Caring about health

The Canadian Public Health Association Issue Paper on Federal/Provincial/Territorial Arrangements for Health Policy

Preamble

The Canadian Public Health Association (CPHA) is a national, independent, not-for-profit association representing public health in Canada with links to the international public health community. CPHA's members believe in universal and equitable access to the basic conditions which are necessary to achieve health for all Canadians.

In addition to social, economic and lifestyle factors, CPHA has always been concerned about the direction and structure of Canada's health care system as an important determinant of health status.

When a convergence of pressures threatened to erode the principles of the national health care insurance system at the beginning of the last decade, CPHA joined with other organizations to support introduction and passage of the Canada Health Act. In 1983 CPHA passed a resolution pledging the Association to work actively to support the maintenance of a health care insurance system in which the five principles of Medicare are upheld.

Now as Canada's health care system has once again come under the scrutiny of public attention partly in response to tensions resulting from escalating costs and recurring concerns about quality of care, CPHA has acted in the interests of better health and health care for all Canadians.

In the fall of 1991 a CPHA working group on Canada's Health Care System headed by President Fran Perkins and President-elect Merv Ungurain met with Dr. Michael Rachlis, noted author, authority, and spokesperson on health and Canada's health care system, to develop an issue paper that would help guide CPHA's activities in this area.

A first draft of the paper was presented to the CPHA Board of Directors in December 1991 where the content was endorsed. Following additional consultations with the Board, the paper, Caring About Health, is ready for release.

The author of this paper is Dr. Michael Rachlis to whom the Association owes a debt of gratitude for his contribution of time, expertise and experience. In the on-going process of developing and communicating the position of public health on the future of Canada's health care system CPHA is indebted to the volunteer members of the working group, Fran Perkins and Merv Ungurain for their contributions.

Executive Summary

The Evolution of Medicare and its Problems

There were almost no formal health care services at the time of confederation. There was no permanent board of health until the second decade after 1867. During the latter third of the nineteenth century, health policy was, essentially, public health policy. The provision of clean water, adequate housing, and safe food and the removal of sewage were largely responsible for ending the epidemics of infectious diseases which plagued cities after the industrial revolution. These public health measures have been responsible for the majority of the improvement in population health in the last one hundred years.

Scientifically-based medicine began to develop in the early twentieth century. By the second world war advances in surgery, anesthesia, diagnosis, pharmaceuticals and other areas had made modern medicine appear invincible against disease. It was at this time that Canada and other western nations developed national health programs. Medicare reflected the uncritical belief that scientific medicine could solve most of society's health problems.

The majority of medicare's basic principles are as sound now as they were 40 years ago. For example, public administration results in universal coverage and lower overhead. The accessibility criterion prohibits user charges. Many studies have concluded that user charges deter the people who need care most and increase, not decrease, overall costs of health care. However, the 1940s paradigm of health, illness, and health care has proven to be an incomplete view. The social, physical, and economic determinants of health have proven to be more significant for determining the overall health of the population. Even an excellent health care system cannot compensate for the structural inequalities which lead to so much premature death and disability. Furthermore, the health care system, although staffed by dedicated persons, has many structural inefficiencies.

No particular group or party is responsible for these problems which currently affect our health policy. However, national leadership is a necessary condition for reform.

A Vision for Canada 's Health Policy

There is considerable guidance which may be drawn from the Constitution, the Canada Health Act, and various federal and provincial/territorial government reports of the past five years.

1. The federal and provincial/territorial governments are committed to providing essential public services of a reasonable quality across the country.
2. Health policy is much more than simply health care policy and therefore governments must coordinate overall strategies to protect the health of their populations.
3. Health services are very important to Canadians and the federal and provincial/territorial governments are committed to providing funding for government-operated health plans.

Recommendations

1. Canada needs to establish an overall strategy for health. This strategy requires clear goals for health status and a multisectoral approach. The federal and provincial/territorial governments should take the responsibility for creating the overall environment which is conducive to the achievement of the established goals.
2. National leadership is required to achieve health goals. National health goals should be broad in nature and related to the remediation of structural societal inequalities.
3. The federal government should consider pooling some of its existing transfers to the provinces and individuals (e.g. the funding transferred to the provinces under the Established Programs Financing Act and the Canada Assistance Plan and the funding to individuals under the family allowance and old age security programs) to establish new programs which would more effectively reduce social and economic inequality and improve health status. This new funding structure should involve enhancement of disease prevention, community health and health promotion activities.
4. To facilitate the measurement of the attainment of the health goals, regular health surveys should be conducted at the national level.
5. Because legislation in other areas often has a significant impact on health status, the federal and provincial/territorial governments should institute appropriate health impact assessments of proposed policies.
6. The federal government should ensure that enough targeted cash is transferred to the provinces/territories to provide reasonable equality of health and social service delivery across the country and to permit compliance with national standards for health insurance. This cash should grow at the same rate as the country's gross national product (GNP).
7. National leadership is required to reform the health care system. A national conference should be convened with federal and provincial/territorial representatives to define the criteria for health insurance and the process for compliance with them.
8. The federal and provincial/territorial governments should initiate new cost-shared programs to encourage projects in specific areas of need such as the frail elderly, community mental health and health promotion.
9. A National Health Council should be established which would take the responsibility and authority for strategic research and development of standards for quality assurance programs for health professionals and institutions.
10. The National Health Council should have representation from governments, consumers, and the various providers of health care. A voting majority of the council should represent governments and consumers. Some of the council might be appointed by different levels of government, others might be elected from specific sectors (e.g. consumers, public health, medicine, nursing, institutions, etc.).
11. The National Health Council should take the initiative in technology assessment and the establishment of clinical standards for health professionals. The council should also take the responsibility for establishing priorities for biomedical, health promotion, and health services research.
12. Research and development in health and health care should be increased by 0.2% of total health spending per year until it reaches 3% of the overall health budget. An increased share of the allotment should be targeted to public health research including epidemiology, quality assurance, health services organization and management operations research.
13. Within these recommendations, the provinces and territories should still be responsible for the routine operation of the health care systems. The federal government, if it complied with recommendation No. 6, would continue to transfer cash to the provinces/territories for their health care programs. It would retain the right to withhold some of these funds if a province breached national standards for health insurance.