.8% 13.5% 13.5% 13.3% 42.5% 25.7% 16.7% 57.6% 34.9% 22.7% 28.3% 7.0% 5.3%
Programs
Financing 1979/80 12.1% 2.9% 11.6% 1.8% 11.7% 9.7% 7.3% 11.6% 13.8% 13.3% 14.9% 43.3% 26.1% 17.2% 59.8% 36.1% 23.8% 27.8% 6.9% 5.2%
(EPF 1977) 1980/81 16.4% 5.6% 15.8% 5.1% 16.4% 16.5% 15.4% 16.4% 13.5% 11.8% 17.0% 41.9% 24.6% 17.3% 57.8% 34.0% 23.8% 28.7% 7.1% 5.4%
1981/82 17.8% 4.6% 18.4% 4.9% 18.6% 17.7% 20.0% 18.7% 13.3% 13.1% 13.7% 39.8% 23.2% 16.6% 55.3% 32.3% 23.0% 29.2% 7.3% 5.5%
1982/83 17.1% 4.8% 17.6% 5.5% 17.7% 18.1% 24.3% 18.0% 14.8% 15.7% 13.1% 38.0% 22.1% 15.9% 52.7% 30.6% 22.1% 29.5% 8.1% 6.2%
1983/84 10.7% 3.9% 11.2% 5.3% 9.6% 9.4% 14.3% 9.8% 10.4% 14.6% 2.2% 38.3% 23.4% 14.8% 53.2% 32.5% 20.6% 30.1% 8.3% 6.4%
1984/85 7.9% 3.6% 7.2% 3.3% 6.3% 6.1% 10.3% 6.5% 7.5% 6.8% 9.0% 39.0% 23.7% 15.2% 54.3% 33.1% 21.2% 30.8% 8.2% 6.2%
1985/86 8.4% 4.4% 7.6% 4.0% 7.8% 7.0% 3.0% 7.6% 7.7% 6.9% 9.5% 38.9% 23.4% 15.4% 54.6% 32.9% 21.7% 30.2% 8.2% 6.2%
1986/87 8.8% 4.8% 8.1% 4.7% 8.2% 9.7% 10.8% 8.4% 6.3% 4.3% 10.3% 38.3% 22.5% 15.7% 53.0% 31.2% 21.8% 31.4% 8.5% 6.4%
1987/88 8.0% 2.8% 7.8% 3.3% 7.4% 8.1% 5.9% 7.3% 6.2% 3.0% 12.5% 37.7% 21.2% 16.5% 51.9% 29.2% 22.7% 32.3% 8.4% 6.3%
1988/89 8.9% 4.3% 8.8% 4.9% 9.6% 7.8% 15.0% 9.8% 6.5% 4.7% 9.7% 36.4% 19.9% 16.5% 50.9% 27.8% 23.1% 32.4% 8.3% 6.2%
1989/90 10.1% 4.5% 9.8% 4.2% 9.9% 9.1% 9.6% 9.9% 6.9% 5.2% 9.9% 35.2% 18.7% 16.5% 49.7% 26.4% 23.3% 33.2% 8.5% 6.4%
1990/91 8.8% 3.2% 8.4% 2.9% 7.4% 6.6% 19.1% 7.9% 3.1% 3.1% 3.1% 33.4% 17.5% 15.8% 47.3% 24.9% 22.5% 32.8% 9.0% 6.7%
1991/92 8.5% 3.9% 8.5% 4.2% 9.0% 9.3% 3.7% 8.8% 3.6% 6.3% -0.6% 31.2% 16.8% 14.4% 44.2% 23.8% 20.4% 32.4% 9.7% 7.2%
1992/93 5.3% 2.1% 4.7% 1.7% 3.3% 1.6% 4.4% 3.4% 3.2% 5.7% -1.1% 30.7% 16.8% 13.8% 44.1% 24.2% 19.9% 32.5% 10.0% 7.4%
1993/94 2.5% 0.8% 0.6% -0.7% -0.5% -0.3% 3.4% -0.3% 2.4% 2.2% 2.8% 31.2% 17.0% 14.3% 44.9% 24.4% 20.5% 32.7% 9.8% 7.2%
1994/95 2.3% 0.7% 1.4% -0.2% 1.3% -0.7% 12.7% 1.8% 1.3% -0.5% 4.6% 31.2% 16.5% 14.7% 45.7% 24.1% 21.6% 32.7% 9.5% 6.8%
1995/96 1.3% 0.3% 0.2% -0.9% -0.4% -1.8% 3.8% -0.2% 1.7% -1.3% 7.1% 32.1% 16.3% 15.9% 47.7% 24.2% 23.5% 32.2% 9.1% 6.5%
1996/97 0.8% 0.2% 0.0% -0.5% 0.5% 0.5% -4.2% 0.3% -10.0% -20.2% 6.6% 29.7% 12.9% 16.8% 44.2% 19.2% 25.0% 33.0% 8.9% 6.3%
Canada
Health and 1997/98 4.9% 3.6% 4.2% 3.0% 4.7% 4.2% 14.1% 5.2% -3.9% -15.2% 9.7% 28.1% 10.5% 17.6% 41.9% 15.6% 26.3% 34.1% 8.9% 6.2%
Social 1998/99 6.6% 5.1% 7.4% 6.2% 7.0% 6.8% 5.0% 6.9% 3.9% 0.0% 7.5% 27.5% 9.8% 17.7% 41.1% 14.6% 26.5% 32.6% 9.1% 6.5%
Transfer 1999/00 7.2% 5.9% 7.3% 6.5% 7.5% 3.1% 11.7% 7.7% 12.0% 16.0% 8.6% 28.4% 10.5% 17.9% 44.3% 16.4% 27.9% 35.4% 9.2% 6.5%
(CHST 2000/01 7.1% 4.4% 8.9% 6.0% 9.1% 8.8% 8.1% 9.0% 6.1% 6.9% 5.4% 28.5% 11.2% 17.3% 44.6% 17.5% 27.0% 37.3% 9.1% 6.5%
1996) 2001/02 6.9% 5.4% 7.9% 6.8% 7.5% 5.4% 0.1% 7.1% 7.8% 18.1% -1.9% 27.5% 11.7% 15.8% 43.9% 18.7% 25.1% .. 9.3% 6.8%
2002/03 4.1% .. .. .. 4.7% 4.7% .. .. 3.7% 4.4% 2.9% 26.7% 11.2% 15.5% 42.6% 17.9% 24.7% .. .. ..
Projections
2003/04 4.0% .. .. .. 5.0% 5.0% .. .. 3.7% 3.7% 3.8% 26.4% 11.0% 15.3% 42.0% 17.6% 24.4% .. .. ..
2004/05 5.2% .. .. .. 5.1% 5.1% .. .. 3.5% 3.0% 4.1% 26.0% 10.8% 15.2% 41.4% 17.3% 24.2% .. .. ..
2005/06 5.1% .. .. .. 5.0% 5.0% .. .. 3.9% 2.9% 5.0% 25.7% 10.5% 15.2% 40.9% 16.7% 24.2% .. .. ..
Appendix E.1
Column A
CIHI defines total health expenditures as the combined value of both public and private
sector health expenditures. Private health spending includes out-of-pocket expenditures made by
individuals for health care goods and services; the health insurance claims paid by commercial
and not-for-profit insurance firms, as well as the direct cost of administering those claims;
private spending on health-related capital construction and equipment; and health research
funded by private sources. For a detailed definition of public sector health expenditures see
notes for column C.
The figures for total health expenditures are in calendar years. Figures for 2000 and 2001
are forecasts made by CIHI.
1968/69 to 1974/75: Statistics Canada 1983; Canada, Health and Welfare Canada 1979.
1975/76 to 2001/02: CIHI 2001e.
2002/03 to 2005/06: Figures are projections (appearing in red) based on Conference Board
of Canada (2001) annual rates of increase for the health sector applied to CIHI data.
Column B
Constant dollars are used to show real (inflation adjusted) health expenditures. Real health
expenditures are presented in constant 1997 dollars. Constant dollar expenditures were
calculated by CIHI using price indices for public and private expenditures in each province and
territory. The indices are the implicit price indices (IPI) for government current expenditures
used to deflate public sector health care spending, and the health component of the Consumer
Price Index (CPI) used to deflate private sector health spending. Statistics Canada developed
both sets of indices.
Figures for 2000 and 2001 are forecasts made by CIHI.

1975/76 to 2001/02: CIHI 2001e.
Column C
Public sector health expenditures include health care spending by governments and
government agencies and are comprised of four groups of public expenditures: 1) provincial-
territorial governments; 2) federal direct; 3) municipal governments; and 4) social security funds
including workers’ compensation.
For a detailed description of the provincial-territorial government and federal direct sectors
see accompanying notes for columns E and G.
The municipal government sector includes health care spending by municipal governments
for institutional services, including public health, capital construction and equipment, and dental
services provided by municipalities in the provinces of Nova Scotia, Manitoba and British
Columbia. Designated funds transferred by provincial governments for health purposes are not
included in the municipal sector but are included with provincial government expenditure.
Social security funds are social insurance programs that are imposed and controlled by a
government authority. They generally involve compulsory contributions by employees and
employers, and the government authority determines the terms on which benefits are paid to
recipients. In Canada, social security funds include the health care spending by workers’
314 compensation boards and agencies, and the drug insurance fund component of the Quebec drug
STATISTICAL HISTORY OF HEALTH EXPENDITURES AND TRANSFERS IN CANADA, APPENDIX E
subsidy program. Health spending for workers’ compensation includes what is commonly
referred to by provincial workers’ compensation agencies as medical aid.
1975/76 to 2001/02: CIHI 2001e.
Column D
For an explanation of constant dollar calculation see note for Column B.
1975/76 to 2001/02: CIHI 2001e.
Column E
The provincial-territorial government sector includes direct health spending by provinces
and territories, federal health transfers to the provinces and territories, and provincial
government health transfers to municipal governments.
Figures for 2000/01 and 2001/02 are forecasts made by CIHI.
1968/69 to 2001/02: CIHI 2002f.
2002/03 to 2005/06: Figures are projections (appearing in red) based on Conference Board
of Canada (2002) annual rates of increase for the provincial-territorial government health sector
applied to CIHI data.
Column F
Hospital expenditures are defined as expenditures made by hospitals licensed or approved
by provincial-territorial governments and include those providing acute care, rehabilitation and
convalescent care, as well as nursing stations and hospitals in rural and remote areas. Excluded
from the definition of hospitals are mental institutions and special care facilities. This definition
closely approximates those hospital services previously eligible for federal funding under the
Hospital Insurance and Diagnostic Services Act and those services eligible according to the
definition of insured services under the Canada Health Act.
The majority of physician expenditures are professional fees paid by provincial and
territorial medical care insurance plans to physicians in private practice. Fees for services
rendered in hospitals are included when paid directly to physicians by the plan. Also included
are other forms of professional incomes including salaries, sessional (contract) and capitation.
1974/75 to 2001/02: CIHI 2002f.

2002/03 to 2005/06: Figures are Commission projections (appearing in red) based on the
current share of total provincial-territorial expenditures devoted to hospital and physician
services in fiscal year 2001/02. In 2001/02, hospital and physician services accounted for 62.7%
of total provincial-territorial health expenditures. This percentage has been applied to estimates
of total provincial-territorial health expenditures appearing in column E.
Column G
The federal direct sector refers to direct health care spending by the federal government in
relation to health care services for special groups such as Aboriginal peoples, the Armed Forces
and veterans, the RCMP and inmates of federal penitentiaries, as well as expenditures for health
315
research, health promotion and protection. Federal direct health expenditures do not include
federal health transfers to the provinces.
1968/69 to 2001/02: CIHI 2002f.
Column H
Combined federal and provincial-territorial health expenditures in column H are the sum of
columns E and G.
Column I
Major social transfers by the federal government are those made to provincial and territorial
governments for health, social services and post-secondary education. These transfers include at
various times the Canada Health and Social Transfer (CHST), the Canada Assistance Plan
(CAP), Established Programs Financing (EPF) and dedicated cash transfers for health under the
Hospital Insurance and Diagnostic Services Act and the Medical Care Act . The total value of
major social transfers includes both cash payments and tax point transfers (the combined values
of Columns J and K) for the post-1976/77 period.
1977/78 to 2005/06: Canada, Department of Finance Canada 2002c.
Column J
Column K
Column L
Federal transfers for health from 1968/69 to 1974/75 include only cash payments made
under the Hospital Insurance and Diagnostic Services Act and the Medical Care Act.
Notional allocations for health under EPF (1977/78 to 1995/96) are based on the combined
value of cash and tax transfer data for health provided by Department of Finance Canada. The tax
and cash components notionally allocated for health under EPF were originally both set at 67.9%
in 1977, but due to “6 and 5” price controls (begun in 1975) on the post-secondary education
(PSE) cash component, the health cash share increased relative to the PSE component. As a result,
based on Department of Finance Canada data the notional cash allocation for health ranges from
71.7% of total EPF cash in 1977/78 to 74.8% in 1995/96. The notional health allocation under the
tax point transfer remains constant throughout at 67.9% of EPF tax transfers. In addition, because
of associated equalization of the tax point transfers, a portion of the tax transfer was actually made
in cash but is included as part of the tax point transfer component by the Department of Finance
Canada.
The notional allocation for health under the CHST (1996/97 to 2005/06) is based on the
federal Department of Finance document Backgrounder on Federal Support for Health in
Canada (March 2000). This document assumes a notional health allocation for the cash
component of all CHST cash transfers of 43%, which in turn is based on the relative share of the
combined value of EPF and Canada Assistance Plan cash transfers prior to their consolidation
316
under the CHST. The figure is derived by dividing the health cash component under EPF by the
combined value of all EPF and Canada Assistance Plan cash transfers for the final year of these
programs in fiscal year 1995/96. According to the Department of Finance Canada, in fiscal year
1995/96 the combined value of all EPF cash and CAP transfers was approximately $18.47
billion. Of that cash amount, roughly $7.96 billion was notionally allocated toward health under
EPF. The notional allocation of tax point transfers under the CHST remains the same as under
EPF since the tax points originally transferred in 1977/78 were transferred specifically for health
and post-secondary education and did not include social services.
In September 2000, the federal government committed additional targeted transfers under
the CHST for the Medical Equipment Fund, the Health Information Technology Fund, the
Health Transition Fund for Primary Care, and Early Childhood Development. These targeted
funds were intended as separate contributions for health and social services to be disbursed to
provinces and territories between 2000/01 and 2005/06. Data provided by the federal
Department of Finance includes these targeted transfers as part of the total CHST cash
contribution. As a result, the Commission has calculated a basic CHST contribution by
subtracting the value of these supplemental cash transfers from the total CHST cash
contribution. In order to allocate those cash transfers specifically designed for health purposes,
the cash made available to provincial and territorial governments through the Medical
Equipment Fund, the Health Information Technology fund and the Health Transition Fund for
Primary Care have been added to the health cash portion in the year and in the amounts for
which the entitlements were set. Early childhood Development funds have been excluded from
the calculation of the health component.
Column M
Figures for the EPF cash component appear as provided by Department of Finance Canada.
Based on these data the notional health allocation under the cash transfer ranges from a low of
71.7% (1977/78) to a high of 74.8% (1995/96).
The CHST cash transfer data provided by Department of Finance Canada do not include a
notional allocation for health. The notional allocation for the health cash component of the
CHST has been calculated by the Commission based on the 43% allocation described in the
notes for column L and applied to the cash transfer data provided by the Department of Finance.
Column N
Figures for the EPF tax point component appear as provided by Department of Finance
Canada. The notional health allocation under the tax point transfer remains constant throughout
at 67.9% of EPF tax transfers.
The CHST tax transfer data provided by Department of Finance Canada do not include a
notional allocation for health. The notional allocation for the health tax point transfer component
of the CHST has been calculated by the Commission based on the 67.9% allocation described
above in the notes for column L and applied to the tax point transfer data provided by the
Department of Finance.
1968/69 to 2005/06: Canada, Department of Finance Canada 2002c. 317

Appendix E.2
The annual rate of growth is calculated by subtracting the total value in the base year (e.g.
1968/69) from the total value for the following year (e.g. 1969/70) and dividing that sum by the
value of the base year. The resulting value is expressed as a percentage.
Column A
Calculations based on column A from Appendix E.1.
Column B
Calculations based on column B from Appendix E.1.
Column C
Calculations based on column C from Appendix E.1.
Column D
Calculations based on column D from Appendix E.1.
Column E
Calculations based on column E from Appendix E.1.
Column F
Calculations based on column F from Appendix E.1.
Column G
Calculations based on column G from Appendix E.1.
Column H
Calculations based on column H from Appendix E.1.
Column I
Calculations based on column I from Appendix E.1.
Column J
Calculations based on column J from Appendix E.1.
Column K
Calculations based on column K from Appendix E.1.
Column L
Figures are calculated by dividing column L (total federal health transfers) by column E
(total provincial-territorial health expenditures) in Appendix E.1.
Column M
Figures are calculated by dividing column M (health component of federal cash transfers)
by column E (total provincial-territorial health expenditures) in Appendix E.1.
318
Column N
Figures are calculated by dividing column N (health component of federal tax point
transfers) by column E (total provincial-territorial health expenditures) in Appendix E.1.
Column O
Figures are calculated by dividing column L (total federal health transfers) by column F
(provincial-territorial health expenditures for hospital and physician services) in Appendix E.1.
Column P
Figures are calculated by dividing column M (health component of federal cash transfers)
by column F (provincial-territorial health expenditures for hospital and physician services) in
Appendix E.1.
Column Q
Figures are calculated by dividing column N (health component of federal tax point
transfers) by column F (provincial-territorial health expenditures for hospital and physician
services) in Appendix E.1.
Column R
Total program spending includes all provincial-territorial budgetary expenditures except
debt servicing costs.
Figure for 2000/01 is a forecast made by CIHI.
1974/75 to 2000/01: CIHI 2001g.
Column S
All figures are for calendar years.
1968/69 to 2001/02: OECD 2002b.
Column T
All figures are for calendar years.
1970/71 to 2001/02: OECD 2002b.
319
PRIMARY CARE
O RGANIZATIONS IN
CANADA, 2002 F
The table that follows outlines the range of primary health care initiatives that have been
undertaken or are being planned in each of the provinces and territories. The information for
each jurisdiction was compiled by Commission staff from federal, provincial and territorial
government publications and Web sites, but the information was verified by officials in each
provincial or territorial department of health. What is immediately apparent is the variation in
structure, governance and funding of primary health care initiatives across the country. In
addition, some initiatives are relatively recent in origin while others have existed for a couple
of decades.
321
322
Primary Care Sites Established Governance Funding Other Initiatives
Newfoundland 3 community health 1984, 1995, Health boards Provincial government The province has created an Office of Primary
and Labrador centres 1997 Health Care to develop a provincial Primary
Health Care Framework and Implementation Plan.
3 primary health 1997 Health boards Provincial government The province aims to establish, over the next five
enhancement sites years, a network of Primary Health Care Teams.
Prince Edward 4 community health 1995 to 2000 Regional health board Provincial government or Development of family health centres.
Island centres health board
Nova Scotia 9 community health 1972 to 2002 Volunteer or elected board of District health authority, “Strengthening Primary Care in Nova Scotia” will
centres (listed by the directors Department of Health, continue with provincial funding until 2003.
Federation of fundraising
Community Health
Centres of Nova Scotia)
New Brunswick 2 existing community 1994 to1995 Regional health authorities Provincial government 2 community health center pilot projects that
health centres not meet the primary care criteria to be established in
presently accessible the province by late Fall 2002.
24/7 Interdisciplinary Team Shared Practice Model.
Collaborative practice demonstration project in
family physician offices: implemented in 1999 and
evaluated in 2000 – discontinued.
Québec 147 Centres locaux de 1972 Elected board of directors Provincial government Family medicine groups.
santé communautaires Stated objective is for 300 primary care sites.
Ontario 55 community health 1970s Elected community board Provincial government. Also Expansion underway through creation of special
centres regional bodies, federal purpose agency, the Ontario Family Health
government and non- Network Agency, including recently announced
governmental organizations expansion of 4 additional Family Health Networks.
such as United Way Recently announced additional investment in
primary care in conjunction with the federal
2 family health 2002 Governance agreement required Provincial government government through the Primary Health Care
networks as part of the funding contract Transition Fund.
14 primary care 1999 Governance agreement required Provincial government

networks as part of the funding contract
52 health services 1970s No specified governance Provincial government

organizations structure
23 community 1999 Governance requirements in Provincial government

sponsored contracts funding contract
Group health centre 1970s Community board Provincial government
13 Northern Group 1999 Governance agreement required Provincial government

Funding Programs as part of the funding contract
Primary Care Sites Established Governance Funding Other Initiatives
Manitoba 27 sites including health 1994 to Regional health authority Mainly regional health A Primary Health Care Network, made up of
centres, community present (all rural centres) authorities, a few by Manitoba representatives of the regional health authorities
nurse resource centres, board, service purchase Health and providing support to a provincial strategy,
primary health centres agreement with regional was formed in 2001.
and community health health authority 12 planned community health and social service
centres (urban centres, access centres in Winnipeg, one under
except one which is construction and 2 currently in planning.
governed A provincial Primary Health Care Policy
by Manitoba Health) Framework, which was approved in principle in
March 2002, has been distributed broadly among
regional health authorities.
Saskatchewan 3 community clinics 1962 Board of directors accountable Provincial government Establishment of primary health care teams and
to Saskatchewan Health networks.
21 primary health 1998 to 2002 Regional health authorities Provincial government
service sites
(2 of the 21 are also
community clinics for a
total of 5)
Alberta More than 8 community 1980 to Regional health Regional health authorities/ Alberta Health and Wellness is conducting
health centres present authorities/community boards community board stakeholder consultations to identify primary
health care strategies and develop a proposal for
federal funding through the Primary Health Care
Transition Fund.
Development of a proposal for the federal Primary
British At least 25 community Since 1970 Ranges from board of Local health authority through Health Care Transition Fund led by the Division of
Columbia health centres directors, local health the Ministry of Health or Primary Health Services, Ministry of Health
authority or advisory Medical Services Branch of Services.
8 primary health care Since 1992 committees Health Canada if for First
organizations Nations.
Yukon Health centres Yukon government Yukon government Currently no primary care renewal initiative
underway in the Yukon.
Northwest 23 community health 1992 to 1998 Health and social services Department of Health and As of 2002, the Department of Health and Social
Territories centres authorities as described under Social Services Services has been developing an integrated services
the Health Insurance and Health delivery model. This model will describe core
PRIMARY CARE ORGANIZATIONS IN CANADA,2002 • APPENDIX F
and Social Services Act. services and the applicable distribution, placement
and delivery of primary health services.
Nunavut 26 health centres April 1, 1999 Territorial and federal Territorial and federal Expansion of telehealth and health promotion
governments governments activities.
323
CONSULTANTS’ E STIMATES
ON COSTS OF
TARGETED H OME CARE G
John P. Hirdes, Ph.D., University of Waterloo and Homewood Research Institute
Jeff Poss, P.Eng., MBA., University of Waterloo
John N. Morris, Ph.D., Hebrew Rehabilitation Center for the Aged, Boston
Brant E. Fries, Ph.D., University of Michigan, Ann Arbor and VA Medical Center
Several Canadian provinces have recently taken steps toward implementation of a common
assessment approach as the basis for a home care information system. However, Canada does
not yet have a comprehensive national database combining clinical, service utilization, cost, and
outcome information for home care. As a consequence, it is not possible to simply summarize
existing administrative data in order to calculate the expected costs of the core home care
services recommended by the Commission. “Synthetic estimation” provides an alternative
approach by combining available demographic data with research findings in order to simulate
the expected rates of needs in the population and the costs of services to be allocated in response
to those needs.
Data Sour es
The primary sources of data for this analysis include: a) vital statistics (e.g., mortality)
reported by Health Canada and Statistics Canada; b) health service utilization data reported by the
Canadian Institute for Health Information; c) scientific publications; d) utilization data from
individual health care agencies; and e) Resident Assessment Instrument – Home Care (RAI-HC)
data from the RAI-Health Informatics Project (RAI-HIP) funded by the Health Transition Fund
(Grant # ON421) and from the Government of Manitoba’s pilot implementation of the RAI-HC.
The RAI-HC is a comprehensive assessment of the needs and services received by the
community-based elderly and adults with disabilities. The assessments were completed by trained
clinicians, and previous research has demonstrated the reliability and validity of RAI-HC data
(Morris et al. 1997). The clinical and service use elements were used to construct groups
corresponding to the expected clients for the four core recommended home care services (post-
acute rehabilitation, post-acute medical care, palliative care and behaviour management). In
addition, data on the receipt of formal services over the previous seven days were combined with
discipline-specific billing rates provided by the Waterloo (Ontario) Community Care Access
Centre (CCAC) to estimate weighted billing costs on a per diem basis by type of client. This cost
325
information could then be linked to population estimates and predicted days of service to
estimate overall costs for the recommended services.
The RAI-HIP and Manitoba data are somewhat over-represented by longer stay, elderly
home care clients. For example, Health Canada (2001) reports that about 73% of home care
expenditures are made on persons aged 65 years or more, but 83% of the sample from which the
RAI-HC data were obtained is 65 or older. The expected result of this modest bias is to over-
estimate home care costs, since these individuals will tend to have more complex health care
needs and potentially fewer informal supports available. The Manitoba and Ontario data are
combined, but it should be noted that prevalence estimates for these groups tend to be lower in
Manitoba than Ontario. Also, clients receiving no services over the past week and those who had
been on service for less than one day were excluded from the analysis. Per diem rates of costs
were calculated using weekly service utilization patterns or service since entry to home care if
the length of stay was less than seven days. Cases with outlier values for certain services were
assigned missing values for that variable. These data do not include out-of-pocket expenditures
by home care clients, but they may include some private pay services.
Syntheti Estimation of Costs by

Type of Servi e
The number of cases for each service was estimated in one of three ways. First, the number
of elderly Canadians was multiplied by the expected proportion of individuals with an acute
hospitalization in order to estimate the denominator for the two post-acute services (medical
care and rehabilitation). CIHI (2001) reported the rates of hospitalization by age between
1994/95 and 1998/99 for 45- to 64-year-olds and 65- to 74-year-olds. The mid-point of the latter
rates (29%) was used to estimate the overall number of post-acute cases. This will tend to
over-estimate hospitalizations for younger individuals and under-estimate hospitalizations for
older individuals. However, it is also important to note that hospitalization rates are falling,
meaning that this approach is likely to over-estimate the number of post-acute cases over time.
The second approach was to use the number of cancer deaths reported by the National Cancer
Institute of Canada (NCIC 1999) as a base for estimating the number of palliative clients. The
third approach was to combine Health Canada’s estimate (MacAdam 1999) of the number of
home care clients (840,000) with prevalence and incidence rates for aggressive behaviour from
the RAI-HIP data. The specific estimates are described below. Table G.1 provides the estimates
for all groups and Table G.2 provides a more detailed methodology for the behaviour management group.
Case Management and Behaviour Intervention:

Home Mental Health
Home care clients requiring special interventions to manage behaviour that can be
dangerous or distressing to others differ from the previous three groups, because they are
expected to have much longer lengths of stay in home care (RAI-HC data suggest an average
two-year length of stay). Therefore, this group will be more costly than others because of their
prolonged lengths of service use. On the other hand, recent research by the RAI-HIP team has
suggested that this group is at a particularly high risk of nursing home or psychiatric hospital
admission, which would result in markedly higher costs to the health care system.
326
CONSULTANTS’ ESTIMATES ON COSTS OF TARGETED HOME CARE • APPENDIX G
RAI-HC data were used to identify home care clients with the presence of any of the
following aggressive behaviours: a) verbal abuse; b) physical abuse; or c) resisting care. The
point prevalence of aggressive behaviours of this type was estimated to be 4.9% in home care,
yielding 41,160 cases. However, 18.7% of these individuals die or are discharged from home
care (typically to long-term care) within 90 days. Also, about one-fifth of the remaining 81.3%
of those clients improve over time, such that they no longer demonstrate aggressive behaviours.
On the other hand, about 2% of the clients not showing aggression at baseline, behave
aggressively after 90 days. Therefore, within one fiscal quarter, one can expect to see 57,137
cases of aggressive home care clients. Since not all of these individuals require behaviour
management services over the entire quarter, groups that had a change in status were assigned
the mid-point of 45 days of service. Using RAI-HC data, the mean per diem cost of home care
for this group was estimated to be $35.15 (Standard Deviation (SD – $69.22). The distribution of
costs is highly skewed as demonstrated by a median cost of $18.16. However, the approach used
here, and for subsequent services, is to err on the side of over-estimation of costs using the
mean.
The quarterly costs were multiplied by four to yield an annual estimated cost of
$527,917,167. However, an additional 10 days per year of more resource intensive service
delivery (double the estimated per diem cost) is allocated to each case in order to support
specialized behaviour management teams working with these clients. The total annual costs of
behaviour management in home care is therefore estimated to be $568,084,478.
Post-acute Rehabilitation
Experts contacted by the research team suggested that about 15% of elderly acute care
clients in the United States receive rehabilitation through home care (Knight Steel, personal
communication). Data on acute care patients from the RAI-HIP study showed that 8% of
patients aged 75 and older were expected to receive occupational therapy on discharge and about
14% were expected to receive physical therapy on discharge. The recommended estimate of
15% of acute patients receiving rehabilitation was used in this estimate resulting in 167,471
cases. On the other hand, it might be reasonably argued that there is substantial untapped
potential for rehabilitation that could be addressed by better access to therapies. The
Commission recommended 28 days of service for this group. Using RAI-HC data for all home
care clients who had been hospitalized in the previous 14 days that were also receiving physical,
occupational or speech therapy, the mean per diem cost of home care was estimated to be $43.63
(SD – $70.94). The median cost for this group was $27.63. The total annual costs of post-acute
rehabilitation in home care is therefore estimated to be $204,588,685.
Post-acute Medical Care

The Health Services Utilization Research Commission (1998) reported that about 24% of
acute hospital patients in the Hospital and Home Care Study received post-acute home care. This
rate was multiplied by the 29% of the elderly population (3,849,897) to yield 267,953 cases. The
Commission recommended 14 days of service for this group. Using RAI-HC data for all home
care clients who had been hospitalized in the previous 14 days, the mean per diem cost of home
care was estimated to be $31.39 (SD – $58.76) and the median cost was $15.35. The total annual
costs of post-acute medical care in home care are therefore estimated to be $117,754,551.
327
Palliative Care
NCIC (1999) reported that there were 63,400 cancer deaths in Canada in 1999. These
individuals could all be presumed to have been eligible for palliative care. However, it is
important for palliative service to also be extended to other persons at the end of life (e.g.,
persons with renal failure, congestive heart failure, chronic obstructive pulmonary disease, ALS,
AIDS). Therefore, the number of cases was increased by an additional 20% to allow inclusion of
these other groups. It will also be true that not everyone will want palliative care at the end of
life, and some deaths will happen faster than expected prior to initiation of palliative services.
Therefore, an estimated two-thirds rate of uptake was used to identify 50,974 cases. The average
length of stay in palliative care programs varies considerably, in part due to differences in
eligibility criteria. The Edmonton palliative care program has an average length of stay of 21
days for an inpatient unit (Edmonton Palliative Care Program 2002). In contrast, the District of
Columbia estimates an average length of stay of 35 to 40 days for palliative home care in the
United States (DC 2002). The Commission recommended an average of 30 days of service for
this population. RAI-HC data were used to identify all home care clients who died and who had
any of these characteristics: a) the goal of care was palliative care; b) the client was reported to
be receiving hospice/palliative services; or c) the client was described as having end-stage
disease with an expectation of 6 months or less to live. The mean per diem cost of home care for
this group was $58.40 (SD – $101.82) and the median cost was $25.21. The total annual cost of
palliative home care is therefore estimated to be $89,305,747.
Con lusions
The estimates provided here are based on current Canadian practice patterns for the
identified core services. That being said, the total cost of the four services recommended by the
Commission to be core home care services is $979,733,461.
328
CONSULTANTS’ ESTIMATES ON COSTS OF TARGETED HOME CARE • APPENDIX G
Table G.1
Estimates of Costs of Home Care Services Recommended by the Commission
Canadian population (all ages) 30,750,087

Canadian population (65+) 3,849,897
Number of home care clients 840,000
Hospitalization rate (65+) 29%
Case Management and Behaviour Intervention

Point prevalence of home care clients with aggression 4.9%
Incidence rate of aggression in home care clients 2%
Number of cases 57,137
Days of regular care Up to 365
Mean cost per day (regular care) $35.15
Annual cost (regular care) $527,917,167
Days of intensive behaviour care 10
Mean cost per day (intensive behaviour care) $70.30
Annual cost (intensive behaviour care) $40,167,311
Annual cost (regular and behaviour care) $568,084,478
Post-acute Rehabilitation
Acute patients receiving home care rehabilitation 15%
Days of rehabilitation 28
Mean cost per day $43.63
Annual cost $204,588,685
Post-acute Medical Care

Acute patients receiving post-acute home care 24%
Days of medical care 14
Palliative Care
Cancer deaths 63,400
Other palliative cases 12,680
Expected uptake of palliative care 67%
Days of palliative care 30
TOTAL COSTS $979,733,461
329
330
Table G.2
Estimates of Costs1 of Regular Care for Clients Requiring Behaviour Management
Cost While Aggressive Behaviour Cost While Aggressive Behaviour
Present Not Present
Cost for All Cases Cost for All Cases
with Behaviour with Behaviour
% N Days Quarterly Cost Present Days Quarterly Cost Not Present
Number of home care clients 840,000
Prevalence of aggressive behaviour 4.90 41,160
Behaviour clients leaving home care
(e.g., death, discharge all reasons) 18.70 7,697 45 $1,581.75 $12,174,603
Behaviour clients still on service after 90 days 81.30 33,463
– Behaviour clients still on service after 90 days
whose behaviour has improved 21.40 7,161 45 $1,581.75 $11,327,069 45 $1,180.80 $8,455,826
– Behaviour clients still on service after 90 days
whose behaviour has not improved 78.60 26,302 90 $3,163.50 $83,206,317
Clients with no aggressive behaviour at baseline 95.10 798,840
– Clients with no aggressive behaviour at baseline
who develop aggressive behaviour after 90 days 2.00 15,977 45 $1,581.75 $25,271,303 45 $1,180.80 $18,865,405
Total for one quarter 57,137 $131,979,292 $27,321,231
Total for one year $527,917,167 $109,284,925
1 Assumes per diem cost of $35.15 for those with aggressive behaviour present and $26.24 for those with aggressive behaviour not present.
ACKNOWLEDGEMENTS
H
A large number of people offered me their advice and support throughout the
production of this report. I would like to specifically thank the following people for their
assistance:
Julia Abelson, Keith Banting, Monique Bégin, Robin Boadway, Nick Black, Allan E.
Blakeney, Patrick Cummings, Jack Davis, Michael Decter, Gérard de Pouvourville, Charles
Doran, Robert G. Evans, Colleen Flood, Ken Fyke, Christopher Ham, John Hobbs, Brian
Hutchison, John Hirdes, Alejandro R. Jadad, A.W. Johnson, David Kelly, Harvey Lazar, Pascale
Lehoux, Jonathan Lomas, Paul McDonald, Ian McKillop, Dale McMurchy, Jack Mintz, Steven
Morgan, Tom Noseworthy, Raymond Pong, Michael Rachlis, John G. Richards, Samuel E.D.
Shortt, Duncan Sinclair, Ingrid Sketris, Jim Stanford, France St. Hilaire, Terry Sullivan, Susan
Tett, Brian Topp, Charles Webster, Durhane Wong-Rieger and David Zussman.
I would also like to thank the provincial-territorial liaison contacts who were nominated
by Premiers to assist in information flow between the Commission and provincial-territorial
governments, and I would like to acknowledge the support provided by the Manitoba Centre for
Health Policy, and the federal, Saskatchewan and Manitoba Departments of Health.
331
LIST OF FIGURES,
TABLES, AND MAPS
FIGURES
1.1 Life Expectancy in Years, by Sex, at Birth and at Age 60,
Canada, Selected Years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 1.2
Life Expectancy in Years at Birth among OECD Countries, 1999 . . . . . . . . . . . . . . . . 12 1.3
Potential Years of Lost Life (Years Lost per 100,000 People)
among OECD Countries, 1998. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 1.4

Disability Adjusted Life Expectancy in Years at Birth
among OECD Countries, 1999. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 1.5
Infant Mortality (Rate per 1,000 Live Births) Canada, 1960 to 2000 . . . . . . . . . . . . . . 13 1.6
Infant Mortality (Rate per 1,000 Live Births) among OECD Countries, 2000. . . . . . . . 13 1.7
Perinatal Mortality (Rate per 1,000 Live Births) Canada and
the United States, 1960 and 1998 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 1.8

Perinatal Mortality (Rate per 1,000 Live Births) among OECD Countries, 1998 . . . . . 13 1.9
Potential Years of Lost Life: Malignant Neoplasms
(Years Lost per 100,000 People) among OECD Countries, 1998 . . . . . . . . . . . . . . . . . 15

1.10 Potential Years of Lost Life: Diseases of the Respiratory System
1.11 Potential Years of Lost Life: Cerebrovascular Diseases
1.12 Potential Years of Lost Life: Ischaemic Heart Diseases
1.13 Life Expectancy in Years at Birth, by Province, Territory and Canada, 1996 . . . . . . . . 17
1.14 Percentage of the Population Reporting “Unmet Health Care Needs,”
by Province, Territory and Canada, 2000/01. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

1.15 Self-reported Health as “Excellent” and “Very Good,”
by Province, Territory and Canada, 2000/01. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
1.16 Population Projections for Canada, Percentage of the Population
Aged 60 and Over, 2001 to 2051 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 333
1.17 Total Health Expenditures by Source of Finance, 1999 . . . . . . . . . . . . . . . . . . . . . . . . 24

1.18 Public Share of Total Health Expenditures as
Tax Funded and Social Security Funds, 1998. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
1.19 Share of Total Health Expenditures Paid “Out-of-pocket,”
among OECD Countries, 1998. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
1.20 Share of Total Health Expenditures Paid by Public Sector, 2000 . . . . . . . . . . . . . . . . . 27
1.21 Per Capita Total Health Expenditures (US$ PPP), 2000 . . . . . . . . . . . . . . . . . . . . . . . . 33
1.22 Total Health Expenditures as a Percentage of GDP, 2000. . . . . . . . . . . . . . . . . . . . . . . 33
1.23 Per Capita Public Health Expenditures (US$ PPP), 2000 . . . . . . . . . . . . . . . . . . . . . . . 33
1.24 Public Health Expenditures as a Percentage of GDP, 2000. . . . . . . . . . . . . . . . . . . . . . 33
1.25 Total Health Expenditures as a Percentage of GDP,
Canada, United States and OECD, 1970 to 2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

1.26 Public Expenditures as a Percentage of GDP,
Canada, United States and OECD,1970 to 2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
1.27 Per Capita Total, Provincial-Territorial and CHA Health Expenditures
(Constant 1997 Dollars) 1975 to 2001 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
1.28 Average Annual Rate of Change in per Capita Expenditures on CHA
and Non-CHA Services (Constant 1997 Dollars), 1976 to 2001 . . . . . . . . . . . . . . . . . . 35
1.29 Distribution of Provincial-Territorial Expenditures between CHA
and Non-CHA Services, 1975 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 1.30
Distribution of Provincial-Territorial Expenditures between CHA
and Non-CHA Services, 2001 (Forecast) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
1.31 Ratio of Annual Rate of Growth in Total per Capita Health Expenditures to
Annual Rate of Growth in GDP for Canada, 1960 to 1964, to 1995 to 2000. . . . . . . . . 39
1.32 Provincial-Territorial Government Sector per Capita Health Expenditures
(Constant 1997 Dollars), 1975 to 2001. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
1.33 Provincial-Territorial Health Expenditures as a Percentage of Program Spending,
1975 to 2001 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 1.34
Ratio of Total Health Expenditures to Economic Growth among OECD Countries
(US$ PPP), 2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
2.1 Federal Contribution to Provincial-Territorial Expenditures on Hospital

and Physician Services, 1974/75 to 2001/02. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 2.2
Federal Contribution to Total Provincial-Territorial Health Expenditures,
1968/69 to 2001/02 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
3.1 Distribution of Health-related R & D Expenditures in Canada ($Millions),

by Source of Funds, 1998 to 2001 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
334
LIST OF FIGURES, TABLES, AND MAPS
4.1 Total Number of Registered Nurses in Canada (per 100,000 People),

1980 to 2001 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 4.2
Number of Registered Nurses (per 100,000 People), by Province, 2001 . . . . . . . . . . . . 95 4.3
Total Number of General Practitioners/Family Physicians and Specialists
(per 100,000 People), 1980 to 2001 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 4.4

Number of General Practitioners/Family Physicians (per 100,000 People),
by Province, 1980 and 2001 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 4.5
Canadians Physicians Moving Abroad and Returning from Abroad, 1996 to 2001 . . . 102
6.1 Selected Imaging Technologies (Number per Million People)

among OECD Countries, 1999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 6.2
Selected Imaging Technologies (Number per 100,000 People),
by Province and Canada, 2001 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
7.1 Population Counts (Thousands) for Canada, Provinces and Territories,

and Census Division by Urban and Rural, 2001 Census – 100% Data . . . . . . . . . . . . 160
8.1 Estimates Percentage Distribution of Home Care Expenditures,

by Source of Finance, 2000/01 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 8.2
Provincial-Territorial Home Care Expenditures as a Percentage
of Total Provincial-Territorial Health Expenditures, 2000/01 . . . . . . . . . . . . . . . . . . . 175
8.3 Provincial-Territorial Hospital and Home Care Expenditures ($Millions),
1980/81 to 2000/01 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 8.4
Inpatient/Acute Care Admissions, Age Standardized (Number per 100,000 People),
Canada, 1994 to 1999. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 8.5
Inpatient/Acute Care Hospitalizations: Average Length of Stay, Aged 65+,
Canada, 1994 to 1999. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
9.l Coverage of Prescription Drug Expenditures, by Source of Finance, 1999 . . . . . . . . .

195 9.2 Prescription Drug Expenditures as a Proportion
of Total Health Expenditures, 1980 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196 9.3
Prescription Drug Expenditures as a Proportion
of Total Health Expenditures, 2001 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197 9.4
Manufacturers’ Sales ($Billions) of Patented and Non-Patented Drugs,
1990 to 2001 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
10.1 NIHB Annual Expenditures by Benefit ($Millions), 1991/92 . . . . . . . . . . . . . . . . . . . 216

335

10.4 Life Expectancy at Birth, Registered Indian Population, 2000 . . . . . . . . . . . . . . . . . . 218
10.5 Life Expectancy at Birth, Aboriginal Peoples and Canadian Population, 1991 . . . . . . 219
10.6 Population Projections for the Aboriginal Population in Canada,
by Age Group, (Thousands), 2001 to 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219

10.7 Incidence of Diabetes among First Nations and Canada, by Age Group, 1991 . . . . . . 220
ABLES
1.1 Average Annual per Capita Expenditure, by Age and Sector, 2000/01 . . . . . . . . . . . . . 22
1.2 Private Sector Health Expenditures, by Source of Finance and Use of Funds,
Canada, 1999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 1.3
Reductions in Federal Transfers Under the Canada Health Act ($Thousands). . . . . . . . 38
2.1 Allocation Formulas for the Cash Base of Health and Social Transfers . . . . . . . . . . . . 69 2.2
Estimates of CHST Transfers and Required Additional Funding under
a Canada Health Transfer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 2.3
One Time Bridge Funding to the Canada Health Transfer ($Billions). . . . . . . . . . . . . . 71
4.1 Percentage Change in the Number of Selected Health Professionals

(Number per 100,000 People), 1991 to 2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 4.2
Distribution of International Medical Graduates, by Province, 2001 . . . . . . . . . . . . . . 103 4.3
Policy and Planning Responsibilities across Canada . . . . . . . . . . . . . . . . . . . . . . . . . . 112
7.1 Health Status for Populations in Predominately Urban, Intermediate

and Predominately Rural Health Regions in Canada, 1996 . . . . . . . . . . . . . . . . . . . . . 161
9.1 Utilization of Prescriptions, 2001 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192 9.2

Increase in Spending for Six Categories of Pharmaceuticals
in the Quebec Drug Insurance Program, 1997 to 2000 . . . . . . . . . . . . . . . . . . . . . . . . 193
10.1 First Nations and Inuit Health – Transfer Payment – 2001/02. . . . . . . . . . . . . . . . . . . 213
10.2 Program Coverage for Different Aboriginal Populations in Canada,
1999/2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215 10.3
Federal Transfers to Territorial Governments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
336
LIST OF FIGURES, TABLES, AND MAPS
MAPS
1.1 Acute Care Facilities in Canada, 1999/2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 1.2
Hip Fracture Hospitalizations by Health Region, 1999/2000. . . . . . . . . . . . . . . . . . . . . 19 1.3
Ambulatory Care Sensitive Conditions by Health Region, 1999/2000 . . . . . . . . . . . . . 21
4.1 General/Family Physicians by Health Region, 1999 . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 4.2

Specialist Physicians by Health Region, 1999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
5.1 “Former” Smokers, by Health Region, 2000/01 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 5.2

“Current” Smokers, by Health Region, 2000/01 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 5.3
Leisure Time Physical Activity, by Health Region, 2000/01. . . . . . . . . . . . . . . . . . . . 133
6.1 Scanners in Canadian Hospitals, 2001 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 6.2

Heart Transplant Recipients, under 18 Years of Age,
by Province of Treatment, 1996 to 1999. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 6.3
Liver Transplant Recipients, under 18 Years of Age,
by Province of Treatment, 1996 to 1999. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 6.4
Single/Double Lung Transplant Recipients, under 18 Years of Age,
by Province of Treatment, 1996 to 1999. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
337
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THE UT REOF E LTH RE F

Perpustakaan Nasional Kanada Katalog dalam publikasi data

Komisi masa depan perawatan kesehatan di Kanada

Membangun nilai: masa depan perawatan kesehatan di Kanada laporan akhir

Komisaris: Roy J. Romanow.

GuidÈ par NOS valeurs: l'Avenir des soins de SantÈ au Canada

3. kebijakan medis Kanada.

RA 412.5 C2S52 2002 362.1 ' 0971 C2002-980275-X

TO HER EXCELLENCY THE GOVERNOR IN COUNCIL

I am pleased to report that my Commission’s multi-faceted consultations with Canadians

and evidence available in coming to my conclusions and recommendations.

Roy J. Romanow, Q.C.

A MESSAGE TO CANADIANS ......................................................... xv

EXECUTIVE SUMMARY .............................................................. xxiii

2 HEALTH CARE, CITIZENSHIP, AND FEDERALISM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

3 INFORMATION, EVIDENCE AND IDEAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

4 INVESTING IN HEALTH CARE PROVIDERS ..................................... 91

5 PRIMARY HEALTH CARE AND PREVENTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

6 IMPROVING ACCESS, ENSURING QUALITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

7 RURAL AND REMOTE COMMUNITIES ......................................... 159

8 HOME CARE: THE NEXT ESSENTIAL SERVICE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171

10 A N EW APPROACH TO ABORIGINAL HEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211

11 H EALTH CARE AND GLOBALIZATION ......................................... 233

LIST OF FIGURES, TABLES AND MAPS ............................................ 333

BIBLIOGRAPHY ........................................................................ 339

Canadians Remain Attached to the Values at the

Medicare Has Served Canadians Extremely Well

The System Is as Sustainable as We Want It to Be

Canadians Want and Need a Truly National

Canadians Want and Need a More Comprehensive

Canadians Want and Need a More Accountable

Making Canadians the Healthiest People in the World

A System Based on Canadian Values

a new Canada Health Act .

expression of social cohesion. Let’s unite to keep it so.

Roy J. Romanow, Q.C.

Chapter 1 – Sustaining Medicare

Directions for Change

Create a Health Council of Canada to facilitate collaborative leadership in health

Address immediate issues through targeted funding

Directions for Change

should be treated as an offense under the Criminal Code of Canada.

Expand the scope, effectiveness and co-ordination of health technology assessment

Create new research centres for health innovation

Directions for Change

Substantially improve the base of information about Canada’s health workforce

Chapter 5 – Primary Health Care

Directions for Change

Integrate prevention and promotion initiatives as a central focus of primary health

Implement a new national immunization strategy

Chapter 6 – Improving 2ccess,

Directions for Change

Implement better ways of managing wait lists

Address the diverse health care needs of Canadians

Chapter 7 – Rural and

Directions for Change

Expand telehealth to improve access to care