CANADIAN HEALTH CARE SYSTEM

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CANADIAN HEALTH CARE SYSTEM

• R.A. Spasoff
• Dept of Epidemiology and Community Medicine

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1. MAIN COMPONENTS OF HEALTH CARE SYSTEM

• Health Professionals...
• Institutions (places with beds)...
• Community Agencies...
• Funders (mainly governments)...
• Industry...
• Planning/Coordinating agencies...
• The public...

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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?

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Supply of Physicians Nurses
(Number /100,000 population, 1998) Canada Ont
ario Quebec Doctors 185 178 211
Generalists 94 85 105
Specialists 91 93
106 Nurses employed in nursing (only 51 are
full-time) Total 750 689
775 Note that these numbers are declining.
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Supply of Institutions
(Beds/1,000 population, 1996-97) Canada
Ontario Quebec All institutions 11.8 11.4 9.3
Hospitals 5.4 4.7 4.6 Short-term
3.8 2.9 4.3 Rehabilitation
0.1 0.0 0.2 Long-term
1.5 1.8 0.1 Residential 6.4
6.7 4.7 Numbers sharply down.
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Community Health Agencies

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

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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 Department

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Community Health Centres (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

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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

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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)

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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)

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Industry

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

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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

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The public

• Patients
• Voters
• Self-Help groups
• Patients rights associations
• Self care and family caregivers
• Board members

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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

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Is it 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)

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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

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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,
  Childrens 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)

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2. FUNDING OF CANADIAN HEALTH CARE SYSTEM
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Where does the money come from? (1)
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Where does the money come from? (2)
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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

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Where does the money go? (1)

• Hospitals 31.8
• Other Institutions 9.4
• Physicians 13.4
• Other Professionals 11.8
• Drugs 15.5
• Other 18.1

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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

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How much money? (1)Total Health Expenditures,
Canada, 1975-1999 in billions of dollars
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How much money? (2)
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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

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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

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3. DECISION-MAKING IN CANADIAN HEALTH CARE
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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)...

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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

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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

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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

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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

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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

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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

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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?)

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4. IS IT A GOOD SYSTEM?
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What we mean by good?

• Effective in treating disease?
• Seems pretty good, but we dont 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

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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)

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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

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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

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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

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References

• Canadian Institute for Health Information, Health
  Care in Canada 2001. (Available, with other
  relevant reports, at www.cihi.ca/)
• Shah CP. Public Health and Preventive Medicine
  in Canada (4th ed), 1998. Part 3, Canadas Health
  Care System, pp 283-458