CANADIAN HEALTH CARE SYSTEM R.A. Spasoff Dept of Epidemiology and Community Medicine

1. MAIN COMPONENTS OF HEALTH CARE SYSTEM Health Professionals... Institutions (places with beds)... Community Agencies... Funders (mainly governments)... Industry... Planning/Coordinating agencies... The public...

Health Professionals Doctors: family physicians, specialists Nurses: BScN, RN, RNA Other health professionals: dentists, physiotherapists, social workers, etc. Chiropractors? Homeopaths? Naturopaths? Reflexologists? Home-makers? Where to stop?

Supply of Physicians & Nurses (Number /100,000 population, 1998) CanadaOntarioQuebec Doctors Generalists Specialists Nurses employed in nursing (only 51% are full-time) Total Note that these numbers are declining.

Supply of Institutions (Beds/1,000 population, ) CanadaOntarioQuebec All institutions Hospitals Short-term* Rehabilitation Long-term Residential *Numbers sharply down.

Community Health Agencies Public Health Units... Community Health Centres... Community Care Access Centres (CCAC)... Voluntary/charitable agencies...

Public Health Units Responsible for communicable disease control, environmental protection, health promotion, etc. Run by local governments (Ontario, 50% provincial funding), regional councils (Quebec, 100% provincial funding) Locally, City of Ottawa Health DepartmentCity of Ottawa Health Department

Community Health Centres (CHCs)CHCs Organized clinics (six in Ottawa) offering a range of health and social services Sponsored by the community and funded by various agencies Medical component funded by Ontario Ministry of Health, on global budget basis

Community Care Access Centres (CCACs) New agencies intended to coordinate long- term care, especially for elders Incorporate home care, patient assessment Funded by Ontario Ministry of Health

Voluntary/charitable agencies Often disease-oriented Range of functions, e.g., advocacy (Canadian Mental Health Association), research funding (Arthritis Society), service provision (Meals on Wheels) Some derive much of their funding from providing services to public agencies on contract (VON)

Funders Governments, especially provincial governments Private insurers (for services not covered by public plan) Charitable foundations (mainly fund research) Consumers (for services not covered by any plan)

Industry Pharmaceutical manufactures Manufacturers of medical devices Insurance (limited; see above) Management consultants, sometimes hired to manage an institution

Planning/Coordinating agencies Ministries of Health, especially provincial (health is a provincial responsibility) Local Health Integration Networks –Champlain LHIN plans health services for Renfrew, Ottawa-Carleton and Eastern Ontario/Seaway Valley Regional Health Boards –All of other provinces

The public Patients Voters Self-Help groups Patients’ rights associations Self care and family caregivers Board members

Is it well-named? Is it Canadian? –Yes, so far, but American hospital and insurance corporations are clamouring to get in Is it a health system? –Mostly health care, actually illness care (well over 90% of all spending is for curative care) Is it a system? –More of a network, rather uncoordinated because most of its components are privately owned and operated

Is it public or private?public or private Public payment of private providers. Most hospitals are private, not-for-profit corporations; most doctors are in private practice; those working in hospitals are not employed by the hospital This arrangement is unique to Canada. Cf USA (private-private), UK (public-public)

Is It Population-Based? Not very: hospitals do not have defined catchment areas, doctors do not have defined patient populations, and population- based components like LHINs and PHUs are relatively weak. Canadians have chosen freedom of choice over population-based health care planning

Can we define its boundary with the social services system? Not very precisely. Interfaces with social services at many places, e.g., community health services like home care, seniors’ housing, Children’s Aid Societies We tend to draw the boundary on the basis of which government ministry pays for a service (but this often differs across jurisdictions)

2. FUNDING OF CANADIAN HEALTH CARE SYSTEM

Where does the money come from? (1)

Where does the money come from? (2)

Where does the money come from? (3) Public-private split: about 70% from government and falling, lowest in ON, AB. Federal-provincial split: by 1995, federal contributions had fallen to 31% of total public spending (22% of total health expenditures), from original 50% Health care spending accounts for over 30% of most provincial government budgets

Where does the money go? (1) Hospitals31.8% Other Institutions 9.4% Physicians13.4% Other Professionals11.8% Drugs15.5% Other18.1%

Where does the money go? (2) Drugs are fastest growing sector (mainly due to increased patent protection), while expenditures on physicians, hospitals and capital are declining (doctors exert their influence on health care costs through their clinical decisions, not their earnings) Other (1996): payment administration 2.4%, public health 5.5%, health research 1.1%

How much money? (1) Total Health Expenditures, Canada, in billions of dollars

How much money? (2)

How much money? (3) Average of $2,600 per Canadian per year; range $2,297 (Quebec) to $2,746 (Ontario) Elders (aged 65+) account for 39% of health care spending, but only 12% of population Variations in health care spending as % of Gross Domestic Product (GDP) are much affected by changes in GDP

Is it the right amount of money? Canada is the 10th highest spender in absolute terms, and falling We have a relatively young population US spends too much (14% of GDP); UK probably spends too little (just under 6% GDP) No one knows what amount is appropriate. Among developed nations, there is no correlation between amount spent and health status of population

3. DECISION-MAKING IN CANADIAN HEALTH CARE

Who makes the big decisions? Federal government... Provincial Ministries of Health... Regional Health Boards (all provinces except Ontario); Local Health Integration Networks [formerly District Health Councils] (Ontario)... Hospital boards... Hospital administrators (presidents)...

Role of Federal Government Has the greatest taxing power Its provision of funding allows it to enforce the Canada Health Act, despite its lack of constitutional authority... Reductions in federal contributions will reduce its influence

Canada Health Act Provincial plans must meet 5 conditions: –Universality: entire population must be covered –Comprehensiveness: all “medically necessary” medical and hospital services must be covered –Accessibility: in practice, no user fees –Portability: benefits must be portable from province to province. –Public administration: plans must be operated by a public (governmental) agency. Mnemonic ‘UnCAPP’

Role of Provincial Governments The constitution assigns responsibility for health (and most other expensive services) mainly to the provinces Provinces provide most of the funding for health services Therefore, they are the main decision- makers

Role of Regional Boards Regional Health Boards (all provinces except Ontario) are responsible for planning and sometimes for allocating resources to local health services District Health Councils (Ontario) were the old planning and advisory bodies; their mandate was unclear and continually changing. They were replaced by the Local Health Integration Networks in 2006; not yet clear what has changed

Role of Hospitals Hospital boards collectively wield much influence, partly because their members are often selected for their political connections Hospital administrators (presidents) have enormous and growing power at the local level

Role of the Medical Profession Modest influence at the macro level (policy-making) through advisory role, although perhaps less than in the past Doctors makes the key decisions in patient care, and thus have immense influence on how well the system works, at micro level

Role of the Public Traditionally, passive consumers Population health requires the system to be responsive and accountable to the public Patients’ rights and other advocacy groups often involve both providers and consumers Members of the public dominate advisory councils and hospital boards (but are these non-elected bodies representative?)

4. IS IT A GOOD SYSTEM?

What we mean by “good”? Effective in treating disease? –Seems pretty good, but we don’t monitor this much Efficient in treating disease? –Less good than many other systems Effective in promoting health, preventing disease? –Only fair, based on surveys and expenditures Accountable to the public? –Not very: providers and consumers are not clearly linked

Is it the “best in the world”? UN report ranks it 30th overall, mainly because of of its high cost. This falls to 35th when our high income and education levels are considered (they think we should do better than we do) France is first overall (and spends 9.8% of its GDP on health care). Japan is 10th (7.1%), UK 18th (5.8%), US 37th (13.7%)

Strengths of the System Very well resourced, relative to most countries Minimal financial barriers to access; one- tier system contributes to equity Probably provides a rather high quality of services Our most popular social program, central to our Canadian identity

Weaknesses of the System Inefficient Fragmented Still rather institutionally dominated Does not emphasize prevention Not very accountable to the public Not very well equipped to address population health

5. FUTURE DIRECTIONS Institutional down-sizing: shift to community care Increasing coordination: hospital mergers, community hospital management boards Primary care reform: payment of groups of physicians by capitation Integrated Delivery Systems: responsible for all care required by a defined population Increasing privatization: insurance, hospital management, perhaps provision of services

References Canadian Institute for Health Information, Health Care in Canada (Available, with other relevant reports, at Shah CP. Public Health and Preventive Medicine in Canada (4 th ed), Part 3, Canada’s Health Care System, pp