occupies 9.5 million square kilometres, or about 95 percent of Canada’s
territory. Approximately nine
million Canadians, or about 30 percent of the total population, live in rural
and remote areas of the country. Rural
and remote areas in Canada embrace varied terrain and economic activities
spanning resource, manufacturing and service industries.
Observations about rural Canada suggest some defining characteristics:
Rural Canada includes rural and remote
communities as well as small towns outside major urban centres.
Rural populations that are more distanced
from urban centres continue to decline, particularly as young people leave for
educational and employment opportunities and as seniors leave to seek greater
access to long-term care.
Rural populations in closer proximity to
cities or in recreational areas are increasing.
Across Canada, more than half of the
Aboriginal peoples (whether on reserves or in Inuit or Métis communities)
live in rural areas.
Ontario and British Columbia have the lowest
percentage of rural residents while the territories and Atlantic provinces
have the highest. Almost half of
the population in Atlantic Canada live in rural areas.
Seniors, children and youth under the age of
20 are over-represented in rural regions of Canada.
More precisely, the 1996 Census shows that, compared with the national
average, rural Canada has a higher percentage of children between the ages of
5 and 19, a lower percentage of males between 20 and 39 and females between 20
and 49, and a higher percentage of males over 55 and females between 60 and
Rural areas have generally higher
unemployment rates and lower formal education levels.
Rural people living in the Prairie provinces
have a lower unemployment rate than do people living in Atlantic Canada.
A recent report, entitled Rural, Remote
and Northern Health Research: The Quest for Equitable Health Status for All
Canadians, points out that there is not a great deal of information
available on the health of rural Canadians, although data on life expectancy,
death rates and infant mortality rates give some broad indicators of health.
Overall, compared to urban areas, life expectancy in rural regions is
shorter while death rates and infant mortality rates are higher.
In 1996, life expectancy for rural females was 80.82 years as opposed
to 81.31 years for urban females. The comparable figures for rural and urban
males were 74.67 years and 75.67 years, respectively.
the health status of rural and remote residents is lower than that of their
urban counterparts. Dr. Peter
Hutten-Czapski, President of the Society of Rural Physicians of Canada, noted:
Health status decreases as one travels
to more rural and remote regions. As an example, heart disease is common in
northern Ontario. Certain types
of cancer are found among miners and farmers.
There are substantially higher rates of diabetes, respiratory and
infectious diseases, as well as violence-related deaths, in some aboriginal
communities. Combined, there is an increase in mortality in rural regions as
evidenced by life span.
The lower life expectancies are not
associated with just a few specific causes; rather, the mortality rates in
these regions are higher for most causes of death. Consistent with other
measures of the health of the population, there is an association with
socio-economic factors: life expectancy decreases as the rate of unemployment
increases and the level of education decreases.
The health and health care needs of rural
Canadians are different from those of Canadians living in urban areas.
As Health Canada’s Office of Rural Health pointed out:
Rural realities and health needs differ
from those of urban areas. These
needs may be particular to the environment (e.g., the need for education on
tractor roll-over prevention), changing demographics (e.g., an increase in the
seniors’ population in some rural areas), a common health need present in a
rural environment (e.g., the health status of First Nations’ communities),
or the need for health concerns to be expressed in a ‘rurally sensitive’
way (e.g., obstetrical services that do not generate an excessive ‘travel
burden’ on rural women).
This statement highlights some of the
particular populations in rural Canada that may have special needs based on
factors such as age, gender, ethnicity, and occupation.
For example, various studies have shown that:
Seniors in Canada are over-represented in
rural regions, as are children and youth under the age of 20.
There are particular issues for seniors needing assisted home care or
long-term care and for children and youth with special medical needs or who
are in abusive situations.
Farmers, fishers, foresters, and miners can
face serious health hazards in their jobs. In addition to accidents related to the increasingly complex
machinery used in these occupations, there are hazardous exposures to
chemicals, noise, long working hours, temperature extremes, infectious
diseases, and stress.
While Aboriginal peoples face an array of
health problems related to their socio-economic status, they also experience
some of the cultural insensitivity experienced by new immigrants such as lack
of services in their own language, health care personnel who are unaware of
cultural practices, and problems associated with services designed for a
accessibility criterion of the Canada
Health Act requires that reasonable access to insured health services be
provided to all Canadians on uniform terms and conditions and without
financial or other barriers. Dr.
John Wootton, former Executive Director of the Office of Rural Health (now
Special Advisor on Rural Health, Population and Public Health Branch, Health
Canada) raised the problem of accessibility for rural residents, when he
stated: “If there is two-tiered medicine in Canada, it’s not rich and
poor, it’s urban versus rural.”
Canadians living in rural and remote areas
are limited to a smaller range of health care providers when seeking care than
are their urban counterparts. Rural
hospital closures and centralization of health services have had an impact on
rural residents. Rural physicians
explained that, when the insured health services are not available from local
providers in local health care facilities, rural residents must travel long
distances and incur additional costs for transportation and other needs such
as hotels. This can also
negatively affect their health:
We must understand that if rural people
are forced to travel for care, some will not travel. If they do not travel,
they cannot achieve the health outcomes of people who are able or willing to
travel. Some will travel, but the delay caused by the travelling or the need
to travel will be costly to them. Others will be subject to the hazards of
transport or inclement weather. Collectively forcing people to travel long
distances for health care, even to a centre of the highest standards, will
adversely affect health outcomes.
This is a particular concern for
women's health. Studies show that women do poorly if they must travel long
distance to give birth. In Saskatchewan, it should be noted, the 1993 closure
of 53 rural hospitals was followed by an increase in its perinatal mortality
rate. We cannot say that these things are causal, but it is certainly
The recruitment and retention of health
care personnel including physicians, specialists, nurses, technicians, social
workers, physiologists and nutritionists, in remote and rural areas of Canada
have been ongoing concerns. Access
to physician services is a particular problem.
For example, Dr. Hutten-Czapski stated:
are concentrated where the most healthy people in the country live, and the
sickest populations have the least access to health care, so the gap between
urban and rural grows.
Physician shortages in rural and remote
communities have been persistent and are expected to continue.
According to the Canadian Medical Association:
While approximately 30% of Canadians live in
rural or remote areas, only 10% of Canadian physicians practise outside Census
Metropolitan Areas or Census Agglomerations;
Of the approximately 5,700 rural physicians,
87% are family physicians;
majority of rural physicians (72%) graduate from Canadian medical schools, the
number of Canadian graduates varies from region to region.
In Newfoundland, one-third of the rural physicians are Canadian
graduates; in Saskatchewan, one-fifth of rural doctors have graduated from
Canadian medical schools. In
Quebec, 95% of rural physicians have been trained in Canada.
In the early 1990s, the federal and
provincial/territorial Ministers of Health considered strategies for physician
resource management and by the end of the decade were examining options for
both physicians and nurses through the Federal/Provincial/Territorial Advisory
Committee on Health Human Resources. A
discussion paper prepared for this Committee in 1999, entitled Improving
Access to Needed Medical Services in Rural and Remote Canadian Communities:
Recruitment and Retention Revisited (Barer and Stoddart, 1999), attributed
the lack of access to physicians services in remote and rural areas compared
to urban settings to “a fundamental mismatch between the needs of rural and
remote communities … and the needs and choices of (and influences on) those
who become physicians.”
Barer and Stoddart also pointed out:
There are many communities across the
country that are simply too small to support a general practitioner, or that
are large enough to support one but too small to support two or three, let
alone the full range of specialists found in large urban centres.
For their part, most Canadians who are accepted into the medical
schools across the country have grown up in urban settings; the bulk of their
medical training occurs in urban settings; that training takes place largely
in tertiary hospitals which are only found in urban settings; much of the
training is provided by physician-educators who work in urban settings; there
are (given in per capita terms) more practice opportunities in urban settings;
access to specialist colleagues and other complementary treatment and
diagnostic resources are more plentiful in urban settings; hours of work are
more likely to be ‘regular’ in urban settings and, in particular, call
schedules are less onerous; and there are many more social, educational,
recreational, employment and cultural opportunities for physicians and their
families in urban settings.
Experts suggest that, while policy
approaches to dealing with physician shortages in rural and remote areas have
been economic or financial, most of the determinants of practice location
involve a complex mix of factors involving far more than financial
Personal background, professional education and practice factors,
(e.g., children’s education, recreation, spousal job opportunities) and
community size and are also important influences in practice locations.
Financial considerations, however, are not as important as personal
factors. The physicians who moved
for professional reasons also indicated that the presence of certain factors
such as additional colleagues, locum tenens (physicians who temporarily
carry on the practice for an absent colleague), opportunities for group
practice, specialist services and alternative compensation would have
influenced them to remain in rural practice.
Unfortunately, there is very little data on
registered nurses or other health care providers in similar settings.
A variety of measures have been proposed to
help alleviate the shortage of physicians in under-serviced areas.
For example, these include:
Reserving undergraduate medical school places
for qualified applicants willing to commit to rural area practice;
Revising admission criteria for medical
schools to favour qualified rural applicants;
Enhancing rural area exposure in both
undergraduate and post-MD training;
Developing new residency training programs
designed explicitly to prepare specialists to serve as rural regional
Introducing or increasing financial
incentives to encourage choices of specialties in short rural supply.
and territorial governments have used a number of incentive programs to
attract physicians to practice in rural and remote areas.
Most of these are financial in nature, but some focus on working
conditions, some seek to direct where physicians can establish practices,
others recruit foreign medical graduates and others focus on attracting rural
residents to attend medical school and providing rural exposure in the course
of medical training. Research
demonstrates that a greater proportion of trainees from rural settings will
return to rural areas because they are already comfortable with the rural
culture. As governments
acknowledge that it may be easier to retain physicians in rural and remote
areas if they have grown up there, programs to attract rural residents to
become doctors are becoming more common.
One such program will be the creation of a rural medical school in
northern Ontario – the “Thunder-Barrie Medical School”.
Rural physicians challenged the federal government to commit half of
the funding for the establishment of rural medical schools in Canada.
Wood and Schneider (1999) also pointed out that while all provinces and
territories face similar issues and problems in relation to the distribution
of health services and personnel, there has not been a great deal of
cooperation among them in attempting to solve these problems.
William Tholl, Secretary General and CEO of
the Canadian Medical Association (CMA), attributes this lack of success to the
fact that these financial programs have little to do with the major factors
involved in a physician’s decision to locate and stay in a rural or remote
area – those that are non-financial in nature.
Moreover, the lack of cooperation among the provinces suggests that the
federal government could play a useful role in fostering inter-provincial
It is important to note that Canada is not
alone in experiencing problems in providing health services to rural and
remote locations. Significant variations in the geographic supply of health
services occur in virtually every industrialized country. The United States, Australia and New Zealand, for example,
are experiencing health care personnel distribution problems similar to those
found in Canada. Like Canada,
these countries have adopted a number of policy approaches to deal with these
experts see telehealth as an important vehicle for delivering health services
to rural and remote areas. Supporters
of telehealth believe that it holds significant promise in this regard. The Office of Health and the Information Highway at Health
Canada is promoting telehealth as a way to offer fairer distribution of health
resources and to connect patients and health care providers separated by
geographic distance. The Society
of Rural Physicians of Canada sees both potential and risks in telehealth.
The potential lies in its ability to supplement the skills and
abilities of existing rural health care workers to deal with problems that
would otherwise require patients to travel out of the community to access
needed care. The risks, on the
other hand, lie in its potential to divert resources away from the local
community with the result that needed care can be accessed only from outside
Witnesses confirmed that many gaps exist in
information on the health status of individuals and communities in rural
Canada. Similarly, there is not a
substantial body of research on rural health issues. In the view of witnesses, rural health issues tend to be
eclipsed by those in urban areas. Policy
solutions often are based on experiences in urban areas and rely on urban data
and research. A position paper
prepared for the Canadian Health Services Research Foundation and the Social
Science and Humanities Research Council pointed out:
Because the health problems confronting
rural Canada are serious, complex, interrelated and evolving, research should
have a critical role to play in examining the nature of these problems,
monitor their progress or deterioration, identifying their causes, finding
solutions and evaluating the effectiveness of various interventions. However,
to date, rural health research has not received substantial or sustained
support from major health research granting agencies in Canada.
Generally speaking, within the health research community, rural health
issues are either overlooked or dealt within a “generic” manner.
In “generic” studies, even when rural is mentioned, it is commonly
used as a convenient comparison category to illustrate urban-rural
differences. Rural is rarely the
focus of attention, yet findings and recommendations from urban-based research
are often considered universally applicable or are extrapolated to rural
One of the weaknesses identified in rural
health research is lack of coordination and planning.
A 1999 Rural Health Research Summit was held to develop a
“Blueprint” for future action in rural health research.
Other initiatives such as the development of the Canadian Institutes of
Health Research (CIHR), increases in health research budgets and the
appointment of a special advisor on rural health to CIHR’s President have
been important developments in rural health research. In addition, a Rural Health Research Consortium was formed in
1999 to build capacity in research endeavours related to health in rural and
The federal government has responded to the
concerns of rural Canadians in a number of ways. For example, the Office of Rural Health was established in
September 1998 to ensure that the views and concerns of rural Canadians are
better reflected in national health policy and health care system renewal
strategies. In February 1999, the
federal government announced funding of $50 million over three years (from
1999-00 to 2001-02) to support pilot projects under the “Innovations in
Rural and Community Health Initiative.”
In June 2000, the federal government
announced a National Strategy on Rural Health that it sees as an important
milestone on the road to ensuring that all Canadians have reliable access to
quality health care. Then, in
July 2001, the federal government announced the establishment of a Ministerial
Advisory Committee on Rural Health to provide advice to the federal Minister
of Health on how the federal government can improve the health of rural
communities and individuals.
The Canadian health care system faces many
challenges, some of the greatest of which are providing for the health care
needs of those who live in rural and remote areas of the country.
We know that, generally, rural Canadians have: higher death rates;
higher infant mortality rates; and shorter life expectancies than do urban
Canadians. We also know that certain types of diseases and conditions are more
prevalent in rural areas and among occupations associated with a rural
environment. But witnesses
pointed out that little is known about the overall health status of rural
Canadians. Dr. Judith Kulig,
Consortium for Rural Health Research, characterized the adequacy of
information on the health status of rural residents as very poor.
She attributed this to the limited number of individuals pursuing rural
health topics and the limited number of dollars to support research in this
Providing equal access to health care is a
challenge in rural and remote areas of Canada.
The Committee was told that systemic trends such as inadequate numbers
of rural doctors and increasing centralization of medical services have the
effect of impeding access. The
current medical education system is not geared to producing sufficient numbers
of doctors who are interested in committing to rural practices; as well,
provincial financial incentive programs to attract and retain rural physicians
have not had high success rates. Telehealth
applications can help solve some of these problems, but they constitute only
one part of the solution.
Witnesses emphasized the importance of
federal, provincial, and territorial cooperation in developing national
strategies to deal with rural health issues whether in the areas of planning,
research, health human resources or reducing structural barriers to national
rural health policy advancement. They
argued for a federal presence in areas such as funding, immigration, planning,
evaluation, information-sharing and co-ordination, technology, facilitating
consensus, promoting innovative solutions to rural health issues, and an
expansion of the mandate of the Health Canada’s Office of Rural Health.
The Committee hopes that the recently
established Ministerial Advisory Committee on Rural Health will lead to
concrete policies and programs that will effectively contribute to enhancing
the health of rural Canadians.
Myths And Realities
As mentioned in the
Phase One report, the debate about Canada’s health care system and its
future has generated a great deal of confusion.
In this chapter, the Committee briefly analyzes a series of arguments
in order to help separate myth from reality.
We hope that this information will contribute to an informed,
fact-based debate on health and health care.
single biggest increase in health care spending is attributable to the needs
of older Canadians.
Persons over 65 consume, on average, more health services than those under 65.
However, the aging of the population is only one of the many factors
– related to both supply and demand – contributing to increasing health
care costs. Other cost drivers
include the use of new technology, the cost of new drugs, changing public
expectations, and new and changing patterns of diseases.
These all have a significant influence on the cost of health care.
Canadians are living both longer and more
healthily. Therefore, the
anticipated demographic impact of aging on the health care system needs to be
revisited. Moreover, while the
costs associated with aging must be analyzed and managed, a more significant
issue concerns the health care costs that are generally incurred during the
last six months of life, regardless of age.
The cost of medical care that individuals receive skyrockets as they
near the end of their life. As a
result, it is not the aging per se of the population which has an impact on
health care costs, but rather the overall increase in the population.
Spending on drugs is increasing because of higher drug prices.
A number of factors are responsible for increased spending on drugs
such as increased utilization, a shift in prescribing patterns away for older
less expensive drugs to newer costlier medications, and prices increases.
Using data from British Columbia, the Federal/Provincial/Territorial
Task Force on Drug Utilization (see Chapter Two) found that that changes in
prescription drug spending could be attributed to the following cost drivers:
increased utilization of existing drugs (50%), sales of new drugs in
their first full year (32%) and price increases of existing drugs (18%).
Thus, increased utilization and a shift to newer drugs, not prices
increases have been largely responsible for recent increases in spending on
Canadians in all parts of Canada have equal access to prescription drugs under
provincial government Pharmacare plans.
There are significant regional variations in who is eligible for coverage and
the reimbursement levels under government drug insurance plans.
Residents of Atlantic Canada do not fare as well as residents in other
parts of Canada. Also,
substantial numbers of people have inadequate coverage or no coverage at all.
Part-time and low-income workers are particularly vulnerable because
they often do not qualify for government plan coverage and do not have access
to employee benefits plans with drug coverage.
Drugs prices are the same throughout Canada.
Drug prices vary from province to province.
The Federal/Provincial/Territorial Task Force on Pharmaceutical Prices
reported significant differences in the manufacturers’ prices across Canada
for the same drug products. In
1993, prices in Ontario (the highest-price province) were 8.8% higher than the
prices in British Columbia (the lowest-price province).
By 1997, the last year covered by the report, price differences had
been reduced, with Nova Scotia (the highest-price province) having prices that
were 5% higher than the lowest-price province, Manitoba. The Task Force also found that if all provinces in the study
had paid the lowest available prices for the same products in 1997,
$60 million would have been saved.
Despite various efforts to control prices,
drug spending is expected to continue to escalate largely because of increased
utilization and increased consumption of newer more expensive drugs.
health care technologies currently used within the Canadian health care system
have been evaluated in term of their safety, clinical efficacy and
Unfortunately, this is not the case. As
mentioned in Chapter Three, Canada does not devote a great deal of money to
health care technology assessment (HTA).
On a worldwide basis, Canada spends less on HTA activities than do
other countries. For example, all
levels of government invest less than $8 million in Canada, whereas the United
Kingdom provides some $100 million to its national HTA body – the National
Institute for Clinical Excellence (NICE).
As a result, health care technologies are often introduced into the
Canadian health care system with only superficial knowledge of their safety,
effectiveness and cost.
federal government pays for the health services for all Aboriginal people in
Health care to Aboriginal Canadians is delivered through a complex array of
federal, provincial and Aboriginal-run programs and services. Métis and non-status Indians are not eligible for most
federal health-related programs. Health
Canada provides services to First Nations (status Indians) and Inuit.
community-based health promotion and
prevention programs to status Indians living on reserves and in Inuit
non-insured health benefits (NIHB) to status
Indians and Inuit peoples regardless of residence in Canada. (As explained in
Chapter Five, the NIHB program provides a range of health-related services to
eligible beneficiaries who are status Indians, recognized Inuit or Labrador
Innu. Benefits include drugs,
medical supplies and equipment, dental care, vision care, medical
transportation, provincial health care premiums, and crisis mental health
primary care and emergency services in nearly
200 isolated and semi-isolated areas where no provincial services are
public health services in over 400
funding for addiction services through
treatment centres and addiction treatment workers.
Aboriginal population enjoys the same health status as other Canadians.
The life expectancy of Aboriginal peoples in Canada is at least five years
below the average for all Canadians. This
is an enormous gap. It has been
estimated that increasing the life expectancy of the Aboriginal population by
five years would require the elimination of all deaths from cardiovascular
diseases (the leading cause) and almost all deaths from cancer (the second
cause of death). Although this
would appear to be an insurmountable obstacle, the Committee was told that
some progress is being made.
Although the discrepancies in the health
status of the Aboriginal population are evident, the underlying causes are not
easily identified. Aboriginal
Canadians are less likely to have finished high school, and are twice as
likely to be under Statistics Canada’s low income cut-offs.
This could help explain some of the factors contributing to the
Aboriginal population’s higher incidence of health problems.
Overall, a variety of determinants affect
the health of Aboriginal Canadians. Witnesses
told the Committee that, because many federal departments are currently
responsible for delivering a wide range of programs that can have an impact on
Aboriginal health, the federal government is, therefore, well positioned to
develop and implement population health strategy designed specifically for
Fee-for-service is the only model that physicians will accept.
Most physicians are currently paid under a fee-for-service scheme in Canada.
There is evidence, however, that many physicians would prefer an
alternative mode of remuneration. A
1999 survey by the Canadian Medical Association reported that only 33% of
respondents would prefer to be paid on a fee-for-service basis.
Another 21% would prefer to be salaried, while less than 1% would
select capitation. Approxiamately
35% indicated a preference for a blend of payments (e.g. mix of
fee-for-service and capitation). Data
from CIHI (2000) shows that, at present, the proportion of physicians
remunerated by non fee-for-service mechanisms ranges from 2% in Alberta to 53%
The fee-for-service scheme has some
drawbacks. First, fee-for-service
actively discourages physicians from promoting teamwork, as their individual
remuneration depends on the number of patients they see.
Second, fee-for-service encourages family physicians to refer as a
matter of course many of the more complex cases to specialists because they
have no incentive to spend more time with “difficult” cases.
Finally, fee-for-service reinforces the public’s perception of the
current “hierarchy” within the health care system, and can only serve to
accentuate demand on the part of individual patients to always consult the
most “highly” qualified provider, regardless of whether or not they are
the one best-suited to meeting the patient’s needs.
Canada’s health care system is structured like a 21st century
On the contrary, witnesses stressed that a major weakness in our current
health care system is that it still operates as a “cottage industry”,
despite the fact that the health care sector is an extremely
information-intensive industry. Indeed,
the most important single ingredient in any diagnosis, treatment and
prevention is information. As
mentioned in Chapter 8, the health care sector in Canada is not making use of
information and communications technology to the same extent as do other
information-intensive industries. Moreover,
the health care system is not integrated:
physicians and other health care providers, hospitals, laboratories and
pharmacies all operate as independent entities with limited access to
electronic linkages that would enable a better sharing of information.
Greater use of information and
communications technology along with better integration of health care
providers and institutions would facilitate the determination of causal
relationships between the various inputs typical of the health care system and
the resulting outputs or outcomes. This
would greatly improve evidence-based decision-making by health care providers,
health care managers and health care policy-makers.
This would allow us to answer such questions as: Are we investing
enough, too much, or too little in health care technology? Are there too many,
too few, or just enough physicians, nurses, or other health care
professionals? Are we getting our money’s worth?
Currently, we simply do not know the answers to these questions.
The Committee believes that many of the
problems facing the health care sector can be successfully addressed only if
the industry is prepared to transform itself into a
21st century service industry, rather than remaining mired in a 19th
century structure and outlook. In
our view, the federal government could provide assistance to encourage this
care is only for people who are old.
Although many home care services are aimed at the frail elderly, there are no
upper or lower age or other limits for home care requirements. Home care may be appropriate for people with minor health
problems and disabilities as well as for those who are acutely ill requiring
intensive and sophisticated services and equipment. Services are available to children recovering from acute
illness, adults with chronic diseases such as diabetes, persons with physical
or mental disabilities, and individuals needing end-of-life care.
The health and health care needs of rural Canadians are the same as
those of Canadians living in urban settings.
Health Canada’s Office of Rural Health points out that rural health needs
differ from those of urban areas. These
needs stem from the particular environment, such as the hazards associated
with rural occupations including mining, fishing and farming; demographic
trends such as an increase in the seniors’ population in some rural areas;
and the common health needs associated with the presence of a significant
number of Aboriginal communities. In
addition, there are more problems associated with delivering health services
in rural and remote environments compared to an urban setting – distances
are greater, the numbers of health care providers are smaller and specialist
services may not be readily available.
rural health issues faced by Canada are unique to this country.
Rural health issues tend to be similar throughout the world.
Significant variations in the geographic supply of health services
occur in virtually every industrialized country.
The United States, Australia and New Zealand, for example, are
experiencing health care personnel distribution problems similar to those
found in Canada.
completes Phase Two of the Committee’s study on health care. It summarizes the evidence we heard from March 2001 to June
2001, and makes reference to documents that were either tabled with the
Committee or brought to the attention of the Members.
During Phase Two, the Committee learned a
great deal about the major trends that are having an impact on the cost and
the method of delivery of health services and the implications of these trends
for future public policy and funding. We
have heard that issues with respect to demographic aging, the growing cost of
new drugs and technologies, shortages of health care providers, the burden of
illness, and the particular needs of rural Canadians and Aboriginal peoples
all need to be addressed if Canada is to sustain its health care system.
The Committee now has a better understanding of how health research and
the deployment of a pan-Canadian health info-structure can help improve both
the quality of care and the effectiveness of health services delivery in the
future. We also understand that
health and wellness promotion, disease prevention and population health
strategies can contribute to curbing the costs of health care by enhancing the
overall health status of Canadians.
With all this background information, we
attempted, as in the Phase One report, to shed some light on the current
debate over health care in Canada by separating myths from realities.
We hope that this report will serve as a useful reference document to
anyone who wishes to participate in future phases of the Committee’s study
on health care.
Wednesday, March 21, 2001
Réjean Lachapelle, Director,
Jean-Marie Berthelot, Manager, Health
Analysis and Modeling Group, Social and Economic Studies Division
Brian Murphy, Senior Research Analyst,
Socio-Economic Modeling Group
Institute of Actuaries:
David Oakden, President
Rob Brown, Manager of Task Force on
Health Care Financing
Daryl Leech, Chair, Committee on
Advisory Council on Aging:
Dr. Michael Gordon, Member
Board of Canada:
James G. Frank, Ph.D., Chief Economist
Glenn Brimacombe, Director of Health
Thursday, March 22, 2001
William B.P. Robson, Vice-President
and Director of Research
Byron G. Spencer, Professor
Dr. William Dalziel
Wednesday, March 28, 2001
Dr. Roger A. Korman, President
Association of Pharmacists:
Dr. Jeff Poston, Executive Director
Dr. Robert Coambs, President and CEO
Barbara Ouellet, Director of Home Care
and Pharmaceuticals, Health Care Directorate, Policy and Consultation Branch
Thursday, March 29, 2001
Association of Radiologists:
Dr. John Radomsky
Thursday, March 29, 2001 (cont’d)
Coordinating Office for Health Technology Assessment (CCHOTA):
Dr. Jill Sanders, President and CEO
Martin Zelder, Director of Health
Professor David Feeny
Wednesday, April 4, 2001
Dr. Christina Mills, Director General,
Centre for Chronic Disease Prevention and Control – Population Public Health
Dr. Paul Gully, Acting Director
General, Centre for Infectious Disease Prevention and Control
Dr. Clarence Clottey, Acting Director,
Diabetes Division, Bureau of Cardio-Respiratory Diseases and Diabetes, Centre
for Chronic Disease prevention and Control
Nancy Garrard, Director, Division of
Aging and Seniors
Dr. David MacLean, Departmental Head,
Community Health and Epidemiology
Thursday, April 5, 2001
Abby Hoffman, Director General, Health
Care Directorate – Health Policy and Communications Branch
Cliff Halliwell, Director General,
Applied Research & Analysis Directorate, Information, Analysis and
Nancy Garrard, Director, Division of
Aging and Seniors
Thursday, April 26, 2001
Institute of Health Research:
Dr. Alan Bernstein, President
Kimberly Elmslie, Acting Executive
Director, Health Research Secretariat
T. Scott Murray, Director General,
Institutions and Social Statistics Branch
Wednesday, May 9, 2001
Research-Based Pharmaceutical Companies:
Murray Elston, President
for Biomedical and Health Research:
Dr. Barry McLennan, Chairman
Charles Pitts, Executive Director
for Excellence for Women’s Health:
Dr. Pat Armstrong
Wednesday, May 9, 2001 (cont’d)
Genetic Diseases Network:
Dr. Ronald Worton, CEO &
Thursday, May 10, 2001
William J. Pascal, Director General,
Office of Health and Information Highway, Information, Analysis and Connectivity
Institute for Health Information:
Dr. John S. Millar, Vice-President,
Research and Analysis
Society of Telehealth:
Dr. Robert Filler, President
of Health and Wellness of New Brunswick
David Cowperthwaite, Director of
Wednesday, May 16, 2001
Dr. Peter Barrett, President
Medical Forum Task Force 1:
Dr. Hugh Scully, President
Provincial Territorial Advisory Committee on Health Human Resources:
Dr. Thomas Ward, Chair
Sandra MacDonald-Remecz, Director of
Policy, Regulation and Research
Federation of Nurses Unions:
des infirmières et infirmiers auxiliaires du Québec:
Régis Paradis, President
Practitioners Association of Ontario:
Radiation and Imaging Societies in Medicine (CRISM):
Dr. Paul C. Johns, Past Chair
Canadian Chiropractic Association:
Dr. Tim St. Dennis, President
Society for Medical Laboratory Science:
Kurt Davis, Executive Director
Thursday, May 17, 2001
Home Care Association (CHCA):
Nadine Henningsen, Executive Director
Association for Community Care (CACC):
Dr. Taylor Alexander, President
Order of Nurses for Canada (VON Canada):
Diane McLeod, Vice-President, Policy,
Planning and Government Relations, Central Region
Wednesday, May 30, 2001
Ian Potter, Assistant Deputy Minister,
First Nations and Inuit Health Branch
Jerome Berthelette, Special Advisor,
Office of the Special Advisor Aboriginal Health, First Nations Inuit Health
Dr. Peter Cooney, Acting Director
General, Non-Insured Health Benefits, First Nations and Inuit Health
and Northern Affairs Canada:
Chantal Bernier, Assistant Deputy
Minister, Socio-economic Development Policy and Programs
Terry Harrison, Director, Social
Services and Justice
of First Nations:
Elaine Johnston, Director of Health
Gerald Morin, President
Women’s Association of Canada:
Michelle Audette, Interim Speaker and
President of the Native Women Association of Quebec
of Aboriginal Peoples:
Scott Clark, President, United Native
Tapirisat of Canada:
Larry Gordon, Member ITC, Health
Inuit Women’s Association:
Veronica N. Dewar, President
Aboriginal Health Organization:
Dr. Judith Bartlett, Chair
Richard Jock, Executive Director
Institutes of Health Research:
Dr. Jeff Reading, Scientific Director,
Institute of Aboriginal People’s Health
Ron Wakegijig, Healer
Indian and Inuit Community Health Representatives Organization:
Margaret Horn, Executive Director
Thursday, May 31, 2001
Dr. John Wooton, Special Advisor on
Rural Health, Population and Public Health Branch
William Tholl, Secretary General and
Chief Executive Officer
of Rural Physicians of Canada:
Dr. Peter-Hutten-Czapski, President
for Rural Health Research:
Dr. Judith Kulig
Wednesday, June 6, 2001
Professor Martha Jackman, Faculty of
of Calgary: (by videoconference)
Professor Sheilah Martin, Faculty of
Thursday, June 7, 2001 (11:00 a.m.)
Nancy Garrard, Acting Director
General, Centre for Healthy Human Development, Population and Public Health
Tom Lips, Senior Policy Advisor for
Mental Health, Population and Public Health Branch
Carl Lakaski, Senior Analyst, Mental
Health, Health Human Resources Strategies Division, Health Policy and Communications Branch
Dr. John Service, Executive Director
Alliance on Mental Illness and Mental Health:
Phil Upshall, Coordinator
Mental Health Association:
of Health and Wellness of New Brunswick:
Ken Ross, Assistant Deputy Minister,
Mental Health Services
Kimberly Elmslie, Health Research Secretariat (Health Canada), Brief to the
Committee, 26 April 2001, p. 1
Sonya Norris, Nancy Miller-Chenier and Odette Madore, Federal Funding for
Health Research, TIPS 56E, Parliamentary Research Branch, Library of
Parliament, 11December, 2000.
Dr. McLennan, The Improving Climate
for Health Research in Canada, Brief to the Committee, 9 May 2001, p. 2.
The conversion into purchasing power parity (PPP) per capita eliminates
price disparities between countries and evaluates spending that is adjusted
to population size.
Dr. Alan Bernstein (9:17).
Dr. Alan Bernstein, Brief to the Committee, p. 5.
Kimberly Elmslie, Health Canada (9:24).
Dr. McLennan, Brief to the Committee, p. 2.
While sex refers to the biological differences between men and women, gender
refers to the social or cultural roles and characteristics that define them.
Centre for Excellence in Women’s Health, Champions
of Research Innovation, p. 2.
Kimberly Elmslie (9:23).
Murray J. Elston, The Implications of the Revolution in Genetics Research on
Public Policy Development, Brief to the Committee, 9 May 2001, p. 4.
McLennan, Brief to the Committee, pp. 8-9.
William J. Pascal, Office of Health and the Information Highway (Health
Canada), A Health Infostructure for
Canada, Brief to the Committee, 10 May 2001, p. 1.
Dr. Jill Sanders, CCOHTA (5:16).
Dr. John S. Millar, CIHI (12:13).
David Cowperthwaite, Director, Information
Systems, New Brunswick Department of Health and Wellness,
A Provincial Perspective on Health
Related Information, Brief to the Committee, 10 May 2001, p. 1.
The concepts of “health infoway” or “health information highway” can
also be used interchangeably.
Report of the National Conference on Health Info-Structure, February 1998,
Michel Léger, The Canadian Health
Infoway: A Vital Link to the Future, May 2000.
Office of Health and the Information Highway (Health Canada), Virtual
Integration for Better Health: from Concept to Reality, September 1998,
First Ministers Meeting, Communiqué
on Health, News Release, 11 September 2000.
First Ministers Meeting, Funding
Commitment of the Government of Canada, News Release, 11 September
David Cowperthwaite, Brief
to the Committee, p. 1.
William J. Pascal, OHIH, Brief to the Committee, p. 7.
William J. Pascal, OHIH, Brief to the Committee, p. 8.
OHIH (Health Canada), Virtual
Integration for Better Health: from Concept to Reality, September 1998.
William J. Pascal, OHIH, Brief to the Committee, pp. 8-9.
David Cowperthwaite, Brief
to the Committee, p. 4.
Nadine Henningsen (14:8).
Canadian Institute for Health Information, Health Care in Canada: A First
Annual Report, Ottawa: 2000, p. 58.
Kathleen Connors (13:70).
Dr. Taylor Alexander (14:24).
Dr. Thomas Ward (13:24).
Jean-Marie Berthelot (2:10).
Dr. Taylor Alexander (14:10).
Canadian Institute for Health Information, Health Care in Canada: A First
Annual Report, Ottawa: 2000, p. 58.
Federal, Provincial and Territorial Ministers Responsible for Social
Services, In Unison: Persons with Disabilities in Canada, Ottawa:
2000, p. 5.
Nadine Hennigsen (14:8).
Dr. Taylor Alexander (14:10).
CIHI, Health Care in Canada 2001, Ottawa: 2001, p. 54.
CIHI, Health Care in Canada, A First Annual Report, Ottawa: 2000, p.
Dr. Patricia Armstrong (11:22).
Nadine Hennigsen (14:8).
Dr. Robert Filler (12:15).
Nancy Miller Chenier, Home Care: A Federal Perspective, Ottawa:
Parliamentary Research Branch, Library of Parliament, TIP 77-E December 19,
Dr. Taylor Alexander (14: 11).
Centre of Aging, University of Victoria, “The National Evaluation of the
Cost Effectiveness of Home Care”, Newsletter, 1(1), March 2000.
Manitoba Centre for Health Policy and Evaluation, “A New Tool for Costing
Health Care in Canada,” Cost List example comparing
the cost of providing care in hospital with the cost of providing home care
plus drug therapy, April 1999.
Health Services Utilization and Research Commission, Hospital and Home
Care Study, Summary Report No. 10, March 1998.
Diane McLeod (14:16).
Dr. Taylor Alexander (14:12).
Nadine Henningsen (14:8).
Régis Paradis (13:52).
See Canadian Home Care Human Resources Study website at www.homecarestudy.ca
Hollander Analytic Services et al., The National Evaluation of the
Cost Effectiveness of Home Care, ongoing studies, website: http://www.homecarestudy.com
Dr. Alexander Taylor (14:32) and Nadine Hennigsen (14:33).
Bonnie Pape (19:41).
Dr. Taylor Alexander (14:20).
Nadine Henningsen (14:20).
Kathleen Connors (13:71).
Kelly Cranswick, “Canada's Caregivers,” Canadian Social Trends,
Winter 1997, Statistics Canada, No. 11-008-XPE.
National Advisory Council on Aging, Position on Home Care, No. 20,
Ottawa: March 2000.
Roeher Institute, When Kids Belong: Supporting Children with Complex
Needs – At Home and In the Community,
North York (Ont.) Roeher Institute, 2000.
Tom Lips (19:20).
Régis Paradis (13:53).
Dr. Taylor Alexander (14:25).
Senate Subcommittee to Update of Life and Death, Quality End-of-Life
Care: The Right of Every Canadian, June 2000, Appendix I: Update 2000.
William Pascal (12:24).
Dr. Thomas Ward (13:26).
Nancy Miller Chenier, Home Care: A Federal Perspective, Ottawa:
Parliamentary Research Branch, Library of Parliament, TIP 77-E 19 December
Canada, Canadian Rural Partnership, Questions for Rural Canadians: Rural Dialogue Workbook,
Ottawa, 1998; Canada, Rural Secretariat, Working
Together in Rural Canada: Annual Report to Parliament, Agriculture and
Agri-Food Canada, May 2000.
M. Watanabe with A. Casebeer, Rural, Remote and Northern Health Research:
The Quest for Equitable Health Status for All Canadians, A Report of the
Rural Health Research Summit, January 2000, p. 21.
Peter Hutten-Czapski, State of Rural Health Care, Brief to the
Committee, 31 May 2001, p. 3.
Health Canada, Rural Health (http://www.hc-sc.gc.ca/ruralhealth/).
For an overview of these factors, see Therese Jennissen, Health
Issues in Rural Canada, Parliamentary Research Branch, BP-235E, 1993.
Interview with Dr. John Wootton, “New Office to Focus on Rural Health
Issues,” Farm Family Health,
7(1) Spring 1999.
Dr. Peter Hutten-Czapski (17:13).
Canadian Medical Association, Rural and Remote Health in Canada,
Brief to the Committee, 31 May 2001.
Morris L. Barer and Greg L. Stoddart, Improving Access to Needed Medical
Services in Rural and Remote Canadian Communities: Recruitment and Retention
Revisited, Discussion paper prepared for the
Federal/Provincial/Territorial Advisory Committee on Health Human Resources,
June 1999, p. 3 (available on the Internet at http://www.srpc.ca/librarydocs/BarSto99.htm).
Morris L. Barer, Laura Wood, and David G. Schneider, Toward Improved
Access to Medical Services for Relatively Underserved Populations: Canadian
Approaches, Foreign Lessons, Centre for Health Services and Policy
Research, The University of British Columbia, May 1999, p. 7.
William Tholl, Secretary General and Chief Executive Officer, Canadian Medical Association (17:8).
William Tholl (17:9).
Society of Rural Physicians of Canada, Brief, p. 4.
Raymond W. Pong, Anne Marie Atkinson, Andrew Irvine, Martha MacLeod, Bruce
Minore, Ann Pegoraro,
J. Roger Pitblado, Michael Stones, and Geoff Tesson, Rural Health
Research in the Canadian Institutes of Health Research, A position paper
prepared for Canadian Health Services Research Foundation and Socia Sciences
and Humanities Research Council, p.3.
Dr. Judith Kulig (17:4).
In September 1998, the Office of Rural Health was established in Health
Canada to apply a “rural lens” to the federal government’s policies,
programs and services. The
Office’s mandate is to:
Provide policy advice on rural health
Identify rural health issues in relation to
broad federal, departmental and regional priorities;
Foster understanding about rural health
issues of national concern and build consensus on how to address them;
Identify emerging trends;
Work with others to promote, encourage or
influence action on rural health issues; and
Promote the involvement
of rural citizens, communities and health care providers.
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