A Fine Balance: A Public Health Perspective on Health System Reform
Presentation to the Commission
on the Future of Health Care
Christina Mills, MD, FRCPC
President, Canadian Public Health Association
Ottawa, April 4, 2002
CPHA's mission is to constitute a special national resource in Canada that advocates for the improvement and maintenance of personal and community health according to the public health principles of disease prevention, health promotion and protection and healthy public policy.
On behalf of the Canadian Public Health Association (CPHA) I would like to thank you for this opportunity to speak with the Commission on the Future of Health Care in Canada about the future of Canada's health system.
The CPHA is a national, independent, not-for-profit, voluntary association representing public health in Canada. The public health community is multidisciplinary and multisectoral in nature, including many different professions, among them administrators, policy makers, academics, community health nurses, medical officers, health educators, health promoters, environmental health workers, public health inspectors and nutritionists. Through these diverse professionals, CPHA addresses a broad range of health and social issues, and has links to almost every community in Canada and to the international public health community.
CPHA members believe in universal and equitable access to the basic conditions that are necessary to achieve health for all Canadians. We are keenly interested in helping the Commission fulfil its mandate to recommend policies and measures to ensure the long term sustainability of a "universally accessible, publicly funded health system, that offers quality services to Canadians and strikes an appropriate balance between investments in prevention and health maintenance and those directed to care and treatment."1
I would like to underscore the fact that the mandate statement speaks of the health system, not the health care system. Unfortunately, the scope of the mandate seems to fade somewhat in the glare of media and political attention to the problems of the treatment sector.
The UK's Acheson Report defines public health as "the science and art of preventing disease, prolonging life and promoting public health through organised efforts of society."2 By that definition, public health is more than a set of functions within the health system (monitoring the population's health situation and the determinants of health; prevention and control of disease, injury and disability; health promotion; and protection of the environment): it encompasses the entire social endeavour of assessing population health status and threats to it, developing policies and strategies across the full spectrum of intervention (from health promotion and disease prevention to treatment and care), and assuring that health needs are met and that services meet agreed-upon standards.
The fundamental question
The question on which the entire debate hinges is this: is Canada still a country that believes in health as a public good, or do we "let the devil take the hindmost?"
That is, do we still hold the principle, manifest in the creation of Medicare, of a collective social responsibility for our shared problems?
CPHA believes that the answer to that question is yes, and that the health system (including but not limited to the health care system) is a public good and not a commodity: All Canadians should have access to the benefits of our available knowledge and resources for preserving and enhancing their health, regardless of their ability to pay or where they happen to live in Canada.
If we say yes to this fundamental question, then the next question is not whether to pay for it through investment of public funds, but how to organize the system in such a way that the investment produces the best possible health outcomes for Canadians and with the greatest efficiency.
If the answer is yes, two of the four scenarios presented by the Commission for consultation would not be acceptable from a public health point of view because they would increase inequities in access and health outcomes. Even the technical arguments for either scenario are weak: research shows that user fees reduce access for the poor without achieving their ostensible aims of reducing waste and mobilizing resources to increase quality and effectiveness of services,3,4 and that for-profit health services are not only more expensive but lead to poorer health outcomes than publicly administered or not-for-profit services.
A fifth scenario for the future of health system in Canada
Neither of the other two scenarios, increasing public investment and reorganizing health services, is likely to suffice on its own, but there is a fifth possibility: more public investment and re-organized service delivery. This is consistent with the National Forum on Health's conclusion that, contrary to the public system being unaffordable, strengthening it and increasing its scope might be the key to reducing total costs.5 A brief description of the basic attributes of this fifth scenario follows.
- Ensure ongoing, adequate financing and stability for the full health system.
Canada's health spending, as a percentage of GDP, is less than it was in 1992 - clearly continuing that particular trend is unsustainable! We need to establish an appropriate growth factor (or a cost escalator) and provide system managers with sufficient stability and predictability of funding to be able to plan effectively and use their resources to greatest effect. This will require mechanisms for jointly developing the growth factor and funding formulae, to ensure that governments follow through on their commitments, and to jointly re-assess funding formulae in light of changes in demographics or technology.
- Expand the coverage of the principles of the Canada Health Act.
Whether through expansion of the Act itself or through complementary legislation, the principles of portability, public administration, universality, accessibility and comprehensiveness should cover the full spectrum of intervention from prevention through to palliative care. A practical implication of this would be the implementation of the National Forum on Health's recommendations for home care and pharmacare.4 It is difficult to mention the principle of comprehensiveness without being painfully aware that it rings hollow, limited as it is to physician and hospital services. It is an anachronism to have coverage of the Canada Health Act's principles depend on the service setting or provider rather than the need for the service and evidence for its effectiveness.
- Invest in public health infrastructure.
Cuts in public spending in the past decade have seriously eroded capacity to provide essential public health services such as environmental protection (the E.coli contamination of the Walkerton water supply is just one case in point), and recent events have highlighted the need for better systems to ensure health security and emergency response. The tragic events of September 11 alerted Canadians to the necessity of a strong public health infrastructure capable of delivering emergency public health services across the whole population. Our infrastructure will require immediate and significant upgrading if we are to enhance our ability to protect the public health and our capacity to monitor health status, trends in risk and health outcomes.
- Invest upstream now to contain downstream expenses in the future.
With Canada's changing demographics, strong, well-funded prevention strategies will be increasingly critical to the health system as a whole. An immunization strategy, for example, could be used as a model for federal, provincial and territorial governments to improve public health management, planning, forecasting, evaluation, inventory control, health training and public or community outreach. Immunization, moreover, is one of the single most cost-effective health investments that can be made. Only by giving due attention (and allocating resources accordingly) to prevention, can we even hope to achieve sustainability. Otherwise, the best we will ever be able to do is get a bit better at mopping up. Treatment interventions are usually assessed in terms of costs per year of life saved or quality-adjusted year of life saved, or in terms of their cost for a given effect relative to alternative treatments. In contrast, many public health interventions in primary prevention and health promotion are not only cost-effective, but cost saving. For example, interventions to increase bicycle helmet use and well-designed worksite health promotion programmes can return as much as three dollars for every dollar invested.6,7 Complementing these savings with reorientation of the treatment system to make better use of clinical opportunities for prevention can also make important and cost-effective contributions.8 The Stanford Coronary Risk Intervention Project achieved significant reductions in second heart attacks or strokes with a benefit-to-cost ratio of at least two to one.9
- Invest in community supportive (including palliative) and long-term care.
Investment in supportive services and long-term care facilities is an important part of a strategy to reduce demand on the much more expensive acute care system. This is not simply through moving patients from acute beds to other settings: there is good evidence, for example, that appropriately-designed supportive programming for the elderly can significantly reduce hospital utilization.
- Reform primary health care.
Community-based, multidisciplinary primary care centres serving given populations (along the lines of the CLSCs in Québec) can provide more comprehensive care, better integrate clinical and population-based approaches to prevention, and implement innovative solutions to disease and resource management. As a point of entry to a coordinated and integrated care network through which to access more specialized services, they can be the key to the seamless continuum of health services Canadians increasingly expect.
- Strengthen the scientific underpinning of the health system.
Public health services and approaches are based on the science and research of many disciplines. We need to invest, not only in the research and surveillance that provides the evidence on which to base policy and program decisions, but in ways to ensure that new knowledge is accessible and actually used by those who need it for decision-making. Those making decisions about where to allocate resources need to know not only which interventions are proven effective, but which market-driven innovations they need to resist because they are unproven or whose risks exceed their benefits.
- Establish effective, collaborative, pan-Canadian mechanisms for governance and accountability of the health system.
Mechanisms are needed to develop goals, strategies and quality standards, and to report back to Canadians on progress. They should include appropriate involvement of citizens and health workers, as well as the now traditional triad of governments, NGOs and researchers. Sound decision-making depends not only on enhanced research and surveillance, but also on setting clear health goals that matter to Canadians, and designing accountability measures such as Report Cards and public watchdogs or champions, that verify whether or not the programs are working as intended. We also need mechanisms for intersectoral collaboration on policies that affect health; the more we learn about the determinants of health, the more we realize that, just as no one part of the health system can "go it alone," nor can the health system itself.
Public health involves many balancing acts; there is no single "biggest bang for the buck," no "one size fits all." We have to aim for the greatest overall benefit to the population, while ensuring that we address the specific needs of vulnerable or disadvantaged groups. We need both an emergency response capacity and the ability to forecast and plan for outcomes that won't happen for decades or generations. Evidence-based decision-making is a norm, but sometimes we have to act in the absence of conclusive evidence.
So we're sympathetic to the dilemma faced by the Commission in its deliberations on how to ensure the long term sustainability of a "universally accessible, publicly funded health system, that offers quality services to Canadians and strikes an appropriate balance between investments in prevention and health maintenance and those directed to care and treatment." There are many dimensions along which we can identify a need to strike a balance, but the fulcrum is our understanding of health as a public good: we urge you to speak out unequivocally in support of a publicly funded health system that benefits all Canadians. If we still believe in health as a public good, in collective social responsibility for our shared problems, not only can we afford to publicly fund our health system, we can't afford not to.
Christina Mills, MD, FRCPC
President, Canadian Public Health Association
- P.C. 2001-569, Minute of a Meeting of the Committee of the Privy Council, approved by Her Excellency the Governor General on the 3rd of April 2001
- Committee of Inquiry into the Future Development of the Public Health Function. London: Her Majesty's Public Health Stationery Office, 1988. ("The Acheson Report")
- Arhin-Tenkorang D. Mobilizing Resources for Health: The Case for User Fees Revisited. CMH Working Paper Series Paper No. WG3 : 6. WHO Commission on Macroeconomics and Health, 2000.
- Canadian Health Services Research Foundation. Myth: User fees would stop waste and ensure better use of the healthcare system. Ottawa: CHSRF, 2001.
- National Forum on Health. Canada Health Action: Building on the Legacy (Final Report). Ottawa: Minister of Public Works and Government Services, 1997.
- Ginsberg GM, Silverberg DS. A cost-benefit analysis of legislation for bicycle safety helmets in Israel. Am J Public Health 1994;84:653-56.
- Pelletier KR. A review and analysis of the health and cost-effective outcomes of studies of comprehensive health promotion and disease prevention programs at the worksite: 1991-1993 update. Am J Health Promotion 1993;8:50-62.
- Pearson TA, Jamison DT, Trejo-Gutierrez J. Cardiovascular disease, In: Jamison DT, Mosely WH, Measham AR, Bobadilla JL (Eds.), Disease Control Priorities in Developing Nations. New York. Oxford University Press, 1993;577-94.
- Haskell WL, Alderman EL, Fair JM, et al. Effects of intensive multiple risk factor reduction on coronary atherosclersosis and clinical cardiac events in men and women with coronary artery disease: The Stanford Coronary Risk Intervention Project (SCRIP). Circulation 1994;89:975-90.