The Romanow Commission has embarked on a daunting and very important task – to evaluate a wide range of issues related to understanding and strengthening Canada’s health system and health care system. The Commission has challenged Canadians to engage in a dialogue on the future of this defining institution. The timing is critical, as we now are at a crossroads. Resource constraints are forcing us to face three options (not necessarily mutually exclusive): finding more money; considering greater rationing on the basis of medical necessity; or rationing more on the basis of ability to pay (relying on market mechanisms).
The RNAO submission is organized around the four themes identified by the Commission. Section A addresses the starting point – Canadian values. Universal access and the enduring principles of the 1984 Canada Health Act are now at the core of Canada’s soul. Although medicare is relatively new, the principles flow from a strong Canadian tradition of collective action for the common good. Canadians quickly embraced medicare, and it has achieved iconic status. Section A traces the development of the health care system, which remains incomplete, but still a monumental achievement.
In recent years, a gradual erosion of access via privatization represents a challenge to the system. We call on all levels of government to reaffirm their commitment to all of the principles of the Canada Health Act: universality, accessibility, comprehensiveness, portability and public administration.
Section B discusses growing challenges to sustainability. An examination of health care spending reveals that spending is not out of control. Rather, the problem is that government spending is sharply shrinking as a share of Gross Domestic Product (GDP). This jeopardizes the sustainability of all social programs, including health care. We
call on government to take appropriate macro steps to protect health and health care:
Recognizing the importance of employment to population health, government should make full employment a high priority.
Recognizing that providing health care and other essential public services costs money, governments should be fiscally prudent, and not engage in tax cuts before alternative revenue sources are found. These alternatives
could include health-promoting options such as green taxes.
Recognizing that health care has failed to keep pace with economic growth, government should consider heeding the call to devote a stable share of GDP to health care expenditures Government must respond to a number of
urgent issues concerning health care:
Long waiting times for certain procedures are a major public concern. Better management of waiting lists and – in some instances, more resources – are required.
Far too many health care providers face unsustainable workloads and intolerable work circumstances. This is particularly true for the nursing profession. Urgent attention and collaboration is required at the federal and provincial levels.
Drug expenditures are running out of control. A comprehensive response is needed, including support to best-practice prescribing, co-ordination of purchasing, a national drug formulary, and an aggressive response to monopoly drug pricing.
Credible commitments to health care must be made at both levels of government. This will require leadership by all concerned.
Government must explicitly exclude health care and other essential social services from free trade agreements. These services are already dangerously exposed to challenges under existing agreements, and must be protected.
Evidence from Canada, the US and elsewhere is very strong: public payment for health care services not only yields better access and improved health outcomes, it is also cheaper. The evidence also leads us to conclude that not-for-profit provision is superior in terms of efficiency, cost and quality. Given the evidence, we make the following
There should be a moratorium on privatization of health care funding, and on transfer of provision to for-profit institutions.
User fees should be banned for any essential health care services. These user fees constitute a barrier to access for poor people, and do not save the system money in the long run, because they do not discriminate between appropriate and inappropriate use of the system.
Canada must find a way to extend coverage of the Canada Health Act to all uncovered areas, including home care, pharmacare, long-term care, rehabilitation services, public health and truly comprehensive primary health care. The path will take time, cannot be done all at once, and must be responsive to fiscal realities.
The federal government must raise its cash contribution to 25% of provincial health care spending, and tie this contribution to the above expansion of coverage of the CHA.
In addition to the above recommendations, there are a number of other ways to enhance sustainability by improving delivery. Section C includes recommendations on efficiency and effectiveness, and recommendations on accountability and governance.
Efficiency and Effectiveness:
There is broad agreement among health care experts on the need to commit fully to primary health care reform, with 24/7 service being delivered by interdisciplinary teams. This would enhance the scope and quality of services delivered, and reduce the costly and unnecessary use of the hospital system.
Government must commit more resources on a permanent basis to the integration of prevention and population health concepts into policy. We as a society must address all of the determinants of health: income, income
distribution, employment, stress, environment and social support. There is a role for all sectors of government, and not just the health care sector.
Government must introduce more appropriate incentives for users, providers and providing institutions. For
example, the fee-for-service mechanism rewards assembly-line medicine and punishes more conscientious treatment.
Government should strengthen its support for the systematic identification and implementation of more effective and responsive health care interventions. We know that many physicians could improve their practice by implementing existing best practice guidelines.
Accountability and Governance:
The public wants greater participation in the governance of our health care system, along with greater accountability and transparency. Accountability and transparency offer mechanisms for promoting more effective and efficient delivery of care and system utilization.
Government must continue to devote resources to improving co-ordination and integration of health care. The creation of regional health authorities has been one approach widely used, and is a step in the right direction.
A national health care advisory council formed by the two levels of government could perform a number of important functions:
consultation on health policy
provision of a forum for collaboration in defining the scope of medicare programs
monitoring of programs facilitation of co-operation in improving the efficiency and
effectiveness of health care programs (including setting up an information system that could allow cost-benefit analyses of health treatments) performing an accountability service
Section D addresses the challenges of implementing our vision:
Canadians’ confidence in government commitment to medicare has been shaken, and can only be regained by consistent and substantial steps by governments determined to show leadership The lack of co-operation and co-ordination between provinces and the federal government is a serious hindrance.
Many domestic and foreign interests would gain from the Americanization of the Canadian health care system, at the expense of the health of Canadians.
There are powerful and well-placed interests promoting unhelpful forms of deregulation, globalization and withering
of the state. Arrayed against them are many citizens’ groups. In spite of this opposition, Canada has already endured considerable harmful restructuring, such as the weakening of the social safety net.
Proponents of the traditional methods of organizing health care (curative, physician-centred, fee-for-service, etc.) are still predominant. The good news is that the public is not ready to let go of Medicare – a system that for the most part has served them well. Indeed, in our public forums we have become keenly aware that the public is looking for leadership to sustain and strengthen Medicare. The public wants universal access to essential health care services and does not mind paying taxes for it. However, they want assurances that the system will be there for them when needed.
Section E speaks to federal-provincial relations. It calls on both sides to put aside disagreements and find ways to fully realize universal access to essential health care services in Canada. In particular, it invites the federal government to be inventive in finding ways within its power to extend coverage of medicare over uncovered areas. Experts suggest that national home-care and pharmacare programmes would be ideal starting points.
Universal access to essential health care services is a simple and compelling idea. It fits squarely with Canadian values, and it makes good health and economic sense.
Fully realized, it would be the completion of a visionary dream, and a tool for a positive national unity. We must do more than merely save our health care system – we must make it the envy of the world. It will be a major undertaking, but anything of enduring value takes real commitment, vision and work. We owe that much to the people whose struggles have brought us this far.