1. Health System Change and Reform in Canada Monitoring Health System Change/Health Reforms PAHO/WHO Seminar, Belize, 30 May 2006 Gregory P. Marchildon Canada Research Chair in Public Policy and Economic History Graduate School of Public Policy, University of Regina

2. G.P. Marchildon Graduate School of Public Policy 2 Outline of Presentation Organization Fiscal Resources Physical and Human Resources Health Services Health Reforms: Phase I Health Reforms: Phase II Performance Indicators

3. Public, Mixed and Private Systems of Health Care FundingAdministrationDelivery Public Canada Health Act services (hospital and physician services plus) and public health services Public TaxationUniversal, single-payer provincial systems. Private self-regulating professions subject to provincial legislative framework Private professional, private not-for-profit, private-for-profit and public arm’s-length facilities and organizations Mixed goods and service, including most prescription drugs, home care and institutional care services Public taxation, private insurance and out-of- pocket payments Public services that are generally welfare-based and targeted, private services regulated in the public interest by governments Private professional, private not-for-profit and for-profit, and public arm’s-length facilities and organizations Private goods and services including most dental and vision care as well as over-the-counter drugs and alternative medicines Private insurance and out- of-pocket payments including full payments, co-payments and deductibles Private ownership and control; private professions, some self regulating with public regulation of food, drugs and natural health products Private providers and private for-profit facilities and organizations

4. Organization of the Public Health Care System Canadian Constitution Provincial and Territorial GovernmentsFederal Government Canadian Institutes for Health Research Statistics Canada Minister of Health Regional Health Authorities Ministries of Health Mental Health and Public Health Home Care and Long- Term Care Single Payer Hospital, primary care and physician Services Canada Health Act, 1984 Health Canada Public Health Agency of Canada Patent Medicine Prices Review Board Provincial and Territorial Prescription Drug Subsidy Programs Federal-Provincial- Territorial Advisory Committees and Councils Transfer payments Canada Health Infoway Canadian Coordinating Office of Health Technology Health Council of Canada Canadian Institute for Health Information Canadian Blood Services

5. G.P. Marchildon Graduate School of Public Policy 5 Revenue Sources for all Health Expenditures, 2003

6. Overview of Canadian Health System: Expenditure Perspective Private Sector 30.4% Private Health Insurance Other Dental and vision care, drugs, complementary and alternative medicine, and some long term care and home care Out-of-Pocket Expenditures Commercial Insurance Firms Not-for-Profit Insurance Firms Public Sector 69.6% Provincial Government Sector 63.3% Hospitals Long-term Care Other Public Sector 6.3% Federal Direct 4.2% Municipal (Public Health) 0.7% Community Care Social Security Funds 1.4% Quebec Drug Insurance Fund Physician Remuneration Provincial Drug Plans Home Care Regional Health Authorities Total Health Expenditures 2005 $142 Billion Worker’s Compensation

7. Trends in Health Expenditures, 1976-2005

8. G.P. Marchildon Graduate School of Public Policy 8 CHA $55.7B 39.2% Canada Health Act Expenditures as a Share of Total Health Care, 2005

9. G.P. Marchildon Graduate School of Public Policy 9 1998199920002001200220032004 1998- 2004 Provincial/Territorial Rx plans except Quebec 10.713.316.614.612.210.411.712.8 Quebec Rx Plan 26.821.025.914.318.622.412.520.2 NIHB Rx Plan 7.63.79.6 9.512.911.39.2 Private Rx Plans 15.620.1-12.432.511.59.69.812.4 Hospital Expenditures 5.14.28.35.46.87.15.76.1 Physician Expenditures 4.84.36.27.7 6.44.86.0 Gross Domestic Product 3.77.49.62.94.25.46.15.6 Annual Growth Rates of Prescription Drug (Rx) Plans, other Components of Health Expenditures and Canadian GDP, 1998-2004 (Current Prices)

10. Total Health care expenditures as a share of GDP in Canada and selected countries, 1960 to 2002

11. Public Health Care Expenditures as a share of GDP in Canada and selected countries, 1960 to 2002

12. Comparison of Selected Imaging Technologies (per million)

13. Health Care Personnel in Canada (per 1,000 people), 1991-2003 1991199520002003 Family Physicians 1.071.031.000.97 Specialist Physicians 1.051.081.100.91 Registered Nurses n/a7.937.587.60 Dentists 0.520.540.560.58 Pharmacists 0.710.760.800.87 Physiotherapists 0.390.430.470.49 Optometrists 0.10 0.110.12 Medical Laboratory Technician 0.700.650.580.60 Medical Radiation Technologists 0.500.490.470.48 Occupational Therapists 0.190.240.290.33 Psychologists 0.330.380.410.45 Chiropractors 0.140.150.180.21 Midwives 0.00 0.01

14. Province% Decline British Columbia Alberta Saskatchewan Manitoba Ontario Quebec New Brunswick Nova Scotia Prince Edward Island Newfoundland and Labrador -14.6 -2.8 -19.2 -12.2 -12.3 -14.2 -12.1 -19.1 -12.8 -21.3 Canada-12.9 Decline in the number of recorded hospital admissions for Canada and provinces, 1995-2001 Note: The % decline is calculated on age-standardized hospitalization rates for all conditions, per 100 000 population

15. Comparison of Active Physicians (per 1,000), 1980 to latest year

16. Comparison of Active Nurses (per 1,000), 1980 to latest year

17. G.P. Marchildon Graduate School of Public Policy 17 Health Services I Public health Primary care Secondary/inpatient care Rehabilitation/intermediate care Long-term care, home care and other community care Prescription drugs …

18. G.P. Marchildon Graduate School of Public Policy 18 Health Services II Palliative care Mental health care Dental health care CAM products and services Maternal and child health care Services for informal caregivers Aboriginal Canadians

19. G.P. Marchildon Graduate School of Public Policy 19 Health Reforms I, 1988-1996 Public fiscal restraint due to –Rapidly growing health care costs –High public debt Cost-cutting and disinvestment and patient dissatisfaction but also… Profound Organizational and Managerial change: integration and coordination The regionalization revolution

20. G.P. Marchildon Graduate School of Public Policy 20 Health Reforms II, 1997 to now Public reinvestment and growing costs Rival hypotheses as to cause and effect –Public-private debate: delivery and financing Major Consensus –Primary Care Reform –Managing system: regionalization and integration Post-Chaoulli –Move from delivery to heart of medicare –Single-payer administration and finance

21. Performance Indicators

22. Life Expectancy and Mortality Indicators, 1970-2001

23. Factors Influencing Health Status, 1981- 2002 1981198619911996199719981999200020012002 Total calories intake (per capita) 2337241123562585n/a27152725273227572788 Alcohol consumption (litres per capita, 15+) 97.892.283.477.878.579.880.881.280.681.1 Daily smokers (% of pop.)32.828.325.924.523.823.720.919.818.017.8 Obese population (% of total pop. BMI > 30kg/m2) n/a 12.2 14.6n/a14.5n/a14.9 Immunizations Measles (% of children >2 years of age) n/a 97.096.096.2n/a Diphtheria, Tetanus and Pertussis (% of children >2 years of age) n/a 87.186.884.2n/a

24. Table 2.3A: Overall Provincial Performance Based on Conference Board of Canada’s Weighted Count of Health Indicators Province and RankingWeighted Count Number of Indicators Reported Weighted Count per Reported Indicator 1. British Columbia1531171.31 2. Alberta1331191.12 3. Saskatchewan1251111.13 4. Ontario1221131.08 5. Quebec121 991.22 6. New Brunswick113 1.00 7. Prince Edward Island104 1.00 8. Newfoundland and Labrador 981030.95 9. Nova Scotia 981140.86 10. Manitoba 921140.81 Source: Derived from Conference Board of Canada (2006), tables 1-2, p. 4.

25. Malignant Neoplasms (2000) Cerebro- vascular Diseases (2000) Respiratory System Diseases (2000) Ischaemic Heart Diseases (2000) SWEDEN1 (2)5 (11)1 (4)4 (16) CANADA4 (15)1 (2)3 (10)3 (12) AUSTRALIA2 (8)4 (5)4 (12)2 (11) FRANCE5 (18)2 (3)2 (8)1 (3) UK6 (20)6 (18)6 (25)6 (22) USA3 (14)3 (4)5 (22)5 (21) Comparative Disease Indicator Rankings (OECD rankings in brackets), 2000

26. G.P. Marchildon Graduate School of Public Policy 26 2001 - % Excellent or Good 2003 - % Excellent or Good BC AB SK MB ON QC NB NS PEI NL YK NT NU CANADA 84.0 83.6 85.6 80.3 84.5 85.0 82.8 85.3 89.6 88.9 81.7 80.5 70.8 84.4 82.8 85.7 88.4 85.6 87.1 89.0 86.9 87.3 88.6 86.1 85.3 79.1 77.1 86.8 Satisfaction with Health Care and/or Health System