05 Jul Health Accord Negotiations

Secure the Future of Medicare: A Call to Care
Canadian Health Coalition brief to the
Standing Senate Committee on Social Affairs, Science and Technology on its Review of the progress in implementing the 2004 Health Accord

Introduction
We believe the future of health care in Canada can only be secured with strong federal leadership. The Canada Health Act is a symbol of Canada as a compassionate and caring community. The Act states that the primary objective of Canadian health care policy “is to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers.” (CHA, art. 3).

The Canada Health Act, in essence, is a call to care. As Tommy Douglas said: “When we are talking about medical care we’re talking about our sense of values. Do we think human life is important? Do we think that the best medical care which is available is something to which people are entitled, by virtue of belonging to a civilized community?”

Roy Romanow wrote in his final report entitled ‘Building on Values’: “Canadians view Medicare as a moral enterprise, not a business venture”. The ethical imperative of the Act – reasonable access to health services without financial barriers – is obviously not a business proposition. In fact the legal principles of the Canada Health Act are in blunt opposition to the legal principles that regulate the market.1

A public, not-for-profit system based on the Canada Health Act, puts government at the service of the people and not at the service of private enterprise. Health care is supposed to be delivered solely on the criterion of the need of patients, without regard for their ability to pay, their socio-economic status or where they live. The Act is supposed to protect Canadians from markets in health care that fragment services and avoid “unprofitable” populations, “unprofitable” regions and “unprofitable” services. The Act also offers the best guarantees of cost effectiveness and sustainability.

Access to health care based on need and not ability to pay is a core social right in Canada. The iconic status of the Canada Health Act and the Medicare system; Canada’s health- related obligations under the Universal Declaration of Human Rights, the International Covenant on Economic, Social and Cultural Rights and other international human rights treaties ratified by Canada; domestic commitments under section 36 of the Constitution Act, 1982; and Canadian Charter of Rights and Freedoms guarantees of security of the person and equality all support the existence of a right to publicly funded health care. In the words of Roy Romanow: “Canadians consider equal and timely access to medically necessary services on the basis of need as a right of citizenship, not a privilege of status or wealth.”2

The Canadian Health Coalition is a public advocacy organization dedicated to the preservation and improvement of Medicare. Our membership is comprised of national organizations representing nurses, health care workers, seniors, churches, anti-poverty, women, students and trade unions, as well as affiliated coalitions in 9 provinces and one territory. The CHC was founded in 1979 following the SOS Medicare conference in Ottawa organized by the Canadian Labour Congress and attended by Tommy Douglas, Emmett Hall and Monique Bégin.

The 2004 Health Accord represented a major reinvestment by the federal government and stabilized the health care system following deep cuts in 1995, which seriously compromised access to care. Significant progress has been made as a result of the major re-investment by the federal government, in the first 10-year accord – wait times are improving, more Canadians have access to primary care.

The success of the 2004 Health Accord is the reduction in wait times. Wait times for a significant number of surgeries and diagnostics have decreased. In fact, over the duration of the Accord, across Canada our publicly-funded health system has expanded to include a newer generation of technologies for cancer care, diagnostic scans, communications technology and wait list management. We have seen a dramatic increase in the number of elective surgeries, diagnostics, and better access to cancer and cardiac care. On some key health indicators, Canada is showing well. Our life expectancy has increased. Frequency of and mortality from heart attacks have declined. Stroke rates have declined. And cancer survival rates have increased. Our progress shows that with investment and support, our public health care system continues to improve and serves Canadians well.

But our health system is also contracting. In a number of provinces, rehabilitation services such as physiotherapy are being cut, delisted and privatized. More and more, longer-term care is subject to user fees and two-tier access, yet progress on a national home care strategy has been derailed. Similarly, progress on Pharmacare – identified as a priority in the 2004 Health Accord – has stalled, while drug costs continue to escalate faster than any other health care expenditure.

While our successes have come from expansion and improvements in the public non-profit health system, the Canada Health Act is not being enforced. In British Columbia, in particular, where a significant for-profit health care industry has emerged, clinics are openly charging patients fees for medically necessary services in contravention of the Act. The provinces with the most for-profit clinics (Quebec and British Columbia) are experiencing more violations as the clinics maximize their profits through extra-billing and user charges. In fact, our research has found that the majority of private for-profit clinics in Canada are selling access to health care, promoting two-tier health care, despite the Act’s prohibition of user fees and extra-billing. These clinics have not improved access. In fact, they have demonstrably reduced access in our local public hospitals and worsened human resource shortages in the public system while selling two-tier health care, regardless of medical need. The impact of for-profit privatization has not been adequately assessed, nor addressed, by the federal government, despite the reaffirmation of the principles of the Canada Health Act in the Accord.3

The biggest impediment to progress in implementing the 2004 Health Accord has been the withdrawal of the federal government from the essential role of national coordination in health care policy. There is a deficit of political leadership in health care, especially at the federal level. The Harper government never misses an opportunity to say that health care is a provincial responsibility and to avoid accountability for its important roles in health care, including: using federal spending power to achieve health objectives for the good of all Canadians, aboriginal health, food and drug safety, and enforcement of the Canada Health Act.

Developing national approaches on health system issues and promoting the pan-Canadian adoption of best practices and innovation is the glue that keeps Medicare together. This role cannot be performed by provinces and territories alone. As a result of the vacuum in federal leadership, the health care system is fragmenting more than ever, into 14 separate systems operating independently from each other. This fragmentation undermines the core principles of the Canada Health Act, especially comprehensive coverage and portability between provinces and territories. Lack of federal coordination and guardianship means that more and more Canadians lack access to comparable health services in primary care, prescriptions drugs, home care, rehabilitation and longer-term care.

Recommendation 1:
A renewed 10-year plan is needed, with stable and adequate funding, including the 6% escalator, in order to maintain the momentum, expand the innovations, and address unmet needs of Canadians including continuing care and Pharmacare. It is essential that the federal government perform its roles and duties in a renewed health accord. This includes:

    a) working closely with provincial and territorial governments to develop national approaches on health system issues;
    b) promoting the pan-Canadian adoption of best practices and innovation; and
      c) actively enforcing national standards and compliance with the

Canada Health Act.

I

Accountability and Enforcement of the Canada Health Act

Medicare belongs to Canadians. They pay for it and are the shareholders. Medicare should be accountable to the public, but currently it is not. Federal guardianship is necessary to ensure that public funds are used to protect and strengthen Medicare. In the 2004 Accord there was a significant increase in public funding for Medicare, funding that should have been accompanied by more accountability, not less. Canadians need to follow the money -$41 billion a year – and insist on a better accounting for how the money is spent. Weak accountability mechanisms facilitate privatization. It is no coincidence that the governments with the most resistance to meaningful accountability are the ones leading the way in transferring the delivery of insured services to commercial, private for-profit corporations. Proponents of privatization in health care delivery do not want public funds accounted for or traced, but this is what public administration and real accountability requires.

According to reports of the Auditor General of Canada, the Minister of Health is unable to tell Parliament the extent to which health care delivery in each province and territory complies with the criteria and conditions of the Canada Health Act. Parliament should hold the Minister of Health to account and should not be approving the transfer of health care funds to provinces unless it is demonstrated that they are in compliance with the Act. The Minister of Health’s annual report to Parliament on the Canada Health Act consistently fails to identify, let alone to assess, significant privatization initiatives currently underway in these and other provinces.

Yet, according to an internal Health Canada report:

“Although not a CHA issue per se, private delivery of CHA insured services can have CHA implications if providers of such services charge patients for insured services and/or allow them to jump the queue. Notwithstanding the federal government cannot control private delivery, the federal government is free to say, in policy terms, it is concerned about CHA risks. Similarly, it is free to point out that there is no evidence to suggest private delivery is more cost-effective, or higher quality or more efficient than public delivery”. *4

Since the 2004 Health Accord we have lost ground in the area of accountability. In fact, the federal/provincial/territorial advisory committee on governance and accountability has been disbanded. This means that information about how governments spend targeted funds is either not available at all or not easily available. To make matters worse, it appears that the current federal government is opposed to pan-Canadian health outcomes, and the adoption of comparable indicators. The official line is: “Let the provinces experiment”. The implicit assumption is that Canada should not maintain national standards in health care or strive for national objectives. Canadians want and need the highest possible national standards, not a fragmented patchwork.
A full public accounting would expose unfavourable comparisons between private for-profit and public not-for-profit delivery of health services. These include:

higher costs;
more serious deficiencies of human (staffing) and material resources;
higher morbidity (a higher rate of complications);
higher death rates and poorer quality care;
greater inefficiencies;
marketing of inappropriate services;
conflict of financial interest;
greater waiting times for those who can’t afford to queue jump;
secret contracts that compromise professional ethics;
cherry picking to shift cost, risk and liability to the public system; and
opportunities for fraud.
Recommendation 2:
that the federal Minister of Health correct the deficiencies in monitoring, reporting and enforcing the Canada Health Act. In particular, the ban on queue jumping, user-fees and extra-billing by doctors must be strictly enforced.

Recommendation 3:
that federal regulations under the Canada Health Act be enacted to require annual mandatory disclosure from provinces and territories on the number of private for-profit facilities, the number of services they provide, and the payments they receive. This information must be provided in the Annual Report to Parliament on the administration and operation of the Act.

II Aboriginal Health gap must be addressed
There are significant overall health and economic disparities between the Aboriginal and the non-Aboriginal Canadian population. Nothing could illustrate the link between socio- economic conditions and health status in a more dramatic fashion. Aboriginal populations:

are more likely live in poor health and die prematurely;
face a higher burden of chronic health conditions and infectious diseases;
are more likely live in poverty which leads to higher incidence of poor nutrition, obesity and living in overcrowded and substandard housing ;
are less likely to graduate from high school and more likely to be unemployed; and
are more likely that Aboriginal children will die in the first year of life.
In the June 2011 Status Report that examines previous recommendations made with regards to programming for First Nations living on reserve, the Auditor General concluded that regardless of efforts made, there were limited improvements, and in many cases, the situation has worsened: “The education gap between First Nations living on reserves and the general Canadian population has widened, the shortage of adequate housing on reserves has increased, comparability of child and family services is not ensured, and the reporting requirements on First Nations remain burdensome.” *5

The health gap will not improve without closing the housing, education, and economic opportunities gap. We support the Assembly of First Nations’ call for a fundamental transformation of the relationship between First Nations and Canada in order to achieve better results for Aboriginal people.

Recommendation 4:
that the Government of Canada invite the representatives of the Aboriginal people to be at the table with the First Ministers when discussing the renewal of the 2004 Health Accord as solutions to urgent health problems involve all levels of government.

First Nations water quality continues to be a national concern. The National Engineering Assessment released by the Federal Government on July 14, 2011 identifies needs of $6.578 billion. This very thorough study concludes that 73% of First Nation water systems are at risk. 118 First Nations communities remain on boil water advisories. Access to clean drinking water is a universal human right, recently affirmed by the United Nations. Canada has a responsibility to ensure clean drinking water in First Nations communities.

Recommendation 5:
that the Government of Canada engage with all First Nations on a plan to implement recommendations of The National Engineering Assessment and take action, with a clear plan of investment, to ensure clean drinking water.

The Non-Insured Health Benefits (NIHB) Program provides coverage for over 800,000 registered First Nations and recognized Inuit. Benefits include: pharmacy (including prescription and over-the-counter drugs, as well as medical supplies and equipment); dental services; eye and vision care services; medical transportation; and crisis counseling. It is estimated that approximately 45,000 individuals will be added to the NIHB program as a result of Indian Act amendments. This amounts to a 9.7% increase in the eligible population growth. In addition, the AFN has estimated that increases of 6.3% to 9.3% are required in various benefit areas when growth of the existing client population, inflation, changes in health service utilization and health status, and effects of technological change are examined. This is contributing to a funding crisis that will result in First Nations children, adults, and elders facing an uphill battle in accessing basic health care needs. *6

During the past fifteen years, NIHB has been actively implementing cost containment measures, or raising barriers to accessing NIHB health care, which presents a significant risk to maintaining patient safety. With over 30% of First Nations communities located more than 90 kilometres from a physician, it is common for First Nations to travel long distances to receive basic health care, including dental services, dialysis, mammography, chemotherapy and mental health. Not only do First Nations have to receive pre-approval to receive support for transportation, dental, vision and other benefits, more and more policy restrictions mean more frequent denials in needed care, such as for endodontic and orthodontic treatments for teeth.

Health care professionals working with Aboriginal patients are concerned that the Non-Insured Health Benefits program is becoming a well-oiled American-style health insurance system with reviewers who “second guess” everything that health care practitioners recommend.

Recommendation 6:
that the government of Canada make new investments in the Non-Insured Health Benefits (NIHB) Program that take into account the new growth in eligible population in order to ensure that health care needs are met.

III

The National Pharmaceutical Strategy is Essential for Health Care Renewal

The one area where the federal leadership vacuum is most damaging is in pharmaceutical management. Federal pharmaceutical policies governing the approval, pricing and marketing of prescription drugs are a failure. As a consequence, millions of Canadians are not receiving safe, effective, appropriate and affordable medication. Skyrocketing drug costs are out of control and put unnecessary financial pressure on federally funded drug plans, other governments, employers, and individuals who can least afford it.

In 2004, when the health accord was negotiated, pharmaceutical costs were the fastest-growing segment of health care budgets. It is not surprising, then, that pharmaceuticals management was such a major focus of the agreement. What is surprising is the decision of the Harper government to walk away from a signed agreement on national pharmaceutical management. In fact, the Minister of Health even denied there ever was agreement on pharmaceuticals in the 2004 Health Accord. *7

For the record, here are the main elements of National Pharmaceutical Strategy contained in the 2004 Health Accord, as found on Health Canada’s website: 8

  • develop, assess and cost options for catastrophic pharmaceutical coverage;
  • establish a common National Drug Formulary based on safety and cost effectiveness;
  • strengthen evaluation of real-world drug safety and effectiveness;
  • pursue purchasing strategies to obtain best prices for Canadians for drugs;
  • enhance action to influence the prescribing behavior of health care professionals so that drugs are used only when needed and the right drug is used for the right problem;
  • broaden the practice of e-prescribing;
  • accelerate access to non-patented drugs and achieve international parity on prices of non-patented drugs;
  • enhance analysis of cost drivers and cost-effectiveness, including best practices in drug plan policies.

It is difficult to overstate the damage to people and to Medicare of the federal government walking away from a key element of 2004 Health Accord – namely nation-wide solutions to some of the concerns about safety, accessibility and affordability of prescription medicines. Here are some of the consequences of this abdication of federal responsibility for safe and affordable medication:

  • First, inappropriate use of pharmaceuticals in Canada continues to be a leading cause of death;
  • Second, 8 million Canadians continue to suffer because of lack of affordable access to medicine because they are uninsured or underinsured;
  • Third, prescription drugs in Canada are 30% more expensive than the international average primarily because of federal price regulations;
  • Fourth, rather than accelerate access to generic drugs, the Harper government is actually negotiating a trade agreement with the EU that could increase the cost of prescriptions by $2.8 billion a year;
  • Fifth, rather than strengthen drug safety, Health Canada has draft legislation to weaken drug safety regulation and speed up drug approvals without producing evidence that drug safety will not be adversely affected;
  • Sixth, rather than take action to improve the prescribing behavior of health care professionals, the federal government fuels inappropriate prescribing by allowing illegal direct-to-consumer advertising and off-label promotion. and by continuing to allow the pharmaceutical companies to regulate their own promotion.

It is perverse for the federal government to encourage excessive growth of pharmaceutical costs and abusive marketing practices, and then pass the bulk of the cost and the damage on to provinces, territories, employers, and individuals. You can’t claim to be concerned about rising healthcare expenditures and then let the 800-pound gorilla in the healthcare system – the pharmaceutical industry – drain billions of dollars out of health care budgets through excessive pricing and abusive marketing practices.

The Health Council of Canada observed that advances in pharmaceutical management policies are integral to overall health care renewal, since drugs are the second highest spending area in the Canadian health care system. *9 Federal pharmaceutical management is a failure that threatens the integrity and sustainability of all aspects of the health care continuum, including primary, hospital, home and continuing care. By derailing the national strategy for pharmaceutical management, the Harper government has, in effect, severely impeded overall health care reform.

A groundbreaking research study concluded that a universal public drug plan would save Canadians up to $10.7 billion a year. *10 The dramatic cost savings with a universal public drug plan are achieved by various measures, including: eliminating various subsidies; using competitive purchasing; a more rigorous assessment of new drugs; and improved prescribing practices.

Politicians can no longer hide behind the excuse that universal public drug coverage is too expensive. We can save lives, cover everyone and save money. Canadians cannot afford not to have universal Pharmacare.

As more Canadians lose their jobs and the associated health benefits that go with full-time employment, more people are likely to need help with the costs of their medications. The work of the National Pharmaceuticals Strategy is more important than ever. It has become even more critical to find ways to reduce the costs of prescription drugs, and to ensure that Canadians have access to safe and appropriate medications. *11

A national strategy that manages pharmaceuticals in a safer and more efficient manner is an essential element of health care reform, including financial sustainability, and must figure prominently in the 2014 Health Accord.

Recommendation 7:
that the federal government begin immediately to work with the other governments in Canada to implement the National Pharmaceutical Strategy as agreed to in the 2004 Health Accord.

Recommendation 8:
that the federal government work with provincial and territorial governments to establish a Pan-Canadian universal Pharmacare program based on the principles of

i) universal and equitable access for all;

ii) improved safety and appropriate use; and

iii) cost controls to ensure value for money and sustainability.

Recommendation 9:
that the legislation governing the Patented Medicines Prices Review Board (PMPRB) be amended so the cap on introductory prices of brand-name drugs be calculated based on a basket of 13 comparable OECD countries (instead of the current basket of 7 countries). This would generate approximately $2 billion annually in savings and would be a first step by the federal government towards ensuring access to affordable medicine for all Canadians.

Recommendation 10:
that the federal government call a public enquiry into the regulation and marketing of pharmaceuticals in Canada with particular attention to illegal advertising, off-label promotion, self-regulation by the pharmaceutical industry and weak regulations governing the safety of new drugs

IV

Canadians Need Comprehensive Home and Continuing Care

The 2004 Health Accord represented modest advances on home care, with the goal of first dollar coverage for some short-term and end-of-life care, but it fell far short of what is needed. Across the country, care is being moved out of hospitals into long-term care facilities and home care, which is too often rationed and subject to user fees. Access to longer-term care is now a patchwork of programs and services with vast inequities. The elderly and those with chronic illnesses and disabilities find themselves facing financial hardship when they are least able to pay for needed care. Progress in ensuring access to broad, equitable publicly funded home and longer-term care services has been slow and piecemeal. Because governments have been reluctant to commit to a comprehensive, publicly funded home care program, there has been a proliferation of private for-profit corporations – some covered by public insurance and others requiring out of pocket payment.12

The failure of the 2004 Accord to require provinces to spend home care funding on non- profit home care providers is a serious deficiency that must be corrected. In spite of US and Canadian research finding a link between for-profit ownership and inferior quality of care in home care and nursing homes, the for-profit sector in Canada is expanding at the expense of the nonprofit sector.13 Profit seeking diverts funds and focus from care and can lead to the abuse and neglect, especially of the frail elderly.14

Competitive bidding is harming patients and diverting money from direct patient care to company profits. In Ontario alone, the handover from longstanding community-based agencies like the Victoria Order of Nurses to for-profit agencies, some of them investor- owned multinationals, has meant cuts in services, a chill on cooperation, and ballooning administrative costs. Staff turnover rates in that province now approach 60 percent.15

Completely absent from the 2004 Accord is long-term care. Despite the obvious and growing need for nursing home care and its connection to wait times in the acute care sector, the First Ministers failed to address the issue, and the federal government has done nothing to address the gap. Tens of thousands of Canadian seniors are waiting on nursing home lists, and thousands more are anxiously approaching that day, knowing how difficult it is to find accessible long-term care.

Recommendation 11:
that the 2014 Health Accord articulate the vision of continuing care (including home, long-term and palliative care) as integral to Medicare, establish clear targets with significant resources, and evaluate and report regularly to Canadians on the results.

Recommendation 12:
that the federal government introduce legislation, parallel to the Canada Health Act, stipulating conditions, including not-for-profit provision, for federal financing of continuing care programs.

Recommendation 13:
that funding for continuing care services must be in addition to existing health care funds. To this end there must be a moratorium on any further cuts to acute care, home care, and long-term care services while building the community infrastructure and public confidence.

Recommendation 14:
that continuing care include home support services, such as housework and meal preparation. These home support services are in high demand, essential to supporting people at home, and are severely underfunded in every jurisdiction.

 

V

Primary Health Care Reform Must Be Sped Up

As the Health Council reported in March of this year, expanding use of teams is key to renewing primary health care. In 2008 however, only 17% of Canadians reported having team-based primary health care. Millions of Canadians are awaiting meaningful changes that establish access to primary care on a 24/7 basis with interdisciplinary teams of caregivers. Studies comparing Canada to 10 other OECD countries with respect to primary care, shows Canada lagging behind in

a) the number of doctors working in teams;
b) access to primary health care outside regular hours; and
c) electronic patient records. 16

The Community Health Centre model has proven to be successful in delivering primary care in this way. Yet, governments have taken few or no concerted steps to promote this model. On the contrary, the Quebec government has taken steps to dismantle the highly successful CLSCs.

Provinces and Territories have to clearly articulate the need for change with medical associations to achieve real reform in primary care. The challenge is to organize and pay physicians in ways that provide better incentives for high-quality, cost-effective care and interdisciplinary teams including: physicians, RNs and NPs (nurse practitioners), pharmacists, physiotherapists, dieticians and social workers. Solo practice and fee-for-service reimbursement of doctors is a barrier to progress in primary care. If not dealt with, excessive and inappropriate use of expensive diagnostic technology and dubious prescribing behavior will result in excessive expenditure and poor health outcomes.

Promoting the Community Health Centre model will help Canada’s health system evolve toward what Tommy Douglas and Medicare’s other founders called the “second stage of Medicare”. In setting up Medicare, they argued that once the “first stage of Medicare” – a system of universal, publicly-funded health care coverage for Canadians – was achieved, it would be necessary for us to refocus our energies on reforming the way actual services are delivered so that we do a better job preventing illness in the first place, and providing more timely, coordinated and appropriate care when it is required. This means that while we continue to complete the “first stage of Medicare” by bringing publicly-funded drug coverage (Pharmacare) and dental care to all Canadians, we also need to get to work in achieving Tommy Douglas’s vision for the second stage of Medicare by reorganizing the way that health care services are coordinated and delivered.

One of the areas of health services requiring urgent reform and, coincidentally, one of the best places to move forward in achieving the second stage of Medicare, is the area of primary health care – frontline services that, essentially, are focused on health promotion, and early intervention, prevention and mitigation of illness. Federal standards and targeted resources are required for primary health care across Canada in order to improve the distribution, equity, timeliness and coordination of these services.

As the Canadian Alliance of Community Health Care Associations observed through experience, access to individual health care providers alone is not enough. We must move beyond stand-alone clinical services and beyond a mere “headcount” of doctors, nurses and other health care providers. What is needed is: i) better coordination of all primary health care services at the local level; ii) more Canadians being provided access to integrated, inter-professional, team-based primary care; iii) assurance that health promotion and community health programs are a part of the primary health care “system” within every Canadian community; and iv) community members being given a greater say in identifying local health and health care priorities. *17

The need for this coordinated, holistic approach is particularly urgent for the millions of Canadians with complex care needs, as well as those who face increased social barriers to health such as those on low-income or living in poverty, or those lacking appropriate housing or facing other barriers. We must make primary health care services across Canada more responsive to diverse community needs and realities at a local level, ensuring that the right mix of primary health care services and organizations is available, including access to a Community Health Centre wherever possible.

 

Recommendation 15:
that Federal standards and targeted resources for primary health care reform across Canada form part of the next Health Accord in 2014, including plans to expand access for Canadians to Community Health Centre services — start by expanding access first to those individuals, families and communities identified as being most urgently in need.

Recommendation 16:
governments link their funding agreements with physicians to public policy goals for primary health care.

VI

Public sector solutions to reduce wait times must be encouraged.

The 2004 Health Accord has helped to demonstrably improve access to care. Wait times for a significant number of surgeries and diagnostics have decreased. In fact, over the duration of the Accord, across Canada our publicly-funded health system has expanded to include a newer generation of technologies for cancer care, diagnostic scans, communications technology and wait list management. We have seen a dramatic increase in the number of elective surgeries, diagnostics, and better access to cancer and cardiac care. On some key health indicators, Canada is showing well. Our life expectancy has increased. Frequency of and mortality from heart attacks have declined. Stroke rates have declined. And cancer survival rates have increased. Our progress shows that with investment and support, our public health care system continues to improve and serves Canadians well.

Dramatic improvements have been made in reducing wait times especially for elective surgeries in the priority areas identified in the Health Accord. The methods used included promoting the use of guidelines to reduce unnecessary procedures and applying queue-management techniques and teamwork.

Early efforts to cut wait times focused on surgery. However, in the last few years, important progress has been made in expanding wait times management beyond the five clinical areas mentioned in the 10-Year Plan to Strengthen Health Care (cancer, heart, diagnostic imaging, joint replacements, and sight restoration).

Many governments are continuing to develop comprehensive queue-management strategies. Importantly, they have moved beyond the five clinical areas mentioned in the accords. Some governments are addressing wait times in emergency departments. The solution to this problem lies beyond the hospital walls. To tackle emergency room waits, we need concerted action by governments and health authorities to improve access to care in the community. As the Health Council reported, Canadians need faster and smoother transitions to long-term and home care, particularly for the growing number of seniors in need of support.

Despite the fact that the 2003 accord created a separate Diagnostic and Medical Equipment Fund of $1.5 billion to shorten wait times, long waits for diagnostic imaging (particularly MRI scans) persist in many jurisdictions, and there is reason to believe that some people waiting in the queues don’t medically need to be there. This lack of progress, according to the Health Council of Canada, shows that it takes more than money to reduce wait times. *18 A comprehensive strategy, linked to best practice guidelines, should also help physicians order the appropriate tests.

We agree with the Health Council of Canada’s progress report on wait times: “continued coordinated effort and greater use of effective management tools could make wait times management one of the success stories of the health accords”. *19 This must take place in the public not-for-profit sector. There is significant and robust evidence that contracting out to for-profit companies undermines quality and leads to higher costs, particularly in the area of health care cleaning and infection outbreaks. The direct costs of hospital acquired infections in Canada are estimated to be $1 billion annually. As the Romanow Commission concluded: “Rather than subsidize private facilities with public dollars, governments should choose to ensure that the public system has sufficient capacity and is universally accessible.” * 20

Recommendation 17:
that the federal government encourage their provincial and territorial partners to adopt public sector innovations as the evidence demonstrates contracting out services is less cost-effective and undermines the public system.

VII

Federal leadership Essential for a Health Human Resource Strategy

There were measures in the 2004 Accord to address health human resources problems, but there remains no comprehensive pan-Canadian strategy. There is a great need to coordinate health human resource strategies. This is why we have a federal government. Saskatchewan, Prince Edward Island and Newfoundland & Labrador, for example, lose as much as 30% of their nursing graduates to other provinces. Evidently, planning for health human resources must be pan-Canadian, taking into account mobility and the policy levers that can affect the degree of mobility between provinces. Too often, employers are expending resources competing for the same health care professionals. Moreover, much time and energy is lost in addressing the workplace shortage because the knowledge of successful innovations and planning models is not crossing regional barriers. The federal government is in a unique position to help rectify these health labour problems.

The CHC supports upgrading, language training, and credential recognition for internationally-educated healthcare workers, including those already in Canada and employed in healthcare; in fact, many nurses, doctors and paraprofessionals who are underemployed in Canada face constant barriers to training and professional certification. Laddering programs, for example for care aides to become nurses, are similarly underfunded.

Meanwhile, health employers are poaching healthcare workers from developing countries and relying more and more on migrant workers. In fact, the federal government has, without public debate, expanded the Temporary Foreign Worker Program – a program in which workers are subjected to exploitative recruitment fees, withholding of pay, and often dismal living and working conditions, with no universal right to pursue permanent resident status in Canada. *21

Instead of poaching from other countries and creating a larger underclass of migrant workers, the federal government should support and implement a World Health Organization ethical recruitment policy, and it should suspend the Temporary Foreign Worker Program and address the widespread abuses occurring in this program.

A pan-Canadian health human resources strategy must also address the poor working conditions and wide wage gaps that characterize the healthcare sector. One in ten support workers in Canada has income below the Statistics Canada poverty line. Two-thirds have no pension, and less than half have extended health or dental coverage. *22 Because of contracting out, the wages of healthcare support workers in British Columbia are now the equivalent of what was paid in 1968. *23

Wages and working conditions as a factor in retention and recruitment have featured in federally commissioned health human resource sector studies. What has been done to implement the recommendations of those studies? In particular the home care sector study seems to have been shelved despite acute and worsening recruitment and retention problems in this sector.

Recommendation 18:
The federal government should coordinate a pan-Canadian health human resources strategy that achieves better working conditions, training and upgrading programs, and wage parity to improve retention and recruitment across the health sector in Canada. A key objective must be to stop the unethical poaching of internationally trained healthcare workers, the exploitation of temporary migrant workers and poaching between jurisdictions in Canada.

1 Marie-Claude Prémont, The Canada Health Act and the Future of Health Care Systems in Canada,Romanow Commission Discussion paper No. 4, 2002.
2 Romanow Commission, Final Report, p. vi.<
3 Ontario Health Coalition, “Eroding Public Medicare: Lessons and Consequences of For-Profit Health Care Across Canada”, October 6, 2008.
4 Source: Health Canada, “Strategic Overview”, July 2004, obtained by the Canadian Health Coalition under
the Access to Information Act.
5 Office of the Auditor General of Canada, Status Report of the Auditor General of Canada, Chapter 4:
Programs for First Nations on Reserves, June 2011.
6 Assembly of First Nations, “Structural Transformation & Critical Investments in First Nations on the Path to
Shared Prosperity”, Pre-Budget Submission, 2011 to the House of Commons Standing Committee on
Finance, August 12, 2011.

7 House of Commons Canada, Standing Committee on Health, 2nd Session, 40th Parliament, Evidence, Tuesday, February 10, 2009.
8 http://www.hc-sc.gc.ca/hcs-sss/delivery-prestation/fptcollab/2004-fmm-rpm/index-eng.php
9 Health Council of Canada, Progress Report 2011: Health Care Renewal in Canada, p.12
10 Marc-André Gagnon, The Economic Case for Pharmacare, Canadian Centre for Policy Alternatives, Ottawa, 2010: http://pharmacarenow.ca/wp-content/uploads/2010/09/Universal-Pharmacare-Report-e.pdf
11 Health Council of Canada, A status report on The National Pharmaceuticals Strategy: A Prescription Unfilled, 2009
12 Health Council of Canada, Rekindling Reform: Health Care Renewal in Canada, 2003-2008. Margaret J. McGregor and Lisa A. Ronald, Residential Long-Term Care for Canadian Seniors Nonprofit, For-Profit or Does It Matter? IRPP Study,  No. 14, January 2011.
13 Margaret J. McGregor and Lisa A. Ronald, Residential Long-Term Care for Canadian Seniors Nonprofit, For-Profit or Does It Matter? IRPP Study, No. 14, January 2011.
14 Harrington, C. et al, “Does Investor Ownership of Nursing Homes Compromise the Quality of Care?” American Journal of Public Health, September 2001, Vol. 91, No.9, pp. 1452-1455.
15 Caplan, E., Realizing the Potential of Home Care: Competing for Excellence by Rewarding Results, 2005, p.23.
16 Health Council of Canada, “How do Canadians rate the Heath Care System? Results from the 2010 CWF International Health Policy Survey”, Bulletin 4, November 2010.

17 Improve Health and Health Care for All Canadians, Background to online petitions in Canada’s Provinces
and Territories, August 2011, http://www.cachca.ca/news/documents/Improve%20Health%20and%20Health%20Care%20for%20All%20Canadians%20-%20Aug%202011%20backgrounder.pdf
18 Health Council of Canada, Progress Report 2011: Health Care Renewal in Canada, May 2011, p.8. Health Council of Canada, “Report to the Standing Senate Committee on Social Affairs, Science and Technology”, March 10, 2011.
19 Commission of the Future of Health Care in Canada, Final Report, November 2002, p. 9.
20 Commission of the Future of Health Care in Canada, Final Report, November 2002, p. 9.
21 Valiani, S., Analysis, Solidarity, Action – a Worker’s Perspective on the Increasing Use of Migrant Labour in Canada. Canadian Labour Congress, 2007.
22 Pat Armstrong, Hugh Armstrong and Krista Scott-Dixon. 2006. Critical to Care: Women and Ancillary Work in Health Care, p. 35. National Network on Environments and Women’s Health. Accessed May 5, 2008 at: http://www.womenandhealthcarereform.ca/publications/criticaltocarereport.pdf
23 Cohen, Marjorie Griffin and Marcy Cohen. 2004. A Return to Wage Discrimination: Pay Equity Losses Through Privatization in Health Care. Vancouver: Canadian Centre for Policy Alternatives. Page 4.